Teaching Psychotherapy to Psychiatric Residents in Israel
Shalev, Arieh Y., The Israel Journal of Psychiatry and Related Sciences
Abstract: This work examines the rationale for, and the feasibility of teaching psychotherapy to psychiatric residents, and the "what if" of dropping it from the curriculum. Psychotherapy is one of the pillars of psychiatry. However, current economic constraints and the increasing weight of phenomenological and biological psychiatry make it more difficult to prioritize and allocate resources to its teaching. The term psychotherapy encompasses several techniques, some of which are extremely effective. It often confounds skills, attitudes, theory, body of knowledge and specific practices. Looking at each component separately, a stepped curriculum for teaching is outlined; alternatives to traditional theories are offered; and the need to allocate time and resources for teaching and learning are shown as the rate-limiting factor for the survival of psychotherapy within psychiatry. Not limited to residents, the debate about psychotherapy in psychiatry concerns the professions core identity and its traditional person-centered nature.
At first blush, everything is in favor of teaching psychotherapy to psychiatric residents in Israel. Psychotherapy is one of the pillars of psychiatry. Psychotherapy offers effective tools for treating anxiety and mood disorders. Learning psychotherapy improves residents' listening and understanding of their patients. Many medical graduates opt to specialize in psychiatry with the hope of becoming psychotherapists.
Moreover, psychotherapy in Israel is in a renaissance. Much of its core literature has been translated into Hebrew. Cross-over psychotherapy books were among Israel's best sellers. A recent television series that described, session by session, five psychodynamic therapies was highly rated by lay spectators and professionals. Israel has a widely read, peer-reviewed periodical of psychotherapy (Sihot - Dialogue, the Israel Journal of Psychotherapy). Each of Israel's major universities has a psychotherapy program. Learning psychotherapy should be easy in Israel.
Nonetheless, the teaching of psychotherapy to psychiatric residents in Israel is in poor shape. Judging from residents' performance during Board examinations, the achievements are quite limited: Reports of psychotherapies are often hesitant, schematic and poorly articulated. Theory rarely seems to be clear to the examinee, or integrated in his or her report. Many reports quote entire books, or drop names of famous theoreticians, without reference to specific portions of their writings. Examiners often get an impression of insufficient teaching and major gaps between residency programs.
From the residents' perspective, the psychotherapy portion of the Board examination has gained a bad reputation: It is perceived as a major hurdle, and even worse, as having unexpected content and unpredictable outcome. Some residents use surrogate writers to write up their cases. Other residents turn to their supervisors for careful review of their reports in an effort to link their practices to theoretical constructs. Preparing for the examination is, very often, the first opportunity to seriously reflect on previously completed therapies.
Thus, discomfort with teaching of and learning psychotherapy affects both providers and receivers. One can only wonder what the underlying reasons of the discontent are: Is the teaching that bad? Are current residents reluctant to learn psychotherapy? Have other areas and skills become prominent and exclusive? Has psychotherapy grown old - or obsolete? Is there a cultural gap between residents from different countries of origin?
These are important questions, but even more important is the effect, on teaching psychotherapy, of the larger context of practicing psychiatry in Israel. The syndrome-based, pharmacotherapy-oriented approach to treatment is currently prominent. Biological psychiatry dominates psychiatric discourse. Time and economic pressures allow but the reputedly most "effective" diagnostic and treatment modalities. …