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Guest Editorial
Psychotherapy Education: Innovation and Evolution
Daniel H Greben, Zindel V Segal
(PDF)

In Review
Implications of Psychotherapy Research for Psychotherapy Training
William E Piper
(PDF)

Advances in Psychotherapy Education
Paula Ravitz, Ivan Silver
(PDF)

Integrative Dimensions of Psychotherapy Training
Daniel H Greben
(PDF)

Original Research
Forty Years of Deinstitutionalization of Psychiatric Services in Canada: An Empirical Assessment
Patricia Sealy, Paul C Whitehead
(PDF)

Comparisons Between the South Oaks Gambling Screen and a DSM-IV-Based Interview in a Community Survey of Problem Gambling
Brian J Cox, Murray W Enns, Valerie Michaud
(PDF)

Spirituality and Psychiatry in Canada: Psychiatric Practice Compared With Patient Expectations
Marilyn Baetz, Ron Griffin, Rudy Bowen, Gene Marcoux
(PDF)

Differences Between Only Children and Children With 1 Sibling Referred to a Psychiatric Clinic: A Test of Richards and Goodman's Findings
Jacques D Marleau, Jean-Jacques Breton, Gisèle Chiniara, Jean-François Saucier
(PDF)

Book Review
(PDF)

The Infant and Family in the Twenty-First CenturyReviewed by
Pratibha N Reebye

Letters to the Editor
(PDF)

High Frequency of Bipolar Spectrum in Outpatients With Depression

Long-Term Lamotrigine Adjunctive to Antipsychotic Monotherapy in Schizophrenia: Further Evidence

Evidence for Early Intervention in First-Episode Psychosis

D₂ Antagonist Augmentation in Patients With a Partial Response to Atypicial Antipsychotics

In Review

Advances in Psychotherapy Education

Paula Ravitz, MD, FRCPC¹, Ivan Silver, MD, MEd, FRCPC²

Acquiring expertise in psychotherapy is central to the professional development of psychiatrists and to their capacity to employ a broad therapeutic repertoire in clinical practice (1–4). The Canadian Psychiatric Association (CPA) Psychotherapy Task Force has articulated standards of practice for the psychotherapies in comprehensive psychiatric care and has stated that expertise in the psychotherapies is a core skill. The Coordinators of Postgraduate Education in Psychiatry (COPE) have also developed guidelines and enabling objectives that identify psychotherapy as core and central to a psychiatrist’s identity (1–5). The Royal College of Physicians and Surgeons of Canada (RCPSC) requirements stipulate a minimum number of hours of supervision in short- term and long-term psychotherapy, along with learning objectives in the domains of knowledge and skill (1). Although standards and guidelines beyond the (RCPSC) minimum requirements have been suggested (1–4,6–8), there is variation and debate on their implementation, both within and among postgraduate psychiatry programs. Psychodynamic training is considered essential, but no longer sufficient in itself, for the development of a broader base of psychotherapy expertise in several forms of contemporary therapy (4). The emphasis on social and fiscal responsibility has influenced curriculum priorities and psychiatry practice guidelines (9–11): there is increasing attention paid to delivering empirically validated brief psychotherapies (12,13) that alleviate morbidity and have the potential to service larger numbers of patients. This is the context within which psychotherapy educational programs have evolved over the past decade.

This article’s focus is twofold: to report the results of a national survey of trends and advances in medical psychotherapy education programs and to consider these in association with principles of adult learning and health education research. We examine issues related to the teaching, development, and evaluation of psychotherapy expertise.

Adult Education Principles and Health Education Research Relevant to Psychotherapy Education

Studies and reviews of continuing medical education (CME) emphasize that didactic educational activities alone do not necessarily lead to sustained improved performance by trainees or improved health care outcomes (14–17). Educational researchers stress the importance of attending not only to content but also to teaching process and methods to ultimately influence learners’ professional behaviours. Despite educational programs that aim to disseminate research-based clinical practice guidelines, there is often a gap between the guidelines—the “state of the art”—and what physicians actually do.

Educational research (14–17) has demonstrated that methods which tend to more effectively facilitate sustained practice changes include longitudinal programs that are “learner- centered, active rather than passive, relevant to the learner’s needs, engaging, and reinforcing”(14, p 871). The traditional format of longitudinal one-on-one psychotherapy supervision (18–20) applies theory to clinical practice and meets many of the current recommendations for best teaching practices. Psychotherapy researchers Henry and Strupp further examined different styles of teaching that use the same format of one-on-one, longitudinal, case-based psychotherapy training. They compared pre- and posttraining adherence and competence measures of trainees taught by 2 different psychotherapy expert supervisors with differing levels of activity and focus (21,22). They found that a more active teaching style relying on specific learning tasks and specific feedback about interventions, with reinforcement of core concepts derived from clinical material, was most effective. Global positive comments that focused more broadly on developing an understanding of the patient were less effective (22).

Psychotherapy supervision in postgraduate psychiatry residency programs can provide a longitudinal, clinically integrated learning experience. For psychiatrists in CME, however, the traditional format of short, cross-sectional workshops is less likely to change practice behaviours without longitudinal follow up to reinforce the integration of new learning. Training of longer duration, using an educational approach that facilitates active participation and integration of learning into clinical work, is more likely to effect sustained practice improvements (14,17).

Cognitive theories of adult education illuminate how students integrate new knowledge and acquire expertise. From the learner’s perspective, the transformation from novice to expert practitioner involves changes in mental processing through experiential learning. Binder describes a trajectory of learning in which one initially constructs a cognitive foundation of abstract, “declarative” knowledge and theory that provides organizing principles for integrating clinical information (18,23). With experience comes an increased capacity to understand when and how to extrapolate from this knowledge base. The concept of “knowing in action,” which cognitive scientists refer to as “procedural knowledge,” emerges with the development of expertise (18,24, p 22–40). Experts know when and how to apply knowledge in real-world situations. Performing in a context such as psychotherapy, where problems shift their form and where the meaning of specific actions can change, requires adaptive flexibility and improvisational capacity. We reflect on action during psychotherapy supervision, and we hope that over time trainees will develop the capacity to reflect in action, strategically synthesizing knowledge and applying techniques in the midst of such complex and emotionally charged interpersonal situations as a psychotherapy hour (18,24).

Professional development needs to be considered not only from the individual learner’s point of view but also from a systems-based perspective. Learning can take place and be integrated into communities of practitioners in both residency and CME settings. “Communities of practice” are groups who share expertise and interest about a topic on an ongoing basis, interacting at times informally. These physician interactions with colleagues are an important, often-unacknowledged source of professional development wherein learning is integrated with practice (25,26). Different from “teams,” communities of practice usually develop laterally within an organization, rather than from the top down. During postgraduate training, learning is a primary peer-group activity in which communities of practice naturally emerge. However, upon completing residency, psychiatrists can become isolated, despite participating in CME, if those activities do not foster sustained learning with professional peers. Emerging literature supports ongoing physician and peer interaction as an ideal environment for sustaining and enhancing professional development (25,26). Examples of effective communities of practice in psychiatry include longitudinal study groups as well as academic clinical, supervisory, or research groups. More recently, electronic technology has been used to link practitioners from geographically distant communities (27–29).

Electronic communications technology has also been used to extend educational offerings to individuals or settings where geographic barriers or time constraints might otherwise be a limiting factor. As the costs of distance education (DE) technology decrease and as universities become increasingly international, the use of DE in the health professions has increased (29). DE allows health professionals to continue their practice while pursuing CME, and it brings together learners outside the institutional educational environment. This benefit is an especially important one for underserviced regions and for regions where geographic barriers might limit group learning opportunities.

In addition to the importance of attending to the context, process, and methods of teaching, health educators also suggest that CME curricula should be based on careful learning needs assessments, which can differ from course planners’ assumptions (17). Historically, CME course content was selected according to clinical educators’ assumptions about practitioners’ deficits in knowledge or skills. For psychotherapy CME, this may require precourse surveys or a focus group to identify participant interests and needs. In addition, it is important to address attitudes that may represent significant unrecognized barriers to learning new material (17).

Evaluation of expertise assesses educational effectiveness and can also serve as an impetus to consolidate learning. Consensus exists on the need to establish standards and improve ways of evaluating psychotherapy competence (30–34). Evaluating competencies represents a change from documenting what is taught to documenting what the residents have actually learned (32–34).

Psychotherapy curricular guidelines articulate learning objectives such as theoretical knowledge, technical skills, and professional attitudes, each of which can be evaluated separately. Technical skills represent an aspect of psychotherapy competence and, in the manualized therapies, can be evaluated with adherence measures. However, skills are considered necessary but not sufficient for the acquisition of expertise (18,35), and it is important to differentiate between therapeutic adherence and competence in the manual-based therapies. Achieving competence implies expertise in effectively applying what has been taught, beyond simply adhering or conforming to specified manual-based interventions (35). Research on the outcome of time-limited dynamic psychotherapy training concluded that training methods were more effective at facilitating the acquisition of prescribed techniques than in teaching their skillful use, particularly in regard to managing the processes associated with therapeutic relationships (21). Henry and Strupp demonstrated that, despite improved adherence to a manualized therapy after 1 year of comprehensive psychotherapy training, some of their learners paradoxically deteriorated in certain interactional aspects of their therapeutic behaviours. The authors commented that “although the ‘treatment was delivered,’ the therapy (at least as envisioned) did not always occur” (21, p 438). This highlights both the importance of teaching skillful application of technique and of evaluating psychotherapy competence, since theoretical understanding and technical exposure does not routinely lead to effective changes in therapeutic practice. The evaluation of educational programs often does not include monitoring sustained impact on practice or patient outcome, particularly in psychotherapy.

Most Canadian postgraduate psychiatry programs currently base evaluations on global supervisor ratings of knowledge, skills, and attitudes gleaned from narrative accounts of patient interactions. Many programs do not rate observed therapeutic performance, apart from mock oral examinations in preparation for the RCPSC credentialing exam, which has historically been a diagnostic interview that requires therapeutic engagement. Although evaluating competence in medical psychotherapy requires dedicated resources and can be difficult to implement, it is essential to ensure that knowledge is translated into the implementation of best practices.

Advances in Psychotherapy Education in Canada

Postgraduate Psychiatry Programs
During the past decade, psychotherapy education curricula in both postgraduate and CME programs across Canada have changed significantly with expanded offerings and requirements, as well as with innovations in teaching and evaluation methods. From January 1 to December 31, 2003, we conducted a Delphi survey in which we interviewed postgraduate psychotherapy training coordinators or faculty from departments of psychiatry at 14 Canadian universities (Dalhousie University, McGill University, McMaster University, University of Alberta, University of British Columbia, Université de Laval, University of Manitoba, Université de Montréal, Université de Sherbrooke, University of Ottawa, University of Saskatchewan, University of Toronto, University of Western Ontario, and Queen’s University). We asked them to comment on their postgraduate psychotherapy curricula, teaching methods, and evaluation, and we also sought their perspectives on changes in their departments over the last 10 years with regard to psychotherapy education. This survey aimed to include nation-wide perspectives from expert educators in university-affiliated medical psychotherapy programs and to get a sense of how psychotherapy education has evolved over the past decade. Every effort was made to contact and interview the coordinators of every psychotherapy program in the 16 universities in Canada that offer psychiatry training. In some cases, we interviewed other knowledgeable staff involved in the programs. Interviews averaged 30 minutes; the first author conducted most in English over the telephone. A bilingual research assistant conducted the interviews with Université de Laval, Université de Sherbrooke, and Université de Montréal in French. The French interviews were translated into English and submitted via e-mail to both interviewees and authors. The interviewees verified and approved the translated versions. We then analyzed the interviews for trends and themes. (Note that the survey does not include non–university-affiliated programs, psychology programs, or industry-sponsored, private programs.)

Since the early to mid 1990s, the University of Toronto and McMaster University (7,8,33) have taken a lead in expanding the psychotherapy training component of their programs. At the University of Toronto, the psychotherapy curriculum has changed from a traditional psychodynamic and analytically oriented focus toward a more comprehensive curriculum that incorporates brief, manualized, evidence-based therapies. Residents are expected to attain proficiency in both short- and long-term dynamic therapy, one of either cognitive-behavioural therapy (CBT) or interpersonal therapy (IPT), and one of the multiperson modalities (that is, either group, couple, or family therapy). Additionally, integrative approaches are taught throughout, with special emphasis for the senior residents. Integration of psycho- therapeutic approaches is encouraged in clinical areas that have historically not employed them, including chronic care and geriatrics. Learning objectives specify requirements in knowledge, skills, and attitudes for supervised clinical work at both core and proficiency levels of expertise, which residents log with periodic review. The program is working toward converting the logs and evaluations to an electronic, Web-based format. This will potentially increase communication between and among faculty and trainees and residents and offer access to resources related to psychotherapy research, practice, and education.

McMaster University offers dynamic, multiperson, and time- limited psychotherapy training (specifically, emotion- focused therapy, CBT, and IPT), and in addition, the sequence of learning is staged with embedded mechanisms to comprehensively evaluate competency. Pantheoretical factors, including empathic engagement, are taught first. The multiperson and systems-based therapies that require a higher level of skill are introduced later in the residency. Further, all sessions are taped and supervision does not rely on narrative accounts. This permits comprehensive feedback on actual in-session material during supervision, along with competence assessments performed by faculty trained to achieve interrater reliability in the use of validated therapist rating scales. Supervisors who are not currently teaching specific residents then rate the sessions. Although psychotherapy research employs methods to evaluate adherence and competence, they have not historically been implemented in most postgraduate programs. Not only do such evaluation and feedback give trainees objective measures of their performance and emergent expertise, they also give clinical educators objective measures of the impact of their teaching, so that areas of weakness for both teachers and students can be identified. Dr P Weeraseka, postgraduate psychotherapy coordinator at McMaster University, has published preliminary program results that demonstrate positive improvements in trainees’ competence (7,33).

At Université de Laval, educators have created a “guide d’encadrement clinique” that provides guidelines for clinical supervision, and they are in the process of developing a clinical performance appraisal model to evaluate residents’ clinical competence. Both University of Western Ontario and Queen’s University have recently redefined and articulated psychotherapy competencies in the context of CanMEDS roles and physician competencies defined by the RCPSC (31,36). These include the roles of collaborator-consultant, medical communicator, scholar, manager, health advocate, and professional.

Over the past 5 years, numerous other Canadian postgraduate programs have expanded psychotherapy training to include time-limited, evidence-based, manualized therapies as articulated in Canadian clinical practice guidelines (9,10). Increasing attention is also paid to the sequence of learning and evaluation of expertise. The University of British Columbia sequences its curriculum to begin with a course in the basics of psychotherapy (M Corral, personal communication, 2003). Residents start their psychotherapy training with a modular approach developed by Beitman (37,38), who emphasizes the nonspecific and pantheoretical therapeutic aspects known to be critically important to outcome. This serves as a foundational building block for subsequent learning in the psychotherapies. The early Beitman modules focus on verbal response modes, including empathic and supportive techniques. Modules in inductive reasoning follow; these assist therapists-in-training to examine their patients’ problematic patterns and review strategic techniques that can facilitate more adaptive behaviours. In addition to this course, residents at University of British Columbia receive sub- sequent training in dynamic, cognitive, interpersonal, and multiperson approaches to therapy.

Dalhousie University has developed an innovative program of intensive small-group learning that incorporates comprehensive videotape review of both faculty and trainees. The groups comprise residents and community practitioners who follow intensive weekend workshops with this program of longitudinal group supervision. Teaching, feedback, and evaluation of emergent proficiency is based on observation of in-session videotapes. Use of videotape in groups reinforces the development of a reflective capacity, essential for life-long continued learning. The group format provides valuable interactive learning experiences with peers at differing learning stages (A Abbass, personal communication, 2003). In addition to the training in time-limited dynamic psychotherapy, residents at Dalhousie also receive training in IPT and CBT, as well as exposure to multiperson psychotherapies.

Faculty Development
Another important trend identified in this survey is related to faculty development for psychotherapy supervisors. Academic physicians, although clinical experts, are rarely trained in supervision or in educational approaches (39). Nevertheless, just as we advocate dissemination of the best evidence-based practices in the psychotherapies, we can also strive for best practices in teaching (17,40). Major revisions in psychotherapy curricula have required collaboration among staff supervisors who often hold divergent views on therapeutic approaches. Institutional leadership can facilitate a collegial learning community that promotes shared teaching values and offers opportunities for faculty development to psychotherapy educators. Psychotherapy education usually occurs outside core rotations with minimal contact among supervisors. However, psychotherapy supervisor groups can create cohesion, build morale, and refine skills and knowledge of faculty engaged in this essential line of training. At McMaster, part of faculty development has included training in psychotherapy adherence and competence rating scales (33).

The University of Toronto and McGill University have long- standing postgraduate supervisor groups that meet monthly. Invited speakers include faculty and residents who present on topics related to the practice and supervision of psychotherapy. Attendance is not compulsory, and the meetings attract a small percentage of supervisors. At the University of Manitoba, meetings are interactive and structured around clinical supervisory material, with review of taped teaching sessions. New supervisors are required to attend for 1 year prior to being allowed to work with residents. To enhance our capacity and impact as psychotherapy educators, given the complexity of the subject and the challenges of teaching and evaluation, we need to nourish professional development in this area.

This concludes the summarized findings from our survey. This survey is limited by the narrative nature of the data. Obtained from only a single faculty member at each university, it is not comprehensive. We did not obtain perspectives from learners or trainees, nor did we gather any objective data from observations or site visits. It is possible that what we describe does not represent what actually occurs but, rather, intended programming ideals. Therefore, we wish to qualify that what has been described may not reflect the full spectrum of postgraduate psychiatry psychotherapy educational activity.

Continuing Education (CME) Programs
Over 90% of Canadian psychiatrists devote a significant portion of their time to the practice of psychotherapy and have identified an interest in CME in this area (41). However, constraints to professional development and maintenance of psychotherapy competence by credentialed psychiatrists exist; among them are lack of protected time and limited accessibility to training, especially outside academic centres and in smaller urban and rural settings. Although it is beyond the scope of this article to review all CME offerings, several continuing psychotherapy education programs have implemented innovative longitudinal courses that blend didactic models with electronic interactive technology, integrating distance education and new information technology. As well, some groups are tracking higher levels of educational impact, including evaluation of changes in practitioner–trainees’ clinical behaviours and patient outcomes. Further, courses that integrate learning with clinical practice have emerged in response to the learning needs of communities of practitioners. This educational strategy embodies recommendations made by health education researchers and exemplifies best practice in teaching.

Copen, Zaretsky, and Jerome (28) conducted a pilot study that examined changes in psychotherapy practice among psychiatrists following a 9-session CBT course. This course used group supervision of clinically applied material delivered via televideoconferencing. It linked communities of learners from 2 separate centres with academic clinical educators and experts. The curriculum was based on learning needs identified by the community practitioners, and it used electronic information technology to overcome the geographic barriers that have historically limited access to CME. The instructors combined didactic and interactive teaching methods contextually applied to the trainees’ selected clinical training cases. They examined outcome measures in the domains of knowledge, attitudes, skills, and behavioural practice patterns, including CBT use and patient outcome. Results demonstrated improved knowledge, a more open attitude to the potential benefits of CBT, and greater CBT use, as determined by chart review. Additionally, patient outcome improved, with posttraining decreases in symptoms and improvements in Global Assessment of Functioning scores. Although the numbers in this study are small and there was no control group, the results are compelling. As well, the design integrates many educational ideals. The curricular content was derived from professional learning needs, the pedagogic methods placed the material into an active clinical context, a community of practice was fostered through electronic technology, and evaluation was comprehensive.

The American Group Psychotherapy Association recently held an on-line accredited CME symposium with a panel of clinical experts in traumatic grief (42). An intensive process of daily to weekly interaction included on-line discussion of readings and interchange on posted clinical questions. Over 2000 participants enrolled. This is another example of a longitudinal educational program that integrated active learning with clinical material. The innovative technology was user- friendly. It created an electronic platform for exchange of ideas and dialogue among learners and faculty that overcame geographic barriers. Linking diverse communities of professionals from distant sites, it also created a cohesive virtual group-learning experience.

The Ontario College of Family Physicians Collaborative Mental Health Care Network has implemented a mentoring primary health care program for family physicians who work with patients suffering from serious and persistent mental illness (27). Although the focus on psychiatric care is broad, psychotherapeutic clinical challenges are often central. Physicians are linked with a psychiatrist and general practitioner psychotherapist mentor whom they contact on a case-by-case, as-needed basis for guidance and help with clinical management through e-mail, telephone, fax, listserver, or face-to-face contact. This is coupled with CME events gleaned from participants’ needs assessments. It provides an opportunity for professional development in a substantive, innovative, and immediately useful way.

Discussion and Recommendations

Curriculum and Teaching Methods
Psychotherapy curricula have expanded to add empirically validated time-limited therapies to training in traditional, open-ended psychodynamic therapy. The evidence for efficacy of some of the manualized time-limited therapies, including CBT and IPT, empirically supports their implementation as articulated in clinical practice guidelines (9–11,36). Thus, an imperative exists to confer these additional therapeutic skills on training psychiatrists, thereby expanding their clinical repertoire and disseminating best practices. Manuals standardize curriculum guidelines for educators and trainees by clearly articulating goals and therapeutic techniques. Further, adherence can be measured and evaluated—important issues in this age of accountability, when increasing attention is being paid to the establishment and maintenance of competence.

There are, however, many patients for whom time-limited therapy is not suitable or adequate. As well, concern has been expressed that, in shifting educational priorities toward training in the time-limited therapies, we may neglect to confer the knowledge, skills, and attitudes needed to service patients with more complex problems that may need a longer, less structured, and more comprehensive, integrative, and flexible approach (35). Thus, we recommend and support the continued centrality of open-ended psychodynamic psychotherapy education in Canadian postgraduate psychiatry programs.

The traditional format of one-on-one psychotherapy supervision effectively teaches learners to apply knowledge in action and to become experts rather than technicians. From an educational perspective, this master–apprentice model of longitudinal contact, with theory applied to active practice, meets many of the current recommendations for best teaching practices. However, its reliance on clinical encounters for the acquisition of expertise limits it. Relying on such encounters exclusively does not address the issue of teaching novice learners; that is, the consequences of making tactical errors in clinical performance can feel high in the early stages of clinical education. Learning on real clinical cases has been compared to asking a novice musician to practise basic technique on a concert stage (18,23). Opportunities for more comprehensive and standardized learning of therapeutic skills are needed. Some programs have staged the curricular sequence to provide basic psychotherapy skills earlier in residency, have employed small-group learning to allow for exposure to more clinical material in a community of learners, or have used taped sessions in supervision. Although narrative reporting of sessional material during psychotherapy supervision can develop both reflective capacity and narrative competence, review of actual taped sessions can lead to more detailed feedback in addition to increased self-awareness. For some psycho- therapeutic modalities, though, taping is viewed as an intrusion in the therapeutic process. Other teaching methodological innovations might include the use of standardized simulated psychotherapy patients, more role-plays, the creation of benchmark psychotherapy practice videos to illustrate techniques, and the use of such electronic commun- ication technologies as electronic discussion or interactive– immersive environments (43).

Expert professionals have identified interest in more accredited psychotherapy CME opportunities (41). While peer and study groups, private supervision, or intensive training in dynamic and analytic institutes offer valuable educational opportunities, there appears to be limited organized longitudinal CME psychotherapy training for those constrained by time or geography. Innovative on-line learning potentially fills a gap in this area. Some groups in CME settings are using Web-based electronic technology to create psychotherapy DE opportunities. DE gives learners control of and access to educational activities and materials on their own time, and it can foster a community of psychotherapy practitioners and learners with the potential for “nearly uniform participation regardless of status or gender” (29). Although there is no evidence that DE is more effective, it can be a helpful adjunct if there is sufficient access to and proficiency with DE technology. Patient confidentiality must be vigilantly maintained through use of encryption and password protection when clinically sensitive material is communicated electronically. Unique features and additional challenges of DE relate to minimizing the effects of mediated communications and simulating lifelike interactions between teacher and student. Almost no research exists in these areas.

Evaluation
Greater specification of learning objectives has led to the articulation of training and competence guidelines. This has set the stage for increasing attention to the evaluation of therapeutic expertise. Several programs are evaluating clinical expertise more comprehensively, using direct observation, rating actual taped sessions according to the use of standardized therapeutic adherence and competence scales, or tracking patient outcome. Not only does this enable one to evaluate the effectiveness of teaching and redress aspects of educational programming that appear to be ineffective (as exemplified in rigidly adherent applications of manual-based therapies), it can also instill more confidence in trainees, grounded as it is in real performance appraisals. Additionally, this supports the critically important imperative of maintaining high standards of effective medical psychotherapy. Further developments might include longer-term follow-up evaluation of modifications in psychotherapy practice beyond immediate changes in attitudes, skills, and knowledge. Recommendations include moving beyond global evaluations by using standardized rating scales of adherence and competence, being careful not to overemphasize adherence at the expense of competence; pre- and posttraining measures of trainees’ changes in knowledge, skills, and attitudes; monitoring patient satisfaction through direct session-feedback rating forms or 360° evaluations (34), which allow multiple raters, including teachers and patients, to rate therapist performance. Further, patient outcome can be considered as a measure of applied clinical expertise, although this can be confounded by the complexity and severity of clinical cases. Evaluation of psychotherapy competence is an area with both the opportunity and the need to develop more effective methods and measures (32–34,44,45).

The delivery of psychotherapy education has changed significantly over the past decade, with developments in the areas of curriculum, teaching methods, and evaluation. In an era of health care reform and training priorities competing between biological and psychological aspects of psychiatric care, psychotherapy education has advanced to incorporate both outcome-based evidence and consensus guidelines. It remains a critically important aspect of training and practice in psychiatry. For novice and expert professional learners, it is vital to embed adult-education principles in the design, implementation, and evaluation of courses. Exciting opportunities exist to creatively collaborate, to research, and to further refine advancements in psychotherapy education, disseminating best practices in psychotherapy through best practices in training.

Acknowledgements

We are extremely grateful to Dr Molyn Leszcz and Dr Alan Ravitz for their careful reading of earlier drafts and for their extremely helpful comments.

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Author(s)

Manuscript received and accepted December 2003.

1. Assistant Professor of Psychiatry, University of Toronto, Toronto, Ontario; Head, Interpersonal Psychotherapy Clinic, Centre for Addiction and Mental Health, Toronto, Ontario.

2. Professor of Psychiatry, University of Toronto, Toronto, Ontario; Director, Centre for Faculty Development at St Michaels Hospital, Faculty of Medicine, University of Toronto, Toronto, Ontario.

Address for correspondence: Dr P Ravitz, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8

e-mail:Paula_Ravitz@camh.net

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