Implementing Team-Based Instructional Strategies in Psychiatry Resident CBT Training Kim A. Coon,...
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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
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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
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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
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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
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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
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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 .
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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.”
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Second Pilot of TBL
TBL training use in Cognitive-Behavioral therapy (CBT) curriculum– Modifications – Outcomes– Challenges
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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
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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?
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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)
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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)?
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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?”
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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
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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
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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
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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
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Instructor
Learning materialInstructional
Methods