Slowly.

Unlike our psychology colleagues, psychiatry residents, as a result of our general medical training, are first thrown into situations with patients before learning little (if any) theoretical underpinnings of psychotherapy. We learn how to interview and interact with patients from a medical perspective. Most (if not all) training programs assign junior residents to inpatient psychiatric wards, where psychotherapies frequently fall into the shadow of biological interventions (i.e. medications). Furthermore, the brief lengths of stay for hospitalizations do not necessarily facilitate the rapport that ideally characterizes a psychotherapeutic relationship.

You probably won’t share your wishes, hopes, dreams, and fears with someone you just met… and whom you may never see again after seven days… especially if your interactions with them are limited to ten or fifteen minutes a day. If that.

Most training programs schedule an outpatient clinic for residents in their second year of training. Usually, residents will have learned some essential basics to psychotherapy before seeing their first “long-term” psychotherapy patient.

And, let me tell you, residents are usually pretty freaked out before that first session—arguably more so than the patient. Most of us are not accustomed to sitting in the room for fifty minutes with a patient. Fifty minutes is a long time. Especially when one is absolutely convinced that s/he has absolutely no idea what s/he is doing. (”What if I don’t talk enough? What if I talk too much? What if I say the wrong thing? What if I do something terrible and the patient never comes back? What if I end up really screwing up the patient?” etc. You can see who the resident is really concerned about.)

Thus, part of our psychotherapy training is literally learning how to sit in a room with someone and be present with that individual for fifty minutes. Most residents settle down within the first month of weekly appointments. The focus eventually shifts more towards the patient.

Most residencies provide mandatory instruction on two types of psychotherapy: Psychodynamic psychotherapy and cognitive-behavioral psychotherapy (CBT). This is generally our first exposure to psychotherapy theory. (Our psychology colleagues follow a more logical course: They learn theory first, then see patients.) Residents can arbitrarily transform a given patient into a “psychodynamic patient” or “CBT patient”. (Indeed, we do not learn how to treat individuals; we learn how to apply theories to individuals….)

Residents have psychotherapy “supervisors”. Ideally, one supervisor (an attending psychologist or a psychiatrist) works with a resident for one psychotherapy patient. The time spent with the supervisor is termed “supervision”. For each hour of psychotherapy, there is one hour of supervision. Each supervisor is (hopefully) well-versed in a specific type of psychotherapy and provides supervision for that specific modality. This helps the resident gain mastery over that given psychotherapy.

In supervision, the supervisor and resident discuss the psychotherapy session. Many supervisors request that the resident videotape sessions (with patient consent, of course) so that the supervisor and resident can review them. Otherwise, residents can audiotape sessions, take notes during sessions, or scribble notes afterwards. (Allow me to take this moment to thank all of those patients who have ever agreed to videotaping of psychotherapy sessions—as usual, patients are the best teachers. Your generosity allows residents to monitor our progress, thus decreasing the likelihood that we’ll consistently behave like complete jack@$$es in the future. Thank you.) The supervisor may offer feedback about the content (what was actually discussed) and process (how it was discussed) of the session, as well as suggestions for improvement. There may also be discussions about the internal experiences (emotions, thoughts, hunches, etc.) of the resident and how they may (or may not) be relevant to the therapy. The supervisor may use events in the session to highlight the applicability of the psychotherapy theory and teach further details about its utility in that given (or similar) situations.

Thus, assuming that the resident is heeding the suggestions of the supervisor in this apprentice model, the quality of the supervisor will absolutely affect the therapy the patient has with the resident. Although the supervisor is not physically in the room with the resident and patient, it kindasortamaybe is like the patient is actually in therapy with the supervisor. And some supervisors are, frankly, pretty awesome.

Most residencies offer education in several types of psychotherapy, such that the curious resident (because, remember, not all psychiatrists are interested in psychotherapy…) can learn and attain basic competency (if not greater proficiency) in several modalities. This allows for greater flexibility in interacting with patients in a therapeutic fashion, which facilitates appropriate treatment of the patient, rather than treatment of the therapy. (My personal bias is obviously showing—please indulge me and allow me to opine that every single encounter with a patient can be therapeutic, even those interactions that aren’t considered “therapy”.)

It takes a long time to learn how to “do” therapy skillfully. (Please note that “do” is not the right verb.) I don’t think there are any studies to support the following assertion, though people have remarked upon this in an anecdotal way: Internal medicine docs who are just a few years out of residency are probably on top of their game; they know all about the latest updates in medical care and all that information is still fresh in their minds. Psychiatrists who practice psychotherapy are not on top of their game upon finishing residency; they’ve only laid the foundation for their clinical careers. And, it seems that most psychiatrists agree that a sense of confidence and mastery in therapy doesn’t solidify until eight to ten years after completion of residency.