Basic Psychiatry Psychotherapy Training

Comments and Suggestions

Dr Jeffrey Streimer, Dr Loyola McLean & Joanne Shaw

(The views expressed in this brief overview are entirely those of the authors and do not represent the official position of the RANZCP or other Training organisations. The authors acknowledge the NSWIoP for permission to circulate this information.)

Introduction:

Basic Training in Psychiatry includes many explicit and implicit psychotherapy elements. We suggest that these elements should now be brought together and integrated to keep up with similar developments internationally. The following is an overview of the current situation with some suggestions for the future.

Background:

Psychotherapy is a central plank in the training of Psychiatrists. Psychotherapeutic skills and knowledge are a core part of psychiatric practice and not just the preserve of specialist psychotherapists (Guidelines for Psychotherapy Training as part of General Professional Psychiatric Training: Royal College of Psychiatrists, 2001).

The basic function of psychotherapy training is five-fold:

It provides:

1. Essential training in communication and alliance building skill as well as actual technical skills applicable in all fields of Psychiatry (Gabbard, 2007).
   1. The theoretical framework for psychotherapeutic treatment
   2. Experience in treating individual patients with psychotherapy as the primary treatment
   3. Key understanding of ‘Systems’ work with dyads, families and groups  to deliver  integrated (bio-psycho-social) management plans

1. The essential experience of developing reflective psychiatric practice

Psychiatric training has lagged behind in the last generation, an age called ‘mindless’, because of the overemphasis on biological approaches at the cost of training in psychotherapy (Gabbard 2007).

Psychotherapy Training Overview

• Provision of high quality psychotherapy training to Psychiatry registrars during basic training is crucial. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) requires every registrar to undertake theoretical learning and skills training in psychotherapy (Regulations 5.11 and 8.10).

• Traditionally regarded as a central part of the psychiatrists’ role, training in psychotherapy skills requires support. Psychiatry graduates need psychotherapy skills to complete their understanding of the biopsychosocial model of healthcare, as the context of life events and relationships which have meaning to the patients (Mellman and Beresin 2003). Some of the forces that have adversely affected these skills are addressed in recent reviews (Lieberman and Rush 1996; Plankun 2006).
• Locally, recent COAG reforms have recognised the centrality of psychotherapy skills. There is a growing research evidence base for both the therapeutic and cost effectiveness of psychotherapy treatments (for example Vos, Corry et al. 2005, Stephenson & Meares 1999, Leichsenring 2005, Shedler  2010).

Proposed RANZCP Model of Training

• As part of the federally-funded structural reform of Psychiatry Training, the Curriculum Improvement Committee within the RANZCP has recommended the adoption of a competency based curriculum for Psychiatry training. Under the model proposed by the RANZCP Competency Based Fellowship Program (CBFP), training will be modular & skills-based to remove the structural divisions within training and provide formal integration of training within the workplace. Assessable core competencies will increase transparency and provide a more standardised level of training (http://cip.ranzcp.org/). The competency based framework that the RANZCP propose to adopt is based on the CanMEDS Physician Competency Framework model adopted by the Royal College Physicians and Surgeons of Canada (RCPSC) (Frank 2005). There is therefore now a need to reform psychotherapy training into a set of integrated competencies.

Outline of International Psychiatry Psychotherapy Training

Internationally Psychiatrist training bodies have responded to the need for improved competencies in psychotherapy. The Canada, UK and the USA have all recently adopted competency based training approaches as follows:

Canada

CanMEDS: The competency based framework that the RANZCP propose to adopt is based on the CanMEDS Physician Competency Framework model adopted by the Royal College Physicians and Surgeons of Canada (RCPSC) (Frank 2005). The standards describe the abilities needed for quality health care and have been integrated into the RCPSC's accreditation standards, objectives of training, final in-training evaluations, exam blueprints, and the Maintenance of Certification program. The CanMEDS framework provides both trainees and educators with a guide to the essential abilities physicians need for optimal patient outcomes.

Development of this competency-based framework involved a process of identifying the core abilities of the practice of medicine and translating the available evidence on effective practice into educationally useful elements. The result is a new multifaceted framework of physician competence that comprises numerous competencies. To be useful, these are organized thematically around “meta-competencies” or physician roles.

The framework is organized around seven roles: Medical Expert (central Role), Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional.

Traditionally medical education has articulated competence around core medical expertise. In the CanMEDS construct, medical expert is the central integrative role, not the only one. Domains of ability that have long been described for or displayed by the effective physician were made more explicit and re-emphasized. The roles and competencies outlined in the CanMEDS framework are not specific to any one specialty but apply across disciplines, although specialties may emphasise some competencies more than others

Psychiatric Training in Canada (RCPSC 2009): Post graduate training in Psychiatry in Canada is five years duration and is offered by sixteen accredited residency programs across Canada. The structure of the programs are standardised across institutions, with the specific objectives of training determined by the RCPSC. According to the RCPSC, the first year of residency involves development of general interaction skills, greater independence in clinical decision-making and technical skills across a broad range of medical practice. This usually involves rotation through several areas of medicine in addition to psychiatry training. Residents gain experience in adult general psychiatry and six months in chronic care psychiatry and six months of child & adolescent psychiatry. In fourth year residents gain experience in one of the sub-specialities, including psychotherapy, while in fifth year residents may choose an area of medical training.

Psychotherapy Training in Canada: Throughout the psychiatry course, the RCPSC requires residents to undertake 2 years of weekly (one hour) psychotherapy supervision. The RCPSC expects residents to achieve differing levels of expertise in the specific psychotherapies, which include:

• proficiency(defined as being the prime therapist with ongoing supervision) in supportive, crisis intervention, psychodynamic, cognitive behaviour and family (or group) therapies;
• working knowledge (observing therapy or co-therapist) in group (or family) therapies, dialectical behavioural, interpersonal and behavioural therapies and brief dynamic therapies and
• introductory knowledge (via seminars etc) in relaxation, motivational interviewing, mindfulness and brief dynamic therapies.
• residents are also expected to demonstrate empathy and rapport and develop trusting and ethical relationships with patients.

UK and Ireland

Core & specialist psychiatry training: A revised competency based curricula for core and specialist psychiatry training is in its first year of implementation in the UK. The curriculum is based on the CanMEDS (2005) competency framework and is a six year training program. The curriculum documents the intended learning outcomes and includes specific competencies that illustrate how these outcomes can be demonstrated (RCPsych 2009). The intended learning objectives in the training program are to:

• be able to perform specialist assessment of patients and document relevant history and examination on culturally diverse patients
• demonstrate the ability to construct formulations of patients’ problems that include differential diagnoses
• demonstrate the ability to recommend relevant investigation and treatment in the context of the clinical management plan
• based on a comprehensive psychiatric assessment, demonstrate the ability to comprehensively assess and document patients’ potential for self-harm or harm to others
• Based on a full psychiatric assessment, demonstrate the ability to conduct therapeutic interviews; that is to collect and use clinically relevant material.
• Demonstrate the ability to record appropriate aspects of the clinical assessment and management plan
• Develop the ability to carry out assessment and treatment of patients with chronic and severe mental disorders and demonstrate effective management of these disease states
• Use effective communication with patients, relatives and colleagues
• Demonstrate the ability to work with colleagues, including team working
• Develop appropriate leadership skill
• Time management and problem solving
• Clinical audit skills
• Clinical governance
• Ensure you are able to inform and educate patients effectively
• Ability to teach, appraise and assess
• Professionalism
• Lifelong learning habits

The specific skills and competencies required to achieve these learning objectives are detailed using the role-based competencies outlined by the CanMEDS framework. Assessment of competency comprises two main elements: workplace assessment and college exams MRCPych. Workplace learning assessments are formative assessments – that is they provide ongoing information regarding level of competency at a given time within training and outline deficiencies that need addressing to attain competence. Admission into advanced training is contingent upon completing a minimum of 36 months approved training in psychiatry and pass in all sections of the MRCPsych examination.

The major focus of learning throughout the curriculum is experiential and practical learning in the workplace, guided and supported by colleagues, mentors and clinical and educational supervision. However, there are important facets that will require other, more traditional, learning resources such as groups learning, textbooks, journal articles and web-based resources such as the College CPD On-line materials.

Essential adjuncts to learning include a Portfolio of Experience, Progress and Attainment which is an essential source of evidence for the Annual Review of Competence Progression, eligibility to enter the College Membership examinations and for CCT application.

UK Advanced Training in Psychotherapy

Having completed core training, trainees nominate their chosen psychiatric specialty from nine specialty training programs, one of which is psychotherapy. As in the core training program, the competencies outlined by the College for Advanced Training in Psychotherapy are arranged under the meta-competencies outlined in the CanMEDS curriculum.

The specialist modules of the College curriculum, including psychotherapy, build on the Core Module Curriculum in two ways. Firstly, Specialty Registrars in Psychiatry all continue to achieve the competencies set out in the Core Module throughout training, irrespective of their psychiatric specialty. This involves both acquiring new competencies, particularly in aspects such as leadership, management, teaching, appraising and developing core competencies such as examination and diagnosis to a high level and, as an expert, serving as a teacher and role model.

Secondly, the specialist modules set out those competencies that are a particular feature of each specialty. These include competencies that are specific to that specialty, or that feature more prominently in the specialty than they do elsewhere, or that need to be developed to a particularly high level (mastery level) in specialty practice.

USA

After a review of the residency training programs in USA, the Accreditation Council for Graduate Medical Education (ACGME) in 1997  mandated six core competencies that that all medical programs must address. These general competencies include: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice (Miller, Scully et al. 2003).

• Psychiatry Training in USA: Residents may enter into psychiatry training in either their first or second post-graduate year (having completed a year of internal, family or paediatric medicine). Residency education in psychiatry is four years, of which 12 months may be completed in Child and adolescent psychiatry. There are 182 psychiatry programs offered in the USA.
• Psychotherapy training in USA: In conjunction with the ACGME review, the Psychiatry Residency Review Committee (RRC) undertook a review of psychotherapy training programs in the USA in 2002.
• This review by the RRC for Psychiatry specified that in addition to the six core competencies of general medicine, psychiatry residents must also demonstrate competence in the following to be certified by their training programs as being competent:
• Brief therapy, combined psychotherapy and psychopharmacology, psychodynamic therapy and supportive therapy. Some of these therapies are closely allied to or derivative of others and there is considerable overlap in practice.
• In addition to setting the training requirements for the process and content of psychotherapy training, the recent changes to training in the US now include a focus on the outcomes of training. Training requirements in psychotherapy, have moved toward evidence-based therapies and emphasising competence and proficiency and accountability outcomes of training (Weerasekerra, Manring et al. 2010).
• The ACGME have subsequently adopted the RRC recommendations and now require that training programs to be structured to develop competence in ‘applying supportive, psychodynamic and cognitive behaviour psychotherapies to both brief and long-term individual practice as well as to assuring exposure to family, couples, group and other individual-evidence based psychotherapies (Weerasekerra, Manring et al. 2010).
• Teaching programs are therefore only accredited by the ACGME if they provide training in five psychotherapies. The Taskforce on Competency for American Association of Directors of Psychiatric Residency Training (AADPRT) has developed sample competencies for each of the five psychotherapy competencies including CBT outlined by the RRC of Psychiatry and provides assessment tools and online resources to help educators assess residents in a standardised and consistent manner in their paper reviewing psychotherapy training in the USA.
• Maring, Beitmann and colleagues (Manring, Beitman et al. 2003) highlighted that it is possible to distinguish between basic skills believed necessary for all psychotherapy from more specialised skills considered necessary for specific kinds of psychotherapies While necessary for effective psychotherapy the general skills are not necessarily sufficient for all psychotherapies or contexts.

A Proposed Approach to Updating Basic Training:

The provision of psychotherapy training needs to be kept current

The following could be observed:

1.  General change Principles

New models should develop which aim to be:

• Cognisant of the competencies based RANZCP Curriculum Improvement Project (CIP):
• Developed with integrated twinned “Psychotherapy Skills & Academic competencies” being:
  • Experiential with an emphasis on the development of actual general and specific technical clinical skills.
  • Evidence based and reflective to both advise the choice & direction of and illuminate the emergent psychotherapy experience.
• Vertically integrated so that deepening clinical and academic competencies emerge as sequential modular advancements towards planned evaluation milestones.
• Horizontally integrated with existing training resources such as the NSW IMET Psychotherapy Educators & other local Area training environments. .

2. General curriculum principles

Basic psychotherapy training should meet current and developing RANZCP curriculum requirements. It could therefore

• Be readily integrated with RANZCP Advanced Trainings’ psychotherapy requirements
• Be developed in modular form.
• Be deliverable in flexible ways including as supported distance education and be web compatible preferably with local face to face seminars & workshops.

Conclusion:

Today & tomorrow’s Psychiatrists will need to be well prepared for the demands of an increasingly educated public who expect us to be first rate psychotherapists as well as competent biologically sophisticated medical practitioners. We need to continue to meet their expectations and to maintain our predominant position in these fields.

REFERENCES

Frank, J. R. (2005). The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa,

 The Royal College of Physicians and Surgeons of Canada.

Gabbard, G. O.(2007)."Psychotherapy in psychiatry. "International Review of Psychiatry 19(1):5-12.

Leichsenring F: Are psychoanalytic and psychodynamic psychotherapies effective:  A review. Int J. Psychoanal; 2005: 86:841-868

Lieberman, J. A. and A. J. Rush (1996). "Redefining the role of psychiatry in medicine." Am J Psychiatry 153(11): 1388-1397.

Manring, J., B. D. Beitman, et al. (2003). "Evaluating competence in psychotherapy." Academic Psychiatry 27(3): 136-144.

Mellman, L. A. and E. Beresin (2003). "Psychotherapy competencies: development and implementation." Academic Psychiatry 27(3): 149-153.

Miller, S. I., J. H. J. Scully, et al. (2003). "The evolution of core competencies in psychiatry." Academic Psychiatry 27(3): 128-130.

Plankun, E. M. (2006). "Finding psychodynamic psychiatry's lost generation." Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 34(1): 135-151.

RCPSC. (2009). "Specialty Training Requirements."   Retrieved 17 March, 2010.

Shedler J (2010).  “Efficacy of Psychodynamic Psychotherapy”● American Psychologist Vol. 65, No. 2, 98–109

Stevenson, J. and Meares, R. Psychotherapy with borderline patients: II. A prelimary cost benefit study.  Australian and New Zealand Journal of Psychiatry, 33(4): 473-7.

Vos, T., J. Corry, et al. (2005). "Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression." Australian and New Zealand Journal of Psychiatry 39(8): 683-692.

Weerasekerra, P., J. Manring, et al. (2010). "Psychotherapy training for residents: reconciling requirements with evidence-based, competency-focused practice." Academic Psychiatry 34(1): 5-12.

Foulkes, P. (2000). "Psychotherapy teaching in psychiatric training." Australian and New Zealand Journal of Psychiatry 34(s1): A23-A24