Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies.

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research. The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient's responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.

Important medical decisions: Using brief motivational interviewing to enhance patients' autonomous decision-making.

GOALS: The use of motivational interviewing (MI) when the goals of patient and physician are not aligned is examined. A clinical example is presented of a patient who, partly due to anxiety and fear, wants to opt out of further evaluation of his hematuria while the physician believes that the patient must follow up on the finding of hematuria. BACKGROUND: As patients struggle in making decisions about their medical care, physician interactions can become strained and medical care may become compromised. Physicians sometimes rely on their authority within the doctor-patient relationship to assist patients in making decisions. These methods may be ineffective when there is a conflict in motivations or goals, such as with patient ambivalence and resistance. Furthermore, the values of patient autonomy may conflict with the values of beneficence. METHOD: A patient simulation exercise is used to demonstrate the value of MI in addressing the motivations of a medical patient when autonomy is difficult to realize because of a high level of resistance to change due to fear. DISCUSSION: The salience of MI in supporting the value of patient autonomy without giving up the value of beneficence is discussed by providing a method of evaluating the patient's best interests by psychotherapeutically addressing his anxious, fear-based ambivalence.

Medical students as teachers: how preclinical teaching opportunities can create an early awareness of the role of physician as teacher.

BACKGROUND: As future physicians, questions about when medical students realize they will have to teach remain under-explored. AIM: To understand when students serving in pre-clinical teaching roles make the connection between teaching and being a physician. METHODS: Medical students involved in a peer instruction program included: (1) archived first-year student interview candidate data (n = 60/150); (2) focus groups of first-year students selected as instructors (n = 16/60); and (3) focus groups of second-year students (n = 16/24) who taught for the program. A modified extended-term mixed-method research design involved data from the pre-hire interviews and post-hire focus group. RESULTS: Prior to teaching, none of the first year interviewees made an explicit connection between teaching and being a physician. The new instructors selected to teach minimally made a connection and only after prompting. The majority of the experienced instructors did make the connection; however, and did so spontaneously. CONCLUSION: It was only after they taught medicine-related material that students saw the benefits of teaching as a way of preparing for becoming a physician and not merely as a way to review or help their peers.

The advisory dean program: a personalized approach to academic and career advising for medical students.

Advising and mentoring programs for medical students vary in their official names, scope, and structures. Catalyzed by negative student feedback regarding career advising and a perceived disconnection between faculty and students, in academic year 2003-2004, Columbia University College of Physicians and Surgeons implemented its formal Advisory Dean (AD) Program and disbanded its former advising system that used faculty volunteers. The AD Program has become a key element for enhancing the students' professional development throughout their student training, focusing on topics including, but not limited to, career counseling, professionalism, humanism, and wellness resources. Advisory deans and the dean for student affairs, familiar with resources for academic development, student support, and extracurricular activities, operate at the nexus of the program, providing personalized mentoring and advising for each student. Fully supported by administration and faculty, the program has shown early success according to student feedback. Early feedback from the Class of 2006, who had been involved in our AD Program for three years, has been encouraging. Out of 152 students, 104 (68%) provided feedback, with 93 (89%) of the respondents reporting the AD Program as a valuable initiative. Expecting to further improve on this early positive response, the AD Program will continue to foster an environment conducive to a seamless transition from student to physician.

How endangered is dynamic psychiatry in residency training?

The future of psychodynamic psychotherapy in residency training is in jeopardy. New priorities and forces currently aligned in academic psychiatry challenge the importance of psychodynamic psychotherapy and, by extension, its core concepts of the unconscious, defense and resistance, transference and countertransference, and the past repeating itself in the present. The exit of psychoanalysts from academic centers in the last quarter of the past century was propelled by forces including biological psychiatry, managed care, and competition from other mental health disciplines. ACGME psychotherapy competencies introduced in 2001 renewed the focus on psychotherapy training in residency and set a residency training standard for psychotherapy competency. A recent shift in academia prioritizing evidence-based medicine and a shortage of psychiatrist researchers may threaten those gains.

Psychotherapy competencies: development and implementation.

New requirements by the Psychiatry Residency Review Committee of the Accreditation Council for Graduate Medical Education maintain that residents must be competent in five specified psychotherapies. This shift toward evidence-based education and assessment highlights psychotherapy as an integral part of a psychiatrist's training and identity, while introducing accountability of training programs, faculty, and individual residents. Training directors must now find the resources in faculty, patients, and residency teaching time to teach, supervise and assess residents so they graduate with competency. The American Association of Directors of Residency Training (AADPRT) appointed a Task Force on Competency to assist training directors with the new requirements. The Task Force, through the establishment of five workgroups, has written sample competencies for each required psychotherapy: brief, cognitive behavioral, psychodynamic, supportive and combined psychotherapy and psychopharmacology. In this article, the authors describe the historical context of the new requirements, and the goals, process and issues that arose in the development of the sample competencies.