PsychotherapyBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7177.2 (Published 16 January 1999) Cite this as: BMJ 1999;318:S2-7177
Not all psychotherapists are doctors, and not all doctor psychotherapists are psychiatrists. Adrienne Key and Christopher Dare discuss the opportunities for both specialists and generalists to develop this skill
- Adrienne Key, lecturer,
- Christopher Dare, reader in psychotherapy
- department of general psychiatry, St George's Hospital Medical School, London
- Institute of Psychiatry, King's College, London
Psychotherapy is the deliberate activity of establishing and using the therapeutic relationship as effectively as possible for the benefit of the patient, and there is now a large variety of methods of psychotherapy and many psychological treatments. Doctors are as unenlightened as the population at large if they consider that psychotherapy lies exclusively within the domain of psychiatrists and professionals in related disciplines. They are also wrong if they think it is an arcane skill of doubtful provenance. All practice benefits from careful attention to the relationship: training in, acquiring, or improving on psychotherapy skills is a useful addition to any doctor's expertise, regardless of specialty. Despite public and professional ambivalence about the subject, doctors sometimes want to learn the art of psychotherapy.
Providing a brief summary of the subject is difficult, as there is such a wide range of activities included within the definition. We focus on the training opportunities and processes for doctors wanting to go beyond the everyday levels of skills that they require in general training, and on some of the experiences of those who have. An NHS review of psychotherapy services provided a useful framework and identified three levels of psychotherapeutic activity(1):
Type A - Psychological treatment as one component of a programme of health care, for example, supportive counselling
Type B - Counselling and eclectic psychological treatments, such as cognitive behavioural psychotherapy
Type C- Formal psychotherapies, such as psychoanalysis.
We concentrate on type B and C skills of formal psychotherapy.
Training to be a consultant
Consultant psychotherapists in the NHS have general psychiatric training and have the MRCPsych. As specialist registrars in psychotherapy, they are trained in assessment and treatment in the NHS setting. This means concentrating on two or three types of treatment - such as time limited psychoanalytic psychotherapy, group therapy, and marital or family therapy - although most will also have skills in some of the psychological treatments such as cognitive behavioural therapy. Alongside training in NHS mental health, many specialist registrars in psychotherapy undertake an intensive training programme in one of the psychoanalytic institutions (which usually continues in their first year or so after consultant appointment). In the major centres most consultant psychotherapists get such training in an institute in London (such as the Institute of Psychoanalysis, the British Association of Psychotherapy, the Lincoln Centre, and the Society of Analytic Psychology) or in the Scottish Institute of Human Relations in Edinburgh. These courses have three components:
Seminars on psychoanalytic theory and technique, and clinical seminars (two or three evening seminars a week is usual)
After one to two years of theoretical training, two cases are seen in long term intensive treatments, for which two separate supervisors are consulted each week
Throughout the training the candidate has personal therapy, which consists of three to five 50 minute sessions a week.
Most consultant psychotherapists regard this experience as invaluable. It is not uncommon to hear consultants regretting not having gone through an intensive training. It is virtually unknown to find a consultant psychotherapist lamenting the investment they have made in their intensive and expensive training. The essentially “bare handed” nature of psychotherapy practice arouses anxiety and uncertainty. Personal therapy is felt by us to be an extraordinarily supportive base from which to face the hazards of psychotherapy practice. Further, much of the time of a consultant is spent doing assessments, supporting and supervising psychotherapy provided by junior and non-medical staff, and being on support groups for ward staff, community teams, and other professional groups. Intensive training is a powerful resource for this work.
Because of the expense and enormous commitment that this training requires, increasing numbers of consultant psychotherapists have undertaken less intensive training in one specific method of psychotherapy but have had a variety of training in, for example, cognitive behavioural therapy, interpersonal therapy, and family or group therapy. Recently, universities have developed training courses for a wide range of therapies - such as the Institute of Psychiatry (King's College, London); Centre for Psychotherapy Studies, University of Kent; Tavistock Clinic and East London University; University of Sheffield; and University of Stafford. Presently, these masters programmes (which are open to all clinical disciplines) offer training in psychoanalytic psychotherapy or family therapy. In time there will be courses in group therapy and cognitive behavioural therapy, and the latter are likely to be dominated by professionals with a primary training in clinical or counselling psychology.
The development of an explicit model of psychopathology - whether it be learning theory, group dynamics, or psychoanalysis - defines the psychotherapies grouped under type C. The private institutions at which consultants take on their additional training are likely to be dedicated to the promotion of particular schools of psychotherapy - freudian, jungian, winnicottian, attachment theory based, group-analytic, etc. The schismatic nature of dynamic psychotherapy has led to a multiplication of these institutes, and, as newer forms of psychotherapy such as family systems treatments evolve, further organisations with accompanying training programmes are founded.
Other routes to practice
In Britain many people now practise psychotherapy, and most are non-medical, having been trained as clinical or counselling psychologists, social workers, occupational therapists, or nurses. Doctors from a wide range of specialties have also decided to train as psychotherapists. We know of general practitioners, dermatologists, medical osteopaths, neuropathologists, physicians, and paediatricians who have done so. If they wish to gain the status of NHS consultant psychotherapist, they usually have to requalify as a psychiatrist.
So why should a doctor want to enter into more intensive training? For a general psychiatrist, developing an interest and then training in a particular model such as psychodynamic psychotherapy or family therapy can complement their everyday practice. Psychiatrists can use a psychotherapeutic framework as an additional dimension to biological and social models when dealing with patients to conceptualise complex psychological difficulties. Beyond this, the ideas provide an understanding of their own emotional reactions to patients. Many also view such training as a personally enriching experience that also serves to maintain effectiveness and enthusiasm in a difficult and challenging subject.
What do these trainings offer doctors outside the discipline of mental health? Some doctors may remain in their specialty and use psychotherapy skills to augment their practice in quite specific ways - for example, a gynaecologist may use skills from training in sexual therapy, and a general practitioner may use family therapy skills.(2) Doctors we have spoken to who combine jobs feel that their additional training has been of enormous benefit to their general medical skills, benefits that far outweigh the heavy financial and time commitments that training demands. The nature of psychotherapy helps clinicians to acquire general skills such as attentiveness, interpreting body language, reflection, and emotional understanding of patients - skills that many doctors feel were not provided by their general training. The specific psychotherapeutic skills of intervention and interpretation may not be appropriate for some patients, but the theoretical integration of ideas with wider medical knowledge has, as with the group of psychiatrists, been experienced as personally and professionally enriching. In addition, the training has the benefit of introducing doctors to other disciplines that have different ways of thinking and working.
There are, of course, disadvantages apart from time and money. There is no all encompassing theory to solve all dilemmas; medical practice will remain frustrating as well as rewarding. Additional knowledge has the nasty habit of highlighting deficits in time and resources. Further, many doctors who have become psychotherapists are absorbed by the subject, give up their jobs in the NHS, and become private psychotherapists. Although psychotherapists, and this article, assume that these skills benefit the patient-doctor relationship, it must also be remembered that, apart from training in the detection of psychiatric disorders, there is little empirical evidence to show that generic counselling adds to standard care.(3) Specific techniques for well defined patient populations with psycho- logical disorders have been shown to improve outcome,(3) but this is because it is only in those situations that statistical power can be achieved with relatively small numbers of subjects.
The Register of Psychotherapists is an important source of accurate information concerning reliable training courses for doctors wishing to train. The document gives the addresses of those institutions and organisations that have programmes meeting the requirements of the register and mainly applies to practitioners of type B and C psychotherapy skills. The British Association of Counsellors has also established standards of training and, particularly, of ongoing professional development and supervision for practitioners who are members of the association. These two organisations go some way towards providing information for doctors about trustworthy therapists and counsellors, and training locations.