Abstract
Although the latter half of the 20th century has seen a biological revolution in both the conceptualization and treatment of psychiatric disorders, it is widely accepted that an understanding of psychological aspects is crucial to being a competent psychiatrist. 1–4 Despite such acceptance, and accompanying recommendations, training in the psychotherapies for psychiatric registrars seems to have diminished in quality and quantity (S Thomas, unpubl. data 1998). There has been a gradual reduction over the last few decades in the value of psychotherapy in psychiatric training and hence less time devoted to developing skills and understanding. 5, 6 Regrettably, there is very little literature evaluating such training, 7–11 and there has been no formal evaluation of psychotherapy education in Australia or New Zealand.
METHOD
In order to ascertain the degree of satisfaction of trainees in both the quality and quantity of training, a 60-item questionnaire was devised. The questionnaire examined the trainees’ perception in both a quantitative and qualitative manner. Degree of satisfaction was assessed through a five-point Likert scale.
The questionnaire was initially tested in a pilot project involving 90 trainees in Victoria and then sent out to 272 senior psychiatric trainees in Australia and New Zealand. It was decided to limit this questionnaire to senior trainees (i.e. 36 months or more of full-time training) in order to allow sufficient time for a more rounded experience of psychiatric training to occur.
RESULTS
A total of 94 replies were obtained, giving a response rate of 35%.
Quantitative findings
These are detailed in Tables 1–7. The data can be summarized as follows.
Most training was received in dynamic therapy and supportive therapy and then a lesser amount of training, in descending order, in cognitive behavioural therapy (CBT), family therapy and group therapy.
There were marked variations in the amount of seminars and supervision received within the same institution. The evidence indicated that it was the individual trainee's orientation and determination in seeking out training that explained the wide range of hours received; a substantial number of trainees indicated that they had pursued their own private supervision or psychotherapy training course.
The proportion of trainees who felt satisfied with the quality of overall psychotherapy training was less than 50% for each form of psychotherapy. The trainees were most satisfied with dynamic therapy (41%), followed by supportive therapy (37%), CBT (31%), family therapy (19%), and group therapy (7%). This was approximately the same picture when seminars and supervision were examined separately.
Overall, there seemed to be less satisfaction with the quantity compared to the quality of psychotherapy education.
The trainees rated supervision as the most useful component of training (72%) followed by case discussions (41%) and seminars (24%). Personal therapy was considered least useful in training, being considered essential by only 22% of trainees.
A number of cross tabulations were performed. The only significant finding was that the degree of satisfaction in the overall quality of dynamic therapy training seemed to markedly decrease for those with 6 or more years of training.
Qualitative findings
Problems in psychotherapy training
Although there were some differences among trainees, consistent themes emerged. These were similar across all branches, and are as follows.
Psychotherapy education was seen as very important in the training of a psychiatrist.
‘I would like to be wise about people, not just neurotransmitters’
Gender, current year of training, seniority and place of training
Average hours of training modalities to date (with standard deviation)
Comparison of institutions hiring multiple trainees
Satisfaction with quality of training
Degree of satisfaction with quantity of training
Problems and suggestions for improvement
Strengths of training
There was a marked deficiency in the quantity of time devoted to such education.
‘I have completed my long case and that's it in 5 years of training, in terms of any sort of therapy-appalling’.
‘Minimum experience in dynamic therapy, inadequate to even decide whether it is a method I would prefer to use’.
There was particularly little explicit teaching in supportive therapy, despite it being the most commonly applicable therapy for the patients seen.
‘Very underrated [supportive therapy] and ought to be taught and thought about with more subtlety and respect’.
Insufficient time for training was attributed to excessive service demands, not enough time with patients and lack of systematized approach to training.
‘A lack of any real commitment of training schemes to train registrars in a complete and thorough way’.
There was ‘an open discreditation of usefulness and efficacy of psychotherapy by some biologically orientated consultants’.
Supervision was too variable and often the supervisors were not regarded as proficient.
A case of the blind leading the blind’.
‘Experts without expertise’.
Good-quality supervision had to be sought outside of the training institution, in the trainee's own time and usually had to be paid for wholly by the trainee.
‘I undertook a lot of initiatives myself. What was formally delivered was minimal and without clarity’.
Strengths and suggestions for improvement
DISCUSSION
One of the study limitations was the low response rate from the trainees, with just over one-third replying. This compares to 42% in the similar questionnaire by Perez et al. 8 Why did so few trainees reply? Possible reasons include restricted availability of time, frustration with the heavy demands of the questionnaire or the subject matter, arousing disappointment. Of course, the interpretation of the findings rests partly upon the representative nature of the trainees who replied. It could be argued that a greater number of dissatisfied trainees would be likely to reply than satisfied ones, as a method of ventilation. However, the pilot study, in which there was a reasonable numbers of replies, had virtually the same results. As well, the remarkable consistency of the qualitative replies in describing the nature of training, even in those trainees who were satisfied with their training, suggests that the respondents may not be biased.
The trainees expressed a low degree of satisfaction with psychotherapy training. Only in dynamic therapy supervision did even half the respondents feel satisfied. One could reasonably expect more than half the trainees to be satisfied with their training. The levels of satisfaction in group and family therapies can only be described as abysmal. If their perceptions are reasonably accurate, then serious deficiencies in psychotherapy education exist.
Is there any support from experts in the field or department heads as to what constitutes adequate training? Mohl et al. in North America suggested an average of 6.5 h per week over 3-4 years in all but the most restricted circumstances. 4 The Royal College of Psychiatrists recommended that a half-day per week be made available for treatment and supervision, in dynamic therapy alone. 3 On average, a trainee in Australia and New Zealand receives 1.5 h per week over their training and that includes all modalities of psychotherapy.
However, it is not just the total number of hours that is important in determining the quality of psychotherapeutic training, but how these hours are spent. The North American, British and European recommendations clearly stipulate the need not just for a psychodynamic understanding of clinical situations and the doctor-patient interaction, but also for some experience in CBT and some further knowledge of group processes and family dynamics. 3,4,12 As regards the culture within which training occurs, the Royal College echoes the Europeans in stating that ‘trainees should be encouraged to see psychotherapy as arising out of and as an integral part of clinical work’. 3
The deficiencies of trainees’ psychotherapy training seemed to reflect a neglect of psychological understanding in the public system. Given the culture and daily operational life of the public mental health institutions described by the trainees, it would be very hard to imagine how a psychotherapeutic understanding of people's emotional distress could legitimately arise, let alone the appropriateness of certain psychotherapeutic methods. Clinicians who are teachers and role models need to demonstrate in their everyday management how good psychiatric treatment includes such psychotherapeutic understanding and techniques. Any institutional culture that has as a norm of neglect or even denigration of a treatment modality cannot provide a fertile place for learning of such a modality.
The concept of ‘training’ in psychiatry even more so than in the rest of medicine, must primarily rest upon an experiential and apprenticeship model, using supervision as the cornerstone. The fact that a considerable proportion of the trainers had to pay for psychotherapy supervision merits further thought. It might be argued that it is appropriate that supervision is not provided free of charge, but because supervision in other areas of psychiatry is not charged for, it seems to suggest that the psychotherapies are not considered part of the central core of psychiatry, but rather a separate entity or an addition. Where such supervision was paid for, the clinician was most likely not the paid staff of the institution. This also creates a split in the mind of the trainee between the psychiatry as practised in the institution and the psychotherapies employed in private practice. Although some trainees showed dedication and determination in obtaining high-quality training, most did not. Strengths of the training appeared to be around supervision of a long psychotherapy case. This seemed to open up the possibility of helping greater numbers of trainees to be exposed to more and better supervision in different modalities.
Training in these areas of psychological psychiatry is important for the integration of psychotherapeutic skills into clinical psychiatry for the future clinician 13 or team manager. 14 If training is as inadequate as the results suggest, then future psychiatrists are receiving deficient training to enable them to satisfactorily manage patients. This is of major concern for several reasons. First, being asked to assess, manage and treat patients with psychiatric conditions but having inadequate skills can lead to dissatisfaction with psychiatry as a career or with the value of a psychological humanistic approach to psychiatry in general. 14 It can also lead to a failure to work through painful experiences due to a lack of a theoretical overview of human psychopathology that may otherwise help to reduce excessive anxiety. This in turn leads to a block in professional maturation that can lead to emotional scarring 15 and further dissatisfaction. Second, deficient training leads in time to a pool of inadequately informed and capable psychiatrists who may not have sufficient interpersonal skills. This in turn can lead to a decrease in the public's confidence in psychiatry as a whole. More importantly, there will not be enough trained psychiatrists to pass on the baton in the form of adequate clinical skills and knowledge to the next generation of psychiatrists. Third, it is the knowledge base of psychiatry as a discipline that will be corroded away due to lack of interest in psychotherapeutic research. Research is an invaluable part of any science and without it any discipline will wither away.
Training in the psychotherapies need not have the primary aim of producing expert psychotherapists. Rather, trainees should be able to use the psychotherapeutic understanding of the human mind and of peoples’ interactions with others gained from the different models, in every facet of their work including the prescribing of medication or understanding team dynamics of a multidisciplinary team. It would appear that trainees are not being adequately taught to optimally manage the patients that they are likely to be asked to treat in the public sector, let alone the private.
RECOMMENDATIONS
A number of recommendations can be made on the basis of the trainees’ replies.
A set of guidelines for psychotherapy training in psychiatry should be produced by a committee consisting of relevant representatives of the different bodies involved in training, including trainers and specialists in the different psychotherapies.
These guidelines should include an idea of the respective quantities of time devoted to training in the biological, psychological, and social dimensions of psychiatry in basic psychiatric training. There needs to be some consensus in the profession concerning what capabilities a psychiatrist should be able to demonstrate at the conclusion of basic training. It cannot be left to the trainees to work it out for themselves.
The guidelines should include aims of training in the different psychotherapies, as well as the minimum expected skills and knowledge base at the successful conclusion of psychiatric training.
Footnotes
Acknowledgements
The author wishes to acknowledge Professor John Tiller and Professor Ken Kirkby for their help in designing the questionnaire, and Associate Professor Jeremy Anderson for his help with statistics. Many thanks also to Dr Jo Beatson, Associate Professor David Clarke and Dr David Mushin for their support and suggestions in writing this paper.