Specialist Psychotherapy is an important part of all psychiatric services, but there is increasing interest in applying psychotherapeutic principles in other settings, such as psychiatric liaison, forensic centres, in the community and in General Practice. In the past, much psychotherapy was psychodynamic (using the therapeutic relationship and helping the patient explore their current problems in the light of past relationships). Now there is more emphasis on the trainee having a wider view which includes cognitive behavioural therapies (concerned with learned patterns of thought and ways of modifying them) and systemic work (understanding the system in which a patient has difficulties, e.g. the family or couple). Modern Psychotherapy is increasingly concerned with the integration of models and their application and evaluation in specific patient populations. It is currently benefiting from government initiatives to improve access to psychological therapies. A new report ‘Psychological Therapies in Psychiatry and Primary Care’ (RCPsych with RCGP, 2008: available via website below) summarises current practice and training.
A wide range of patients are referred to Psychotherapy services, with the emphasis currently (as with much pf Psychiatry) being on those with more serious mental illness, especially personality disorder and co-morbid conditions. Time to assess is usually greater in Psychotherapy than in General Psychiatry, as is therapy contact time. Work is usually arranged within strict time boundaries, so the specialty is suitable for those who work part time. More Psychotherapy research is needed, but clinical audit has become increasingly sophisticated. Psychotherapy was a somewhat lonely as well as emotionally demanding specialty, but clinical liaison with colleagues, teaching and training have become key to the modern consultant’s role.
Specialised training in psychotherapy follows on from core training in psychiatry. At this stage (ST4) prospective trainees should have undertaken significant theoretical training in basic psychotherapy (from MRCPsych and external introductory courses). They will also have undertaken some supervised work with patients in psychodynamic and CBT approaches during their psychiatric placements, with successful completion of WBAs.
Personal qualities should include:
- An ability to get on with a wide range of people and to empathise with their emotional and psychiatric problems
- Ability to work within a team or flattened hierarchies
- Medical consultant psychiatrists in psychotherapy are expected to lead in clinical and management issues
- Ability to reflect and learn from personal experiences