Mid-day Wednesday, after spending the morning on their respective rotations, PGY-2 residents are excused from their clinical responsibilities to attend their weekly classroom didactic curriculum. Consisting of five courses running in parallel, the curriculum is divided thematically into the following areas:
- Psychopharmacology & Neuroscience
- Social & Psychiatry Services
- Process Group
As noted on the overview of the didactic curriculum, several of these courses span between two and three years. Each area is described in detail below.
A primary goal of the residency training program is the cultivation of sophisticated and scholarly clinicians who have theoretical knowledge and practical skills in the psychotherapies. This complements our training in applied neuroscience and fosters the residents’ synthesis and integration of these fields of knowledge. In presenting residents with the major theories, techniques, formats, and modalities of treatment, the psychotherapy curriculum grows in its breadth and depth, such that the 1-hour per week psychotherapy course in the PGY-2 year morphs into a 3-hour per week experience in the PGY-3 year, and then 2-3 hours per week considering advanced topics in the PGY-4 year. (Note that these times only reflect classroom time and do not include other psychotherapy-focused learning experiences for residents, like weekly case conferences, supervision, etc.).
The PGY-2 psychotherapy course begins with a 12-session class on techniques in talking with inpatients. As these residents are now well-versed in the basic care of inpatients, they are asked to begin working more psychotherapeutically with this population, with a greater attention to the moment-to-moment cognitions, emotions, and behaviors of patients and how these may be acknowledged and therapeutically addressed. In this class, residents learn focused and core listening skills applicable to a variety of different therapeutic orientations and techniques, and how to apply these principles in daily sessions with their patients. The questions “What is the patient trying to tell me?” and “What do I say next?”—as well as the How, When, and Why of it—form the core conceptual and pragmatic scaffolding on which this class is built.
Following this practice-heavy introductory course on the core principles of listening and responding, the residents begin more intensive classes on psychodynamic psychotherapy, beginning with an 11-session series on fundamental aspects of psychodynamic theories.
Then, building upon this conceptual framework, residents attend a 4-month course on psychodynamic techniques, including a segment focused on an actual ongoing treatment. Selected readings and actual clinical/process material are used as framework for discussion and learning. Included in this course are the following seminars, among others:
- Indications and suitability of psychodynamic psychotherapy for various conditions
- Requirements of the patient and therapist
- Establishing a framework for treatment
- Commencing treatment
- Working with transferences, countertransferences, and resistances
- What to say when, and how to say it
Once the basic techniques and theoretical frameworks of psychodynamic psychotherapy have been learned, residents are taught a 6-session class on supportive psychotherapy and its direct application to their ongoing cases.
The psychotherapy course ends its PGY-2 iteration with a series on evaluating and contracting for treatment (4-classes) and a series on picking up terminated and transferred cases (4-classes), both in preparation for residents’ assuming a PGY-3 outpatient role.
Phenonemology: Method & Methodology in Descriptive Psychopathology
Bruce Levine, MD
The overall goal of this course is to help the residents develop a vocabulary for the recognition and description of psychopathology (method), and a conceptual framework to classify the techniques used for these descriptions (methodology).
In this course, residents are exposed to two philosophical underpinnings of descriptive psychiatry, that of phenomenology, in which psychic phenomena are represented, defined, and classified (Jaspers, 1912), and that of perspectivism—the idea that “the constituents of mental life are diverse and heterogeneous” (McHugh and Slavney, 1983, 1987, 1999). As residents develop more appreciation for and empathic immersion in the inner experiences of their patients, the importance of meticulous objective descriptions of symptomatology becomes more obvious.
Symptoms and syndromes are first presented from a disease perspective, and diagnostic classification is expanded beyond the DSMs to include more subtle and complex considerations of symptomatology. Both diagnoses and symptom-complexes are then revisited from additional perspectives (behavioral, dimensional, etc), and a complex vocabulary emerges. The topics addressed are outlined below.
- Four Perspectives of Psychiatry
- Life Story
- Introduction to Phenomenological Psychiatry and Descriptive Psychopathology
- Phenomenology of
- Thinking and Thought Disorder
- Perception and Hallucination
- Belief to Delusion
- Negative Symptoms, Apathy, and Abulia
- Affect, Mood, and Emotion
- Fear and Anxiety
- Aggression and Impulsivity
- Sleeping and Wakefulness
- Body Image
- Obsessions, Compulsions, Stereotypies, and Ritualisms
- Consciousness, and On/Off-line Awareness
- The Self
- Personality and Character Types
- Motivation: Want, Need, Desire, and Crave
- The Relaxation Response
- Sexual Identity
- Perversions and Paraphilias
- Childhood and Development
- History of Nosology and Classification and Historiography of Psychiatry
- The DSMs I-V
- Classic and novel syndrome classifications
- Research Domain Criteria (RDoC)
Also included in this course is a 6-session series on the phenomenology and treatment approaches to patients with complex trauma—overrepresented among psychiatric inpatients.
Psychopharmacology and Neuroscience
Course Director (Psychopharmacology)
Daniel Iosifescu, MD
The PGY-2 psychopharmacology course runs for the first 8 months of the year, and then the neuroscience course finishes the year. The psychopharmacology classes begin with a brief overview of the nuts and bolts of the field, including pharmacodynamic and pharmacokinetic principles, the concept of target symptoms, and the assessment of efficacy. The rest of the year then goes on to examine in more nuanced fashion each major class of psychotropic medication, devoting approximately one to two months to each, as well as seminars on evidence-based medicine.
- Introduction and "Nuts and Bolts"
- Mood stabilizers
- Anti-craving and opioidergic drugs
- Cognitive enhancers
Each mini-module is led by an expert in that area—usually a faculty member who is involved in both clinical care and current research.
Goals of the curriculum include mastery of psychopharmacology related to inpatient and emergency psychiatry—including the acute care and management of major psychiatric illnesses and personality disorders—and how to adjust psychopharmacological treatments in the transition of patients from inpatient settings to alternative levels of care. Residents also learn that psychopharmacology is practiced in the context of a psychotherapeutic relationship with the patient, and attention is given to the "art of psychopharmacology," including discussions of how to work with resistant patients.
Course Director (Neuroscience)
Ronald O. Rieder, MD
The neuroscience course in the PGY-2 year introduces residents to the neurobiological and psychobiological currents in psychiatry. The course begins with an overview of the mind/brain dialectic followed by a review of neuroanatomy from a functional perspective. Beyond the usual and expected teaching of the neuroscience of pathological functioning, we believe in the import of first learning what happens in the brain/mind when things go right. As such, we teach residents the neuroscience of normal functions: attention, mood, affect-regulation, reward, belief, memory, insight, etc. Then, we review the basic underpinnings of neuroscience research and apply them to our current understanding of the biology of psychiatric illness. Data studied include those of neuroimaging, receptor physiology, neurotransmitters, pharmacology, neuroanatomy, genetics, molecular biology, neuropathology, developmental neuroscience, synaptic plasticity and remodeling and neurocircuitry as they relate to mood disorders, psychotic disorders, anxiety disorders, ADHD, autism, addiction, movement disorders, personality disorders, etc. Specific education in the neurosciences continues in the PGY-3 year at an increasing level of sophistication, and in concert with more advanced psychopharmacology taught in syndrome-focused blocks.
As Mount Sinai is one of the leading neuroscience research institutions in the nation, the residents have exposure to world-renowned scientists who give lectures in the course (e.g., neuroscientists, psychiatrists, neurologists, dual-boarded psychiatrist-neurologists, neuroradiologists, and psychologists). For residents who have a special interest in neuroscience, this course also serves as a gateway into participating in research projects with the faculty.
Social & Psychiatry Services / Psychiatry in the World
In keeping with the pedagogical philosophy behind the residency curriculum, Social & Psychiatry Services is a comprehensive, multi-year course consisting of several discrete modules. In this course residents learn the principles of publicly-funded mental health services as they pertain to psychiatry. This includes the social, ethical, legal, and clinical facets of treating psychiatric patients and managing systems of care within the public sector, primarily in community settings. Residents gain appreciation and develop facility with all aspects of emergency psychiatry, including clinical care, administrative elements, medico-legal issues, and safety training. Residents are also introduced to increasingly complex issues in forensic psychiatry, including attending mock trials. This course also includes an introduction to consult liaison psychiatry and hospital based ethics.
The outline of the individual modules is as follows:
- Emergency Psychiatry
- Issues in the Emergency Room
- Suicide and Violence
- Consult-Liaison Psychiatry
- Depression and psychopharmacology
- Drug-drug interactions
- HIV and AIDS
- Psychiatric aspects of neurological illness
- Death and dying
- Somatic and factitious disorders
- Motivational interviewing
- The difficult patient
- Delirium and dementia
- Pregnancy and postpartum
- Forensic Psychiatry
- Medico-legal aspects of suicide
- Child abuse
- Competence, Guardianship
- Law and psychiatry, Malpractice
- Mock courtroom, criminal and civil
- Health policy and the physician
- Hospital Based Ethics
- Bad news and truth telling
- Surrogate decision making
- Double agency
- Financing a department of psychiatry
- Running a psychiatry service
Teaching faculty include specialized researchers and clinicians in the department of psychiatry at Mount Sinai, administrative figures in the department of health policy, and other local and nationally-known figures brought in for their unique knowledge and experiences.
The Mount Sinai didactic experience in Social & Psychiatry Services has been recognized by the American Association of Community Psychiatrists as a model in community psychiatry didactics.
Philip Luloff, MD and other faculty
For more than 30 years, Mount Sinai's psychiatry residency Process Group program has offered PGY 2, 3, and 4 residents a unique training experience. Process Group is an unstructured experience in which residents come to learn, first-hand, about themselves, their peers, and to process and examine their experiences in real time. Process Group is an in vivo training in how groups function and the effects of an individual within and upon the group. Residents are invited to share anything about their thoughts, feelings, work, patients, etc. and simultaneously observe the influence and power of a group experience in fostering growth and development.
While not explicitly "therapy," Process Group also fosters self-reflection, cohesion among residents, and an opportunity to discuss, in a confidential and supportive environment, the pressing emotional, social, and interpersonal issues involved in being a resident in psychiatry. The process which unfolds from week to week often helps with the pressures and stresses of residency. A fundamental agreement between members of the group and the leader(s) is that all said within the group is confidential.
Each PGY class has its own weekly group, with leaders who remain the same through all 3 years. The leaders are chosen from experienced members of the voluntary faculty who have no supervisory or evaluative functions in the residency.
Icahn School of Medicine
Department of Psychiatry
One Gustave L. Levy Place
New York, NY 10029