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Education & training |
Upper Poplars, Cherry Knowle Hospital, Sunderland SR2 0NB, email: nrcarley{at}excite.com
Upper Poplars, Cherry Knowle Hospital, Sunderland
S.M. is Chair of the regional psychotherapy trainers’ committee.
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Abstract |
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We conducted this survey to assess the current experience of psychotherapy training in the Northern Deanery and discuss possible effects changes might have on the future of this training. A postal questionnaire assessed the training experienced by the 41 trainees on the Northern Region Senior Unified Senior House Officer (SHO) Psychiatry Training Scheme in 2004. The results were compared with the guidelines from the Royal College of Psychiatrists.
RESULTS
The response rate was 61%. Particular areas of strength included conducting a long case (64%) and obtaining sufficient teaching in psychodynamic and cognitive—behavioural therapy theory (88%); 92% rated their experience of the training as satisfactory or better, and 68% intended pursuing further training in psychotherapy.
CLINICAL IMPLICATIONS
Trainees ought to be familiar with the psychotherapy guidelines from an early point in their training. Specific areas of difficulty within the scheme need to be addressed. Proposed changes to specialist training are likely to have an impact on the psychotherapy training experience.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The theoretical knowledge that is required is outlined in the MRCPsych curriculum (Royal College of Psychiatrists, 2001). In addition, clinical skills should be practised continually and incrementally under adequate supervision. Implementing the guidelines requires an identified consultant (often a psychotherapist) to coordinate available opportunities. Trainers and educational supervisors should be equipped to monitor progress and trainees should record their experience in logbooks. It is intended that the psychotherapy training should be part of the basic training to be completed before taking the MRCPsych part II examination.
Several studies have compared the previous recommendations for psychotherapy training (Royal College of Psychiatrists, 1993) with current practice (McCrindle et al, 2001; Podlejska-Eyres & Stern, 2003; Pretorius & Goldbeck, 2006) and have helped to identify both the deficiencies and the positive experiences of this training. Training schemes differ in geographical size, trainee numbers and organisation from that of the Northern Deanery. However, some similarities exist in the ranges of training offered and the experiences reported.
In a telephone survey of 12 schemes in the south-west (McCrindle et al, 2001), only 10 were offering psychotherapy training, with one psychotherapy post for 95 trainees. However, a range of training was offered, including clinical practice, supervision and theoretical teaching; 7 of the 12 reported using logbooks, and there was limited psychotherapy teaching on the MRCPsych course. Fewer than half provided theoretical teaching, half had significant problems with timetable clashes and 11 out of 12 were dissatisfied with the level of training.
In another study (Podlejska-Eyres & Stern, 2003) 22 out of 23 trainees completing training in an inner city London rotation were surveyed. The rotation had one psychotherapy post but was geographically small and trainees were well supported for study leave. A long case had been completed by 95%, family/marital therapy by 59%, cognitive—analytic therapy (CAT) by 41%, brief focal therapy by 32%, group therapy by 45% and cognitive—behavioural therapy (CBT) by 73%. Psychologists provided some supervision, and 54% of trainees wanted more psychotherapy experience. Courses were recorded as popular.
Two important initiatives are about to introduce considerable change to psychiatric training. These are the Postgraduate Medical Education and Training Board (PMETB) and Modernising Medical Careers.
The aim of this study was to examine the current psychotherapy training experienced by a group of 41 senior unified senior house officers (SHOs) on the Northern Region Rotational Psychiatry Scheme and to evaluate the outcome in terms of practical experience acquired, perceived knowledge acquired and subjective experience.
These trainees have at least 18 months of psychiatry training, and there are two psychotherapy specialty posts. Trainees ought to be aware of the psychotherapy training standards set by the College, and should be working towards these. It was hoped that the survey could then highlight areas where the training could be improved.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The questionnaire covered previous psychiatric experience, awareness of the guidelines for training and use of logbooks. It asked about theoretical teaching and practical experience obtained by the trainee in relation to the College’s requirements. Questions were asked about common difficulties in undertaking psychotherapy (such as bleep-free time and room availability) and intended future psychotherapy exposure. A Likert scale was also included to ascertain the subjective overall experience of psychotherapy. Spaces were available for additional comments and clarification.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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General awareness of trainees
Many trainees (12, 48%) could not identify a consultant responsible for
psychotherapy in their area and 14 (56%) were not using logbooks to record
their experience. However, most were aware of the College guidelines (76%).
The wide geographical distribution might account for the communication with
the responsible consultant being better in some areas than others, and in one
area there was no consultant. However, the College website provides easy
access to the guidelines
(http://www.rcpsych.ac.uk/PDF/ptBasic.pdf).
Practical skills
When asked about practical psychotherapy experience, a large majority
thought they had achieved the objectives of good interview skills, producing a
psychodynamic formulation and conducting a long case, and had experienced
group, couple, family or systemic therapy. Few had completed three short cases
(Fig. 1). The possible reasons
for this include the wide geographical distribution of the scheme, with
rotations between hospitals and trusts making it very difficult to find a
suitable case and complete the therapy before rotating to a new place. In
addition, some areas have only recently identified potential supervisors for
short cases.
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Practical considerations
Practical arrangements for conducting psychotherapy appeared to be
satisfactory in most cases. Bleep-free time and suitable rooms were available
for 22 trainees (88%), adequate supervision for 20 (80%) and suitable patients
for 17 (68%). From the free-text responses, difficulties reported by trainees
included 4% having supervision out of hours, trouble finding a trained CBT
supervisor (16%), travelling long distances for supervision (4%), feeling that
a 6-month post is too short to find patients and treat them (4%), room booking
difficulties (12%) and selection of patients whose problems were too
complicated or who lacked motivation (8%).
Subjective experience of psychotherapy training
It was encouraging to find that 23 trainees (92%) rated this experience as
satisfactory or better; 17 (68%) intended to consider further training in
psychotherapy.
Free-text comments
These varied widely and were both positive and negative. In total, 17
trainees responded in the free-text space; 4 were entirely positive, 7
entirely negative, 3 neutral and 3 demonstrated a mixed response.
The positive comments included finding the experience interesting and useful, particularly the long case. At least three trainees spontaneously reported that it improved understanding of patients’ situations.
However, some SHOs did not know who to approach, two felt they did not discover the psychotherapy training requirements soon enough and two complained of insufficient CBT early in training. The delay in starting a long case was described as frustrating. Transference issues were perceived as difficult (one trainee), as was disengaging patients (one trainee). One student commented that the theory of methods other than psychodynamic therapy was not taught in the MRCPsych course, and one other felt that psychotherapy was irrelevant to clinical practice.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The trainees were at different stages in their psychiatric training and had been in a variety of psychiatric posts in different locations and specialties. The region offers a central MRCPsych course for all trainees, and psychodynamic case discussion groups are provided in all areas of the region. More recently, CBT training and supervision have begun to be provided throughout the region, but this and other therapeutic methods vary in their availability.
As only 61% of eligible trainees responded, it is difficult to establish whether this study is a true representation of all the trainees’ experiences of psychotherapy training. Those who did not reply could be the less motivated trainees, with possibly less knowledge and experience and a worse perception of the subject; although the converse could be true, in that those who were more dissatisfied might have felt more motivated to respond. The response rate might also reflect possible communication difficulties across the scheme.
Currently, trainees must develop interview skills and the ability to make a psychotherapeutic formulation of a psychiatric disorder. The specific skills and core requirements include a minimum of three short-term cases, one from each group of techniques. These cover transference-based therapies, cognitive therapies and integrative therapies. In addition, one long-term case involving any method, and some experience of group psychotherapy and marital or family therapy are required.
The pilot foundation F2 posts in psychiatry have so far proved successful (Royal College of Psychiatrists, 2005). Although there is likely to be little time for formal psychotherapy training in posts of 4 months’ duration, these are surely excellent opportunities to introduce trainees, who may go into specialties other than psychiatry, to a psychological approach. These trainees will be expected to achieve competencies in areas such as effective relationships with patients, communication and team-working (Academy of Medical Royal Colleges, 2005).
The introduction of a unified single-grade training provides the opportunity to distribute psychotherapy training over time and with more continuity. Individual learning plans may shape the trainees’ experiences, with further choice and flexibility in the types of cases chosen. Also, the involvement of patients and carers in psychotherapy training may be a helpful adjunct.
The PMETB emphasises competency-based assessment and trainee performance. Although practice is supervised at present, in the future workplace-based assessments, including mini clinical examinations, direct observed practice and the mini peer-assessment tool, will become the norm (PMETB, 2005). But how will these be carried out in psychotherapy training? It may become increasingly difficult to find suitable patients who also consent to be videotaped, and direct observed practice will be extremely time-consuming in this area. However, some objectives such as interview skills and psychodynamic formulation are currently assessed by such methods in the Northern Region.
In our survey, there was a wide discrepancy between the low numbers aware of a responsible consultant and logbooks, and the high numbers reporting good theoretical and practical knowledge. The forthcoming assessment processes may help us evaluate the discrepancy between subjective (reported) and objective levels of competence.
The results suggest that many trainees feel they are achieving most of the training requirements set by the Royal College of Psychiatrists. A majority of the trainees who responded had had a positive experience of psychotherapy training in the region, and practical considerations such as bleep-free time and the provision of rooms are mostly met. Many trainees have been motivated to pursue additional training in psychotherapy and wish to consider further training in the future. This suggests that psychotherapy training in the region is adequate for most trainees, and can be an enjoyable and useful experience. However, improvements are particularly needed in facilitating short cases, especially CBT; increasing exposure to marital, family or systemic therapy; making all trainees aware of guidelines, use of logbooks; and identifying the consultant responsible for psychotherapy.
Changes to practice are already being implemented, with other members of the multidisciplinary team being increasingly involved as supervisors, more training programmes becoming available and a more structured approach to learning plans, including timescales of when to take on suitable patients. We hope that the reduction in the geographical size of the scheme and the proposed improvements in training continuity will further improve the training experience in psychotherapy. The future looks brighter.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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McCRINDLE, D., WILDGOOSE, J. & TILLETT, R. (2001)
Survey of psychotherapy training for psychiatric trainees in South-west
England. Psychiatric Bulletin,
25, 140
–143.
PODLEJSKA-EYRES, M. & STERN, J. (2003)
Psychotherapy training experience in an inner city psychiatry rotation.
Psychiatric Bulletin,
27, 179
–182.
POSTGRADUATE MEDICAL EDUCATION AND TRAINING BOARD (2005) Workplace Based Assessment http://www.pmetb.org.uk/media/pdf/3/b/PMETB_workplace_based_assessment_paper_(2005).pdf
PRETORIUS, W. & GOLDBECK, R. (2006) Survey of
psychotherapy experience and interest among psychiatric specialist registrars.
Psychiatric Bulletin,
30, 223
–225.
ROYAL COLLEGE OF PSYCHIATRISTS (1993) Guidelines for
psychotherapy training as part of general professional training.
Psychiatric Bulletin,
17, 695
–698.
ROYAL COLLEGE OF PSYCHIATRISTS (2001) Curriculum for Basic Specialist Training and the MRCPsych Examination (Council Report CR95). London: Royal College of Psychiatrists.
ROYAL COLLEGE OF PSYCHIATRISTS (2004) Good Psychiatric Practice (2nd edn). London: Royal College of Psychiatrists.
ROYAL COLLEGE OF PSYCHIATRISTS (2005) The Dean’s Medical Education Newsletter, May 2005. http://www.rcpsych.ac.uk/pdf/DeanMay05.pdf
This article has been cited by other articles:
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  S. E. Dracass, T. Tracey, and K. Bhui What is it about dynamic psychotherapy? Psychiatr. Bull., August 1, 2008; 32(8): 313 - 315. [Full Text] [PDF]
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R. Martinez and R. Horne Setting up and evaluating a cognitive-behavioural therapy training programme for psychiatric trainees Psychiatr. Bull., November 1, 2007; 31(11): 431 - 434. [Full Text] [PDF]
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S. Agarwal, Y. Singh, V. Palanisamy, R. Basker, and R. Van der Speck Psychotherapy requirements as recommended by the College: awareness and achievement by senior house officers Psychiatr. Bull., October 1, 2007; 31(10): 394 - 396. [Abstract] [Full Text] [PDF]
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 S. Mitchison Next year in Jerusalem: psychotherapy training for tomorrow's consultants Advan. Psychiatr. Treat., July 1, 2007; 13(4): 276 - 283. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
