New Idea
A New Psychotherapy Training Program
Description and Preliminary Results
Bernard D. Beitman, M.D.
Dongmei Yue, M.D.
Psychotherapy training programs require a uniform introduction to psychotherapy that
presents the basic, generic concepts common to the major schools in a time-efficient manner.
The program described in this article fits these criteria. The program has been initiated at
seven residency training programs in the United States. The authors describe the six modules
comprising the program—verbal response modes and intentions, working alliance, inducing
patterns, change, resistance, and transference and countertransference. The authors also
report preliminary results of the program evaluation (N=15) from the University of Missouri–
Columbia. By using a well-researched measure of trainee self-confidence as psychotherapist
(The Counselor Self-Estimate Inventory), the authors report a statistically significant increase
in trainee self-confidence beginning and maintained after Module 4. The authors conclude
that this training shows promise as a standard introduction to psychotherapy for psychiatric
residents. (Academic Psychiatry 1999; 23:95–102)
f psychiatric residencies are to maintain psychotherapy
as core to their training programs, a uniform
and consistent standard for psychotherapy education
must be adopted. Without consistent standards
used across training sites, some training programs
will continue to emphasize psychotherapy, whereas
others will gradually lose their psychotherapy content.
Future generations of psychiatrists will no
longer embrace psychotherapy as a core practice of
the profession (1).
The designers of an effective training program
must select a limited number of skills that, if effectively
taught, will lead to effective psychotherapy.
This objective requires the careful selection from a
wide variety of potential alternatives, from both research
and clinical experience (2). The selected alternatives
should include what are generally considered
to be the common factors or pantheoretical elements
of the psychotherapies. It is toward this aim that this
training program is developed. In addition, the program
attempts to help trainees acquire a mastery of
multiple treatment approaches and to adjust their
therapeutic approaches to fit the needs of their patients.
An additional goal is to educate trainees to
Academic Psychiatry, 23:2, Summer 1999
think and perhaps to behave integratively, openly, and
synthetically—but critically—in their clinical pursuits
(3). Trainees are encouraged to examine their own
thinking and to apply critical research attitudes to
what they do and how they do it. They learn to
measure their effectiveness and respond to these evaluations
with a sharpening of behavior and thinking.
Trainees should be informed consumers of research
findings and should respect research evidence that
can contribute to clinical effectiveness.
The characteristics of an ideal introduction to
psychotherapy should include 1) time efficiency so
that much can be taught in a short period of time, 2) a
research base so that well-established ideas are easily
communicated, and 3) an outcomes orientation with
targeted results and the ability to measure them. This
program contains these desirable qualities.
Dr. Beitman is chairman, Dr. Yue is a resident; both are in
the Department of Psychiatry, University of Missouri—Columbia.
Address correspondence and reprint requests to Dr. Beitman,
Department of Psychiatry and Neurology, University of Missouri—Columbia,
Three Hospital Drive, Columbia, MO 65201.
Copyright © 1999 Academic Psychiatry.
I
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A NEW PSYCHOTHERAPY TRAINING PROGRAM
The program described in the following section
was initiated at the University of Missouri—Columbia
in 1995, and beginning July and August 1998 in the
following other departments of psychiatry: Stanford,
University of Southern California, University of
Missouri—Kansas City, University of Michigan, University
of Connecticut, and George Washington Uni-
versity.
PROGRAM DESCRIPTION
The training program uses a once-weekly seminar
format that requires about 30—90 minutes of homework
from each participant almost every week. The
program is generally offered in the second year before
residents enter their outpatient years. Supervisors
are informed of the content of the modules and
encouraged to organize their supervision around
module-specific content. A fundamental aim is training
in the activation and use of each trainee's observing
self (4) under the assumption that greater access
to self-awareness is a crucial variable in therapeutic
effectiveness for both therapist and patient. The modules
are intended to follow the general stages of the
development of the psychotherapy relationship. In
addition to pre- and postmodule activities, the following
modules are presented 1) Module 1: Verbal
Response Modes and Intentions, 2) Module 2: Working
Alliance, 3) Module 3: Inductive Reasoning to Determine
Patterns, 4) Module 4: Strategies of Change,
5) Module 5: Resistance, and 6) Module 6: Transference
and Countertransference.
Premodule
Fundamental to this training program is the development
of a set of baseline measures from which
to compare trainee change. The primary outcome
measure is the Counseling Self-Estimate Inventory (5)
to self-rate therapeutic competence over five subscales.
The 37 items query trainees on items including
"I am certain that my interpretation and confrontation
responses will be concise and to the point," "I feel
confident that I will appear confident and earn the
respect of my patient," and "My assessment of patient
problems may not be as accurate as I would like
them to be."
Trainees are required to make audiotapes of two
third-session psychotherapy relationships. Trainees
rate their verbal response modes (6,7) and intentions
(8) and complete a Working Alliance Inventory (WAI)
(9). Their patients complete the WAI and the Session
Evaluation Questionnaire (SEQ) (10), which measures
general qualities of the session; the Patient Re-action
System (11), which measures specific reactions to
specific therapist interventions during the session; and
a Treatment Outcome Profile (TOP) (12), which
measures satisfaction with treatment, symptoms,
quality of life and work, and social functioning. The
TOP is also completed before the first session.
Module 1: Verbal Response Modes
and Intentions
The purpose of Module 1 is to teach them verbal
response modes and intentions. Verbal response
modes refer to the basic grammatical tools available
to therapists. As defined by Hill and colleagues
(6,7,11), these include minimal encouragement, silence,
approval—reassurance, information, direct guidance,
closed question, open question, restatement,
reflection, interpretation, confrontation, nonverbal
referent, self-disclosure, and other. Verbal response
modes are correlated with patient-rated session outcomes
(13).
If the verbal response modes help the trainees answer
the question "What do I do in the session?",
intentions can help them answer "What do I want to
accomplish in the session?" Hill and O'Grady (8) defined
an intention as a therapist's rationale for selecting
a specific behavior, response mode, technique, or
intervention to use with a patient at any given moment
within the session. Hill and O'Grady originally
described 19 therapist intention categories. Later, Hill
et al. (13) suggested that only seven intentions occur
frequently enough to be used in future research. The
Therapist Intention List, with 19 intentions, includes
the following: set limits, get information, give information,
support, focus, clarify, hope, cathart, cognition,
behaviors, self-control, feelings, insight, change,
reinforce change, resistance, challenge, relationship,
and therapist needs. Hill et al. (11) demonstrated that
therapist intentions provide a more adequate description
of therapist interventions than therapist response
modes.
Trainees are asked to rate two standardized transcripts
for both verbal response modes. They are also
asked to rate the therapist's intentions in one of these.
96 Academic Psychiatry, 23:2, Summer 1999
BEITMAN AND YUE
They are then given one copy of the transcript of one
of their third sessions from the premodule. They are
asked to rate their intentions for each of their speaking
turns on parts of one of these transcripts.
Module 2: Working Alliance
Module 2 teaches trainees the components of the
therapeutic relationship. The WAI (9) measures three
components of the therapeutic relationship: bonds,
tasks, and goals. Trainees are asked to rate two different
therapeutic relationships by using the instrument
and then by discussing their ratings in the
group. One tape used in our program is Carl Rogers'
"Gloria" (14). They then rate a third session from one
of the authors (Beitman BD, videotape of Dr. Beitman's
therapy session with MF, University of Missouri,
1995) under the assumption that trainees can
learn more effectively by seeing local and national
therapists in action. The trainees are shown the patient's
rating of Dr. Beitman's session as well as how
their ratings compare with the ratings of prior trainees
and with a group of experienced therapists. Differences
become subjects for discussion.
A volunteer also plays portions of his/her own
tape to the group, which then rates its working alliance.
These ratings are compared with the patient's
and the therapist's own ratings to demonstrate the
differences among the three perspectives.
Module 3: Defining Patterns
The goal of pattern search is to define patterns of
thought, feeling, and/or behavior that are within the
patient's ability to influence and, that if changed,
would lead toward a desirable outcome (15). Almost
every therapeutic approach, no matter how it explores
and explains human experience, identifies the
patient's general dysfunctional patterns from limited
samples of information that the patient presents
through verbal and nonverbal information during the
session. In addition, each school embraces a limited
collection of general dysfunctional patterns into
which to place each patient's problems. Inductive reasoning
is a necessary process across psychotherapy
schools because all therapists must take individual
bits of data to define general patterns. Because psychotherapy
helps patients change their dysfunctional
patterns, inducing these patterns is a prerequisite to
Academic Psychiatry, 23:2, Summer 1999
patients' change. Training in the use of inductive reasoning
can help students develop efficient ways to
think about the process of elucidating dysfunctional
patterns. Trainees are shown various common inducing
points, in addition to patients' verbal reports, including
diaries, countertransference, and reports by
significant others. An underlying theme of this presentation
is that different labels may be used for similar
patterns and could explain the relative equality of
effectiveness of various schools. The terms of the label
for the pattern(s) must first be compatible with the
patient's self-understanding to be accepted. We compare
this process with trying to sell hats or shoes in
that the pattern must fit and be liked to be used. The
trainees are presented a glossary of terms for the generic
patterns associated with various schools.
The goals of Module 3 include 1) understanding
the concept of inductive reasoning, 2) learning how to
find the patient's patterns from inducing points, and
3) learning how to use the triple-column technique
(16).
The triple-column technique is a structured
homework exercise that promotes ongoing selfobservation
in patients who agree to do it. This exercise
provides one of several ways by which patients
can be taught how to self-observe. By studying their
own inductive reasoning thought processes, trainees
refine their abilities to monitor and direct their
thinking.
At first they are presented brief case vignettes
that require only modest inductive reasoning to
achieve the definition of a dysfunctional pattern. The
students are then presented a pair of transcripts from
which inducing points must be gleaned from the more
extraneous information. Finally, they are presented
videotape vignettes that contain many levels of
information from visual-postural data, to transference–countertransference,
to voice tone and inflection,
and verbal-inducing points. This gradient of
increasing data complexity brings them gradually
closer to the clinical reality.
Module 4: Strategies for Change
This module introduces the complex concept of
change. Trainees are asked to be humble in the face
of the multiple factors contributing to change in addition
to strategies and techniques, including the
strength of the working alliance (17), the patient's
97
A NEW PSYCHOTHERAPY TRAINING PROGRAM
readiness to change (18), and the strength of the patient's
social network (19). The students are introduced
to the substages of change: relinquishing the
old pattern, initiating and then maintaining the new
one. Figure 1 describes the relationship between generic
change strategies and the substages of change.
Trainees are supplied a glossary defining each of the
generic change strategies.
The trainees are then shown a lengthy table with
glossary describing strategies and techniques associated
with the various schools of therapy (Emotionfocused,
Cognitive, Behavioral, Interpersonal—
Psychodynamic, and Systems) or ECBIS. It is
emphasized that each of these perspectives is part of
the general whole, as suggested in Figure 2.
The goals of Module 4 include 1) understanding
the substages of change, 2) understanding the various
strategies for change, and 3) a beginning understanding
of the principles for strategy selection. Trainees
are given two sets of transcripts, each containing 10
different therapeutic interchanges. At the end of each
interchange, they are posed two to three multiplechoice
questions asking them to define the substages
of change being passed through in this dialogue, the
generic change strategies used, and the ECBIS strategies
being used. They are asked to compare their
answers with each other during the seminar and to
explain their differences. Trainees often find this
homework exercise very interesting, exciting, and satisfying
because they are reading real dialogues and
are becoming able to understand what the therapist
is thinking. They are also given two sets of two shortparagraph
vignettes. They are asked to describe what
generic and ECBIS strategies they would use. In these
ways, they become increasingly more familiar with
how these strategies are used. They are also shown
brief videotape vignettes from prominent therapists
representing each of the ECBIS schools (20) as well as
one from one of the authors (Beitman BD, videotape
of Dr. Beitman's therapy session with MC, University
of Missouri, 1996). To demonstrate that psychotherapy
does not always work and that therapists are
sometimes quite helpless, they are shown a videotape
vignette of a frustrated therapist (Beitman BD, videotape
of Dr. Beitman's therapy session with J, University
of Missouri, 1990).
Module 5: Resistance
Trainees are encouraged to activate their ability
to self-observe when they detect a block in the progress
of therapy. They are taught three general
sources of resistance: 1) patient-originated (e.g., fear
of change); 2) therapist-originated (e.g., unrealistic
FIGURE 1. Three substages of change and their associated generic strategies and techniques
Relinquish
Defining patterns
Past vs. Present
i
1
1
Res
98 Academic Psychiatry, 23:2, Summer 1999
How to change
i
Alternatives
Selection
Expectations
Face fear
Reframing
Resolving
conflicts
Stumbling blocks to
stepping stones
II
I I
Initiate
ponsibility
Challenge
Maintain
Operationalizing \
Positive reinforcement
Advantages of change
Practice
BEITMAN AND YUE
expectations of patient change potential); and 3) social
network-originated (e.g., change is disruptive to social
system equilibrium).
They are shown standard expectations for patients,
forms of resistance, and sources of resistance in
each of the stages of psychotherapy. Then they are
introduced to five general therapist responses to resistance,
including 1) empathic encouragement to do
what is needed; 2) explanation of the problems the
resistance causes and how to get past it; 3) interpretation
of the cause, reason, or pattern suggested by
the resistance; 4) ignoring or accepting the resistance
without comment; and 5) paradoxical cooperation with
the resistance.
The goals of Module 5 include understanding the
forms, sources, and management of resistance. After
discussing these issues, they are given 15 case vignettes,
after each of which they are asked to identify
the source and potential management of resistance.
Module 6: Transference and Countertransference
After an introduction to the concepts of transference
and countertransference, trainees are presented
various signs of transference, as illustrated in Table
1. Then they are shown relationships among and between
the working alliance, the real relationship, and
transference—countertransference.
Finally, they are shown several methods of
handling transference and countertransference responses.
The goals of the module are to understand
Academic Psychiatry, 23:2, Summer 1999
and use transference and countertransference, with
particular emphasis on the therapist's and patient's
observing self.
The trainees are shown a videotape of one of the
authors (Beitman BD, videotape of Dr. Beitman's
therapy session with W, University of Missouri, 1988)
demonstrating clear countertransference reactions for
discussion; they are taught the use of the Core Conflictual
Relationship Theme (21), and then in several
homework assignments they rate standardized transcripts
according to this method. They are then asked
to analyze their reactions to both patients and significant
others in their lives (sometimes to find similar
themes). The next homework assignment involves
reading transcripts of borderline patients and then
recording how they would feel if they were the
therapist. They read a transcript and discussion of an
intense erotic transference reaction, which they are
asked to discuss. The trainees are then given 14 case
vignettes containing transference—countertransference
interactions, which they are asked to categorize
as to source (patient or therapist). Then they are given
transcripts containing transference responses and
asked to write how they would respond to what the
patient has just said.
Postmodule
Trainees repeat the acquisition of two thirdsession
audiotape recordings, accompanied by measures
of working alliance completed by both trainee
and patient. In addition, they record their intentions at
each therapist speaking turn and identify from a
transcript their verbal response modes. The distribution
of intentions and verbal response modes is to
be compared with the premodule distribution as a
measure of potentially increased range of responses
and intentions as a result of their experience. The patient
measures are also completed, including TOP,
SEQ, and patient reaction system.
METHODS
The primary outcome measure in this program evaluation
is the Counselor Self-Estimate Inventory
(COSE) (5). Developed by counseling psychologists to
measure therapist confidence in using microskills
(e.g., concise use of reflections and probes); attending
to process (e.g., ability to handle personal anxiety
FIGURE 2. Interactions among E C B I S
System
7' IN
Behavior Emotion Cognition
Interpersonal
99
A NEW PSYCHOTHERAPY TRAINING PROGRAM
about performance); dealing with difficult client behaviors
(e.g., sufficiently broad repertoire from which
to draw); cultural competence (dealing with cultural
differences); and values (being able to respond in a
nonjudgmental way) . Each of the 37 items can be
rated from 1–6 (from strongly disagree to strongly
agree).
Data were gathered from two groups, totaling 15
residents (5 women and 10 men, mean age: 37.5
years), who rated themselves at premodule period
competence and immediately following each of the 6
modules. The training program required 42 one-hour
sessions. Pre- and post-COSE measures were analyzed
by using the paired comparisons with PROC
means (22).
RESULTS
Table 2 displays the mean differences between premodule
COSE and the COSE responses at the end of
each of the modules. Their ratings actually decrease
after the first module, compared with baseline. After
Module 4, their self-reports are statistically significant,
compared with baseline, and remain significant
after each of the subsequent modules.
Table 3 displays COSE results for the subscales
between premodule and the end of Module 6. Each of
the five scales showed statistically significant increase
except for the microskills scale, which was
marginally significant (P = 0.08).
DISCUSSION AND CONCLUSIONS
This group of residents reported a statistically significant
increase in their self-confidence as therapists,
suggesting that this training program may have
played a part in this change. Interestingly, they reported
a drop in self-confidence as therapists after the
first module, which focused on verbal response
modes and intentions, suggesting that at this point
they began to discover what they did not know they
did not know. The results reached and maintained
statistical significance after Module 4, by which time
they had learned the basics of the change process and
related techniques. This latter finding suggests that
their confidence can be greatly increased when they
learn how to help patients change. The marginal significance
on the microskills subscale is consistent
with the objectives of the training, which do not include
direct "hands-on" instructions in the specific
practice of psychotherapeutic techniques. FurtherTABLE
1. Signs of transference and countertransference
Signs
Transference Countertransference
Inappropriate or excessive:
Feelings such as anger, hostility, hurt, envy, distrustfulness,
excessive appreciation, concern, and erotic attraction
Inappropriate or excessive:
Feelings such as anger, irritation, anxiety, guilt, fear, sexual
stimulation, disappointment, shame, helplessness, envy,
boredom, awe, excessive pride in the patient's accomplishment,
high anticipation about seeing the patient, resentment
at having to see a patient or, on the other hand, having to
terminate therapy
Behaviors such as calling the therapist at home, calling the
therapist by first name, asking to see the therapist outside the
office, asking the therapist for personal information, writing
a love letter to the therapist, or excessively criticizing the
therapist
Behaviors such as arranging an opportunity to socialize with
the patient, criticizing the patient, or excessively reassuring
the patient; bragging to other therapists about a patient's
success, making fun of patients, asking favors of the patient,
trying to impress the patient, keeping excessively silent,
reducing or not charging the fee, avoiding discussion of the
patient's boundary violations
Thoughts and fantasies such as fantasy to have a family and
children with the therapist, becoming a colleague of the
therapist, dreaming about the therapist
Thoughts and fantasies such as fantasies of sexual involvement,
of romance, of being best friends, of taking a trip
together, dreaming about the patient
Resistance reactions (see Module 5): any resistance reactions
may suggest transference
100 Academic Psychiatry, 23:2, Summer 1999
BEITMAN AND YUE
more, these are beginners who have had very little
psychotherapy experience. When they are asked to rate
the statement "I don't feel I possess a large enough
repertoire of techniques to deal with different problems
my patient may present," they are likely to express
relatively less confidence, compared with "I feel
confident that I have resolved conflicts in my personal
life so that they will not interfere with my therapy
abilities." This latter item is a major focus of the
training program, which emphasizes the need to be selfaware
during the therapeutic encounter.
This study lacks a control group to help explain the
influence of the other factors in the psychiatric
residency training program that may help to increase
their self-confidence as therapists. However, this report
falls more closely under program evaluation than
formal research. Like clinical outcomes measurement,
training program evaluation emphasizes service
delivery (in this case adequacy of training) over
controlled trials. The positive results reported here
could be a product of the enthusiasm of the originators
rather than the content and process of the pro-gram
itself. To answer these problems, we have initiated a
multisite evaluation of the program including using an
additional site as a control group.
Another limitation of this study concerns the failure
to report the degree to which the training pro-gram
influences subsequent patient care. We are gathering
and analyzing data on patients seen in the premodule,
compared with those seen in the post-module, to gain
objective information about it and how the trainees
change their conduct of psycho-therapy. What we really
want to see is whether this program influences trainee
involvement in psycho-therapy as practitioners and the
degree to which it influences clinical effectiveness after
completing their residencies.
We have presented an outline of an innovative
introduction to psychotherapy training program that has
been started in seven residency training pro-grams. The
program shows promise in the significant increase in
therapist self-efficacy associated with the training
experience. As training programs in psychopharmacology
become increasingly more standardized
in an effort to provide information in time-efficient
ways, training in psychotherapy should also be
considered for standardization for the same reasons.
Psychotherapy is a crucial element of resident
education; its generic components are well-established.
This program offers a possible answer to the need for a
time-efficient training program in the basics of
psychotherapy.
TABLE 2. Counselor self-estimate ratings: baseline vs. each postmodule
Comparison N Mean Std Error T pro I TI
Postmodule 6 vs. Premodule 14 29.07 9.0823 3.2008 0.0070'
Postmodule 5 vs. Premodule 13 19.9230 7.9263 2.5135 0.0272a
Postmodule 4vs. Premodule 13 22.8461 8.2515 2.7687 0.0170'
Postmodule 3 vs. Premodule 13 9.61538 7.0977 1.3547 0.2005
Postmodule 2 vs. Premodule 8 5.6250 8.8235 0.6374 0.5441
Postmodule 1vs. Premodule 10 - 5.8000 6.9806 - 0.8308 0.4275
'Significant at P = 0.05.
TABLE 3. COSE Subscales: Postmodule 6 vs. Premodule
Analysis Variance: Difference N Mean Std Error T pro I TI
Microskills 14 7.4285 3.9470 1.8820 0.0824
Counseling process 15 8.8666 2.5539 3.4717 0.0037'
Dealing with difficult client behaviors 13 6.7692 2.0100 3.3676 0.0056'
Cultural competence 15 2.9333 0.9074 3.2324 0.0060'
Values 15 3.1333 0.8556 3.6621 0.0026'
Note:COSE = Counselor Self-Estimate Inventory.
aSignficant at P = 0.05.
Academic Psychiatry, 23:2, Summer 1999 101
A NEW PSYCHOTHERAPY TRAINING PROGRAM
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