Implementing Team-Based Instructional Strategies in

Psychiatry Resident CBT Training

Kim A. Coon, Ed.D.Bryan K. Touchet, M.D.

OU College of Medicine - TulsaDepartment of Psychiatry

Session Objectives

Factors leading to TBL implementation– Impact from accreditation outcomes

project Resident learning and faculty teaching time

– Desire to apply adult learning principles Undertake complex learning tasks

Review of modified TBL as instructional strategy in our curriculum– Exploration of process and outcomes

ACGME Accreditation Mandates

Stimulated instructional strategy review– Time required for volume of new

learning material– Documentation of competency

requirements– Traditional didactics fail to promote

ideas of life-long and self-directed required for learning complex concepts

Use of adult learning theory may increase faculty effectiveness as well as promote resident learning complexities of therapy

Responsibility of Educators

Facilitator and provocateur– Assist learners with reflection on

learning process– Expand trainees’ frames of reference

Faculty, patients, peers and supplementary resources

– Initiate innovative instructional strategies to promote high level learning

Learning Domains Bloom’s Taxonomy, 1956

Levels of learner activities & objectives:

(low level to high level)

1. Fact – list, recall, recognize2. Comprehension – describe, explain3. Application – demonstrate4. **Analysis – compare and contrast5. **Synthesis – create, develop, design6. **Evaluation – defend, judge, predict

Adult Learning: Theoretical Foundations

High level learning activities promote High level learning activities promote questioning of current knowledge questioning of current knowledge and experiences throughand experiences through– Validation of beliefs through discourseValidation of beliefs through discourse– Critical assessment of new awarenessCritical assessment of new awareness– New action on reflective insightNew action on reflective insight

Merriam SB & Caffarella RS: Learning in Adulthood: A comprehensive Guide, 2nd ed.

Error-correcting feedback Error-correcting feedback loop loop

Receiver/transformer Comparator

Pattern of expectation (target, set point, goal – desired state)

Failure to pattern match

Decision making for corrective action

Input pattern

Corrective action

Sensory input

Reference signal

Powers WT. Feedback: Beyond behaviorism. Science 1973 Jan;179(71):351-6.

Error-correcting feedback Error-correcting feedback loop loop

Didactics focus attention,helps transform unique patient data into psychotherapy “language”

Clinical supervision; Group analysis; exams

Didactic pattern instruction; therapy demonstrations; manual-based instruction, formulation template

Failure to pattern match

Clinical supervision; Group analysis; study

Input pattern

Psychotherapy caseworkSensory input (psychotherapy cases, simulated cases)

Reference signal

Adult Frames for Learning

Enhanced learning frames incorporate Actual clinical experiencesGroup interaction to encourage reflection, information analysis, and skill comparators

Self-study, simulations of learning application and role play, case studies, and group problem-solving projects

Central Tasks of Adult Learning

Primary Goal = teach the learner to learn

Conceptualize the learning process Pay attention to initiating task of

learning Manage the process of learning Recognize personal learning patterns

–Self-understanding enhances learning

Specific tasks of effective learning:Conti & Kolody, Developing an instrumentfor identifying groups of learners.Proceeding of 39th Annual Adult Ed Conference, 1998 , Texas Sacred Heart University

Task #1 - Metacognition

Understanding and directing one’s thinking and learning process through:– Planning

Best way to proceed with a learning task?

– Monitoring How am I proceeding through the task?

– AdjustingDirecting and improving learning processes

Task #2 - Metamotivation

Factors that energize and direct learning– Attention

Focus on the material to be learned– Reward and Enjoyment

Value and satisfaction of learning activity

– ConfidenceLearning task was worth doing

Task #3 - Memory

Knowledge storage, retention, and retrieval– Organization

Structuring or processing of information– External Aids

Reinforce memory– Application

Remembrances or mental images to facilitate planning or carrying out learning

Task #4 - Critical Thinking

Reflective thinking process using higher order thinking skills to improve learning– Test Assumptions

Evaluating learning material– Generate Alternatives

Imagining and exploring options– Conditional Acceptance

Developing best hypothesis

Task #5 - Resource Management

Process of identification, evaluation, and use of resources– Identification

Locate best source of information– Critical Use

Appropriate resource choice– Human Resources

Integrate others into the learning process

Rationales for TBL Use Increasing motivation for learning

through– Group dynamics– Engaging in-class activities

Emphasizing student or resident accountability for learning

Increasing learning efficiency Promoting instructor role as facilitator

Research Support For Team Learning

Active involvement in learning process results in better learning and retention of complex concepts (1)

TBL improves critical thinking, comprehension, and information retention (2)

Team-oriented approaches to realistic learning tasks improves decision making (3)

1. Light R: The Harvard Assessment Seminars. Cambridge, MA: Harvard Graduate School of Education, 1990. 2. McInerney M, Fink LD: Team-Based Learning Enhances Long-term Retention and Critical Thinking in an Undergraduate Microbial Physiology Course. Microbiology Education, May 2003. Available at http://www.microbelibrary.org/index.asp. 3. Michaelson LK, Watson WE, Black RH: Realistic test of individual versus group decision making. J Appl Psychol 1989; 74, 834-839.

Psychiatric Training and TBL

Levine and colleagues introduced TBL into student psychiatry clerkship experience

Touchet and Coon introduced TBL into psychiatry resident theory-intensive segment of psychodynamic psychotherapy didactics

Levine R et al. Transforming a Clinical Clerkship with Team Learning. Teach Learn Med 2004 Summer; 16(3):270-275.

Touchet B, Coon K. A Pilot Use of Team-based Learning in Psychiatry Resident Psychodynamic Psychotherapy Education. Academic Psychiatry, 2005;29:293-296 .

Resident Feedback TBL Pilot #1

“I have learned so much more this year with this teaching method.”

“I’m finally getting this stuff – thank you!”

“I think TBL has been a very effective teaching tool.”

Second Pilot of TBL

TBL training use in Cognitive-Behavioral therapy (CBT) curriculum– Modifications – Outcomes– Challenges

CBT TBL Format Rationale and goals for TBL

implementation Teams – mixed PGY level resident learners Repetitive three-phase learning cycle

– Phase I: Pre-class prep through on-line lecture and home practice

– Phase II: Motivational Assessment Tool (MAT) by individuals and teams

– Phase III: Team experiential learning projects and information analysis

Example: Online Didactic Slide

Review Home Practice With Your Patient If home practice is not completed, some

time in the therapy session may be devoted to completing some of the assignment– Remind patient that more can be covered, and

therapy moves faster, when practice outside of session occurs

Discussion of home practice– Does the patient see why practice helps?– Does patient understand what you want?– Did patient collaborate in the development of

the new home practice?

Example: New Home Practice Assignment for Resident Learners

Bring all handouts with you and keep handy for therapy and didactics

Read J. Beck: Basics and Beyond pp. 45-74

Read handouts about reasons for poor compliance with home practice– Identify personal reasons for not doing home

practice (IF you’re not doing it)– Be ready to problem-solve compliance with

home practice in didactics TEAM LEADERS: Chose one of your CBT

patients for your formal team project(s)

Example: CBT MAT #7

Name: ___________Date: _________

1. When creating and assigning home practice to evaluate automatic thoughts, briefly describe how the therapist can create a no-lose proposition.

2. J. Beck provided a list of questions for evaluating automatic thoughts. List as many as you can remember.

3. What are some additional ways to evaluate automatic thoughts without filling out a dysfunctional thought record (DTR)?

Example: Group Problem-Solving Exercise

Addressing Opposition to Home Practice Team One - Patient Response #1:

– “I am just too busy to do this stuff at home.”

Team Two - Patient Response #2:– “My problems are caused by my husband,

why should I have to work at changing?” Team Three - Patient Response #3:

– “I just don’t see the point of having to write down what I think; can’t I just tell you when I come in for therapy?”

CBT TBL Pilot #2 Pre-Post Test

Cognitive Therapy Awareness Scale Cognitive Therapy Awareness Scale (CTAS)(CTAS)– Ten questionsTen questions

4 true/false responses under 4 true/false responses under eacheach

Total possible score 44Total possible score 44

38

36

34

32

30

28

26

ScoreGroup="Pre"

ScoreGroup="Post"

Paired samples t-test. Matched sample size = 8. Two-tailed probability = 0.0412

p = .05 considered significant

TBL Pilot #2 Pre/Post Results

Summary of TBL Implementation

Demands for maintaining Demands for maintaining accreditation and adult education accreditation and adult education principles provided rationale for principles provided rationale for using TBL as an instructional strategyusing TBL as an instructional strategy

TBL outcomes in our training TBL outcomes in our training program look promisingprogram look promising

TBL Challenges

Developing and maintaining resident motivation and accountability to learn outside and inside the classroom– Non-grading evaluation system– Residents who do not access assigned

“lectures” or perform “home practice”– Residents who depend on their colleagues

to process new information for them– Senior resident does work for team

Instructor

Learning materialInstructional

Methods