Psychotherapy training in residency has lost much of it’s importance due to the increasing interest for biological psychiatry and biological treatments. Especially those using long term psychotherapy haven’t supplied the answers for the growing demand for evidence based treatment. In the US the residency review committee has reduced the number of psychotherapy schools back to three: supportive-, cognitive-behavioral- and psychodynamic psychotherapy.
For this the development of an integrated model for teaching psychotherapy competencies across the three forms of psychotherapy was recently published. It’s: The Y Model: An Integrated, Evidence-Based Approach to Teaching Psychotherapy Competencies. This article offers the Y Model as a means of structuring the teaching of all the core psychotherapy competencies.
The Y model is based on three publications by two groups. Two reviews by authors from Harvard Medical School and one empirical study by a Dutch group.
This Y Model structure describes the core features, or factors, common to both CBT and psychodynamic psychotherapy and then describes those features that are particular to each school. The core features form the stem of the Y, while particular aspects of psychodynamic and cognitive-behavioral therapies form the branches of the Y.
The authors state that negotiating a therapeutic alliance is common to all therapies. But the way to achieve this is very different for different therapy forms. Nevertheless they encourage their model to teach the skills at the beginning combined with the underlying theoretical underpinnings that explain how a school of therapy works. Residents are also introduced to the differences between the
two major schools in a way that foreshadows the branches of the Y.
Teaching these common characteristics to residents first may help to decrease the confusion that often arises when residents are taught multiple therapeutic approaches as if each one requires very different basic assumptions.
Combining psychotherapy with medication and brief psychotherapy is also incorporated in the stem of the Y, since it is assumed that any school of therapy can modify its techniques and goals in relation to a limitation of time. The basics of supportive psychotherapy, one of the most difficult forms of psychotherapy is also educated during the stem of the Y but will be broadened during the teaching of the two branches: Cognitive behavioral therapy and psychodynamic therapy.
The authors next describe the discussions in the Commission on Psychotherapy by Psychiatrists (COPP). These discussions had to result in the differences between the psychodynamic and cognitive behavioral therapy as the heuristic elements located on the branches of the Y. These differences were based on the 7 core features of psychodynamic psychotherapy that differentiated it from CBT as described by the Harvard Medical school group. Members of the committee couldn’t decide whether the finding of repeating patterns in a patient’s life was considered a feature of psychodynamic therapy or CBT. The solution was to name it a core feature for both therapies, leaving 6 differences to be defined.
The therapies differed in:
- Psychodynamic therapy focus more on affect and expression of emotion, they encourage the expression of feelings to expose unconscious issues. CBT uses these affects as an opportunity to identify automatic thoughts
- Psychodynamic therapists explore the patient’s avoidance of topics and behaviors while in CBT it is a maladaptive coping style needed to be modified.
- Psychodynamic therapy places more emphasis on past experiences than CBT, looking for unresolved past conflicts. CBT focusses on patients’ future experiences, patients are taught skills to use with future problems
- Psychodynamic psychotherapists place more emphasis on the therapeutic relationship and the notion of transference in sessions than cognitive-behavioral therapists. In CBT the relationships is one of collaborators.
- Psychodynamic therapists explore the patient’s wishes, dreams, and fantasies, which are seen as central opportunities for accessing the unconscious, while these are de-emphasized in CBT.
- In CBT there is a focus on how the emotions and behavior of the patient is influenced by beliefs or thoughts about the world. In psychodynamic therapy the focus is on impulses, affects, conflicts, wishes and fantasies
- CBT is more likely to assign homework as part of the treatment
- Sessions during CBT are structured and use active guidance, discussions with the patient
- CBT teaches skills to cope with symptoms much more than in psychodynamic psychotherapy.
- CBT provides information about their ailment, therapy and symptoms more often than psychodynamic therapy
You can see a narrated PowerPoint presentation suitable for teaching an overview of the Y Model without charge on line at www.austenriggs.org in the Continuing Education section on the left margin of the home page. You will have to register first but that’s simple and easy.
I think this model is a deterioration of teaching psychotherapy to residents.
These differences between psychodynamic therapy and cognitive behavioral therapy. I don’t think that residents are often confused when they are taught multiple therapeutic approaches. I think we can improve the education of psychotherapy for residents when using modern insights of the different schools, loosing a lot of old theoretical education and using more active learning methods.
What I mean is that reading most of Freud’s work although very interesting does not contribute much to the understanding of psychodynamic psychotherapy. Active learning means e.g. the use of camera recordings.
The Y model is to simplistic obscuring the different frame works for different kind of therapies. Interpersonal therapy is lumped together with psychodynamic psychotherapy and family therapy is completely absent. For psychiatrists it is important to learn the differences between therapies, learn the indications for the different therapies. Psychiatrists are the ones to assign patients to suited forms of therapy and they should focus on the difficult forms of psychotherapy with the difficult to treat patients, for complex mental disorders. Our focus on teaching residents psychotherapy should be directed to learning them to indicate the right form of therapy and teach them the more difficult forms such as long term supportive psychodynamic psychotherapy for complex mental disorders.
Nevertheless I think the authors and those in the committees did a great job, it will improve the education of psychotherapy to psychiatric residents in the US but in The Netherlands the situation is different. The critique has not yet resulted in an almost disappearing education of psychotherapy to residents. Most patients are insured for most forms of psychotherapy. But we will have to come up with improvements for educating psychotherapy before it’s to late and we will also have to cope with faculty programs educating only 2 forms of psychotherapy.
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Plakun, E., Sudak, D., & Goldberg, D. (2009). The Y Model: An Integrated, Evidence-Based Approach to Teaching Psychotherapy Competencies Journal of Psychiatric Practice, 15 (1), 5-11 DOI: 10.1097/01.pra.0000344914.54082.eb