The new milestones: do we need to take a step back to go a mile forward?

The Milestones Project, like all previous systems and changes in graduate psychiatric education, for example, moving from 3 to 4 years of training or adopting six competency domains, has been devised without any supporting data and does not assess meaningful outcomes, such as improved patient outcomes. No evidence is presented that Milestones-based training will produce better psychiatrists. There is a path forward. First, replace unproven expert consensus with scientific and evidence-based approaches. Second, exchange endpoints that are easy to assess but uncorrelated with real world functioning (e.g., multiple-choice examinations) for outcomes that are meaningful and external to the training program (e.g., patient outcomes). Finally, to prevent possible waste, excess burden, or harm, no changes should be mandated until proven in prospective studies.

Learning psychotherapy in the digital age.

There is substantial literature documenting the process factors that lead to effective psychotherapy. Similarly, there is now a wealth of data attesting to the effectiveness of several psychotherapy brands. Little is known about the elements that facilitate learning how to be an effective clinician. One important step, after reading about a treatment model and seeing techniques demonstrated, is having the chance to practice the approach and receiving feedback and coaching from an experienced, knowledgeable supervisor. To accomplish this efficiently, most programs rely not only on trainee accounts of what went on in their therapy sessions, but also on recordings and videos of therapeutic encounters. This article describes our experience over a 5-year period in developing the use of Webcams for training psychology interns and psychiatric residents in the delivery of psychotherapy services. Pragmatic and technical details are given about how we went about establishing a recording system that is easy to use and provides secure, confidential storage of information at a reasonable cost. Discussion addresses both the weighing of choices that need to be made and overcoming the hesitation of trainees to reveal their work during treatment sessions.

Psychotherapy training for residents: reconciling requirements with evidence-based, competency-focused practice.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) and the Royal College of Physicians and Surgeons of Canada (RCPSC) changed the training requirements in psychotherapy, moving toward evidence-based therapies and emphasizing competence and proficiency as outcomes of training. This article examines whether the therapies selected for training are evidence based and the authors review research concerning methods for training and assessment that effectively lead to competence in these psychotherapies. METHODS: The authors searched PsycINFO and PubMed for studies from 2000 to 2009 using the terms meta-analysis, meta-analyses, and psychotherapy combined with specific psychotherapies listed in the ACGME and RCPSC requirements to determine if high-level evidence supported the use of these therapies in patients with psychiatric disorders. A similar systematic search was carried out using the same search engines for all years with the terms psychotherapy, competence, training, evaluation, and therapist rating scales for the specific therapies selected by the ACGME and the RCPSC to determine if empirically validated therapist competency scales and specific teaching methods that enhance competence could be identified. RESULTS: Meta-analyses support the use of several psychotherapies in the treatment of patients with psychiatric disorders and specifically those selected for training. Empirically validated rating scales assess therapist competence in several therapies, and specific teaching methods enhance therapist skill. CONCLUSION: The Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada have incorporated evidence-based psychotherapies in their new guidelines. Evidence-based methods for assessing competence and for teaching psychotherapy are available and could be encouraged or required in the future.

Personality traits related to chronic pain location.

BACKGROUND: Previous research has yielded inconsistent findings on the relationship between personality characteristics and chronic pain. The present study examines measures of alexithymia, somatosensory amplification, attachment, counterdependency, and emotional distress in 140 consecutive general medical outpatients seen in psychiatric consultation. METHODS: Forty-five subjects having no chronic pain (NP) were compared to 49 subjects with chronic pain restricted to their back and/or extremities (BE) and with 46 subjects having pain involving other regions of the body (OP). RESULTS: Findings demonstrated marked counterdependency traits in the BE group relative to the other two groups. By contrast, traits of alexithymia and somatosensory amplification, insecure attachment, and a high level of emotional distress characterized the OP group. A multiple logistic regression model combining counterdependency and secure attachment was 86% accurate in predicting BE (c = 0.86). CONCLUSIONS: The study's findings suggest that personality traits vary according to chronic pain location, although the nature of the relationship still needs to be determined.

Evaluating competence in psychotherapy.

BACKGROUND: The Residency Review Committee (RRC) for Psychiatry has recently charged psychiatry training programs with developing methods to demonstrate competence of trainees in five areas of psychotherapy. Each program must decide what specific skills are essential for competence in each of the five listed psychotherapies. This requires determining whether those skills that are necessary are also sufficient for effective psychotherapy and whether additional specific skills are required for each one. METHOD: Two lists of general skills for psychotherapy are compared, one from the perspective of specific "schools" of psychotherapy and one from a more eclectic "integrative" approach. The issue of measuring competence is addressed by placing ratings of "competent" midway on a continuum from "novice" to "expert." Thirteen methods for measuring competence from the Accreditation Council for Graduate medical Education (ACGME) "tool-box" are described and reviewed with respect to applicability to psychotherapy. Examples of toolbox implementation are described based on a functioning psychotherapy evaluation program at the University of Missouri. RESULTS AND CONCLUSIONS: The authors found both theoretical as well as practical problems in measuring competence in psychotherapy. We propose that global rather than highly specific assessment methods may be more practical in these early stages of development, and we offer specific suggestions for assessment components that can currently be implemented.