18. Please describe some module variations.
Answers
A1. It is best to transcribe both sessions so that each may be used in supervision. It is also a good idea to have a page or 2 from both transcripts for the 6th session of Module 1 discussion instead of just one session. Both third sessions are used as baselines for comparison to posttraining in which two third sessions are once again obtained.
A2. Gather the supervisors together. Give each a copy of each book. Train them a little in each module to give them a flavor and then suggest the following for each supervisor for each trainee in the modules:
1) Discuss the seminar material for this week.
2) Review the transcripts from the Pretraining each session until their learning potential is exhausted.
3) Define for the trainee the ideas you most cherish about psychotherapy which you would like to get across.
4) Focus on the timing of interventions by selecting individual cases (does not have to be psychotherapy could be ER, consults or inpatient.
Try to gather them together a few times per year.
A3. The therapist's name is "Morris," not "Mirris." People who are interested in ordering this tape should note that Morris is on Tape 12, Psychotherapies, which is part of the World of Abnormal Psychology series. You can order this tape by calling
1-800-532-7637.
A4. Anywhere you can find them--wherever the trainees are. Here we stumbled upon involving patients on the VA Substance abuse Unit. These patients have time and are usually interested.
A5. Best is outside the last session of each Module but in the first year or two you may need to have them complete it in the session.
A6. Right. We, at Missouri-Columbia, are beginning our 5th group. This year (September, 1999)was the first time that every trainee got the Pretraining done on time. And with little pushing. Completing the COSE and GI, doing the homework, participating in discussion will all take time. A major variable is the group leader. If and when you become confident about what you are doing and that what you are doing is useful (and fun), then a major cultural shift will have taken place.
A7. Correct. Please change in your Seminar Leader's Manual.
A8. The challenge for the case vignettes in Module 3 Session 2 is to "say what it is." Our residents as do many seminar leaders want to jump to inference before stating what the patient just said. We clarified today that we are intending to restate the brief summary from the inducing point vignettes BEFORE going to inference. Being an expert may mean being simple first. Being simple means relying on the idea that for a patient to hear back a brief summary of a critical pattern stated in the patient's own words can be transforming. For example, Case 6 on p. 113 of Trainee Manual could involve inferences about control but more simply be stated using the wife's "independence" i.e.: "You seem to think that your wife is being too independent because she in not considering your opinions." Inference comes after stating and agreeing about the obvious.
A9. We are developing 6 new modules. We are distributing them as follows
(the new ones have asterisks):
First Year Module 0: Basic Listening Skills*
Module 1: Verbal Response Modes and Intentions
Module 2: Working Alliance Second Year
Module 3: Inducing Patterns
Module 4: Change
Module 5: Resistance
Module 6: Transference and Countertransference
Module 7: Termination* Third Year
Module 8: Formulation*
Module 9: Integrating Pharmacotherapy and Psychotherapy*
Module 10: Alcoholism*
Module 11: Anxiety disorders*
Module 12: Depression*
A10 David Goldberg from U of Connecticut suggested that current resident experiences with patients be interwoven with the modules. Along with that suggestion, he has found excellent receptivity of Module 1 and 2 in the first year since these are basic to interviewing skills. If they are used in the first year that leaves time in the second year for more real time vignettes which for those seeing outpatients can be discussed in an ongoing correlate with the modules content.
A11. Your question is central to my view of psychotherapy itself. We have emphasized the schools for too long, missing process in favor of ideology. The modules turn psychotherapy schools on their heads, making the common elements most critical and the individual contributions less important. We expect them to learn cognitive, interpersonal ideas from the anxiety and depression and alcoholism modules. We are, however, also teaching cognitive therapy, psychodynamic and family therapy in separate seminars. I am hoping that other people develop modules that are school specific for those people who continue to embrace this approach.
A12. 1) Implementation in different PG years. Some programs teach the bulk of the Modules to PG-2's, some to PG-3's. Some programs combine residents from two or three different years. Other programs mix in trainees from other disciplines.
2) Breaking up the Modules through several years of the training program. At U. of Missouri-Columbia, for instance, Modules 0,1 and 2 are taught to PG-1's; Modules 3,4,5,6 and 7 are taught to PG-2's, and Modules 8 (Formulation),9 (Integrating pharmacotherapy and psychotherapy),10 (Anxiety disorders),11 (Depression),12 (Alcoholism) and Q&A are taught to PG-3's.
3) Supervisors' groups. Some programs are recruiting a cadre of supervisors who are familiar with the Modules (give them a free book) and who agree to keep a finger on the pulse of the Modules progression as they supervise the resident. Some programs have quarterly meetings of the supervisors, to discuss the whole process.
4) Role-playing of transcripts. Most programs have discovered that role-playing transcripts, both those in the book and those obtained from other sources, is very helpful. IMG's are especially assisted in their development by role-playing. It helps with their command of English, including how to communicate with emotion.
5) Expanding, contracting, or elaborating on certain Modules or components of Modules. Examples: moving more quickly through the early Modules; moving more quickly to pattern search; emphasizing reflective listening,including telephone crisis call training; encouraging residents to bring in material from their own patients throughout the course; watching more videotapes, such as Rogers, Perls, Ellis and whatever the program has available; stopping a videotape and challenging the residents to formulate a therapist intervention.
6) Expanding the length of the sessions, e.g. to 1 1/2 hours, sometimes to accomplish the homework in the class. Some programs are choosing to omit the homework, and some are omitting the outcome measures. The success of the homework seems to be a local culture issue, reflective of the enthusiasm and/or clout of the group leader.
7) Contracting the number of sessions to fit the Modules into the restrictions of a given program's curriculum.
8) Use of ex-patients. Some programs have discovered that patients who have been in psychotherapy (typically not a patient of the group leader) make excellent sources of inspiration for trainees.
9) Combining Modules with other texts. Some programs are weaving parts of the Modules into courses using other, standard texts on psychotherapy or psychodynamics (e.g. Basch, Gabbard).
10) Use of co-leaders. Having a co-leader can be very helpful. This person may be more or less senior, may be from another discipline, or may be a senior resident who has already taken the Modules. 11. Size of group. The number of trainees taking the Modules together varies widely, from 5-6 to 3x that number. We did not attempt to determine the optimal size. (written by Jim Nash)
A13. The first year is the hardest.
1) Trust the group process. Successful seminars rely on the group to teach
as well as the leader to instruct.
2) Residents avoid homework in the first year or two. Takes a few years for
the modules to become part of the culture and then they seem to do the
homework much more willingly.
3) If you do not do premodule transcripts, etc at least get 2 pages of
transcripts for Session 6 in module 1 where they try to guess each other's
intentions. This session helps to solidify group cohesion by helping them to
learn from each other in the here-and-now.
4)Start Module 0 and any other modules you can in the first year.
A14. There are too many varieties of integrative psychotherapy for anyone to have tried real clinical trials. I think such a trial could be designed that built upon a base of specified common factors, plus a variety of school techniques within a flexible framework.
A15. Steve McCutcheon from University of Washington:
Steve describes his first 2 years and plans for the coming year. He illustrates a variation that uses the modules as a framework for his own ideas and teaching methods. He also gives no homework and brings in at least one psychotherapy patient to discuss the experience. I am amazed at how much ground his groups cover as well as his managing a group of 18. He has much experience as a group leader which I have come to believe is very important for successful modules teaching.
" In our first year, we ran 2 separate sections with small groups (approx 8 each) of R-2's. Each section was led by a faculty member with the help of an advanced resident. The two sections had different degrees of success, based on response to teaching style. As a conseqeunce, we offered one larger section last year for all the R-2's (approx 16), taught by myself and a 5th year resident (completing a fellowship in medical education). I'll be launching our third year of the modules next month. (I much prefer the larger size--more interactions and ideas).
The class (called "Introduction to Psychotherapy") meets weekly for an hour, during a morning devoted to didactics, for a 6-month period. It is the foundation "building block" in a sequential and cumulative program of courses in psychotherapy (later courses focus on schools of therapy and technique, inc CBT, IPT, brief analytic, DBT, etc). Residents start the course as they're ending their inpatient assignments, and just prior to starting outpatient clinics. As intended, the course takes a "common factors" approach to teaching the fundamentals; I adhere closely to the "stages" of relationship/alliance, pattern recognition, pattern change/resistance, and termination as outlined in the text.
The actual content adheres closely to the modules curriculum in many sessions, though I've improvised in some areas, and expanded others, based on response of the residents. During the initial sessions on the therapeutic relationship, I spend a number of hours on instruction, modeling and role-playing of "microcounseling skills" (ie., verbal response modes). I constantly emphasize to the residents that--as socially skilled persons--they have the requisite abilities to develop as therapists, but need practice in learning how to adapt and apply their native interpersonal skills (and learn how to think as a therapist). Safran has recently published a "manualized" text on the alliance, which has useful applications.
The pattern recognition sessions closely follow the text, and are enlightening to the residents. It's fun to watch them learn to see beyond the surface, and to read interpersonal patterns. I have the residents give brief presentations of patients currently under treatment, and then use large group "brainstorming" sessions in which the residents speculate about the possible "patterns" revealed by the patient's history, complaints, and in-session behaviors. As you note in the text, the residents benefit from the experience of discovering that there isn't a "correct" interpretation, but there are multiple reasonable interpretations of patterns that are more or less useful.
During the change strategies sessions, I continue to emphasize the "common factors" approach (utilizing alot of skills practice and role-playing -- probably reflecting my work as a group therapist, and as ehaviorally-trained psychologist). Our residents have always complained that they lack a conceptual framework for understanding theory-based supervisors, so I do deviate from the text at this point, and spend a handful of sessions giving a "Cliff's notes" overview of the major therapuetic schools (behavioral, dynamic, humanistic, and systems/contextual). For each of these lectures, I show a corresponding videotape therapy session. I've been using tapes provided by the American Psychological Association (their "Master therapist" tapes). These have their limitations, but are clear demonstrations that good therapists do similar things, no matter their explanatory model. The residents also seem to be relieved to see the range of reasonable therapist behaviors. During the change strategies section, I also cover resistance, and introduce the residents to Motivational Interviewing (as a particular strategy in addressing resistance). Miller and Rollnick have a series of 12 videotapes which offer interesting samples.
We cover ALOT of material in the 6 months, but my goals are actually basic: 1) to reduce the anxiety of beginning therapists, 2) to increase their psychological mindedness (about themselves as well as their patients), and 3) to give them confidence that they can actually learn to do therapy by practicing a core of skills (rather than encouraging the disheartening belief that therapy is an arcane skill only for the select few). I truly believe in the power of "common factors" underlying change--whether the change occurs in therapy or in the classroom. While we cover alot of content in the course, I believe the course is valuable because it makes residents excited to learn about therapy, and confident that they can master it over time. If they leave my course with the desire to learn more, then I've succeeded.
A16. I checked the Allyn and Bacon website (www.allynbacon.com) and I could not find a listing in their catalogue section for the Student Guide CD ROM by Seven, Cummins, and Madrigal. I finally just called their 800 number (1-800-666-9433) and they were able to locate the "workbook - CD ROM package." Total cost is $40.00 plus shipping. Make sure to give them the "ISBN number," which is: 0205294553. I ordered one copy; maybe they would give a discount for larger orders.
A18. From Stanford:
Involving anxious beginning residents in learning psychotherapy can be a difficult task for both residents and instructors. Stanford's Residency Training Program has extensive experience and success with Beitman and Yue's Modules. This symposium will provide examples of the use of role-play to successfully increase resident interaction while covering the Modules' major teaching points. In Module 1 for example, the important concepts of verbal response modes and therapeutic intentions can be conveyed quite vividly by giving each resident a 3x5 card with a unique verbal response mode (e.g. "reflection") or intention (e.g. "clarify"). Residents then interact with an instructor playing the "patient." Afterwards residents attempt to guess what was written on the other cards. In Module 2, with its focus on teaching the importance of the Working Alliance, residents are given a verbatim list of provocative statements made by "Gloria." Before watching the Carl Rogers' tape, they are asked to role-play (in groups of two) potential responses. This helps make the subsequent viewing of the tape more interactive, with much discussion of the particular choices Rogers actually makes during the interview.
