Psychiatric Residents’ Interest in Psychotherapy and Training Stage: A Multi-Site Survey

A.B.’s story is not unique. Residents enter psychiatric training eager to become well-trained in both psychotherapeutic and psychopharmacology ( Davydow, Bienvenu, Lipsey, & Swartz, 2008; Sledge, Leaf, & Sacks, 1987). Yet attaining these aspirations—practicing the well-integrated art and science of both modalities—remains an unfulfilled promise for many psychiatrists (Carlat, 2010). Nationwide, research findings have documented the fading role of psychotherapy in modern psychiatric practice and the concomitant rise of the brief “med check” (Clemens, 2009; Mojtabai & Olfson, 2008). Recognizing the growing gap between a broadly agreed-upon definition of a competent psychiatrist and the focus of contemporary psychiatric practice, the Accreditation Council of Graduate Education Training (ACGME) established core competencies in psychotherapy that programs must provide and assess, including short- and long-term individual psychotherapy, psychodynamic psychotherapy, family and couples therapy, group therapy, cognitive behavioral therapy (CBT), crisis intervention, and concurrent use of medications and psychotherapy (Mellman & Beresin, 2003). However well-intentioned these programmatic requirements, however, they will not have lasting effects if residents are not interested in providing psychotherapy after finishing their training.

Therefore, to better understand contemporary psychiatric trainees’ interests, attitudes, and intentions regarding psychotherapy during and after their training, we surveyed residents from 15 residency training programs across the country. The initial report from that survey found that most residents viewed their psychotherapy training positively and felt their competence as a psychotherapist improved as they progressed through training (Calabrese, et al., 2010). The second report, focusing on residents’ emerging professional identities (Lanouette, et al., In press), found that while most (82%) residents viewed becoming a psychotherapist as an integral part of their identities as psychiatrists, almost two thirds (62%) anticipated psychopharmacology would form the foundation of treatment for most of their patients, and only slightly more than half (54%) planned to provide much formal psychotherapy in their post-residency practices.

Given the strong evidence base for the efficacy of psychotherapy (Leichsenring, 2005; Leichsenring & Rabung, 2008; Leichsenring, Rabung, & Leibing, 2004; Persons, Thase, & Crits-Christoph, 1996), the knowledge that many patients prefer psychotherapy over medication (Dobscha, Corson, & Gerrity, 2007; Raue, Schulberg, Heo, Klimstra, & Bruce, 2009; Unutzer, et al., 2003), the Accreditation Council for Graduate Medical Education (ACGME) mandate to teach psychotherapy skills (Mellman & Beresin, 2003), and the satisfaction most residents express about the quality of psychotherapy education and their growing psychotherapeutic competence (Calabrese, et al., 2010), it was disappointing to learn that PGY1 residents were much more likely than more senior residents to identify as psychotherapists, pursue psychotherapy training beyond residency, and anticipate that psychotherapy would be central to their future practice (Lanouette, et al., In press). Yet, these findings do not exist in a vacuum and are congruent with data and opinions from others (Gabbard & Kay, 2001). Using data from the 1996-2005 cross-sectional National Ambulatory Medical Care Survey, Mojtabai and Olfson found that the percentage of psychiatry visits involving psychotherapy declined from 44% in 1996 to 1997 to 29% in 2004 to 2005 (Mojtabai & Olfson, 2008). Moreover, the number of office-based psychiatrists who provided psychotherapy to all of their patients declined from 19% in 1996 to 1997 to 11% in 2004 to 2005.

What happens during residency training to dampen this initial enthusiasm is the focus of this report. Using the collected survey data, we examined residents’ attitudes and other factors associated with self-reported decreased interest in psychotherapy since the beginning of training.

For more than 20 years, psychiatric educators have expressed concerns about adequate training standards for residents in psychotherapy (Mohl, et al., 1990). To some, psychotherapy training is in jeopardy because advances in neuroscience and psychopharmacology have tipped the balance in residency training away from psychotherapy to the detriment of the profession (Drell, 2007; Mellman, 2006). Others lament that since the advent of managed care, psychiatry has been paying lip service to the biopsychosocial model of psychiatric training and practice (Gabbard & Kay, 2001). Concerns about the future of psychiatry as a discipline—the field’s ability to integrate rapid advances in neuroscience with the unique skills of psychotherapy and to train new generations of psychiatrists to treat patients with the artful application of the best tools in their arma-mentaria—are central to many of the most heated debates in psychiatry today.

The present findings, from a multi-site survey of U.S. psychiatry residents, suggest that today’s residents remain highly interested in psychotherapy, yet their interest and overall positive attitudes toward psychotherapy do not translate neatly into their future practice plans. We have previously reported that, on average, residents were neutral in their level of agreement with a statements regarding intention to practice formal psychotherapy after graduation (Lanouette, et al., In press). In addition, analyses by year of training revealed a more nuanced picture. First-year residents, in contrast to more senior residents, were more likely to plan on providing a great deal of formal psychotherapy after graduation and to believe that their department’s leadership supported psychotherapy.

These results may evoke mixed feelings among psychiatric educators. On one hand, only a minority of resident respondents (11.8%) reported decreased interest in psychotherapy during training. This can be interpreted as reassuring, since more positive attitudes towards psychotherapy among residents have been found to be associated with psychotherapy competence (Coon, Yates, Touchet, & Lund, 2006). On the negative side, a substantial percentage of senior residents (16.4%) reported decreased interests during residency, and there was a robust correlation between decreased interest and plans for to provide psychotherapy in future practice. As an early step in addressing these disturbing aspects of psychotherapy training in residency programs, we examined the relationship between each of the attitudinal and behavioral features we collected and decreased interest in psychotherapy and uncovered the following associations.

Factors associated with a decreased interest in psychotherapy were grouped under institutional variables (curriculum quality, supervision quality, and access to appropriate patients) and individual characteristics (general attitudes, personal experience with psychotherapy, perceived competence as a psychotherapist). In terms of the latter, the features that most highly correlated with maintaining one’s interest in psychotherapy were positive attitudes—pride in being a psychotherapist, believing that psychotherapy is integral to one’s professional identify and rewarding to practice, and believing that psychotherapy is a necessary skill for practice. In addition, greater self-perceived competencies in CBT and psychodynamic psychotherapy were positively associated with maintaining interest in psychotherapy. In many programs, residents’ outpatient experiences have become focused on severely disturbed patients with decreasing opportunity to provide treatment to patients functioning on higher levels. Thus, psychiatric trainees often lack the kinds of psychotherapeutic experiences with higher-functioning patients that help build a sense of mastery and competence. Unfortunately, the study was not designed to shed light on whether interest leads to competence or whether competence breeds interest. Likely, the relationship is bidirectional. It was somewhat surprising that previous or present experience with personal psychotherapy was not related to maintaining or losing interest, especially in light of our previously reported findings that personal experience was associated with practice plans (Lanouette, et al., In press). Future research should focus on disentangling the relationships among attitudes, perceived competence, and interest in psychotherapy.

In terms of institutional variables, several potentially remediable features stood out. In particular, it was striking that a perceived negative attitude from the program was associated with decreased interest. This argues for curricular changes that go beyond didactics to encompass the program’s values conveyed implicitly—through role modeling, and other components of the “hidden curriculum” (Hafferty, 1998). It is difficult to overemphasize the power of the chair’s role in addition to that of the entire faculty in establishing a value system within the residency training program that provides respect and intellectual excitement about working with patients in an in-depth fashion. The quality of the didactic curriculum was the next most highly correlated feature and suggests that in programs with a significant drop-off in interest, an investment in improving the didactics could be a relatively straightforward strategy to stoke and maintain interest. Teaching evidence-based practice in regards to psychotherapy and finding skilled supervisors able to convey positive attitudes about the value of psychotherapy also emerge as possible strategies to maintain or even enhance interest.

Limitations of this study include those inherent to surveys, including the possibility of bias due to social desirability. Furthermore, the response rate of 49% was relatively low, although comparable to the rates of other surveys with residents and practicing physicians in the U.S. (Astin, Sierpina, Forys, & Clarridge, 2008; Kuhn, Goldberg, & Compton, 2009). The present findings, thus, may not generalize to the entire population of psychiatry residents, although a 15-program sample is respectable. In addition, the cross-sectional design used here is not as robust as a longitudinal, within-subjects design would have been for examining changes in attitudes over the duration of training. Finally, we did not specifically ask residents for the underlying reasons for their scaled responses, a limitation that could be overcome in future research using mixed methods. Finally, one global item, asking whether “Since beginning residency training, my interest in learning psychotherapy has decreased” is not the ideal way to study a phenomenon as complex and multifaceted as this. Thus, we view these findings as preliminary, but worthy of further study with larger samples and more finely crafted measures.

In summary, this study revealed a perplexing pattern in which most residents do not endorse a decrease in interest in psychotherapy during their training, yet plans for future practice among those preparing to graduate do not prominently feature psychotherapy. Our findings are consistent with research documenting the strong interest in psychotherapy among residency applicants, coupled with the decline in psychiatry visits involving psychotherapy, as documented in national health insurance figures. Our findings suggest that maintaining interest in providing both psychotherapy and pharmacotherapy among psychiatry residents requires intensified efforts to improve the curriculum, teaching, and supervision throughout training, as well as a renewed commitment by departmental leadership to support—in both word and deed—trainees’ original intent to become comprehensively trained psychiatrists.