A number of textbooks^22–34 provide comprehensive presentations of technique and theory. Although they are indispensable to psychotherapy education, they do not provide a concise framework from which to organize a training program. A model curriculum for teaching psychodynamic psychotherapy in psychiatric residency programs was developed by members of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry.³⁵ It contains a consensus about core goals, an educational philosophy, and a recommendation for sequencing training over the course of the entire residency.

Further development of a curriculum approach to psychotherapy training will produce more consistent and effective methods of education. Overtly defined goals and objectives that are organized and sequenced can enable educators to approach the questions of what, when, how, and in what context to teach. Students and teachers can work more collaboratively when they share a defined set of educational tasks. A concise description of the areas and skills relevant to psychodynamic psychotherapy can be used to augment education that takes place in individual supervision and case-based seminars. There is always a need for balance between an objective curriculum approach and the individually focused orientation of traditional psychotherapy education.

A number of authors have directly addressed the question of educational goals and their possible sequence. Fleming and her co-workers^{7, 36,37} developed an educational model that moved from listening and gathering information to organizing and processing the data into meaningful units, integrating what has been learned, and responding to the patient. Fleming stressed the importance of beginning within a phenomenological context. She also advocated a planned learning approach in which both teacher and student actively work to meet overtly defined teaching objectives. Ornstein³⁸ shares the view that early training should focus on observable data. The teacher's role is to facilitate the student's discovery of ways of observing and forming intuitions from the clinical situation without the early encumbrance of theory. Ornstein specifically elaborates the basic skills of observation, evocative listening, empathy, intuition, and introspection for beginning training in psychotherapy. Ralph¹³ describes a series of four developmental steps: 1) observation and listening, 2) a patient-centered approach within the theoretical framework of the training institution, 3) a relationship-centered approach that focuses on process, and 4) a self-perspective. Levenson³⁹ favors a style of supervision that begins with boundaries of therapy, moves to a developmental history, and finally focuses on the analysis of transference. This method is for supervision of analytic candidates, but it is noteworthy that even here, emphasis on theory is saved for later in training. Melchiode⁴⁰ describes a developmental supervisory model for psychiatric residents in six stages: 1) elaborating the history, 2) observing affect, 3) developing empathy, 4) recognizing unconscious processes, 5) using the therapist's fantasies, and206) understanding theory. Rodenhauser¹⁵ provides a comprehensive summary of developmental training approaches and offers an interactional developmental schema involving the supervisor, the supervisee, and the patient.

In all of these phased-learning approaches to education, there is remarkable consistency in moving from a descriptive position to various ways of organizing clinical data. An early focus on clinical phenomenology is also reflected in the results of research on residents' preferences in supervision.¹⁹ These models have the attributes of clarity and a sense of movement over time. They present organizing principles in stages, but they do not delineate the multiple areas of psychotherapeutic work. A more fully articulated developmental model describing core skills and concepts is a natural progression from these earlier conceptualizations.

The model presented here is an amalgamation of a developmental approach with a more inclusive list of discrete learning tasks such as those found in many psychotherapy texts and described by Buckley and co-workers.^16,41 This model provides a framework from which to develop a sequence of seminars. It also provides a framework for periodic review by residents and supervisors to focus learning and evaluate progress. It is not intended to impose a static structure on psychotherapy education. Rather, it adds a counterpoint to the richness and diversity contained in individualized, process-oriented, student/patient-focused teaching.

The model as illustrated in Table 1 describes a traditional analytic approach. It does not include the most recent advances in psychodynamic psychotherapy or make specific connections to cognitive, interpersonal, and other approaches. The model structure can include such additions as they become relevant to a specific emphasis or are indicated by an evolving consensus in the field. The details presented here represent a classical or baseline approach so that the model can be presented most clearly. In actual practice, newer ideas are included, as well as links to other psychotherapeutic disciplines. Advances in technique, especially brief treatment models,^33,34 integrate various approaches, and integration is increasingly a central focus in education. This is particularly true after basic skills are acquired and the emphasis of each approach is understood. This model is helpful in articulating the analytic perspective, presenting aspects common to all psychotherapies (particularly in Phase I), and providing points of connection to other techniques. The ultimate purpose of the model is to facilitate education for practice in the evolving mental health environment. Brief psychotherapy, focused interventions, and integration with psychopharmacologic treatments all benefit from a psychodynamically informed perspective.

The model consists of two coordinates: the “phases of learning” along the horizontal axis and the “developmental categories” along the vertical axis. The concept of “phases of learning” is an attempt to delineate broad sequential steps in the educational process. Each phase describes the primary learning perspective for the educational objectives within it. The “developmental categories” are groupings of closely related learning tasks that evolve toward increasing complexity and sophistication. The phases and developmental categories are described in detail in the next section.

Phase I, Observation and Description, focuses on the student's ability to observe, collect clinical data, and describe what is seen, heard, and experienced. There is little attempt to organize observations around theoretical knowledge. The student learns how to describe the patient and his or her behaviors in detail, enable the patient to talk freely, listen openly and carefully, and pay attention to the interactive nature of the clinical encounter. An important aspect of this work includes consensual validation by teachers and peers. Students are also asked to pay attention to themselves as participants. Most of these skills, although difficult to work on, require no leap of faith. Working from the manifest data is in the biomedical tradition, so residents do not need to see psychotherapy as an unfamiliar departure from their work up until that point. Phase I includes many skills that are basic to all forms of psychotherapy.

Phase II, Conceptualization, centers on placing manifest communications, behaviors, and interactions within frameworks that help to explain psychotherapy process and aid in the choice of interventions. Students begin paying attention to repetitive themes and behaviors, patterns of interactions, latent communications, and the ebb and flow of the therapeutic working relationship. At this point, a variety of clinically useful theoretical concepts are learned and integrated directly with clinical data. An overview of the analytic theory of technique as well as a psychodynamic view of behavior are needed. The Conceptualization phase therefore represents a major shift from manifest phenomena to more covert data and abstract levels of understanding.

Phase III, Synthesis, involves a fuller integration of the skills, knowledge, and behaviors learned up until this point. The most important abilities needed here are a fluidity of thinking that can integrate multiple areas of knowledge about the patient and the therapy process, the ability to understand complex interrelationships, and the freedom to see the same phenomenon from different perspectives. Although new knowledge is continually being introduced, the major emphasis is on the integration of already existing knowledge and its increasingly skillful applications during clinical work.

The five developmental categories are 1) Goals, Roles, and Boundaries; 2) Participants; 3) Verbal Flow; 4) Technique; and 5) Theory. Each group of learning goals will be briefly described over the course of its progression through the three phases of learning. This is not a comprehensive review, but rather a demonstration of the ways in which this form of organizing educational goals can be useful.

This model is an attempt at delineating those aspects of training that can be described objectively and placed within a structure that demonstrates interrelationships and a progression in learning. A major constraint has been the desirability of constructing a model that not only accurately reflects the practice of therapy and helps to inform educational efforts, but is also concise enough to be of use in ongoing training and for evaluation purposes. Three separate steps have been taken in the construction of this model: specifying training goals, organizing them into categories, and placing the categories within learning phases. Each step offers advantages and imposes limitations, and each can be evaluated on its own merits, but it is the combination of the three that gives the model depth and provides educators and students with guidelines for training.

The discrete goals have been chosen as being most representative of the practice of traditional dynamic psychotherapy. Some goals are more specific than others. Although the list is comprehensive, it does not include the nonspecific aspects of therapy, such as warmth, sensitivity, compassion, and a sense of humor. Recent contributions have not been included here. Training programs interested in teaching dynamic psychotherapy will vary considerably with respect to how traditional their approach will be. Some will lean more toward a focus on the elucidation of meaning and observable interpersonal process, while others will prefer an accent on dynamics and transference/resistance interpretation. Although there are important differences among them, all dynamic approaches derive from a perspective that includes influences from development, the unconscious, subjective meaning, process between patient and therapist, and insight.

Placing the educational goals into the categories of development aids training by creating manageable gestalts that serve to highlight important interrelationships and trends. Some of the arbitrariness of this kind of categorization is balanced by an awareness of the dynamic interconnections across boundaries and the constant flow between larger perspectives and minute details. This is an aspect of education that can only be hinted at in an organizational map.

Placing the categories within the sequential learning phases provides an overall dimension to training at different points in the process and helps to further define the progression of specific areas of knowledge. This approach is of help in addressing the difficult questions of what to teach when. The model does not presume a naturally occurring sequence, but rather that such a structure helps to prioritize areas of training. The phases are intended to be used flexibly to orient rather than to strictly define or limit teaching practices. There is always a mixture of observing, conceptualizing, and synthesizing.

The model makes no attempt to suggest how far an individual resident should be expected to progress in training. It is helpful for the resident with no interest in practicing this form of treatment to know how certain clinical skills relate to the dynamic treatment method. Establishing boundaries and rapport, enabling the patient to speak openly, listening, and experiencing oneself as part of the treatment process are examples of core clinical skills that all psychiatrists should possess. Understanding the purview of psychodynamic psychotherapy can enable clinicians to recognize problems and look for help or refer a patient when that is needed. Those residents who wish to become competent dynamic psychotherapists can use the phases to measure progress and help guide ongoing education far beyond residency.

The sequential training model was developed 15 years ago with the primary purpose of constructing a progressive series of seminars that followed a consistent set of overtly defined expectations. With the timing and specifics of the training goals established, there was greater freedom to develop various teaching strategies. A mixture of readings and didactic discussions, process notes and audiotaped case material, roleplaying, and use of the teacher's clinical work all became organized around a progressive set of educational objectives.

Once this model was used to develop and teach a series of seminars, other advantages followed. The Director of Education was able to more consistently assess the progress of individual residents as well as begin to set goals and standards for the program. All residents and teachers had a better sense of what was expected from their work together. The evaluations of supervision, completed by both resident and supervisor, began to reflect a more consistent focus on learning expectations related to timing in training.

Psychiatric residents begin doing psychotherapy in advance of much knowledge of the process. The lack of an organized framework within which to anticipate their work with patients causes more anxiety and confusion than necessary and can interfere with early learning. This model provides an overview of therapy in a concrete format that can be supportive. It provides a context and rationale for educational goals. The specification of skills and knowledge gives residents a tangible place to start. They can actively pursue agreed-upon objectives rather than believing that they have to learn everything at once and therefore feeling incompetent or paralyzed. As residents progress, they can continue to use the model for orienting current learning and for assessing growth. Since the model encompasses advanced areas of learning, it can continue to be valuable long after formal training has ended.

The supervisor must focus on the resident's educational and emotional needs, the patient, the progress of the therapy, and a diverse variety of related issues. Each supervisor develops a way of using different kinds of information to teach, but some consistent organizing principles can be of great benefit. Without a structure, it becomes easier to become stuck on one area and to miss the possibility that movement in this area is premature or first requires education in other related aspects of therapy. A structure can also help to prevent idiosyncratic choices or education solely based on the needs of the patient presented in supervision. The use of this model encourages the supervisor to be more selective and cautions against moving ahead to complex tasks before basic areas are understood. The overt delineation of current training objectives with the resident enhances the working relationship and improves learning. Impasses between supervisor and supervisee can often be resolved with a refocusing on the most relevant phase-appropriate learning objectives. A rigid adherence to any group of educational goals, however, leads to a stale supervisory experience.