Teaching Psychotherapy Skills in Acute Psychiatry

Psychotherapy is often treated as a specialized skill learned after the demanding early years of psychiatric residency, yet patients on acute wards frequently need clinicians who can understand their psychological experience and use therapeutic methods alongside medication and risk management. A pilot program at Weill Cornell Medicine suggests that this training can begin in the first postgraduate year without creating a separate course or requiring a large psychotherapy faculty. Investigators added a psychotherapy component to an established introductory psychopathology curriculum for postgraduate year-one psychiatry residents, covering psychotic, depressive, anxiety, substance use, bipolar and personality disorders. The study was small and focused on perceptions and self-reported confidence rather than clinical outcomes, but its results point to a practical way to close a gap between what psychiatry residents learn in lectures and what they may need when evaluating and treating acutely distressed patients.

The modified curriculum was built around six one-hour lectures in the residency program’s core didactics. Three postgraduate year-four resident lecturers worked with the investigators to retain the original emphasis on differential diagnosis, risk assessment and psychopharmacological management while adding a dedicated psychotherapy segment to each session. That segment introduced a psychological model for the illness category, techniques associated with that model and a sample dialogue intended to demonstrate how the concepts might appear in conversation. The design deliberately placed psychotherapy within an established course, reflecting a broader problem in residency education: early trainees may have little time for separate instruction, even though acute inpatient work is an important setting for developing relational and psychological skills.

For psychotic disorders, residents were introduced to the aberrant salience model of psychosis and cognitive behavioral therapy for psychosis. The model links delusions and hallucinations to altered attention and salience, offering a framework for examining the evidence a patient uses to sustain a belief. Instruction emphasized an inquisitive, nonjudgmental stance, careful inquiry into perceptual experiences, alliance building and assessment of safety. For depression, the curriculum combined cognitive therapy with behavioral activation: residents learned to identify automatic thoughts involving hopelessness, unworthiness or self-inefficacy, use Socratic questioning to examine them and encourage engagement in physical and social activity. These approaches give junior clinicians a way to discuss psychological patterns while preserving the central psychiatric tasks of diagnosis, safety assessment and medical management.

The anxiety lecture used the same cognitive framework to address catastrophic thinking and exaggerated estimates of risk, alongside distress-tolerance techniques for somatic anxiety. For substance use disorders, residents were taught motivational interviewing rather than a confrontational model of change. They learned to recognize ambivalence as a normal feature of substance use, ask rather than dictate, elicit the patient’s own arguments for change and use those “change talk” to strengthen motivation. This orientation is particularly relevant in acute care, where patients may be medically unstable, ambivalent or asked to engage in treatment before they are ready to commit. Rather than treating resistance as a character defect, the method gives clinicians a way to explore what matters to the patient and connect that perspective with possible change.

Other sessions tackled interpersonal and personality dimensions of acute illness. A psychodynamic model of mania was used to explain how an acutely manic patient may exploit another person’s vulnerabilities to support grandiosity, test limits and shift responsibility onto the clinician. Residents were also taught to monitor countertransference and set boundaries. For borderline personality disorder, the curriculum presented both Marsha Linehan’s biosocial model and a brief introduction to Otto Kernberg’s object relations account of borderline personality organization. Dialectical behavior therapy skills included distress tolerance and emotion regulation, while transference-focused psychotherapy concepts included countertransference monitoring, gentle clarification and confrontation. Clinical vignettes from acute settings were used to make the more abstract concepts clinically legible, including the dynamics of splitting and projective identification.

Ten postgraduate year-one residents took part in the course. Because residents missed some sessions while covering vacation, night float or other duties, the investigators distributed optional, anonymous surveys before and after individual lectures, producing 90 survey sets. A five-point Likert scale measured confidence in understanding psychological features, comfort using psychotherapeutic interventions, likelihood of applying those interventions and the perceived helpfulness of the lectures. Six patient vignettes with multiple-choice questions assessed competency. The researchers used one-tailed Welch’s t-tests to compare average pre- and post-lecture ratings and a Fisher exact test for competency. The institutional review board determined that the curriculum evaluation did not constitute human-subjects research, while the dataset was made available from the corresponding author on request.

After the lectures, residents reported substantially greater comfort with the psychological features of psychiatric conditions, rising from a mean of 3.57 to 4.33 on the five-point scale. Comfort using psychotherapeutic techniques increased from 2.82 to 4.17, and the reported likelihood of using those techniques rose from 3.09 to 4.48. Each change was statistically significant at p less than 0.001. Participants also generally rated the lectures as very to extremely helpful for improving their psychotherapeutic technique. These findings are consistent with a familiar challenge in medical education: a short, structured intervention can increase learners’ confidence and intention to apply a skill, even when a small test cannot demonstrate that their actual performance has improved. The particularly large shift in reported willingness to intervene may be practically important, because a technique a resident does not feel able or willing to use cannot affect patient care.

Objective competency results did not improve significantly. Residents answered 92 percent of the multiple-choice questions correctly before the sessions and 96 percent afterward, a difference that the investigators did not regard as statistically significant. The authors noted that the near-ceiling baseline score suggested the test lacked discriminatory power. The result also illustrates why validated performance assessments are needed: vignettes may test recognition of concepts, but they do not necessarily show whether a resident can conduct an alliance-building interview, regulate countertransference or apply motivational interviewing with a real patient. The pilot therefore establishes feasibility and a promising signal of engagement, not proof that the curriculum changes long-term clinical competence or patient outcomes.

The teaching approach also suggests that psychotherapeutic expertise need not be concentrated entirely in experienced faculty. The course was delivered by several senior residents who were not described as psychotherapy experts, using prepared material, clinical examples and established models. Its success may reflect the accessibility of structured techniques that can be linked directly to a psychiatric condition: cognitive methods for depression and anxiety, motivational interviewing for substance use, alliance-focused CBTp for psychosis, and interpersonal or attachment-related frameworks for mania and borderline personality disorder. Future studies should test the curriculum across multiple residency programs, use larger and more diverse cohorts, track whether the changes persist after the lectures and measure performance with more demanding assessments. Even so, the pilot makes a clear case for a simple proposition: psychotherapy is not confined to outpatient clinics or the final stage of training, and acute care can become a deliberate classroom for learning how to understand and respond to the mind in distress.

Subject of Research: Pilot psychotherapy education for first-year psychiatry residents in acute psychiatric settings

Article Title: A Pilot Psychotherapy Curriculum for Early Psychiatry Residents in Acute Settings

Article References: Greenberg, N. R., Levit, J., & Gorun, A. (2026). A Pilot Psychotherapy Curriculum for Early Psychiatry Residents in Acute Settings. Academic Psychiatry. https://doi.org/10.1007/s40596-026-02458-x

Image Credits: AI Generated

DOI: 10.1007/s40596-026-02458-x

Keywords: psychiatry residency, psychotherapy training, acute mental health, medical education, cognitive behavioral therapy, motivational interviewing, psychodynamic therapy, resident education, clinical competence, Pilot, Psychotherapy, Curriculum