Trainees ’ Attitudes towards Psychotherapy

Background: Psychotherapy education is one of the essential components of specialist training in psychiatry according to the Royal College of Physicians of Canada. How psychiatry trainees perceive psychotherapy has major implications for how trainees will learn about psychotherapy during training, how they will utilize it in their future practice, and how they will integrate it into their professional identity. Methods: The study involved the distribution of questionnaires to psychiatry residents at an Atlantic Canadian Medical School. The survey consisted of Likert-scaled items which assessed residents’ attitudes towards being a psychotherapist and their future study and practice plans in psychotherapy. Results: Surveys were completed by 18 out of 25 residents (72% response rate). Half of participants indicated that conducting psychotherapy was highly rewarding and the majority of residents planned to incorporate psychotherapy into their future practice. Several mean differences were also noted between those residents who completed their undergraduate medical education in Canada versus at International locations. Conclusion: Despite the recent changes in psychotherapy training requirements and concerns about psychotherapy’s role in psychiatry, many residents perceive psychotherapy skills as being important for competent psychiatry practice and plan to incorporate their psychotherapy training into their future practice. Additional implications for teaching, future research, and practice are discussed.


Introduction
Psychiatry has been challenged to harmonize biological and psychological therapeutic approaches, especially in terms of the role of psychotherapy as a treatment option.On the one hand, many psychiatrists provide short appointment times with more medication checks and fewer psychotherapy sessions [1] [2].This trend has resulted in less use of psychotherapy by many psychiatrists and has even led some to debate its value in psychiatry education [3]- [5].Alternatively, there is a substantial amount of scientific literature validating the use of psychotherapy and there are many psychiatrists and psychiatry educators who believe psychotherapy is a fundamental dimension of the role and identity of a psychiatrist [4] [6]- [8].In 2008 the Royal College of Physicians and Surgeons of Canada implemented new requirements for psychotherapy training for residents.Psychiatry residents are now required to attain increased competencies in a broad range of psychotherapies throughout their training in psychiatry [9].
This study explored psychiatry trainees' attitudes towards psychotherapy in order to provide data on how psychiatry trainees at an Atlantic Canadian medical school perceive psychotherapy.Such data is critical for psychiatry educators involved in curriculum development and psychiatry education for psychotherapy competencies.

Psychiatry Residents' Attitudes towards Psychotherapy
A national survey of 385 Canadian psychiatry residents conducted before recent changes to the Royal College of Physicians and Surgeons of Canada psychotherapy training requirements found that 99% of participants perceived psychotherapy as having an important role in contemporary psychiatry.Eighty-four percent of residents anticipated practicing psychotherapy to some degree and most said psychotherapy was important to their identities and planned to use it in future practice [3].A more recent study which surveyed psychiatry residents from 15 US programs found that 82% viewed becoming a psychotherapist as integral to their professional identity.Ninety-three percent said psychotherapy was a necessary skill to have, 54% agreed to provide a great deal of psychotherapy in future practice, while 62% reported psychopharmacology would be the foundation of treatment for most of their patients [10].
As seen, there is limited research on residents' attitudes towards psychotherapy, especially Canadian research since the major Royal College of Physicians and Surgeons of Canada changes to psychotherapy requirements and competencies.This is problematic as the new expectations raise questions about the possibility of an even bigger split between the call for significantly more training and the current trend of less use of psychotherapy in psychiatric practice.It is important for psychiatry educators to gauge future psychiatrists' attitudes about the role of psychotherapy in their practice after graduation since it might have implications on how to respond to the needs of the community they serve.The current research explored Atlantic Canadian residents' perceptions toward psychotherapy post Royal College of Physicians and Surgeons of Canada changes to psychotherapy requirements.

Procedures
An email, including an informed consent form, was sent to all 25 psychiatry residents at a large Atlantic Canadian university, inviting them to participate in this study by printing and completing the study questionnaire.Questionnaires and informed consent forms were also distributed at regularly scheduled academic activities.
Participants were asked to return completed questionnaires to a specific location.The study was reviewed and approved by the provincial Health Research Ethics Authority.

Questionnaire Development
The survey included 20 Likert-scaled items.The survey contained questions on residents' attitudes toward their psychotherapy training, their perceived level of psychotherapy competence, the role of psychotherapy in their professional identity and their future education and practice plans.Each item was rated on the following scale: 1 = "not at all", 2 = "somewhat", 3 = "moderately", 4 = "a lot" and 5 = "very much".Three demographic items asked participants about their current level of training in psychiatry, previous training in psychotherapy or counseling and if they completed their undergraduate degree in Canada or at an International program.The survey used in this study was adapted, with permission, from a survey developed at the University of California, San Diego [10].

Data Analysis
All data was analyzed using SPSS Version 22.0.Descriptive statistics were used to gauge residents' attitudes toward psychotherapy and their future practice plans.We constructed overall mean scores for participants' responses to the various survey questions and also created sub group scores based on where respondents completed their undergraduate medical education (i.e., Canada or International).

Description of Respondents
Surveys were completed by 18 of the 25 residents in the psychiatry program at a large Atlantic Canadian university, thus our overall response rate was 72%.Residents in post graduate year (PGY) 1 to PGY 3 were considered junior residents and PGY 4 to PGY 5 were considered senior residents.There were 12 junior and six senior residents who participated in this study.Previous training in psychotherapy was rare, with only one resident reporting previous training in psychotherapy.Our participants reported having Canadian (n = 8) or international (n = 10) undergraduate medical education experiences.

Attitudes towards being a Psychotherapist
Half of participants reported that conducting psychotherapy is "a lot" (33.3%) or "very much" (16.7%) rewarding while 22.2% and 27.8%, respectively, reported that conducting psychotherapy was "somewhat" or "moderately" rewarding.The majority of residents agreed that psychotherapy skills are necessary to being a competent psychiatrist (see Figure 1).Many residents agreed that providing psychotherapy is time consuming with over 80% of respondents reporting a four (a lot) or five (very much) on our five point Likert Scale.For the question on how much being a psychotherapist is part of the resident's identity, 5.6% reported "not at all", 27.8% reported "somewhat", 38.9% said "moderately", 16.7% said "a lot" and 11.1% reported "very much".The majority of the residents reported that their psychotherapy training only "moderately" (27.8%) or "somewhat" (27.8%) influences their life outside of work.Similar results were found when asked if psychotherapy influences their clinical work (see Figure 1).Figure 1.Psychiatry residents' attitudes towards psychotherapy and being a psychotherapist.

Future Plans to Study and Practice Psychotherapy
When asked how much of their psychotherapy training they plan to incorporate into their practice, the majority of residents reported "somewhat" (38.9%) and "a lot" (27.8%).Most of the residents reported that they plan to integrate psychotherapy with psychopharmacology in their practice (see Figure 2).The greatest portion of residents (33.3%) reported that they expect to provide "a lot" of formal psychotherapy after residency, while 27.8% reported moderate level expectations, and 22.2% reported 'not at all'.Residents were also asked how likely they were to pursue additional training in psychotherapy as part of their formal training and how likely they were to pursue additional training in psychotherapy outside of their residency training (see Figure 2).Respondents did endorse a strong willingness to receive psychotherapy education and training from a wide array of mental health professionals such as psychologists (see Figure 2).

Differences in Undergraduate Medical Education
The means of responses from residents who graduated with a Canadian undergraduate medical education (CMG) and residents who graduated with an International undergraduate medical education (IMG) were computed (see Table 1).When asked how much being a psychotherapist is part of their identity, CMGs' mean response was 2.38 (SD = 0.74) while the IMGs' mean response was 3.50 (SD = 1.08).CMGs' mean response to how rewarding conducting psychotherapy was for them was 2.75 (SD = 0.89) while IMGs' mean response was 4.00 (SD = 0.82).Residents were asked how much their training influences their clinical work and CMGs' mean response was 2.63 (SD = 0.92) while the IMGs' mean response was 4.00 (SD = 0.82).When asked how necessary psychotherapy skills were to be a competent psychiatrist CMGs' mean response was 3.75 (SD = 0.89) and the IMGs' mean response was 4.50 (SD = 0.71).
The mean responses for both CMGs and IMGs for the question on how much they plan to incorporate their psychotherapy training in their practice were 2.50 (SD = 1.07) and 3.60 (SD = 1.26), respectively.Additionally, when the residents were asked how much they plan to incorporate psychotherapy with psychopharmacology in  their practice, CMGs' mean response was 2.88 (SD = 0.99) while IMGs' mean response was 3.50 (SD = 1.18).The mean response for CMGs for how much formal psychotherapy they plan to provide following residency was 2.38 (SD = 1.06) while the IMGs' mean response was 3.00 (SD = 1.25).

Discussion
Psychotherapy is a time consuming yet valuable approach to the education and clinical practice of psychiatrists.
Training in psychotherapy brings psychiatrists a needed approach that provides a base for required skills and attitudes that are essential to an understanding of the individual, interpersonal and social dimensions of mental illness and vital to the complete spectrum of competent care.Learning psychotherapy is more than building competency in therapeutic theories and techniques; it is a foundational component in the professional identity of a psychiatrist who develops a sophisticated understanding of the person's brain and mind and their relationship to one's physical and social being.
There is significant evidence to support psychotherapy's efficacy and central place in best clinical practice guidelines for management of mental disorders yet some have questioned its value and place within psychiatry [3] [4] [11].Having both general medical and psychiatric education, psychiatrists are uniquely positioned to understand and manage complex mental health disorders through their focus on an integrated bio-psycho-social approach to patient care.Psychotherapy is a key component of the comprehensive treatment for all disorders treated by psychiatrists.The interaction, communication and psychotherapy provided by psychiatrists in conjunction with medication in the relationship with their patients have been shown to decrease relapse and increase recovery [12].
The current study sought to examine the attitudes of psychiatry residents at a large Atlantic Canadian University in terms of their views toward psychotherapy.Results have suggested that our study participants see psychotherapy as a time consuming, yet relatively rewarding option in their future clinical practice.Part of the explanation for participants seeing psychotherapy as such a time consuming process could be due to the fact that psychiatry residents have limited, if any, previous exposure to the basics of human psychology and prior exposure to formal training or exposure to psychotherapy is limited, with only a minority of residents having had some previous basic teaching in counselling skills [13] [14].
An important consideration for psychiatry educators was that many current residents who participated in this study reported seeing value in psychotherapy.It may reflect residents' appreciation of the role psychotherapy training plays in their development of effective communication and human relation skills, and/or awareness and comfort with managing all aspects of the relationship with patients.This is a strong endorsement for psychotherapy training in psychiatry residency programs.Many participants in this study also perceive psychotherapy skills as being important for competent psychiatry practice.This is similar to US based research on psychiatry attitudes towards psychotherapy [10].
The majority of respondents reported planning to incorporate their psychotherapy training into their future practice and plan to provide formal psychotherapy after residency.Again, this is an encouraging finding for proponents of psychotherapy education and for justification of the significant and various system and human resources needed for such training.This is also a finding that is consistent with previous research, including Canadian research that occurred before the Royal College of Physicians and Surgeons of Canada's new requirements for psychotherapy training [3].Importantly, a large number of participants reported they would not be pursuing additional training in psychotherapy highlighting that for many residents their residency may be the only psychotherapy training they receive.This raises important questions about ongoing competency and also highlights the high level of importance of quality residency training in psychotherapy.Participants in this study also reported a high degree of support for allied health professionals (e.g., psychologists) contributing to their psychotherapy supervision and education.This is an important finding for psychiatry educators.Psychologists have significant training in psychotherapy and counselling and can offer valuable education and supervision in this area.
Our participants reported completing either Canadian undergraduate medical education or International undergraduate medical education.We found a number of mean differences for participants from Canadian versus International undergraduate medical schools in terms of their attitudes towards, and future plans regarding, psychotherapy.Albeit relatively large mean differences, these numbers were non-significant, potentially due to small sample sizes.Nevertheless, future research could explore the impact of geographical location of medical education on residents' perceptions of psychotherapy.Psychiatry educators could also consider these findings in their curriculum development and delivery.

Conclusions
This study sought to understand the perspectives of psychiatry residents in terms of their views on psychotherapy.Many residents perceived psychotherapy skills as being important for competent psychiatry practice and reported plans to incorporate their psychotherapy training into their future practice.Despite this, some residents noted few plans to continue their training in psychotherapy following their residency.A high number of respondents strongly endorsed involving allied health professionals such as psychologists in their training and supervision.
Despite a high response rate to the questionnaire, the current study results should be interpreted with caution due to the relatively small sample size.Future research could include a larger sample of a range of programs in this post Royal College of Physicians and Surgeons of Canada new psychotherapy training requirement era.

Figure 2 .
Figure 2. Psychiatry residents' future plans to study and practice psychotherapy.

Table 1 .
Mean and standard deviation responses of residents with a Canadian undergraduate medical education versus residents with an international undergraduate medical education.