UK Psychotherapy Training Survey Summary Core Psychotherapy Training in Psychiatry Advanced Training in Medical Psychotherapy 2011-2012 Dr James Johnston Consultant Psychiatrist in Psychotherapy Dr Barbara Wood Consultant Psychiatrist in Psychotherapy Mr Adrian Husbands Research and Methodology Consultant Medical Psychotherapy Faculty Education and Curriculum Committee March 2013
SUMMARY POINTS This summary of the UK Survey of the Provision of Psychotherapy Training in Psychiatry covers 3 areas: 1. Provision of psychotherapy training for the core psychiatry curriculum 2. Advanced Psychotherapy Training Schemes 3. Dual Training in Medical Psychotherapy and General Adult Psychiatry 1. PSYCHOTHERAPY IN THE CORE PSYCHIATRY CURRICULUM Royal College of Psychiatry Curriculum Requirements The minimum core psychiatry psychotherapy curriculum requirements which must be achieved for progression to specialist training (ST) are: 1. Balint groups (30 sessions) 2. One shorter term therapy case (GMC require the duration to be specified: proposed duration up to 6 months or 12 to 20 sessions) 3. One longer term therapy case (GMC require the duration to be specified: proposed duration: 9 months to 1 year or 30 to 40 sessions). Satisfactory competences with curriculum emphasis on qualitative rather than purely quantitative for both cases as assessed by the formative Structured Assessment of Psychotherapy Expertise (SAPE) and the summative Psychotherapy Assessment of Clinical Expertise (PACE). The Survey The delivery of the core psychiatry psychotherapy curriculum of the Royal College of Psychiatrists was evaluated across all training programmes in the UK over the first six months of 2012. Surveys were completed by the Psychotherapy Tutors for the core training programmes. Main Findings (Figures 1 3) 58 of the 70 UK core psychiatry training schemes responded, a response rate over 80%. 49 (84%) of these schemes were fulfilling the core psychotherapy curriculum requirements. 38 (66%) of these schemes have a Consultant Psychiatrist in Psychotherapy with a CCT in medical psychotherapy as the Psychotherapy Tutor The curriculum was significantly more likely to be fulfilled when a Consultant Psychiatrist in Psychotherapy with a CCT in medical psychotherapy was the Psychotherapy Tutor (Fisher s Exact test, p<0.05). The odds of the curriculum being fulfilled were 5 times higher if the Psychotherapy Tutor was a Consultant Psychiatrist in Psychotherapy. 30 of 40 (75%) of Psychotherapy Tutors report that their ARCP boards require all competencies to be completed before progression to higher specialty training (ST4). Several modalities of therapy are used as psychotherapy experience across the UK although the commonest are CBT for the short case (35%) and psychodynamic psychotherapy for the long case (69%). 2
Discussion This survey shows that the large majority of core psychiatry training schemes are fulfilling the curriculum for psychotherapy training and that local ARCP panels generally regard completion of the psychotherapy competencies as mandatory for progression from CT3 to ST4 (specialist training). The majority of the core training schemes have a Consultant Psychiatrist in Psychotherapy (a psychiatrist with a CCT in Medical Psychotherapy) as the Psychotherapy Tutor, of importance given that such schemes are significantly more likely to be fulfilling the curricula requirements. Though the response rate of over 80% is high for survey studies, there is no data about non-responders. Where a Psychotherapy Tutor is not a Consultant Psychiatrist in Psychotherapy, so not a member of the organisation conducting the survey (the Medical Psychotherapy Faculty of the Royal College of Psychiatrists), they may be less inclined to respond. If this were the case, the percentage of UK schemes fulfilling the core psychotherapy curriculum requirements may be lower than the 84%. Role of Consultant Psychiatrists in Psychotherapy in Delivering Core Training The essential role of the Consultant Psychiatrist in Psychotherapy in the role of Psychotherapy Tutor to lead the development of psychotherapeutic psychiatry training is clearly supported by the evidence of this survey. These Consultants are also directly involved in the training in providing facilitation of Balint groups, case supervision and liaison with supervisors from other psychiatric specialties and other professional backgrounds. Consultant Psychiatrists in Psychotherapy bring a particular range of experiences to the core psychotherapy training. They have trained in physical medicine, psychiatry and psychotherapy and are particularly well placed to help trainees new to psychiatry to more fully develop and integrate psychosocial and biomedical considerations of psychiatric illness and to develop a therapeutic attitude and self-reflective stance to all their work in psychiatry. They share common educational and career experiences with the psychiatry trainees and so have a particular understanding of the stage of training, the roles and work situations and the emotional challenges the trainees face. In addition they will have had training in at least 3 modalities of formal psychotherapy, group work and supervision and are skilled at using and moving between different theoretical and therapeutic models to best understand and treat patients. The Royal College of Psychiatrists recognises this unique blend of skills and experience in the recommendation that Consultant Psychiatrists in Psychotherapy act as leaders for the Balint groups. The size of core psychiatry training schemes, extent of involvement of Consultant Psychiatrists in Psychotherapy and so the amount of Consultant time required for delivery of the psychotherapy curriculum is very variable and though data is available, it could not be reliably quantified in this survey. However, adequate time for the assessment of training therapy cases and the coordination and delivery of training needs to be accommodated within the wider clinical context of the role of a Consultant Psychiatrist in Psychotherapy. Diversity in Training The role of the Consultant Psychiatrist in Psychotherapy is to lead the educational governance of the development of psychotherapeutic psychiatry to establish, maintain, develop and quality assure the culture of the psychotherapy training for future psychiatrists. The survey showed that a number of other professions across the UK are involved in providing supervision of clinical cases including Consultant Psychiatrists, other psychiatrists (specialty trainee and staff grades), Adult Psychotherapists, Clinical Psychologists and nurse therapists. 3
The therapeutic culture of psychiatry relies on the relationship with other professions as well as psychiatry. The spread of different professions and therapeutic models in core psychotherapy training enriches the training and promotes an attitude of working therapeutically and not defensively alongside other professionals. Hence involvement of other professions in the delivery and experience of training is to be encouraged and is welcomed in the evidence from the survey. Regular liaison between the Psychotherapy Tutor and other professionals involved in delivering the training is clearly of great importance, including for discussion of medical aspects of the presentation of patients in therapy, raising of concerns about particular trainees who appear to be struggling and for quality control of the overall training and assessment process. Figure 1 Fulfillment of the Core Psychotherapy in Psychiatry Curriculum and relationship with Consultant Psychiatrist in Psychotherapy as Psychotherapy Tutor 40 35 30 25 20 15 10 5 Consultant Psychiatrist in Psychotherapy with CCT NOT Consultant Psychiatrist in Psychotherapy with CCT 0 Curriculum Fulfilled Curriculum Not fulfilled Consultant Psychiatrist in Psychotherapy with CCT NOT Consultant Psychiatrist in Psychotherapy with CCT Curriculum Fulfilled Curriculum Not fulfilled 35 3 14 6 When the Psychotherapy Tutor was not a Consultant Psychiatrist in Psychotherapy, the professions listed were: General Adult and Old Age Psychiatrists (a few specifying therapy training) Clinical Psychologists Adult Psychotherapists 4
Figure 2 Models of Therapy used for the Short Case 30 25 20 15 10 5 0 Models of Therapy Frequency CBT 25 Psychodynamic 13 CAT 10 Systemic / Family Therapy 8 IPT 4 Motivational Interviewing / MET 4 Solution Focused Therapy 3 DBT 2 Groups 2 Total 71 5
Figure 3 Models of Therapy used for the Long Case 35 30 25 20 15 10 5 0 Models of Therapy Frequency Psychodynamic Psychotherapy 29 CBT 6 CAT 3 Group Therapy 2 Systemic /Family Therapy 2 Unspecified 10 Total 52 6
2. ADVANCED MEDICAL PSYCHOTHERAPY TRAINING The Survey Responses were provided by the Training Programme Directors for Higher Specialist / Advanced Medical Psychotherapy Training Main Findings (Figures 4 10) 1. Size of Advanced Psychotherapy Training Schemes Scheme sizes for 18 schemes across the UK ranged between 1 and 7 trainees (with NTNs for psychotherapy) These 18 schemes accounted for 55 training posts. 89% (16 of 18) of schemes had fewer than 5 training posts 28% (5 of 18) of schemes had only one training post 18% (10 of 55) posts were unfilled at the time of the survey. 6 of these were from schemes with 3 or fewer training posts in total. 2. Training received by Specialist Trainees (clinical and educational supervision and academic training) 15 schemes responded Training hours received by STs ranged between 3 and 14 hours per week 80% (12 of 15) schemes were providing at least 6 hours of training time per week 3. Providers of Specialty Training in Psychotherapy a) Training Programme Directors in Psychotherapy 11 schemes responded Allocated PAs for TPDs ranged between 0.13 and 1.0 (30 minutes to 4 hours per week) Schemes with 3 or more trainees had at least 0.5 PA allocated to the TPD b) Consultant Psychiatrists in Psychotherapy 12 schemes responded These consultants were providing between 0.5 and 4 PAs (2 and 16 hours) training time each week For 90% (10 of 11) schemes Consultant Psychiatrists in Psychotherapy were providing at least 50% of the total training hours for STs c) Other Psychological Practitioners 11 schemes responded These professional groups were providing between 1 and 6 hours training time each week For 80% (9 of 11) schemes they were providing at least a third of the total training hours for STs 7
Discussion Psychotherapy is one of the smallest medical specialties, with a total of around 55 to 60 National Training Numbers (NTNs) for the UK. 16 training schemes responsible for 55 NTNs responded to this survey. A significant proportion (20%) of advanced training posts were unfilled at the time of the survey, particularly those from the smallest training schemes. We do not have information about the reasons for this but it may be that at a time of uncertainty for the specialty of medical psychotherapy, trainees are particularly anxious about applying to the smallest training schemes due to perceptions of future employment prospects. The amount of training time received by specialty trainees in medical psychotherapy is at least 6 hours per week in 80% of the schemes. This would include a substantial amount of clinical supervision (as well as educational supervision and academic teaching) - a particular feature of medical psychotherapy training in which in-depth exploration of mental phenomena and interpersonal difficulties within a therapeutic relationship is the keystone. A range of modalities of therapy training are provided, varying between different training schemes but all including individual and group psychoanalytic psychotherapy, cognitive behavioural therapy and systemic or family therapy. The advanced psychotherapy training is provided both by Consultant Psychiatrists in Psychotherapy and other psychological practitioners, including adult psychotherapists, psychologists and nurse therapists. 11 schemes provided data on time spent on training STs for both Consultant Psychiatrists in Psychotherapy and other psychological practitioners. In 90% of these schemes Consultant Psychiatrists in Psychotherapy were providing at least 50% of the total training hours for STs and for 80% of these schemes other psychological practitioners were providing at least a third of the total training hours for STs. The time commitment to training is substantial averaging around 3.5 hours of trainer s time per week per trainee (much of this would be clinical supervision). In keeping with the survey findings for core psychotherapy in psychiatry training, involvement of other professions in the delivery and experience of advanced medical psychiatry training is substantial and welcomed in enriching the training and promoting an attitude of working therapeutically alongside other professionals. Regular liaison between the Training Programme Director and other professionals involved in delivering the training is clearly of great importance. The leadership role of the Consultant Psychiatrist in Psychotherapy in coordinating, developing and quality assuring the delivery of higher medical psychotherapy training includes involving and training other professionals in the educational governance processes of assessment and training (training committees, workplace based assessment guidance and involvement in the annual review of competence progression (ARCP). The General Medical Council validated the leadership role of Consultant Psychiatrists in Psychotherapy following the GMC quality assurance survey of medical psychotherapy in 2011-2012. Included in the GMC action plan following this survey is a requirement that core psychiatry psychotherapy training and higher medical psychotherapy training is led by Consultant Psychiatrists in Psychotherapy (see page 18 below). This GMC directive will mean that every UK deanery is required to ensure that their core psychotherapy schemes are led by a Consultant Psychiatrist in Psychotherapy (with a CCT in Medical Psychotherapy). 8
Figure 4 Total advanced medical psychotherapy training posts (national training numbers or NTNs) in the UK 8 7 6 5 4 3 2 1 0 East Midlands North East Midlands South East of England London: Tavistock London: SLaM London: SW London: WLMHT Mersey North West Northern Northern Ireland: Oxford Peninsula Scotland North Scotland North East Scotland South East Scotland West Severn Yorkshire & Humber Training Posts Trainees Actually in Training Deanery Training Posts Trainees Actually in Training East Midlands South 1 0 East Midlands North 3 2 East of England 1 0 London: N (Tavistock/Portman) 7 7 London: SE (Maudsley) 3 3 London: SW (St George s) 7 7 London: W (WLMHT) 4 4 Mersey 1 1 North West 4 3 Northern 3 2 Northern Ireland: Southern 4 2 Oxford 4 4 Peninsula 1 0 Scotland North 1 1 Scotland North East 0 0 Scotland South East 2 1 Scotland West 4 3 Severn 3 3 Yorkshire & Humber 4 6* Total 58 49* * Includes 2 dual training posts with general adult psychiatry NTNs 9
Figure 5 How many training hours per week do advanced trainees in medical psychotherapy receive? (educational supervision, clinical supervision and academic training) Advanced training hours received by trainees per week 16 14 12 10 8 6 4 2 0 East Midlands East Midlands London: N London: SE London: SW (St London: W Mersey North West Northern Northern Oxford Scotland North Scotland West Scotland West Severn Yorkshire & Advanced Training Hours per Week Deanery Hours per Week East Midlands (North) 8 East Midlands (South) 3 London: N (Tavistock/Portman) 6 London: SE (Maudsley) 8 London: SW (St George s) 6 London: W (WLMHT) 6 Mersey 10 North West 7 Northern 6 Northern Ireland (Northern) 6 Oxford 10 Scotland North 10 Scotland West (North) 5 Scotland West (South) 5 Severn 7 Yorkshire & Humber 14 10
Figures 6 10 Providers of Advanced Medical Psychotherapy Training Figure 6 What amount of PA time is allocated for the TPD (Training Programme Director in Psychotherapy) role? 1.2 1 0.8 0.6 0.4 0.2 0 Training Programme Director Programmed Activities Training Programme Director PAs Deanery PA time East Midlands North 0.25 East Midlands South 0.13 London : SE (Maudsley) 0.5 London : W (WLMHT) 1 London :SW (St George s) 0.5 Mersey 0.25 North West 1 Northern 0.25 Oxford 1 Scotland West South 0.5 Severn 0.5 Yorkshire and Humber 0.5 11
Figure 7 How many programmed activities (PAs) of Consultant Psychiatrist in Medical Psychotherapy time is spent delivering advanced training? 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Medical Psychotherapy Programmed Activities: advanced training Medical Psychotherapy Programmed Activities Deanery (Trust) Programmed Activities East Midlands (North) 2.0 London: SE (Maudsley) 2.0 London: SW (St George s) 1.0 London: W (WLMHT) 1.0 Mersey 1.0 North West 0.8 Northern 1.0 Northern Ireland 2.0 Oxford 4.0 Scotland North 0.5 Scotland West South 2.0 Severn 2.0 Yorkshire & Humber 4.0 % of total training hours per week 62% 62% 50% 50% 80% 60% 40% 62% 33% 50% - 67% 76% 12
Figure 8 Percentage medical psychotherapy time delivering advanced training Medical Psychotherapy % of total training hours per week 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Medical Psychotherapy % of total training hours per week How many hours of other psychological practitioners time is spent delivering advanced medical psychotherapy training? Deanery (Trust) Hours per Week % of total training hours East Midlands (North) 5 38% London: SE (Maudsley) 5 38% London: SW (St George s) 4 50% London: W (WLMHT) 4 50% Mersey 1 20% North West 2 40% Northern 6 60% Northern Ireland (Southern) 2.5 38% Oxford 8 66% Scotland North 2 50% Severn 4 33% Yorkshire & Humber (Leeds) 5 24% 13
Figure 9 How many hours of other psychological practitioners time is spent delivering advanced medical psychotherapy training? Non Medical Psychotherapy hours per week 9 8 7 6 5 4 3 2 1 0 Non Medical Psychotherapy Hours per Week Figure 10 Percentage non medical psychotherapy time delivering advanced training Non Medical Psychotherapy % of total training hours per week 70% 60% 50% 40% 30% 20% 10% 0% Non Medical Psychotherapy Hours per Week % of total training 14
3. DUAL TRAINING IN MEDICAL PSYCHOTHERAPY AND GENERAL ADULT PSYCHIATRY The Survey The survey asked for views on the advanced dual medical psychotherapy and general adult psychiatry training programme developed in Yorkshire (2006). Respondents included Psychotherapy Tutors and Training Programme Directors. Discussion There were 21 responses across the UK from psychotherapy tutors and TPDs concerning this dual training programme developed in Yorkshire. Comments were unanimously positive about dual training with several describing the Yorkshire model of integrated training as excellent or superb. It was noted that other models of dual training for medical psychotherapy / general adult psychiatry run in the UK which are sequential (eg 2 years general adult followed by 3 years psychodynamic) or a hybrid with integrated posts over most years but variable proportions of time in the 2 specialties. Many trainers regard such dual trainings as the way forward for advanced medical psychotherapy training. Most comments could be grouped in 2 areas one being the overall benefits to both psychiatry and medical psychotherapy, the other concerning psychotherapy training in general psychiatric training and higher specialist training in medical psychotherapy. There was broad agreement that a dual training provided a more rounded training, could help bridge the divide between psychotherapy and general psychiatry, increase respect and understanding between the specialties, strengthen their relationship and enhance the credibility of medical psychotherapy. It was noted that specialist trainees in medical psychotherapy are anxious about their prospects of employment as consultants in the current climate and that those who have completed training are having difficulty in finding substantive posts. Several trainers commented that a dual training was more suited to the trend for consultant medical psychotherapy posts to be placed in dedicated higher level personality disorder services where medical, formal psychiatric, risk, substance abuse and pharmacotherapy considerations are prominent. Some medical psychotherapists have reservations about the potential loss of the specialism of medical psychotherapy with its identity becoming submerged in general psychiatry while others saw this as essential to its survival. With regard to wider psychotherapy training for psychiatrists, concerns were raised that the current trend of reduction in medical psychotherapy posts would diminish the provision and quality of psychotherapy experiences that are mandatory for core psychiatry training and cited as competencies for all higher specialty psychiatry training. It was also noted that the high commitment to training was not always acknowledged in consultant medical psychotherapists job plans and this would not be sustainable. This at a time when psychotherapy competencies are increasingly acknowledged as core skills for psychiatrists and when case based discussion, specifically recommended as being facilitated for trainees by consultant medical psychotherapists, is likely to contribute to the revalidation process for senior psychiatrists. The central importance of reflection on clinical practice and self in reflective practice over the course of a career in psychiatry is detailed in the Royal College of Psychiatry s Psychotherapy Faculty Education and Curriculum Committee strategy Thinking Cradle to Grave: Developing Psychotherapeutic Psychiatry. 15
Recommendations of the UK Psychotherapy Survey 1. Consultant Psychiatrists in Medical Psychotherapy should lead the coordination and educational governance of all core psychotherapy training in psychiatry as Psychotherapy Tutors. 2. The aims of core and advanced psychotherapy training need to be linked and developed developmentally focusing on training which is fit for the purpose of the work of psychiatry. 3. Multidisciplinary participation in core and advanced medical psychotherapy training should be developed and coordinated led by Consultant Psychiatrists in Psychotherapy. The recommendations of the UK Psychotherapy Survey received the attention of the General Medical Council as part of a small specialties thematic review of medical psychotherapy they undertook in 2011-2012. GMC Quality Assurance Review of Medical Psychotherapy 2011-2012 The General Medical Council are piloting new methods of quality assuring small medical specialties with fewer than 250 current trainees in post across the UK. Medical psychotherapy was one of three small medical specialties to be reviewed in 2011-2012; (the other two specialties were paediatric cardiology and occupational medicine). The GMC identified this QA review as a matter for UK-wide investigation because they are concerned that there are possible gaps in their evidence base about the quality of these small specialties and want to develop new methods of investigation which would improve the way the GMC quality assures small specialties in the future. The GMC review of medical psychotherapy looked at medical education and training within the speciality and how the stakeholders work together to assure the quality of the training. The GMC confirmed that a number of their findings were supported in the Medical Psychotherapy FECC s 2012 pilot UK Psychotherapy Survey and indicated that they look forward to seeing this initiative of a UK wide medical psychotherapy survey at core and higher levels of training develop. The General Medical Council validated the leadership role of Consultant Psychiatrists in Psychotherapy following the GMC quality assurance survey of medical psychotherapy in 2011-2012. Included in the GMC action plan following this survey is a requirement that core psychiatry psychotherapy training and higher medical psychotherapy training is led by Consultant Psychiatrists in Psychotherapy (see page 18 below). This GMC directive will mean that every UK deanery is required to ensure that all of the core psychotherapy schemes and the advanced medical psychotherapy schemes are led by a Consultant Psychiatrist in Psychotherapy (with a CCT in Medical Psychotherapy). 16
GMC Quality Assurance Review of Medical Psychotherapy 2011-2012 Requirements, recommendations and good practice The GMC action plan for medical psychotherapy core and higher training in psychiatry will be published in March 2013 Requirements 1. Deaneries must ensure that all those completing assessments that contribute to a trainee s CCT, including non-medical supervisors, are trained and supported for this role. Deaneries must ensure that all those completing assessments that contribute to a trainee s CCT, including nonmedical supervisors, are trained and supported for this role. 2. RCPsych to produce training guidance for trainers on assessments, linking into work carried out in this area by NW Deanery (see good practice). 3. Deaneries must monitor the completion of core psychotherapy cases to ensure all trainees meet the curriculum requirements by the end of CT3. 4. The College must clarify the duration of the long case for core psychotherapy competency in the curriculum. 5. Consultant Medical Psychotherapists should lead both core and higher psychotherapy training in psychiatry and be responsible for its educational governance. Recommendations 6. All psychotherapy supervisors should have training in the model of psychotherapy they are supervising and continue to be practitioners of the model. 7. The College should ensure that there are effective structures for communicating guidance about curriculum implementation and psychotherapy supervision requirements to psychotherapy tutors as well as heads of school. 8. The College should check that the mechanisms in place for sharing information with medical psychotherapy training programme directors and trainers are effective for all deaneries and enhance engagement between the College and trainers. 9. The College should work with deaneries to ensure that opportunities for trainee engagement with the College are signposted effectively. 10.The College should work with deaneries to monitor the completion of core psychotherapy cases to ensure consistency in approach. 17
11.The College should work with deaneries to monitor the higher psychotherapy academic programme to ensure consistency in quality. 12.The College should work with deaneries to monitor implementation of the WPBA guide. 13.The College should work with deaneries to monitor ARCP/ RITA outcomes and panel approaches to ensure that outcomes are awarded consistently. Good practice 1. The training provided for non-medical trainers in North Western and Mersey deaneries, recognising the importance of their role in supporting training. 2. Initiatives aimed at medical students and foundation doctors that have improved recruitment into psychiatry. For example, medical student placements in psychotherapy run by Severn deanery; and Balint groups for foundation doctors in Yorkshire and the Humber and North Western deaneries to promote psychological understanding of healthcare. 3. The College s proactive approach to monitoring the relevance of training for workforce needs and identifying possible solutions. For example, the dual training programme in general adult psychiatry and medical psychotherapy as a way to retain medical psychotherapy in psychiatry and to enhance recruitment. 4. The collaborative approach to deanery teaching in Oxford and the West Midlands, and North Western and Mersey which provides a larger trainee peer group and a larger pool of trainers to enhance learning. 5. The mid-year formative review and educational supervisors report for higher trainees in Scotland and Yorkshire, which enables early identification of any gaps in meeting the curriculum requirements. 18