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Original Article

Therapy 101:
A Psychotherapy Curriculum for
Medical Students

Frieda Aboul-Fotouh, M.D.

Ali Abbas Asghar-Ali, M.D.

Objective: This pilot project, designed and taught by a resident, benefit from more exposure to psychotherapy as taught by a
created a curriculum to introduce medical students to the prac- resident.
tice of psychotherapy. Medical students who are knowledgeable
about psychotherapy can become physicians who are able to Academic Psychiatry 2010; 34:248 –252
refer patients to psychotherapeutic treatments. A search of the
literature did not identify a curriculum that introduced psycho-
therapy, its applications, and evidence for its use. P hysicians across a variety of medical specialties
screen and refer patients for psychiatric treatment.
Primary care doctors are expected to understand and start
Methods: The authors worked closely with a faculty mentor to first-line medication treatments for depressive illness and
create a course that fulfilled a perceived need for more psycho- anxiety disorders. Psychotherapy is also an effective, well-
therapy teaching of medical students. “Therapy 101: An Intro- proven intervention for many mental illnesses. More pa-
duction to Psychotherapy” is a 6-hour curriculum that employs tients may have the opportunity to benefit from psycho-
creative teaching techniques such as video clips from TV shows, therapy when their physicians are aware of the concepts of
role play, and recordings of therapy sessions. The series was and indications for psychotherapy.
evaluated using a multiple-choice pre/postcourse test with ques-
Medical school provides a key opportunity for students
tions on psychotherapy, written feedback, and perceived knowl-
to be exposed to psychotherapy as a treatment option. The
edge of psychotherapy.
Association of Directors of Medical Student Education in
Results: The scores from the pre/postcourse test measuring the
Psychiatry (ADMSEP) (1) wrote the following in its 2007
students’ knowledge of psychotherapy did not change signifi- Clinical Learning Objectives with regard to the medical
cantly. However, students’ self-rating of knowledge greatly in- school psychiatry curriculum:
creased after the series. Written feedback showed substantial
Regardless of medical specialty, an effective practitioner should
enthusiasm for the course. have a basic understanding of psychotherapy, recognize the rele-
vance of psychotherapy principles to the doctor-patient relation-
Conclusion: Students can benefit from a short and engaging ship, be aware of those psychotherapies with evidence-based effi-
curriculum on psychotherapy. “Therapy 101” was very well cacy for particular disorders, and be able to refer patients for
accepted by students and has been integrated into the curriculum
for students in the mental health pathway. Medical students may At Baylor College of Medicine, the 2-month psychiatry
core clerkship devotes 1 hour to an overview of psycho-
Received June 1, 2009; revised August 9 and October 14, 2009, and therapy, in contrast to the 6 hours devoted to psychotropic
January 10 and March 9, 2010; accepted March 9, 2010. The authors are
affiliated with the Menninger Department of Psychiatry and Behavioral medications. This brief didactic time is insufficient for
Sciences at Baylor College of Medicine in Houston, Texas; Dr. Aboul- most students to appreciate the range of psychotherapies,
Fotouh is also affiliated with Harvard/Massachusetts General Hospital in
Boston; Dr. Asghar-Ali is also affiliated with the Michael E. DeBakey
their indications, techniques, and evidence for use. At
VA Medical Center, Mental Health Careline, in Houston. Address cor- medical school, no core rotation opportunities provide any
respondence to Ali Abbas Asghar-Ali, M.D., Michael E. DeBakey VA substantial exposure to psychotherapeutic interventions.
Medical Center, Mental Health Careline, 2002 Holcombe Blvd, MHCL-
116, Houston, TX 77030; asgharal@bcm.edu (e-mail). As future physicians, medical students can benefit from
Copyright © 2010 Academic Psychiatry exposure to different treatments for mental illnesses. A

248 http://ap.psychiatryonline.org Academic Psychiatry, 34:4, July-August 2010


student’s experience and understanding of the practice of prepare residents for careers as clinician-educators and is
psychiatry may influence whether he or she pursues a described in another article in this issue (10). The program
career in the field. On reflecting on her own medical requires that participants develop a scholarly project that
school education, the resident author (FA) believed that focuses on an educational activity.
she would have been more confident in her career choice Through mentorship with a faculty member of the Cli-
of psychiatry if, as a student, she had had a better under- nician Educator Track (AA) and discussion with leaders in
standing of psychotherapy. Psychotherapy is an exciting medical education and psychotherapy at Baylor, “Therapy
and integral part of psychiatric practice that can be attrac- 101: An Introduction to Psychotherapy” was developed as
tive to medical students who are interested in pursuing a six 1-hour lectures using electronic presentation software,
career in psychiatry. She felt that her student peers were case examples, and video clips to cover the concepts and
underexposed to therapy during their psychiatry didactics applications of psychotherapy. The course was integrated
and rotations. This personal experience inspired her to into an elective longitudinal mental health experience at
examine how other programs approach teaching students Baylor College of Medicine.
about psychotherapy.
We searched PubMed, PsycINFO, Med Ed Portal, and Methods
the EMBASE databases for the period between 1950 to
June 2009 for a psychotherapy curriculum for medical The resident physician (FA) and faculty mentor (AA)
students using the medical subject heading terms medical met regularly prior to initiating the course to discuss the
students and psychotherapy. Two articles focused on psy- resident’s goals for the project, which included using
chotherapeutic concepts within all doctor-patient relation- slides, developing and teaching a curriculum, and learning
ships, while another two argued for the importance of how to solicit and use student feedback. “Therapy 101”
teaching medical students about these concepts (2–5) was then constructed with four main goals for its students:
without including a recommended curriculum. In 1961, to give students basic theoretical and practical knowledge
Ornstein (6) described a medical student course that intro- of major psychotherapies, to interest students in therapy
duced psychotherapeutic concepts, analyzed a 3-hour ther- and deepen their appreciation of the value of psychother-
apy session, and discussed the role of hypnosis in treat- apy, to give students a broader appreciation for mental
ment. One article (7) discussed teaching French medical health treatments and thus expose them to a different side
students to perform behavioral therapy. In 1999, Cabaniss of psychiatry, and to provide a model of student education
(8) wrote about introducing medical students to psycho- in psychotherapy (Table 1).
analysis over five 1-hour seminars, with 1 hour dedicated The course introduced the theoretical constructs and
to the introduction of concepts and types of psychotherapy application of the most commonly practiced types of psy-
and the remaining 4 hours reading process notes. Among chotherapy. The integration of media and examples of
these articles, only one resident-taught course was found therapy cases prompted students to examine their impres-
(9); it introduced medical students to personality disorders sions of therapy and engaged them in learning how a
in four 1.5-hour weekly sessions using movie clips and patient may be “prescribed” a certain type of psychother-
role plays. Although principles of transference and coun- apy. Finally, the instructor used her recent transition from
tertransference were introduced in this context, no other medical student to resident therapist to relate to students
emphasis on psychotherapy appeared. the personal experience of a therapy session.
Although there is literature on teaching medical stu- We planned each session together to ensure that the
dents about a certain aspect of psychotherapy, we did not goals and the course objectives were being met. Special
find a curriculum that gives students an overview of basic attention was paid to using different teaching techniques to
concepts and applications of multiple types of psychother- keep the students engaged. Each workshop incorporated
apy. This article describes the creation and implementation video clips from TV shows, role play, case examples, and
of a curriculum aimed at educating medical students about electronic slides.
psychotherapy by a third-year psychiatric resident (FA) Eight third-year medical students in the Longitudinal
who is a member of the Clinician Educator Track in the Ambulatory Clinical Experience–Mental Health and Be-
Menninger Department of Psychiatry and Behavioral Sci- havioral Sciences Pathway at the Baylor College of Med-
ences at Baylor College of Medicine. The Clinician Edu- icine participated in this pilot project. At Baylor, students
cator Track is a specialized training track designed to choose from several longitudinal pathway experiences and

Academic Psychiatry, 34:4, July-August 2010 http://ap.psychiatryonline.org 249


are selected to a particular pathway on the basis of essays about psychotherapy with a multiple-choice test and a
expressing their interest. The mental health pathway spans discussion. Media portrayals of psychotherapy were dis-
the academic year and involves weekly meetings with an cussed with two video clips. One clip from the TV show
ambulatory preceptor and community site visits. It teaches ER (11) demonstrated a physician using supportive tech-
students to take an in-depth approach to the psychosocial niques with a grieving patient, exemplifying psychother-
issues associated with mental and physical wellness. apeutic concepts being implemented outside of a therapy
Through collaboration with the faculty directors of the session. The other clip from the HBO series In Treatment
mental health pathway, 1 hour per month was assigned to (12) showed a therapist’s first meeting with his patient and
“Therapy 101.” Institutional review board approval was began a discussion on what brings a patient to therapy and
received to collect data on this project and the medical the challenges of the first session. These two videos were
students were provided cover letters explaining the pur- used to ignite dialogue about media portrayals of the phy-
pose for collecting data. Attendance was not recorded, and sician-patient relationship and psychotherapists in partic-
students were informed that attendance and participation ular.
in the series would not influence their grades for the men- The second session explored transference, mentalizing,
tal health pathway. The first session introduced the lecture and therapeutic alliance, which were considered to be core
series and assessed students’ knowledge and attitudes concepts in a range of psychotherapies. In addition to case

TABLE 1. Therapy 101 Curriculum

Workshops Objectives Teaching Modality

Introduction and Assessment of ● Course overview ● Syllabus
Attitudes and Knowledge ● Assessment of knowledge ● Video clips of ER (11) and
● Impact of media on attitudes about psychotherapy In Treatment clip of Sophie (12)
Transference, Countertransference, ● Students will understand the concepts of ● Electronic slides (13–16)
Mentalizing, and Therapeutic transference, countertransference, mentalization, ● Case examples
Alliance and therapeutic alliance ● In Treatment clip of Sophie (12)
● Students will apply these concepts to brief case
● Students will reexamine video clip from first session
and apply above concepts
Cognitive Behavioral Therapy and ● Students will be able to describe cognitive ● Electronic slides
Dialectical Behavioral Therapy behavioral therapy ● Discussion of written case from
● Students will understand theoretical basis for Cognitive Therapy (17)
cognitive behavioral therapy and dialectical ● Video case example (18)
behavioral therapy
● Students will appreciate uses for cognitive
behavioral therapy and dialectical behavioral
Psychodynamic Psychotherapy ● Exposure to the practice of psychodynamic ● Electronic Slides
psychotherapy ● In Treatment clip with Sophie (19)
● Students will appreciate the role of the
unconscious and be able to define resistance
● Observation of psychodynamic concepts within a
case example
Interpersonal and Supportive ● Students will understand theoretical basis and uses ● Electronic slides (14, 20, 21)
Therapies for supportive therapy ● Role playing of case examples of
● Students will understand theoretical basis and uses interpersonal therapy from
for interpersonal therapy Textbook of Psychotherapeutic
Treatments (14)
● Role playing of case example of
supportive therapy (21)
The Therapy Experience ● Overview of topics covered in the course ● Electronic slides
● Viewing of a recorded therapy session ● Recorded therapy session with
● Students will apply knowledge from the course to course instructor and her
discuss the therapy session therapy patient
● Students will be able to describe their observations
of the therapeutic session

250 http://ap.psychiatryonline.org Academic Psychiatry, 34:4, July-August 2010


examples, the In Treatment video from the first session Discussion

was reexamined.
The next three sessions presented cognitive and dialec- “Therapy 101: An Introduction to Psychotherapy” in-
tical behavioral therapies, psychodynamic psychotherapy, troduces medical students to the concepts and uses of
and interpersonal and supportive therapies. Each hour be- psychotherapy to increase their theoretical and practical
gan with a brief overview of the theoretical basis of the knowledge about psychotherapy. Case examples, video
therapy and included basic techniques of the psychother- clips, and role play were used to give students a feel for
apy and indications and evidence for its use. A case ex- psychotherapy.
ample and discussion concluded the hour. Student scores from the pre/postcourse tests show little
The last lecture discussed a therapy session with the change. It is possible that the higher than expected pre-
intention of demystifying and normalizing psychotherapy. course test scores resulted from superior student knowl-
Students watched a video of a therapy session of the edge at the outset. Students in the mental health pathway
resident-instructor with a patient. (The patient gave written had already identified a greater interest in psychiatry than
consent for the video recording to be used for educational their peers and may have had a higher baseline level of
purposes.) The instructor discussed her thoughts and feel- knowledge than expected, making any gains difficult to
ings during the session while reviewing concepts from the detect with this test. Also, the questions were formulated
previous workshops. before the course was fully designed. The most empha-
Students’ attitudes and knowledge were assessed at ses- sized concepts in the course were only partially reflected
sions 1 and 6 through discussion and written feedback. in the multiple-choice questions. Two of the most com-
Fifteen multiple-choice questions were developed and ad- monly missed questions on the precourse test were also
ministered as a pre/postcourse test (available from the missed on the postcourse test. On further review, these
authors upon request). questions did not reflect the main teaching objectives of
At the beginning and end of the series, students also the course. Now that the curriculum is fully developed,
answered the question “On a scale of 1–10 (1⫽no knowl- future test questions will be extracted directly from the
edge, 10⫽extremely knowledgeable), how would you rate slide presentations to accurately reflect the most empha-
your current knowledge about psychotherapy?” sized concepts in the curriculum. It is also possible that the
Students rated the resident-instructor at the conclusion once-a-month lecture frequency impaired retention of
of each session from 1 to 5 (1⫽poor, 5⫽excellent) in 15 knowledge over the course. To aid in continuity and re-
categories. These evaluations were reviewed weekly with tention of knowledge, future lectures will be scheduled
the faculty mentor (AA) as part of regular reflective exer- weekly rather than monthly.
cises. The faculty mentor, who was present during one Students’ self-rating of their knowledge of psychother-
session, also gave the resident (FA) feedback on items apy greatly increased. We hypothesize that the course
such as the pace of the session, body language, use of provided an increased appreciation for psychotherapeutic
jargon, and the engagement of the audience. interventions that were not reflected in the knowledge-
based, multiple-choice test. On the basis of student feed-
Results back and reflection with the faculty mentor, the resident-
instructor adjusted the pace of the course and increased
The mean number of questions answered correctly was interactive exercises, which could also have led to students
11.3/15 on the multiple-choice precourse test and 11.6/15 feeling more confident in the material.
on the postcourse test. The mean for the students’ rating of Students felt that the course was useful as an exposure
their current knowledge of psychotherapy at the onset of to psychotherapy, and for some it confirmed an interest in
the course was 3.4 (1⫽no knowledge, 10⫽extremely psychiatry. Students who planned to enter a specialty other
knowledgeable). By the last session, this rating had in- than psychiatry said that the concepts and information
creased to 6. learned would be useful in other fields of medicine.
On the instructor evaluation form, the resident was rated Residents are uniquely positioned to contribute to med-
as very good (4) to excellent (5) in all categories. A few ical student curriculum development because of their re-
students noted that the pace of the sessions was too fast cent transition from the student role. The resident-teacher
and that the interactive teaching exercises were the most (FA) clearly remembered never having observed psycho-
beneficial aspect of the course. therapy; learning theory was immensely difficult in the

Academic Psychiatry, 34:4, July-August 2010 http://ap.psychiatryonline.org 251


absence of a real-life context. She identified with the stu- try Education of Medical Students. Omaha, Ne, ADMSEP,
dents’ needs to hear about theory and practice together. 2007. Available at http://www.admsep.org/Clinical_LO_
Her recent experience helped her create a course that
2. Paulley J: Training medical students in psychotherapy. Lan-
emphasized the basic concepts of psychotherapy and re-
cet 1957; 273:1340 –1341
lied heavily on examples to illustrate those ideas. The 3. Steiger W, Hirsh H: The medical student. Int Psychiatry Clin
resident-teacher is also a student of psychotherapy, a dual 1964; 1:293–305
role with which most lifelong learners are familiar. During 4. Tasini M: Teaching psychodynamic psychiatry to students on
the academic year, the resident’s psychotherapy skills im- general medical rotations. J Psychother Pract Res 1999;
proved as her experience with the different modalities 8:204 –209
increased. The growing experience allowed for the use of 5. Tasman A: Teaching psychodynamic psychiatry during med-
ical school and residency. J Psychother Pract Res 1999;
more personal examples as the class progressed and
greater confidence in the resident’s perceived skills in 6. Ornstein P: An experiment in teaching psychotherapy to
teaching. It must be noted that because the resident is still junior medical students. J Med Educ 1961; 36:154 –161
a trainee, a faculty mentor provides additional experience 7. Agathon M, Samuel-Lajeunesse B: Teaching behavioral as-
and expertise in course content and development. sessment and therapy to French psychiatric students. J Behav
The combination of mentorship and initiative at the Ther Exp Psychiatry 1988; 19:27–30
resident level spurred the resident’s professional growth in 8. Cabaniss D: How to think like an analyst 101. J Psychother
Pract Res 1999; 8:198 –200
the direction of academic psychiatry and demonstrated the
9. Ghatani K, Waisman Z: Teaching medical students about
effect a resident can have in the syllabus of a medical personality disorders and psychotherapeutic principles: a res-
student education program. Through coordination with her ident pilot initiative. Acad Psychiatry 2006; 30:178 –179
mentor, this course has been successfully integrated as a 10. Jibson M, Hilty D, Arlinghaus K, et al: Clinician-educator
permanent piece of the mental health pathway curriculum. tracks for residents: three pilot programs. Acad Psychiatry
One of the goals of the Clinician Educator Track at Baylor 2010; 34:269 –276
11. Amblin Entertainment: ER. Season 8, episode 20. “The Let-
is to support and develop resident educators. This course
met that goal and resulted in an enduring curriculum for
12. HBO: In Treatment. “In Treatment: Sophie: Session 1.”
medical students. Available at http://www.youtube.com/watch?v⫽M1iev0zph3o
By increasing an understanding of psychotherapy, the 13. Gabbard G: Psychodynamic Psychotherapy in Practice.
lecture series served the pathway’s objective of expanding Washington, DC, American Psychiatric Publishing, 2005, pp
students’ perceptions of physician roles in the community. 3–91
From the feedback, students had a clearer understanding of 14. Gabbard G: Textbook of Psychotherapeutic Treatments.
Washington, DC, American Psychiatric Publishing, 2005, pp
psychotherapy and the value of referring to psychothera-
43– 67, 239 –338, 727–753
peutic treatment. Our hope is that the student who values
15. Fonagy P, Target M: Attachment, trauma, and psychoanaly-
psychotherapy will be able to take a more in-depth psy- sis, in Mind to Mind. Edited by Jurist E, Slade A, Bergner S.
chosocial approach, which the mental health pathway pro- New York, Random House, 2008, pp 15– 49
motes as its primary goal. 16. Allen JG, Fonagy P, Bateman A: Mentalizing in Clinical
We anticipate that this course will continue to change in Practice. Washington, DC, American Psychiatric Publishing,
response to students’ needs for education in psychother- 2008, pp 25–36
17. Beck J: Cognitive Therapy. New York, Guilford, 1995, pp
apy. Our long-term goal is for the curriculum to be inte-
grated as an elective at Baylor College of Medicine and to
18. Wright JH, Basco MR, Thase ME: Learning CBT: An Illus-
be replicated at other medical schools. trated Guide. DVD. Washington, DC, American Psychiatric
Publishing, 2006
At the time of submission, the authors reported no competing 19. HBO: In Treatment. “Sophie’s Sexual Problem Part 1.” Avail-
interests. able at http://www.youtube.com/watch?v⫽pF6cmqYJk10
20. Winston A, Rosenthal R, Pinsker H: Introduction to Support-
References ive Psychotherapy. Washington, DC, American Psychiatric
Publishing, 2004, pp 1– 43
1. Association of Directors of Medical Student Education in 21. Douglas CJ: Teaching supportive psychotherapy to psychi-
Psychiatry: Clinical Learning Objectives Guide for Psychia- atric residents. Am J Psychiatry 2008; 165:445– 452

252 http://ap.psychiatryonline.org Academic Psychiatry, 34:4, July-August 2010