Abstract
Dr Paul Foulkes wrote to the Victorian branch of the Psychotherapy Section of the RANZCP (13/10/98): ‘The development of a Psychotherapy Training Course continues with General council urging the Section to implement a training course speedily’.
In the second half of 1998, it was clear that such a course should have both post-fellowship and pre-fellowship components. That is, the current arrangements, for giving psychiatry registrars exposure to psychotherapeutic methods, needed to be enhanced.
The present paper aims to describe the current state of the Registrar Psychotherapy Programme in Victoria. I write from the perspective of having been the president of the VAPT for two years and a registrar representative on this body for four years. This discussion is of necessity impressionistic, and represents the evidence of many anecdotal reports: in general, whilst the official training requirements are spelt out in the training manuals, what actually occurs falls far short. Registrars are understandably reluctant to give details in formal questionnaires. They fear retribution by consultant and college alike. However, registrars' desires for an enhanced training experience were documented in an anonymous questionnaire by Foulkes [1].
OVERVIEW OF VICTORIAN REGISTRARS’ EXPERIENCES OF PSYCHOTHERAPY PROGRAMME
The current minimal college training requirements are:
one 40-session individual case, over six months, with at least one session a week, treated by ‘a psychologically based therapy’;
two 10-session cases treated by brief psychologically based therapy;
two 10-session cases treated by cognitive or behavioural therapy;
one patient where marital/family/group therapy was a ‘significant mode of treatment’. Few registrars exceed these minimal requirements, especially point 1, although a minority see their long case patient for some years.
These sessions are to be supervised (see below).
Registrars are required to spend 18 months in an integrated post, with in-patient and community contact, with an emphasis on continuity of care. Our part in treating a person with schizophrenia is generally limited to rapidly confirming the diagnosis, excluding differentials, identifying comorbidity, and medicating. We would typically see this patient every one to three months for ten to fifteen minutes. Talking to the patient for longer periods is strongly discouraged, both attitudinally and because of time constraints. We write up a case of chronic mental illness, usually psychosis, where we were the doctor for 6 months, and ‘a’ doctor of the patient for another 6 months.
Family or systems work is not encouraged, except in the child rotation. Group work is a rarity. Observations from behind a screen of interviews by supervisors are also rare.
ATTITUDE TOWARD PSYCHOTHERAPY ON THE PART OF TEACHING HOSPITALS AND REGISTRARS
High throughput, driven by funding pressure and patient need, means that time-intensive treatments such as psychotherapy are viewed by hospitals less favourably than their quicker pharmacological counterparts. Immersed in this environment, it is difficult (and might be foolish) for registrars not to share this view.
Outcomes of psychotherapy are often not as immediate or tangible as outcomes of pharmacological treatments. The concept of ‘throughput’ focuses only upon the patient's service utilisation, systemic outcomes such as enhanced vocational or social functioning, reduced acute admissions and violent outbursts attracting the attention of a CAT team.
With short registrar rotations, short admissions, and chaotic rostering of allied health workers, anything other than a short-term view of outcome is simply not an option. It would seem that Victorian public psychiatry currently has two main clinical goals: sedate and discharge. A deeper understanding of patients is frequently seen to cost too much in time and money.
ACCESS
Deinstitutionalisation and the existence of CAT teams mean that dangerous patients are more likely to be managed with fewer resources in the community. Registrars in public mental health services must be available to respond immediately to crises.
Given this environment, it is difficult to access patients who are suitable for psychotherapy within the public hospital sector. The priority must be upon the seriously mentally ill. Patients with less dangerous forms of mental illness or character pathology constitute a lower priority but nevertheless consume disproportionate amounts of a service's energy. Patients who may benefit from a reflective approach seldom gain the attention of intake workers and, even if they do, will usually be instantly referred on to private practitioners.
There are informal guidelines regarding timing of treatment for any patient seen by registrars. Outpatient sessions are meant to last no longer than 15 minutes (30 minutes is frowned upon) and if they were to be scheduled as often as weekly for a particular patient, this would attract critical attention from most consultants and team leaders. Most registrar rotations last six months.
Registrars in hospitals, community clinics, and prisons tend to spend most of their time in assessment, certification and medication of violent, brain-injured drug-addicted males and self-harming drug-addicted females. These patients usually have character traits and often cognitive deficits which would make regular therapy heavy going at best, and futile at worst. There is of course no limit to the numbers of such patients a registrar will have to take on, and no guarantee of good-enough access to senior staff for consultation and supervision. One's workload can change overnight, forcing sudden changes in the time one may spend with patients.
Given time pressure and need to attend the most overtly mentally ill, the role of the registrar within a team is eroded to that of a prescriber; a few psychotherapeutic interventions are provided by other workers. The catch-cry of the clinic staff is ‘I'm just squeezing this patient in with you, for a medical review’; which should be understood as, ‘quickly document a mental state, and medicate’.
Thus, it should be apparent that the system within which psychiatry training occurs in Victoria has many built-in disincentives against taking on patients whose treatment involves regular discourse within a stable, trusting relationship.
GENERAL SUPERVISION
The College makes specific requirements for supervision of day to day work. Four hours per week of group supervision should occur: this often is unavailable. Even the compulsory individual hour is sometimes omitted.
Many aspects of psychological management are frequently lacking or absent in supervision. A recent comment by a senior consultant psychiatrist in a case conference illustrates: in response to a request by an allied health professional that the team address the psychosocial aspects of a patient's case, the psychiatrist replied that ‘there are none’. This is a common attitude (more usually latent than so overt).
PSYCHOTHERAPY SUPERVISION
This is generally funded by hospitals, and funding may cease after the 40 session requirement has been satisfied. In some instances supervision occurs only once a month. There is no requirement for the supervisor to be expert in the field (and this most affects the CBT training) but most supervisors of the long case are experts.
CONCLUSION
Patients are not the only customers of the teaching hospital system. Its customers include governments, who demand optimal demonstrated returns for their investment; the RANZCP, which entrusts the training of future members to the system; and the public, who have the right to expect that we have been broadly and adequately trained.
But is it still reasonable to expect an increasingly stressed public system to provide patients and resources for trainees to learn what we must about psychotherapeutic treatment? Need every hospital psychiatry job be accredited as a training position? Closer partnership with psychotherapists in the private sector may help bridge the gap between current reality, and a better state of affairs.
The challenge for us all is to integrate the conflicting demands of service provision and training, for the sake of our patients and the future of our profession. Psychiatry in general, and psychotherapy in particular, can only be as sound as the average training experience permits.