Implementing Team-Based Instructional Strategies in Psychiatry Resident CBT Training

1. Implementing Team-Based Instructional Strategies in Psychiatry Resident CBT Training Kim A. Coon, Ed.D. Bryan K. Touchet, M.D. OU College of Medicine - Tulsa Department of Psychiatry

2. 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

3. 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

4. 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

5. Learning Domains Bloom�s Taxonomy, 1956 Levels of learner activities & objectives: (low level to high level) Fact � list, recall, recognize Comprehension � describe, explain Application � demonstrate **Analysis � compare and contrast **Synthesis � create, develop, design **Evaluation � defend, judge, predict

6. Adult Learning: Theoretical Foundations High level learning activities promote questioning of current knowledge and experiences through Validation of beliefs through discourse Critical assessment of new awareness New action on reflective insight Merriam SB & Caffarella RS: Learning in Adulthood: A comprehensive Guide, 2nd ed.

7. Error-correcting feedback loop

9. Adult Frames for Learning Enhanced learning frames incorporate Actual clinical experiences Group 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

10. 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:

11. 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? Adjusting Directing and improving learning processes

12. 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 Confidence Learning task was worth doing

13. 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

14. 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 Add Bloom�s Taxonomy hereAdd Bloom�s Taxonomy here

15. 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

16. 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

17. 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)

18. 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

19. 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.�

20. Second Pilot of TBL TBL training use in Cognitive-Behavioral therapy (CBT) curriculum Modifications Outcomes Challenges

21. 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

22. 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?

23. 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)

24. Example: CBT MAT #7 Name: ___________Date: _________ When creating and assigning home practice to evaluate automatic thoughts, briefly describe how the therapist can create a no-lose proposition. J. Beck provided a list of questions for evaluating automatic thoughts. List as many as you can remember. What are some additional ways to evaluate automatic thoughts without filling out a dysfunctional thought record (DTR)?

25. 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?�

26. CBT TBL Pilot #2 Pre-Post Test Cognitive Therapy Awareness Scale (CTAS) Ten questions 4 true/false responses under each Total possible score 44

28. Summary of TBL Implementation Demands for maintaining accreditation and adult education principles provided rationale for using TBL as an instructional strategy TBL outcomes in our training program look promising

29. 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