GWU Training Experience

Psychiatric Inpatient Psychiatry Program
Inpatient psychiatry in The George Washington University Hospital consists of a 20 bed unit. Patients referred for hospitalization are from Medical Faculty Associates and community psychiatrists, from the emergency room and medical/surgical wards of the hospital, providing diverse psychiatric diagnoses. An inpatient alcoholism and substance abuse track provides added clinical experience in substance abuse. Residents learn how to utilize electroconvulsive therapy in treatment of severe mood and psychotic disorders.

Psychiatry Consultation-Liaison Service
Treating medically-ill patients with psychiatric symptoms is at the forefront of training in the GWU psychiatry residency. With medically-ill patients, residents learn how to move back and forth among physiological, psychological, and sociocultural understandings of patients' problems, solving problems and tailoring treatments that most appropriately respond to their needs. Residents learn how to utilize psychotherapy, both at the bedside and in outpatient visits, to promote resilience by mobilizing hope, purpose, and supportive family and community relationships for patients who must live under the stress of medical illness. These competencies enable our residents to collaborate effectively with other physicians in the medical community. Among the full-time GWU psychiatry faculty, Drs. Tom Wise, Cathy Crone, James Griffith, and Anton Trinidad all hold subspecialty board certification in Psychosomatic Medicine from the American Board of Psychiatry and Neurology.

Didactic seminars and clinical rotations in consultation-liaison psychiatry are conducted across multiple residency years. PGY-II residents at Virginia Hospital Center conduct weekly liaison Medical and Pulmonary Intensive Care Rounds with attending faculty.

PGY-III residents conduct psychiatric consultations on a 20% time commitment throughout the academic year (approximately 80 * 100 new consultations over the year). Teaching rounds with GWU Hospital are conducted daily with attending consultation-liaison psychiatry faculty. Over the course of the PGY-III year, residents are expected to complete within their outpatient psychotherapy case loads: (1) a trauma-focused brief psychotherapy with a patient who has pseudoseizures (conversion disorder secondary to traumatic stress), (2) a couple or family therapy for a patient coping with medical illness, and (3) a brief individual psychotherapy for a patient coping with medical illness. In addition to listed consultation-liaison psychiatry seminars in the didactic curriculum, PGY-III residents attend three weekly case conferences: Epilepsy Conference (required), Outpatient Medical Illness Conference (required), Sleep Disorders Medicine Conference (elective). A joint Psychiatry-Medicine Case Conference is conducted bimonthly with faculty from the Department of Medicine around complicated cases. During the PGY-IV year, a range of special projects are available for clinical research or specialized training with medically-ill patients. During 2005, two PGY-III residents and a PGY-IV resident each have submitted clinical research projects in consultation-liaison psychiatry for presentation at the Annual Meeting of the American Psychiatric Association.

The GWU-Inova Fairfax Hospital Fellowship in Consultation-Liaison Psychiatry is one of the nation's most highly regarded consultation-liaison fellowships. Under the leadership of Thomas Wise, MD, over 70 consultation-liaison psychiatrists have trained in the fellowship since 1979, including current academic leaders in the discipline. Its curriculum, organized by Program Director Catherine Crone, M.D., balances an array of general hospital and outpatient clinical experiences with academic scholarship and clinical research. Nine additional consultation-liaison psychiatrists on the GWU-Inova Fairfax clinical faculty complement the GWU full-time faculty as teachers and supervisors for the fellowship.

The Global Mental Health Track
George Washington University Psychiatry Residency

• Are portable across cultures
• Treat both psychiatric disorders and human suffering that is a normal response to traumatic stress, loss, stigmatization, violence, or social injustice
• Combine public health and policy perspectives with person-centered therapeutics
• Enable multi-tiered treatment programs that integrate psychosocial therapies, pharmacological therapies, patient and family psychoeducation, mobilization of family and community resources, and political advocacy
• Provide interventions that are implementable within resource-poor environments in accordance with international guidelines and global best practices
• Emphasize prevention and resilience-building strategies at individual, family, and societal levels
• Are consistent with local and international ethical standards for mental health research and intervention.

Designing a Global Mental Health Track faces difficult challenges. First, global mental health as a concept points only to the locus of intervention -
global - and not to any unifying thread that connects its possible clinical activities. The GW curriculum seeks balanced representation of assessment and interventive strategies at the person, family, and societal levels in "neurons to neighborhoods" clinical strategies. Second, cognitive processes for assessing population needs are fundamentally different from those for assessing an individual patient as a person. Clinicians often struggle to maintain a public health perspective for a clinical problem, while also focusing upon the unique suffering of each individual impacted by that problem. The GW curriculum keeps a persistent focus on patient-as-person, but by treating patients within the context of family, community, and culture, including their political and economic realities.

Overview
Psychiatry residents selecting the Global Mental Health Track will complete longitudinal training objectives over the course of residency, in addition to a progression of didactic seminars and clinical supervisions in each residency year. Didactic seminars of the Global Mental Health Track are also core curriculum for non-track psychiatry residents. Enrichment experiences for Global Mental Health Track residents are provided by additional study groups, mentors, international training experiences, and professional conferences and workshops.

Specific Country Expertise as a Longitudinal Aim
As a longitudinal project over course of residency, each resident in the Global Mental Health Track will select an ethnicity, country, or world region for intensive study under the mentorship of a faculty member(s) with specific expertise. This study will include political history; languages, religions, ethnicities; issues of governance; population demographics; health care and educational systems; transnational political issues; human rights; ethnopsychology and ethnopharmacology; as well as salient mental health issues and mental health policies. Each resident will prepare a proposal for a mental health initiative around a significant mental health issue for presentation to a study group or departmental grand rounds.

PGY-I Residency Year

• Didactic Seminars
• Ethnicity and Culture in Inpatient Psychiatry
• Clinical Supervision - Meetings with mentor with focal readings and clinical discussion of inpatient cases
• Cultural Psychiatry Study Group

PGY-II Residency Year
A. Didactic Seminars

• Cross-Cultural Psychiatry (Readings from Rethinking Psychiatry: From Cultural Category to Personal Experience and What Really Matters by Arthur Kleinman, MD
• Sociocultural Assessment, with a sociocultural assessment portfolio
• Global Psychiatry and Psychiatric Policy
• Loneliness: The Science of Social Bonds and Human Relationships
• Lectures on "Neurobiology of PTSD and Dissociative Disorders" and "Pharmacological Treatment of PTSD and Dissociative Symptoms" in Clinical Neurosciences Seminar
• Lectures on antipsychotic, antidepressant, and mood-stabilizer classes of medications that include discussion of ethnopharmacological therapeutics, in Clinical Neuroscience Seminar

B. Clinical Supervision - Meetings with mentor utilizing focal readings and clinical discussion of inpatient cases

• Cultural Psychiatry Study Group

PGY-III Residency Year
A. Didactic Seminars

• Aiding Patients with Demoralization or other Normal Syndromes of Distress
• Somatic Trauma Therapy for PTSD or Dissociative Symptoms
• Social Psychology of Stigma
• Intractable Conflict and Reconciliation
• Conducting Psychiatric Evaluations for Refugees Seeking Political Asylum
• Brief Psychotherapy
• Emotionally-Focused Couple Therapy
• Psychiatry and Spirituality
• Health Policy Rotation

B. Clinical Supervision

• Half-day weekly clinic with immigrants and refugees at Northern Virginia Family Services (NVFS)
• Completion of "Torture-Survivor Treatment Module"
• Treatment of selected torture-survivors in Program for Survivors of Torture and Severe Trauma (PSTT) at NVFS
• Supervised psychiatric evaluation of political asylees in GW Human Rights Clinic

C. Cultural Psychiatry Study Group

PGY-IV Residency Year

• Didactic Seminars
• Psychiatry and Literature
• Political Psychology
• Organizational Psychology
• Clinical Supervision
• Elective rotation in treatment of psychiatric sequelae of torture in PSTT program at NVFS
• Elective rotation supervising and conducting psychiatric evaluations of political asylees in GW Human Rights Clinic, in collaboration with Physicians for Human Rights
• Elective rotation in medical diplomacy or political psychology
• Other elective rotations or research projects tailored around learning objectives germane to resident's career focus
• Graduate school courses in Dept. of Health Policy, Public Policy, or Anthropology
• Clinical Research - Publication or presentation of scholarly work at national conference

Individual Mentors
Full-time and clinical faculty mentors can be identified to work with residents on specific topics according to a resident's particular interests. Some possibler topics include transcultural psychotherapy, ethnopharmacology, political psychology, international relations, immigrant and refugee mental health, conflict transformation and processes of reconciliation in intractable conflicts, and family-based mental health services.

Topical Areas of Training

• International Mental Health Services and Policy Analysis.

• PGY-II Seminar in Global Psychiatry and Psychiatric Policy (8 sessions) - Readings on global mental health are discussed. Each resident selects a mental health issue in a country of interest, conducts a policy analysis, prepares a brief, and makes a class presentation.

• PGY-III Health Policy Rotation (3 weeks full-time) - Morning lectures covering the scope of U.S. health policy are complemented by afternoon field trips to Capitol Hill, Institute of Medicine, NIH, and other sites where health policies are formulated or implemented. Final class project is a health policy analysis with group presentations to the deans of the medical school and school of public health and other medical school faculty.

• ELECTIVE - Graduate coursework in Dept. of Global Health in the GW School of Public Health and Health Services (http://www.GWmc.edu/sphhs/departments/global/deptInfo.cfm)

• Normal Syndromes of Distress in Immigrant, Refugee, and Torture-Survivor Populations

• PGY-II Seminar on "Loneliness: The Science of Social Bonds and Human Relationships" (6 sessions) - The social neuroscience of attachment relationships and other social bonds is studied in regard to implications for physical and mental health. This empirical research provides a conceptual framework that guides clinical interventions.

• PGY-III "Aiding Patients with Demoralization or other Normal Syndromes of Distress" (6 sessions) - Social suffering is constituted by normal stress responses, such as demoralization, emotional shock, loneliness, humiliation from stigmatization or social injustice. Such "normal" responses must be distinguished from psychiatric disorders since they require different therapeutic responses. Strategies for building resilience against demoralization are discussed, with a specific focus upon the role of existential inquiry.

• Social Psychology and Social Neuroscience.

• PGY-III Social Psychology of Stigma (3 sessions) - Residents read and discuss Erving Goffman's Stigma: The Management of Spoiled Identity and Howard Thurman's Jesus and the Disinherited in conjunction with recent social neuroscience research on stigmatization.

• Treating Psychiatric Sequelae of Traumatic Stress, Social Violence, and Torture.

• PGY-II lectures on "Neurobiology of PTSD and Dissociative Disorders" and "Pharmacological Treatment of PTSD and Dissociative Symptoms" in Clinical Neurosciences Seminar

• PGY-III Somatic Trauma Therapy Seminar (11 sessions) - Residents learn somatic trauma therapy as a cognitive-behavioral and psychoeducational therapy for symptom management in posttraumatic stress disorder and dissociative disorders.

• PGY-III Emotionally-Focused Couple Therapy (EFT) Seminar (18 seminar sessions and weekly year-long couple/family supervision sessions) - EFT is a brief psychotherapy for conflicted couple relationships. EFT is derived from the sociobiology of attachment relationships, hence is well-fitted for addressing relational problems secondary to traumatic stress.

(6) Ethnopharmacology.

• PGY-II lectures on antipsychotic, antidepressant, and mood-stabilizer classes of medications in Clinical Neuroscience Seminar. Lectures include discussions of bio-cultural differences in medications including ethnic differences in metabolism, biological differences in susceptibility to side-effects, cultural differences in interpretation of side-effects, and cultural differences in medication adherence.

(6) Medical Diplomacy

• Independent study mentored by Amir Afkhami, M.D., Ph.D.

(7) Human Rights

• PGY-III lecture on "Conducting Psychiatric Evaluations for Refugees Seeking Political Asylum"
• PGY-III and PGY-IV residents conduct supervised psychiatric evaluations for individuals seeking political asylum in the U.S. due to torture, human traffiking, or violence against women in countries of origin.

(8) Sociocultural Assessment in Clinical Psychiatry

• PGY-II Sociocultural Assessment Seminar and sociocultural assessment clinical portfolio (5 sessions) - Residents learn a formal structure for sociocultural assessment based upon Arthur Kleinman's "eight questions" and the DSM-IV Outline for Sociocultural Formulation. Residents each conduct a sociocultural formulation of a patient from a religion, ethnicity, or culture about which the resident had little prior knowledge.

(9) Cross-Cultural Psychiatry and Medical Anthropology (6 sessions)

• PGY-II Cross-Cultural Psychiatry and Medical Anthropology Seminar -

Selected readings from the published work of Arthur Kleinman is used to teach basic principles of psychiatric epidemiology across cultures, reliability and validity of psychiatric diagnoses, the category fallacy, comparison of Western and traditional healers in third world countries, and the role of social stress in psychiatric illnesses.

(10) Transcultural Psychotherapy Training

• Brief Psychotherapy Seminar (6 sessions) - Residents learn a generic framework for conducting brief psychotherapy that is collaborative, action-focused, and usable when time and money are limited.
• Brief Psychotherapy Supervision (weekly, year-long supervision) - Residents learn systematic methods for mobilizing the "common factors" that largely account for efficacy of psychotherapy: building hope and expectations that change is possible; a collaborative therapeutic alliance; utilization of patient's strengths, competencies, and resources in treatment.
• Couple- and Family-Centered Care (weekly, year-long supervision) - In most cultures, families rather than individuals are the primary unit for bearing the distress of chronic illness. Despite this, North American clinicians mostly train in therapeutic methods focused upon individual patients. Residents learn conceptual frameworks and clinical methods for engaging families as systems of care and for utilizing families' strengths, competencies, and resources for healing and optimizing a patient's life quality.

(11) Advanced Topics in Global Mental Health (Study Groups)

• Best practices in global mental health
• mhGAP (WHO Mental Health GAP Action Programme)
• IASC (Interagency Standing Committee Guidelines on Mental Health and Psychosocial Support in Complex Emergencies)
• World Psychiatric Association Guidelines of Psychiatrists' Role in Humanitarian Emergencies
• World Psychiatric Association Guidelines on Community-Based Mental Health Care
• Instanbul Protocol for evaluation of refugees seeking political asylum
• Ethics in cross-cultural mental health intervention and research
• Ethnopsychology and cross-cultural concepts of the self and well-being
• Intersection of culture and stigma from mental illnesses that lead to differential social exclusions across regions and societies
• Cross-cultural application of cognitive-behavioral psychotherapy and other therapies for reduction of traumatic stress symptoms

Educational Structures for the Global Mental Health Track

(1) Study Groups -

• Monthly Cultural Psychiatry Interest (inclusive for both GMHT and non-GMHT residents)
• Monthly Global Mental Health Research Group - Meetings scheduled as indicated for peer presentation of research projects among GMHT residents and faculty

(2) Independent Study Supervised by Mentor - Individually arranged between resident and mentor depending upon learning objectives or type of project

(3) International Clinical Training - Tailored for individual residents as indicated by level of interest, relevance to career trajectory, and availability of funding.

• Substantial time in PGY-IV year can be allocated to international rotations as permitted by funding
• Brief (7 – 10 day) international training experiences can be organized within PGY-II and PGY-III rotations when relevant to career trajectory and permitted by funding

(4) Professional Conferences and Training - Tailored for individual residents as indicated by level of interest, relevance to career trajectory, and availability of funding.

• Limited administrative leave can be available in PGY-II, but more in PGY-III and PGY-IV
• Professional conferences include Society for Study of Psychiatry and Culture; International Society for Traumatic Stress Studies; McGill Advanced Study Institute on Transcultural Psychiatry; World Association of Cultural Psychiatry; World Federation for Mental Health; and Movement for Global Mental Health
• When funding can be mobilized, professional training can include PGY-III or PGY-IV study in distance learning programs such as the "Mastery Certificate in Global Mental Health: Trauma and Recovery" conducted by the Harvard Program in Refugee Trauma or distance learning master's certificate in "Global Mental Health Policy" conducted by the World Health Organization

(5) Specialized Study Tracks

• PGY-IV (Elective Rotation) Mental Health Services for Immigrants and Refugees
• PGY-IV (Elective Rotation) Human Rights Clinic
• PGY-IV (Elective Rotation) Medical Diplomacy
• PGY-IV Political Psychology graduate coursework (on Columbian campus)
• PGY-III and IV Anthropology graduate coursework (on Columbian campus)
• PGY-II, III, and IV Health Policy, Public Policy, or Global Mental Health graduate coursework (in GW School of Public Health and Health Services)