Quantifying the accuracy of forensic examiners in the absence of a "gold standard".

This study asked whether latent class modeling methods and multiple ratings of the same cases might permit quantification of the accuracy of forensic assessments. Five evaluators examined 156 redacted court reports concerning criminal defendants who had undergone hospitalization for evaluation or restoration of their adjudicative competence. Evaluators rated each defendant's Dusky-defined competence to stand trial on a five-point scale as well as each defendant's understanding of, appreciation of, and reasoning about criminal proceedings. Having multiple ratings per defendant made it possible to estimate accuracy parameters using maximum likelihood and Bayesian approaches, despite the absence of any "gold standard" for the defendants' true competence status. Evaluators appeared to be very accurate, though this finding should be viewed with caution.

Issues of spirituality and religion in psychotherapy supervision.

OBJECTIVE: We note gaps between the basic science of psychotherapy and the spiritual dimensions of religious life; between the beliefs and practices of patients and those of therapists; and between evidence for the influence of spirituality on health and the lack of its integration into psychotherapeutic training. We attempt to provide a framework to bridge this gap in supervision. METHOD: We reviewed the literature on the roles of spirituality and religion in mental health and illness; on the place of religion in psychotherapy; and on the pedagogy of spirituality. RESULTS: Issues requiring attention include definitions of terms; awareness of personal beliefs; consideration of the boundaries between religiosity and pathology; and distinction between religious structures and personal beliefs. A format for addressing these issues in supervision includes: assisting the trainee with self-awareness; providing tools for spiritual assessment of the patient; providing developmental schema for spirituality; and maintaining awareness of the intersubjectivity of the patient-therapist field and the trainee-supervisor field. CONCLUSIONS: Existing literature provides usable frameworks for integrating religion and spirituality into psychotherapy supervision. We offer suggestions on how this may be accomplished.

Delayed reaction to trauma in an aging woman.

Events of later life may awaken long-suppressed memories and feelings and yield emotional or behavioral problems that are evidence of an early traumatic experience. It is believed that posttraumatic stress disorder (PTSD)-like symptoms are more prevalent in the younger general population, but the lack of data supporting PTSD in the elderly may be due to the complicated presentation. The elderly often present to psychotherapy with comorbid diagnoses and may underreport their symptoms, or the symptoms may be masked by other diagnoses. PTSD is associated with increased rates of major depressive disorder, substance-related disorders, panic disorder, agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, social phobia, specific phobia, and bipolar disorder. Most of the literature on PTSD in the elderly stems from research on Holocaust or World War II survivors. In this paper, we will explore this particular dimension of late-life onset mental disorder with attention to the relevance of old trauma in performing psychodynamic psychotherapy.

How competent are we to assess psychotherapeutic competence in psychiatric residents?

BACKGROUND: The Residency Review Committee (RRC) for Psychiatry has mandated that training programs "must demonstrate that residents have achieved competency in at least the following forms of treatment: brief therapy, cognitive-behavioral therapy, combined psychotherapy and psychopharmacology, psychodynamic therapy, and supportive therapy." AIM: To analyze the extent to which programs can realistically demonstrate that residents have achieved summative competency in these modalities. METHOD: We briefly review methods from other fields for assuring procedural competence, review methods available to psychiatric educators for assuring competencies in psychotherapy, and assess these methods for their adequacy. RESULTS: Available and foreseeable assessment methods are incapable of demonstrating that residents achieve summative competency in the five specified psychotherapies or of definitively distinguishing potentially dangerous practitioners from safe practitioners. At best, educators may be able to assure formative competencies, including mastery of core knowledge of the psychotherapies, actual undertaking of these psychotherapies, and adequate performance in selected elements of these psychotherapies. CONCLUSIONS: Since it is unrealistic to assume that training programs will ever be able to confirm summative competencies in these psychotherapies, we advise programs to define precisely the levels of formative competence they expect, and design curriculum and measures accordingly. Further, we urge the RRC to revise their requirements to address expectations more honestly, and to re-state the expected competencies more modestly. We believe that the RRC can expect programs to show that all residents can demonstrate knowledge about the evidence base, theories and rules of practice supporting at least the following forms of treatment: brief therapy, cognitive-behavioral therapy, combined psychotherapy and psychopharmacology, psychodynamic therapy, and supportive therapy. We also believe that programs might be asked to demonstrate by means of patient logs and other forms of documentation that all residents have at least conducted such types of psychotherapy under qualified supervision.

Closing the loop: assessing the effectiveness of psychiatric competency measures.

BACKGROUND: During the past several years there has been a growing emphasis on competency assessment in graduate education in all specialties, including psychiatry. Methods of assessment are continuously being devised and refined. OBJECTIVE: To outline principles and methods of assessing the validity of competency measures and their relevance to trainees. METHODS: The authors reviewed the literature relevant to competency assessment and quality improvement in the fields of elementary and secondary education, adult learning, undergraduate medical education, and postgraduate medical training. Three means were used to evaluate the assessment program: 1) The authors surveyed graduates and credentialing agencies for feedback on the relevance of the measures they previously developed for current and envisioned future practice of psychiatry; 2) They measured the completion rates of competency measures by residents in the first 3 years of a program, measuring general psychiatric competencies; and 3) They surveyed residents and faculty regarding satisfaction with the existing process. RESULTS: Despite small numbers, the results indicated that measures devised in 1998 were relevant to the practice of psychiatry in 2001 and envisioned by practitioners for the subsequent 5 to 10 years. Resident completion rates of competency requirements indicated that the structure of the measures was appropriately paced to parallel the learning expectations of the training program. Participant satisfaction with the process of developing and implementing the measures was high. CONCLUSIONS: While devising and implementing competency assessments is critical, the process should not stop with the application of the measures. Ongoing evaluation of these measures for their continued suitability is essential. Training programs can readily determine the effectiveness of competency programs and improve them as necessary.