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Training in psychotherapy
Training
Training in psychotherapy
threatening. A ghastly wrangle about the possible use of a highdependency unit (HDU) developed. Q was then visited by a nurse from the ward, whom she recognized. They began to chat and Q explained how the medication had made her fat and drooling and sleepy, but also began to explain how everything had turned weird in her flat and that she was frightened to be there. The nurse was sympathetic, but suggested Q might be in need of a cup of tea and somewhere safe and a bit less weird. Q agreed to go up to the ward. Perhaps it is hard to realize that this extremely ordinary encounter represents a psychotherapeutic approach at its most basic. Yet understanding that psychotic patients can be bewildered and stressed and scared, and that familiar faces and ordinary actions are a low-cost helpful option at such times, involves the application of simple empathy and a psychologically driven understanding of the experience of mental illness. Of course, psychotherapy, both applied (as above) and formal, can be much harder, involving painful feelings, hostility, and tangled emotions. In another example, a trainee’s efforts to admit a patient to the ward were not going well. L was ‘known’, with a history of violence and drug use. Staff were frightened and contemptuous of a personality disordered time-waster. Yet, in casualty, L was histrionic, weeping loudly and clutching at the trainee’s clothes. He would run out of the interview room disturbing other patients in the minor injuries unit and then be coaxed back in again by a concerned police officer who had brought him in on a Section 136 from a bridge where he had been threatening to jump. Caught between the accident and emergency staff (‘get this loony out of here’), the ward (‘no way he is coming here’), and the police officer (‘this poor man needs help’), the trainee felt harassed, isolated, and abandoned, and reflected wryly that emotionally he and the patient were probably in a rather similar place. The phenomenon whereby a patient’s way of behaving within a social system induces powerful feelings in staff that are connected with the patient’s own inner life – known as ‘countertransference’ – is well described in psychotherapeutic practice. Yet counter-transference is a rather common phenomenon and is certainly not confined to consulting rooms. In this case the ward, accident and emergency department, the police officer, and the trainee all had strong counter-transference feelings in relation to the patient. There are ways of recognizing and managing counter-transference, and it can even be used to help the therapeutic process. Skills in detecting and managing countertransference might have helped this trainee have a less beastly Saturday evening.
Chess Denman
Abstract This article discusses training in psychotherapy for psychiatrists. It sets out the case for undertaking training and then runs through the basic knowledge and skills that trainees should aim to acquire. It offers practical advice and information about how to use training experiences, college structures and self-directed learning to gain the competencies that all psychiatrists should have in this area.
Keywords clinical skills; psychodynamic; psychotherapy
Why bother? For many psychiatric trainees the requirement to take on and treat patients in need of psychotherapy as part of their general training represents a confusing and variably enforced requirement for obtaining the Member of the Royal College of Psychiatrists (MRCPsych) qualification – one of many requirements with potentially little relevance to their regular practice on the wards and in outpatients, and somewhat akin to strange bits of neuroanatomy that persist in the exam curriculum and multiple-choice question (MCQ) bank of the exam. This is rather a shame because, as practitioners of a biopsychosocial discipline, psychiatry trainees appear to be able to understand the relevance to their patients of the ‘bio’ bit (give them pills) and the ‘social’ bit (give them a roof over their heads) but the middle ‘psycho’ bit is harder to pin down – although ‘talk to them helpfully’ would probably cover it, as long as one paused to point out that ‘helpfully’ is the skilful part. In point of fact, by this definition psychiatrists at all levels of training are doing ‘psychotherapy’ in every consultation, so it would seem like a good idea to get better at doing it. Q was a known schizophrenic who presented over the weekend agitated and hallucinated having decided to discontinue her medication some months previously. She was preoccupied and difficult to engage in conversation, and was not willing to be admitted to hospital, becoming rapidly quite verbally abusive towards the junior doctor who was assessing her. A section of the Mental Health Act was put into operation and, while the inevitable delays were endured, Q became more and more agitated, psychotic, and
What to learn So what might a reasonably motivated trainee in the first 3 years of their training expect to learn? Under basic training needs, the minimum requirements needed to acquire the competencies in the new curriculum are listed, and it is shown how these link to good psychiatric practice.
Chess Denman FRCPsych is Consultant Psychiatrist in Psychotherapy in Cambridge. She runs the Complex Cases Service, which specializes in the treatment of patients with personality disorders, and is Chair of the Royal College of Psychiatrists’ Psychotherapy Faculty Education Committee.
PSYCHIATRY 7:5
Basic training needs Theoretical knowledge Psychology and developmental psychology: just as anatomy, biochemistry, and physiology are foundation topics for biological 228
© 2008 Elsevier Ltd. All rights reserved.
Training
psychiatry, so psychology and developmental psychology are basic topics for psychological psychiatry. A working knowledge of the chief principles of these topics is important because it allows trainees to think psychologically about their patients’ experiences. The application of psychological principles to psychopathology is also a vital skill, which requires a working knowledge of the main psychological theories of psychopathology, including both psychodynamic and cognitive views of abnormal human functioning.
these treatments can be adapted to suit briefer timescales or short encounters in the out-patient department. Longer-term therapies can seem like a chore that a timepressured trainee can ill afford. In training terms, however, the experience of delivering a longer-term therapy is as close as a trainee can come to reproducing the emotional atmosphere of the long durations of contact that consultants often build up with some patients whom they see over many years as a result of chronic illness. In such longer-term contacts, emotions build up and the relationship may become complex with a mixture of regrets and pleasures. In such relationships emotional entanglements can lead to therapeutic errors, defensive distancing, or, at worst, boundary violations. Skill in managing such situations is what a longer-term treatment can impart.
Psychological treatments Knowing about the theoretical underpinning of and practical techniques involved in delivering the chief evidence-based psychological therapies, including cognitive behavioural therapy, psychodynamic psychotherapy, family and marital therapy, group therapy, and brief therapies (such as mentalization-based therapy, interpersonal therapy, and cognitive analytic therapy), is as important when thinking about treating patients as is a knowledge of the main classes of psychotropic medication. Knowledge of the indications and contraindications for these therapies and their likely utility in a range of conditions helps doctors to prescribe therapies accurately. Furthermore, a good doctor will be able to explain to their patient what these therapies, in broad terms, entail and why they work.
The ‘psychotherapeutic stance’ Psychotherapists take a particular attitude to all phenomena that present. When achieved, this attitude is one of open enquiry, an attempt not to let anxiety drive thought and action, and a desire to get close to and understand another person’s thoughts, feelings, and wishes. Maintaining this stance under pressure, for example when time is short or risks are high, or there are competing powerful demands running in opposite directions, is one core psychotherapeutic skill, as is the capacity to detect more subtle threats to this stance. In the early hours of the morning P needed to take his medication but was refusing to do so. He was aroused and angry. He was offered the option of taking oral medication, but chucked the liquid over a nurse. A posse formed to deliver an intramuscular dose. Nurses gathered from various wards. A group formed at the door to P’s room. Just before the injection was given, one nurse asked P again if he would take oral medication, and he did. The posse returned to the nursing station but there was anger and muttering. Despite the fact that oral medication is much safer, people thought that an intramuscular dose would have been better. F, the trainee on that night, had similar feelings and could understand that the head of steam that had built up behind injecting P was composed of many feelings, none of which would be easy to admit to – such as anxiety over being assaulted, fantasies about the potency of medical interventions, and vengeful anger with P for his behaviour.
Clinical skills All psychiatrists and other mental health professionals should possess the skills of empathy, tolerance, and narrative orderliness that allow them to gather a fully developed history of their patient’s illness, which they can present not only as a list of facts but also as a meaningful account of at least parts of the patient’s life and illness. This narrative account should then be synthesized into a psychologically meaningful formulation of the patient’s problems. Sample psychodynamic formulation: Petra’s depression began 6 months after her mother died from cancer, which she had never discussed with her daughter. At this point Petra’s father, who was mildly demented, had to move in to live with Petra and her husband. It transpired that Petra was the only child of parents who had not really wanted to have children. Her father suffered with depression and was often hospitalized, and her mother had been competently caring but preoccupied, aloof, and secretive. Petra’s husband was a kindly but taciturn man, who left emotional matters to his wife and worked long hours. Petra’s biological heritage combined with an emotionally sterile childhood to predispose her to depression. This was precipitated by a life event – her mother’s death – that probably brought angry and sad feelings to the fore. Petra’s depressive illness was also perpetuated by the emotionally and physically taxing task of caring for her father, a man who, like her husband had, through no fault of his own, left her to cope alone. A good psychodynamic formulation aids accurate empathy and guides treatment. We can, for example, guess that Petra will be likely to respond badly to a therapist’s or carer’s absence (because of her experience of her father and husband). Knowledge of how to deliver basic psychological treatments in a couple of evidence-based modalities is also a core element of a good psychiatrist’s skills. Although out-patient and in-patient practice may not offer the leisure for formal therapy, many elements of
PSYCHIATRY 7:5
How to learn Find your local trust’s psychotherapy tutor: each scheme has a tutor in psychotherapy who will help you to find training experiences and organize your programme of learning. Take advantage of psychotherapy experiences available in your job: there is a lot of psychotherapy, formal and informal, going on everywhere around you. Get stuck in! For example, if your team has a psychologist, ask whether you can sit in on his or her sessions. Read: if you read only one book, then make it a basic primer in psychotherapy such as Gabbard et al.1 If you can manage three more, then pick a good book of developmental psychology, for example Stern,2 a book that covers research in psychotherapy, for example Roth et al.,3 and something for fun, such as De Board.4 229
© 2008 Elsevier Ltd. All rights reserved.
Training
Consider having personal therapy of your own: this used to be the keen thing to do, but has fallen by the wayside. Psychiatry is strangely stressful in ways that can build up on trainees. Each year a few trainees become ill. You should take your own mental health seriously. A good therapist can be a true friend (someone who speaks the truth about you kindly) and also someone to watch your back. Such things should not be dismissed out of hand. ◆
In addition, you should ‘surf’ the net. www.therapywiki.org is a growing site for trainees in psychotherapy where you can both consult and contribute. Attend a case-based discussion group: these groups, which should be run in your Trust, will allow you to develop your psychodynamic formulation skills and to talk about patients in a way that explores how the person might be conceptualized from the perspective of the psychotherapeutic stance.
References 1 Gabbard GO, Beck JS, Holmes J. The Oxford textbook of psychotherapy. Oxford: Oxford University Press, 2007. 2 Stern DN. The interpersonal world of the infant: a view from psychoanalysis and development psychology. New York: Basic Books, 1985. 3 Roth A, Fonagy P, Parry G, Target M, Woods R. What works for whom? A critical review of psychotherapy research, 2nd edn. New York: Guilford Press, 2006. 4 De Board R. Counselling for toads: a psychological adventure. London: Routledge, 1997.
Treat patients in brief and long-term therapy: your psychotherapy tutor will help you to find patients to treat. You should aim to treat as many as you reasonably can. Join the faculty of psychotherapy: you should already be an inceptor of the college, and receiving the faculty’s mailings regularly is no more onerous than ticking the appropriate box in the list of faculties and sections you would like to join. You will get news about conferences – and probably also an inside line on any breaking news about psychotherapy in the exam.
PSYCHIATRY 7:5
230
© 2008 Elsevier Ltd. All rights reserved.
Training in psychotherapy
threatening. A ghastly wrangle about the possible use of a highdependency unit (HDU) developed. Q was then visited by a nurse from the ward, whom she recognized. They began to chat and Q explained how the medication had made her fat and drooling and sleepy, but also began to explain how everything had turned weird in her flat and that she was frightened to be there. The nurse was sympathetic, but suggested Q might be in need of a cup of tea and somewhere safe and a bit less weird. Q agreed to go up to the ward. Perhaps it is hard to realize that this extremely ordinary encounter represents a psychotherapeutic approach at its most basic. Yet understanding that psychotic patients can be bewildered and stressed and scared, and that familiar faces and ordinary actions are a low-cost helpful option at such times, involves the application of simple empathy and a psychologically driven understanding of the experience of mental illness. Of course, psychotherapy, both applied (as above) and formal, can be much harder, involving painful feelings, hostility, and tangled emotions. In another example, a trainee’s efforts to admit a patient to the ward were not going well. L was ‘known’, with a history of violence and drug use. Staff were frightened and contemptuous of a personality disordered time-waster. Yet, in casualty, L was histrionic, weeping loudly and clutching at the trainee’s clothes. He would run out of the interview room disturbing other patients in the minor injuries unit and then be coaxed back in again by a concerned police officer who had brought him in on a Section 136 from a bridge where he had been threatening to jump. Caught between the accident and emergency staff (‘get this loony out of here’), the ward (‘no way he is coming here’), and the police officer (‘this poor man needs help’), the trainee felt harassed, isolated, and abandoned, and reflected wryly that emotionally he and the patient were probably in a rather similar place. The phenomenon whereby a patient’s way of behaving within a social system induces powerful feelings in staff that are connected with the patient’s own inner life – known as ‘countertransference’ – is well described in psychotherapeutic practice. Yet counter-transference is a rather common phenomenon and is certainly not confined to consulting rooms. In this case the ward, accident and emergency department, the police officer, and the trainee all had strong counter-transference feelings in relation to the patient. There are ways of recognizing and managing counter-transference, and it can even be used to help the therapeutic process. Skills in detecting and managing countertransference might have helped this trainee have a less beastly Saturday evening.
Chess Denman
Abstract This article discusses training in psychotherapy for psychiatrists. It sets out the case for undertaking training and then runs through the basic knowledge and skills that trainees should aim to acquire. It offers practical advice and information about how to use training experiences, college structures and self-directed learning to gain the competencies that all psychiatrists should have in this area.
Keywords clinical skills; psychodynamic; psychotherapy
Why bother? For many psychiatric trainees the requirement to take on and treat patients in need of psychotherapy as part of their general training represents a confusing and variably enforced requirement for obtaining the Member of the Royal College of Psychiatrists (MRCPsych) qualification – one of many requirements with potentially little relevance to their regular practice on the wards and in outpatients, and somewhat akin to strange bits of neuroanatomy that persist in the exam curriculum and multiple-choice question (MCQ) bank of the exam. This is rather a shame because, as practitioners of a biopsychosocial discipline, psychiatry trainees appear to be able to understand the relevance to their patients of the ‘bio’ bit (give them pills) and the ‘social’ bit (give them a roof over their heads) but the middle ‘psycho’ bit is harder to pin down – although ‘talk to them helpfully’ would probably cover it, as long as one paused to point out that ‘helpfully’ is the skilful part. In point of fact, by this definition psychiatrists at all levels of training are doing ‘psychotherapy’ in every consultation, so it would seem like a good idea to get better at doing it. Q was a known schizophrenic who presented over the weekend agitated and hallucinated having decided to discontinue her medication some months previously. She was preoccupied and difficult to engage in conversation, and was not willing to be admitted to hospital, becoming rapidly quite verbally abusive towards the junior doctor who was assessing her. A section of the Mental Health Act was put into operation and, while the inevitable delays were endured, Q became more and more agitated, psychotic, and
What to learn So what might a reasonably motivated trainee in the first 3 years of their training expect to learn? Under basic training needs, the minimum requirements needed to acquire the competencies in the new curriculum are listed, and it is shown how these link to good psychiatric practice.
Chess Denman FRCPsych is Consultant Psychiatrist in Psychotherapy in Cambridge. She runs the Complex Cases Service, which specializes in the treatment of patients with personality disorders, and is Chair of the Royal College of Psychiatrists’ Psychotherapy Faculty Education Committee.
PSYCHIATRY 7:5
Basic training needs Theoretical knowledge Psychology and developmental psychology: just as anatomy, biochemistry, and physiology are foundation topics for biological 228
© 2008 Elsevier Ltd. All rights reserved.
Training
psychiatry, so psychology and developmental psychology are basic topics for psychological psychiatry. A working knowledge of the chief principles of these topics is important because it allows trainees to think psychologically about their patients’ experiences. The application of psychological principles to psychopathology is also a vital skill, which requires a working knowledge of the main psychological theories of psychopathology, including both psychodynamic and cognitive views of abnormal human functioning.
these treatments can be adapted to suit briefer timescales or short encounters in the out-patient department. Longer-term therapies can seem like a chore that a timepressured trainee can ill afford. In training terms, however, the experience of delivering a longer-term therapy is as close as a trainee can come to reproducing the emotional atmosphere of the long durations of contact that consultants often build up with some patients whom they see over many years as a result of chronic illness. In such longer-term contacts, emotions build up and the relationship may become complex with a mixture of regrets and pleasures. In such relationships emotional entanglements can lead to therapeutic errors, defensive distancing, or, at worst, boundary violations. Skill in managing such situations is what a longer-term treatment can impart.
Psychological treatments Knowing about the theoretical underpinning of and practical techniques involved in delivering the chief evidence-based psychological therapies, including cognitive behavioural therapy, psychodynamic psychotherapy, family and marital therapy, group therapy, and brief therapies (such as mentalization-based therapy, interpersonal therapy, and cognitive analytic therapy), is as important when thinking about treating patients as is a knowledge of the main classes of psychotropic medication. Knowledge of the indications and contraindications for these therapies and their likely utility in a range of conditions helps doctors to prescribe therapies accurately. Furthermore, a good doctor will be able to explain to their patient what these therapies, in broad terms, entail and why they work.
The ‘psychotherapeutic stance’ Psychotherapists take a particular attitude to all phenomena that present. When achieved, this attitude is one of open enquiry, an attempt not to let anxiety drive thought and action, and a desire to get close to and understand another person’s thoughts, feelings, and wishes. Maintaining this stance under pressure, for example when time is short or risks are high, or there are competing powerful demands running in opposite directions, is one core psychotherapeutic skill, as is the capacity to detect more subtle threats to this stance. In the early hours of the morning P needed to take his medication but was refusing to do so. He was aroused and angry. He was offered the option of taking oral medication, but chucked the liquid over a nurse. A posse formed to deliver an intramuscular dose. Nurses gathered from various wards. A group formed at the door to P’s room. Just before the injection was given, one nurse asked P again if he would take oral medication, and he did. The posse returned to the nursing station but there was anger and muttering. Despite the fact that oral medication is much safer, people thought that an intramuscular dose would have been better. F, the trainee on that night, had similar feelings and could understand that the head of steam that had built up behind injecting P was composed of many feelings, none of which would be easy to admit to – such as anxiety over being assaulted, fantasies about the potency of medical interventions, and vengeful anger with P for his behaviour.
Clinical skills All psychiatrists and other mental health professionals should possess the skills of empathy, tolerance, and narrative orderliness that allow them to gather a fully developed history of their patient’s illness, which they can present not only as a list of facts but also as a meaningful account of at least parts of the patient’s life and illness. This narrative account should then be synthesized into a psychologically meaningful formulation of the patient’s problems. Sample psychodynamic formulation: Petra’s depression began 6 months after her mother died from cancer, which she had never discussed with her daughter. At this point Petra’s father, who was mildly demented, had to move in to live with Petra and her husband. It transpired that Petra was the only child of parents who had not really wanted to have children. Her father suffered with depression and was often hospitalized, and her mother had been competently caring but preoccupied, aloof, and secretive. Petra’s husband was a kindly but taciturn man, who left emotional matters to his wife and worked long hours. Petra’s biological heritage combined with an emotionally sterile childhood to predispose her to depression. This was precipitated by a life event – her mother’s death – that probably brought angry and sad feelings to the fore. Petra’s depressive illness was also perpetuated by the emotionally and physically taxing task of caring for her father, a man who, like her husband had, through no fault of his own, left her to cope alone. A good psychodynamic formulation aids accurate empathy and guides treatment. We can, for example, guess that Petra will be likely to respond badly to a therapist’s or carer’s absence (because of her experience of her father and husband). Knowledge of how to deliver basic psychological treatments in a couple of evidence-based modalities is also a core element of a good psychiatrist’s skills. Although out-patient and in-patient practice may not offer the leisure for formal therapy, many elements of
PSYCHIATRY 7:5
How to learn Find your local trust’s psychotherapy tutor: each scheme has a tutor in psychotherapy who will help you to find training experiences and organize your programme of learning. Take advantage of psychotherapy experiences available in your job: there is a lot of psychotherapy, formal and informal, going on everywhere around you. Get stuck in! For example, if your team has a psychologist, ask whether you can sit in on his or her sessions. Read: if you read only one book, then make it a basic primer in psychotherapy such as Gabbard et al.1 If you can manage three more, then pick a good book of developmental psychology, for example Stern,2 a book that covers research in psychotherapy, for example Roth et al.,3 and something for fun, such as De Board.4 229
© 2008 Elsevier Ltd. All rights reserved.
Training
Consider having personal therapy of your own: this used to be the keen thing to do, but has fallen by the wayside. Psychiatry is strangely stressful in ways that can build up on trainees. Each year a few trainees become ill. You should take your own mental health seriously. A good therapist can be a true friend (someone who speaks the truth about you kindly) and also someone to watch your back. Such things should not be dismissed out of hand. ◆
In addition, you should ‘surf’ the net. www.therapywiki.org is a growing site for trainees in psychotherapy where you can both consult and contribute. Attend a case-based discussion group: these groups, which should be run in your Trust, will allow you to develop your psychodynamic formulation skills and to talk about patients in a way that explores how the person might be conceptualized from the perspective of the psychotherapeutic stance.
References 1 Gabbard GO, Beck JS, Holmes J. The Oxford textbook of psychotherapy. Oxford: Oxford University Press, 2007. 2 Stern DN. The interpersonal world of the infant: a view from psychoanalysis and development psychology. New York: Basic Books, 1985. 3 Roth A, Fonagy P, Parry G, Target M, Woods R. What works for whom? A critical review of psychotherapy research, 2nd edn. New York: Guilford Press, 2006. 4 De Board R. Counselling for toads: a psychological adventure. London: Routledge, 1997.
Treat patients in brief and long-term therapy: your psychotherapy tutor will help you to find patients to treat. You should aim to treat as many as you reasonably can. Join the faculty of psychotherapy: you should already be an inceptor of the college, and receiving the faculty’s mailings regularly is no more onerous than ticking the appropriate box in the list of faculties and sections you would like to join. You will get news about conferences – and probably also an inside line on any breaking news about psychotherapy in the exam.
PSYCHIATRY 7:5
230
© 2008 Elsevier Ltd. All rights reserved.