The Royal College of Psychiatrists’ guidelines (Reference Bateman and HolmesBateman & Holmes, 2001; Royal College of Psychiatrists, 2001) state a minimum requirement of psychotherapy experience for basic psychiatric trainees and meeting this is now a mandatory part of eligibility criteria for the MRCPsych part II examination. There are five basic requirements: (a) development of interview skills; (b) experience in psychotherapeutic formulation of psychiatric disorder; (c) conducting a minimum of three short-term treatment (12-16 sessions) each using a different psychotherapeutic model; (d) conducting one long-term individual treatment (12-18 months) using any model; (e) gaining some experience of either group psychotherapy or couple, family or systemic therapy. The College recognises the following four modalities of psychotherapy: transference-based therapies, cognitive therapies, integrative therapies and group or family therapies. The primary aims of this survey were to determine whether specialist registrars in psychiatry working in Scotland met the 2001 requirements for psychotherapy experience, whether they considered themselves to be competent or qualified in psychotherapy and whether they had an interest in gaining further psychotherapy experience. The authors intended to determine whether these factors were associated with or predicted each other.
Method
A structured questionnaire was designed to determine demographic information, experience in psychotherapy, interest in psychotherapy and attitudes towards psychotherapy. The intention was to survey all specialist registrars in psychiatry working in Scotland, except for those six specialising in psychotherapy.
Questionnaires were sent in April and May 2003 and were anonymous, apart from numbers on envelopes to track the return of completed questionnaires. Those who did not respond to the initial mailing within 4 weeks were sent a reminder. Data were analysed with the Statistical Package for the Social Sciences (SPSS) version 11 for Windows.
Results
A total of 119 identified specialist registrars were contacted of whom 78 returned completed questionnaires, yielding a response rate of 66%. Of the 78 respondents, 49 (63%) were female and 58 (74%) worked full-time; 43 (47%) were training in general adult psychiatry, 18 (20%) in old age psychiatry, 10 (11%) in child and adolescent psychiatry, 12 (13%) in learning disability psychiatry and 8 (9%) in forensic psychiatry, with 13 (17%) respondents undergoing dual training (Table 1).
Table 1. Demographic details of respondents and numbers meeting College criteria, reporting competence in psychotherapy or interest in further training
| Respondents, | Meet College criteria, n | Competent in psychotherapy, n | Interested in further training, n | ||
|---|---|---|---|---|---|
| n | (%) | ||||
| Gender | |||||
| Male | 29 | (37.2) | 51 | 12 | 23 |
| Female | 49 | (62.8) | 211 | 26 | 39 |
| Employment | |||||
| Full-time | 58 | (74.4) | 17 | 28 | 49 |
| Part-time | 20 | (25.6) | 9 | 10 | 13 |
| Specialty | |||||
| General adult | 432 | (47.3) | 15 | 17 | 34 |
| psychiatry | |||||
| Old age psychiatry | 182 | (19.8) | 4 | 10 | 11 |
| Child and adolescent | 102 | (11) | 4 | 8 | 9 |
| psychiatry | |||||
| Learning disability | 122 | (13.2) | 4 | 5 | 11 |
| psychiatry | |||||
| Forensic psychiatry | 82 | (8.8) | 2 | 3 | 7 |
Of the respondents, 26 (33%) met College requirements. Women (χ2=4.29; P<0.05) and those working part-time (NS) were more likely to do so. In total, 38 (49%) respondents stated competence in at least one modality of psychotherapy, with 8 (10%) in transference-based therapies, 20 (26%) in cognitive therapies, 18 (23%) in integrative therapies and 10 (13%) in group or family therapies. No respondents were qualified (at certificate, diploma or degree level) in transference-based therapies, but seven (9%) were qualified in cognitive therapies, six (8%) in integrative therapies and four (5%) in group or family therapies.
In total, 62 (80%) respondents stated an interest in further psychotherapy experience and training, with cognitive therapies being the most popular modality (χ2=15.71, P<0.01). In addition, 51 (65%) respondents stated a desire to develop a special interest in psychotherapy, with cognitive therapies again being most popular (χ2=8.2, P<0.05). Finally, 20 (26%) respondents stated an interest in dual training in psychotherapy, with integrative therapies being least popular (Table 2). There was no statistically significant association between meeting College requirements and either self-perceived competence, qualification or interest in further psychotherapy training at any level (Table 3).
Table 2. Respondents (n=78) interested in further training in different psychotherapy modalities1
| Interest | Any modality | Transference-based therapy | Cognitive therapy | Integrative therapy | Group or family therapy |
|---|---|---|---|---|---|
| Further training | 62 | 22 (28.00) | 462 (28.00) | 24 (28.00) | 20 (28.00) |
| Special interest | 51 | 14 (13.75) | 213 (13.75) | 6 (13.75) | 14 (13.75) |
| Dual training | 20 | 8 (5.75) | 7 (5.75) | 04 (5.75) | 8 (5.75) |
Table 3. Relationship between meeting College requirements and self-perceived competency, qualification and interest in further psychotherapy exposure1
| Competent in psychotherapy | Qualified in psychotherapy | Interested in further experience | Interested in special interest | Interested in dual training | |
|---|---|---|---|---|---|
| Meet College criteria (n=26) | 13 (12.67) | 6 (4.67) | 21 (20.66) | 14 (13.33) | 8 (6.67) |
| Do not meet College criteria (n=52) | 25 (25.33) | 8 (9.33) | 41 (41.33) | 26 (26.67) | 12 (12.67) |
Discussion
Trainees were previously expected to meet the more demanding 1993 guidelines for psychotherapy training (Reference Grant, Holmes and WatsonGrant et al, 1993). The literature shows that psychiatric trainees generally did not meet the College requirements (Reference Arnott, Wilkinson and AylardArnott et al, 1993; Reference Hamilton and TracyHamilton & Tracy, 1996; Reference Hwang and DrummondHwang & Drummond, 1996; Reference Byrne and MeagherByrne & Meagher, 1997; Reference Rooney and KellyRooney & Kelly, 1999; Reference McCrindle, Wildgoose and TilletMcCrindle et al, 2001). Podlejska-Eyers & Stern (Reference Podlejska-Eyers and Stern2003) showed that it was possible to fulfil some of the College requirements even with a relatively under-staffed and underresourced service, but did not comment on the proportion of trainees fulfilling all requirements.
Bateman & Holmes (Reference Bateman and Holmes2001) described three main reasons for reappraisal and revision of the 1993 guidelines (Reference Grant, Holmes and WatsonGrant et al, 1993): the need to consider core competencies and how to develop and sustain them as part of lifelong learning; the problem and rarity of full implementation of the 1993 guidelines; and a greater concentration on the role of psychological therapies in psychiatry, rather than different modalities of psychotherapy.
A response rate of 66% for a postal survey is acceptable and allows cautious conclusions to be drawn about the study population. The finding that one-third of respondents met the College's requirements is similar to earlier surveys relating to the previous guidelines. It shows that in a substantial majority of cases, trainees did not get the variety of psychotherapy experience expected by the College, despite College guidelines and attempts to advance psychotherapy training.
More trainees considered themselves to be competent in cognitive or integrative modalities of psychotherapy, perhaps a reflection on training in these modalities being easier to access and less onerous. Similarly, more than one-sixth of respondents were qualified in some form of psychotherapy, but none in transference-based psychotherapy. The very weak association between either self-perceived competence or qualification in psychotherapy and meeting the College's requirements for psychotherapy training is not entirely surprising, given their broad focus.
Even those interested in psychotherapy frequently fail to meet the requirements. This suggests that practical and organisational hurdles continue to limit access to the wide range of psychotherapies. The MRCPsych part II candidates may not always accurately declare their actual experience when their own career progress may be threatened by limitations of their training scheme. A subsequent telephone survey of an opportunity sample of six MRCPsych part II candidates, who were eligible to sit the examination in May 2004, found that none knew the exact requirements and that only one met them. It is crucial to ensure that training schemes provide adequate and easily accessed supervision in all modalities of psychotherapy, as well as special interest training posts in psychotherapy, as a compulsory element of accreditation. Anonymous surveying of trainees during accreditation visits would provide a means of verification.
Among respondents who stated an interest in gaining further experience or developing a special interest, cognitive therapies were most popular (Table 2). Janmohamed et al (Reference Janmohamed, Ward and Smith2004) found similar levels of interest in a 1-year psychotherapy post among basic psychiatric trainees (73% in 1998 and 64% in 2002). After the introduction of 2 h of protected psychotherapy time per week, the percentage of trainees in their survey who expected to meet College guidelines increased from 51% in 1998 to 87% in 2002. This shows that organisational change can improve exposure to different psychotherapy modalities.
This survey has a number of limitations. Specialist registrars in psychotherapy were excluded since an interest in psychotherapy has already been demonstrated. It would have been interesting to know whether they were more likely to have met the requirements. The questionnaire did not differentiate well between supervision in the different modalities of psychotherapy. It is therefore not possible to speculate to what extent limits in the availability of supervision, in a wide range of psychotherapies, may contribute to the high proportion of trainees who still do not meet the College's requirements.
Declaration of interest
None.
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