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     PGY 3 - Clinical Assignments

• Adult Outpatient Psychiatry (IOP Clinic).  This is an organized continuously supervised experience in the assessment, diagnosis and treatment of outpatients that emphasizes a developmental and biopsychosocial approach.  Experience with a wide variety of patients and treatment modalities; experience in both brief and long-term care of patients, using individual psychotherapy (including psychodynamic, cognitive, behavioral, supportive, brief), and biological treatments and psychosocial rehabilitation approaches to outpatient treatment. Long-term psychotherapy experience must include a sufficient number of patients, seen at least weekly for at least one year, under supervision. Other long-term treatment experiences should include patients with differing disorders and patients who are chronically mentally ill. The IOP clinic provides a breadth of experience with regard to diagnoses, severity, complexity, and motivations and helps prepare residents for the real world of outpatient psychiatry.  The modal patient has a mood disorder (approximately 60-70% have MDD, Dysthymia or Depression NOS, or various forms of BPAD); 30% have one or more anxiety disorders (Panic, GAD, PTSD; rarely OCD), 10-15% have known substance use disorders, 10% have a psychotic disorder (e.g., schizophrenia or schizoaffective), and 15-20% have personality disorders (total >100% reflects co-morbidities).  The majority of patients receive one or more psychotropic medications, and many have significant medical or neurological illnesses. The typical patient visits the clinic every two to four weeks, but all residents have at least two weekly (rarely twice weekly) patients, and several patients seen at less than monthly intervals. A typical caseload is 15-17 patient hours/week, including one or two new patient evaluations (1-½ hours each). Residents who see patients at Counseling and Psychological Services (Student Health) carry approximately 4 fewer hours/week.  Each resident has 3-4 hours of individual supervision per week. From faculty psychiatrists, psychiatric social workers, or psychologists, each providing 1 hour/wk of individual resident supervision. The seminars (3 hours/wk throughout the year) cover time-sensitive psychotherapy, psychodynamic psychotherapy, and cognitive-behavioral psychotherapy. There is formal teaching on group psychotherapy, family therapy, couples therapy, psychotherapy with special populations, psychotherapy termination, and psychotherapy research. A weekly clinical conference offers demonstrations and practice of different interview techniques.
• VA Outpatient Psychiatry Clinic (Attendings: Drs. Albanese, Wright, Cusack, and Huber). Required ½ day clinic where treatment modalities include individual support and case management, individual or group psychotherapy with or without cognitive-behavioral interventions, and the range of state-of-the-art somatic treatments (e.g., psycho-pharmacotherapy, electroconvulsive therapy) Patients can also be referred for more specialized evaluation and treatment (neuropsychological testing, substance abuse treatment, couples therapy, ECT, group PTSD therapy, etc.) as part of their overall mental health treatment. Prevalent diagnostic groups are major depression, schizophrenia, bipolar illness, schizoaffective illness, substance use disorders, anxiety disorders, and borderline personality disorders. The average resident caseload in the 3nd year VA continuity clinic is 45 outpatients.
• Charleston Community Mental Health Center. Required 1/2-day clinic per week for a period of 6 months in the 3rd year.  Residents are assigned to one of several community-based clinical support and rehabilitation programs that have been nationally recognized as models of care for persons with severe and persistent mental disorders. Residents provide care and treatment with appropriate pharmacologic, psychotherapeutic, and rehabilitative interventions.  Prevalent diagnoses are major psychotic disorders 35% Schizophrenia, schizoaffective, bipolar disorders), other affective disorders 35%, substance abuse disorders 25%, and other disorders 5% (e.g., anxiety disorders, PTSD, adjustment disorders, personality disorders). Under the direct supervision of fulltime clinical faculty, the residents perform assessments and participate in developing and implementing the patient's individual community treatment and rehabilitation plans.  Average clinic caseload per resident is 15 outpatients. There are over a dozen attending psychiatrists supervising resident work at this major residency program affiliate. The medical director is Dr. Patricia Nnadi.
• Child and Adolescent Outpatient (IOP and CMHC clinics).  Required 1/2-day clinic per week for a period of 6 months in the 3rd year provides residents opportunities for exposure to and skill development in outpatient assessment and pharmacologic and psychosocial treatment modalities of a wide variety of child and adolescent psychiatric patients. The average resident caseload is 12 outpatients. The two sites used for these experiences (IOP and the CCMHC) represent typical community samples (e.g., ADHD, oppositional disorders).  Modalities offered include individual support and treatment in the context of individual, group, and family psychotherapies, pharmacological and behavioral interventions, and school consultations. All patients assigned to residents in these clinical settings are seen along with a supervising Attending physician.

     PGY 3 - Lectures/Seminars

• Overview of Psychotherapeutic Theories.  A survey of the history of psychotherapeutic theories including Freud and Ego Psychology, Sullivan and the Interpersonalists, contemporary Kleinian theory, Object Relations, and Self Psychology. Includes readings and case presentations to highlight practical applications and enhance understanding. 
• Dynamic Psychotherapy.  Seminar discussion of readings from Greenson’s The Techniques and Practice of Psychoanalysis. Emphasizes the mechanisms of defense, transference, counter transference, resistance, and interpretation.
• Time-Sensitive Psychotherapy.   A series of seminars with accompanying readings on the principles of solution-oriented treatment and brief therapy. Topics include eliciting the patient’s request and negotiating goals, with a focus upon the language and assumptions of solution-oriented psychotherapy and brief treatment of specific issues such as loss and grief. 
• Motivational Enhancement Therapy.   An introduction to and overview of motivational enhancement therapy with readings from Motivational Interviewing: Preparing People for Change by Miller and Rollnick. The series also includes videos of patients interviewed by Miller and Rollnick as well as role-play among the residents to highlight techniques and encourage practice.
• Cognitive Behavioral Therapy.   The series focuses on the basic elements of cognitive and behavioral theory with sessions dedicated to the therapeutic relationship, general psychotherapy skills, setting goals, structuring sessions, and applying CBT techniques to specific disorders.  Techniques taught include evaluating automatic thoughts, anxiety management, exposure techniques, and problem solving skills, social skills and behavior activation. Teaching methods also include required readings, role-playing, observation of faculty clinicians, critique of resident therapy tapes, and writing assignments. 
• Dialectical Behavior Therapy.   An introduction to the principles of dialectical behavior therapy for the treatment of borderline personality disorder. The focus is to teach the therapist ways to help their patients acquire new skills and overcome motivational obstacles. Videos of therapy sessions enhance understanding of techniques.
• Interpersonal Psychotherapy.   An introduction to the principles of interpersonal psychotherapy. The focus is to teach the therapist ways to help their patients reduce interpersonal deficits by modifying faulty communication, exploring repetitive patterns in relationships, encouraging affect, and using the therapeutic relationship. Specific techniques and the therapist's role are considered.
• Couples and Group Therapies.   A brief series of lectures and seminars designed to provide the basic principles of couples therapy and group therapy. Focus is on improving communication skills and understanding dynamics between the participants. Videos of initial and follow-up couples and group therapies enhance understanding of technique.
• Grief. Brief introduction to grief work with the goal to review depressive symptoms, explore associated symptoms, and teach the therapist how to help the patient reestablish interest and relationships and reconstruct their relationship with the deceased.
• Children, Adolescents, and Families.   Study of normal development and psychopathology in children, adolescents and families. Includes overview and identification of major child/adolescent psychiatry syndromes and their management and treatment within the existing family context. 
• Psychotherapy Research. Introduction to research in psychotherapy, including issues of methodology and meta-analysis. Includes  readings specific to psychotherapy research.
• Culture and Spirituality.  These lectures are part of the core series on spirituality in psychiatry. Specifically covered, are issues of noncompliance secondary to spiritual beliefs and end of life issues. The goal is to enhance the therapist’s awareness of the role of spirituality on treatment.
• Termination.   A focus on the principles and process of psychotherapy termination, with emphasis on “forced termination.” A review of dynamic techniques in relationship to the process of termination.
• PGY-3 Psychopharmacology Seminar.  This seminar has alternating weeks of readings and patient videos that correspond with the selected topics. Each of the readings has two assigned resident presenters, although all residents should be prepared to discuss the material.
• PGY-3 Case Conference.   Two series of clinical case conferences conducted either in a small or large group. In the large group, residents observe colleagues or attendings perform an initial interview with a new  patient. Therapy modalities frequently correlate with concurrent didactic series. In the small group, 2-3 residents observe an attending demonstrate varying styles of evaluative interview with an established patient. The goal is to clarify diagnosis and witness technique.