Psychotherapy and Supervision

Child psychiatry fellows receive teaching and training in a variety of types and modalities of psychotherapy, including cognitive behavioral therapy, dialectical behavior therapy, play therapy, psychodynamic psychotherapy, supportive therapy, group therapy, therapy combined with medication management, and family therapy. Psychotherapy is a skill set that is categorized into the subsets outlined above, but in our teaching of psychotherapy we recognize the importance of integration of the various skills along with knowledge of child development. The ability to apply these skills in multiple settings is critical in order to care for children along a continuum of care ranging from inpatient to consultation to outpatient work. We begin teaching the theories of psychotherapy in the first year and utilize clinical correlation to integrate the theories into practice on the inpatient and consultation services. Fellows are expected to consider the developmental level of each child and family in order to conceptualize and develop an effective treatment plan. The didactic series includes both specifics of normal development as well as discussion of abnormal develop and the implications of developmental level in a clinical setting.

Didactic teaching of family therapy begins in the first year and is a multidisciplinary class that includes fellows from both years as well as graduate students in psychology. First year fellows are expected to participate in the family therapy seminar where they observe family therapy performed behind a one-way mirror. They are encouraged to look for a family for their clinic so that by late in the first year they are able to start working with a family. All are required to start with a family by the beginning of their second year of fellowship. The leaders of the family therapy seminar teach through a combination of didactic classes and observation of therapy behind a mirror with telephone calls in to the therapist (fellow) in the room with the family. In this manner the fellows receive immediate feedback and the observers have an opportunity to consider the process of therapy in detail. The fellows also observe the psychology graduate students perform therapy, emphasizing the value in learning from a variety of disciplines.

 The first-year fellows apply their knowledge of therapy in multiple settings. On the inpatient services they have the opportunity to work with the social workers to lead family sessions for their patients. They also have the opportunity to participate in group therapy on the units and in the Partial Hospital Program. The fellows work individually with the children and teenagers on the inpatient services to provide psycho-education and supportive therapy. They learn about the integration of pharmacologic decisions with appropriate therapeutic interventions.

In the consult setting the fellows participate in family meetings with multidisciplinary teams. They provide brief supportive therapy to children as well as teaching children and families coping skills to help them deal with chronic pain and chronic illness.

Second-year fellows are required to follow at least one case for family therapy and to conduct observed sessions as part of the family therapy seminar. Second-year fellows are also required to identify cases for individual psychotherapy including Cognitive Behavioral Therapy and Psychodynamic Psychotherapy. Fellows with a particular interest in psychotherapy may use their elective time for additional psychotherapy cases or for a specific modality of psychotherapy.

Supervision for the fellows consists of two supervisors for each fellow with weekly meetings to discuss cases. In the first year the supervisors rotate based upon the clinical site to ensure expertise in the clinical skills necessary for the site. Supervision for the consult service is provided by the consult team of faculty, and supervision on the inpatient service is provided by faculty with significant interest in and experience with inpatient work.

Supervisors for the second year fellows are assigned for the entire year. Each fellow is assigned one supervisor who has expertise in psychotherapy to ensure that all fellows have direct supervision as they develop skills as therapists. The second supervisor focuses primarily on pharmacology to ensure a strong knowledge base in medication decisions. Fellows also work directly with faculty in their elective sites, providing additional supervision.

In summary, the fellowship provides a strong foundation for understanding how to practice evidence based psychotherapy for children and adolescents. The teaching factors in the level of training of the fellow, the clinical application of the knowledge and skills, and the emotional impact of the challenges faced when working with psychiatric disorders in children and adolescents. The faculty provides excellent support and education regarding psychotherapy.