Barras & Harris's survey on retention difficulties in psychiatry^{Reference Barras and Harris1} in provoking further discussion about the state of psychiatric training is an important piece of work. The systemic effects of the current economic crisis cannot be separated out from implications to services and in turn their impact is felt by those working and training within the system. Having myself recently completed higher training in psychotherapy, and through my experience of facilitating trainee case-based discussion groups, many of the trainees’ comments picked up by Barras & Harris felt all too familiar.

In terms of trainee concerns over the attitude of others towards psychiatry, I very much agree with the thinking of the authors that better integration of psychiatry with other specialties may increase understanding of both the contribution of psychiatry and challenge of mental health difficulties. Alongside this, I also think it is important to recognise that to bear with the projected ‘madness’ of others, which may mean we are seen as unsettling and to be kept a distance from perhaps by devaluation, is an important function of psychiatrists. Trainees’ function as containers can be fostered, for example, in case-based discussion groups, enabling them to begin to understand and tolerate some of these processes as they are played out in their day-to-day work.

In Barras & Harris's study, when asked about work and patient care, trainees complained about too much paperwork and a pressure to appear to be ‘doing things correctly’, which both undermine the real patient care. The concept of social defence, as described by Menzies-Lyth in her study of poor medical nursing staff retention in hospitals,^{Reference Menzies-Lyth2} is helpful in thinking about some of these difficulties. In mental hospitals, working practices which reduce contact with patients, such as the care of an individual patient being split into tasks or reduplication of checks to eliminate or share the responsibility of decisions, are used by staff/managers because of a fear of being in contact both with patients’ and their own ‘mad violence’ and fragmentation. Further to this, the additional pressures of restructuring may both add to and be part of the same process. Ballatt & Campling in Intelligent Kindness ^{Reference Ballatt and Campling3} remind us that ‘there is certainly evidence that major structural change keeps senior managers and board members detached from the front line of healthcare’ (p. 131). In the face of this poor containment by the organisation, it is not surprising that morale is low among trainees.

The Royal College of Psychiatrists’ Faculty of Medical Psychotherapy has recently been working towards an education strategy for the renewal and development of a more psychotherapeutic psychiatry, with the aim of bringing psychotherapy to the heart of psychiatry. I think that the model of meaning and mind that psychotherapy brings to the practice of psychiatry is crucial in enabling us to work with our disturbed patients, and as such it should be embedded into training.