Training in psychotherapy is a mandatory part of general professional training in psychiatry. The College produced guidelines in 1993 outlining the breadth and depth of training required (Royal College of Psychiatrists, 1993).

Although the Government, the College and our patients expect their psychiatrists to be well trained in psychotherapy, surveys published on psychotherapy training repeatedly show shortcomings in its delivery (Reference Arnott, Wilkinson and AylardArnott et al, 1993; Reference Hwang and DrummondHwang & Drummond, 1996; Reference Hamilton and TracyHamilton & Tracy, 1996; Reference McCrindle, Wildgoose and TillettMcCrindle, et al, 2001). Despite the undoubted good intentions of tutors, it seems difficult to actually deliver training in psychotherapy to the standard required by the guidelines.

In this paper we wish to explore the strengths and weaknesses of different approaches to psychotherapy training and to discuss ways in which it might be improved.

Different models of delivering psychotherapy training

A widely used model of psychotherapy is that of ad hoc training being made available to trainees without a structured programme. Davies (Reference Davies1998) describes his own efforts to arrange psychotherapy training experiences in South Wales, where there was no consultant in psychotherapy and no dedicated service. Ad hoc training often appears to offer a greater range of experience from that on offer from a formal half-day release scheme, but is dependent on the trainee's motivation, and the willingness and availability of others to provide training and supervision. Ad hoc training also makes it more difficult for trainees to ensure training time is protected and College approval visits suggest that this informal way of delivering training is often unsuccessful.

An alternative model is that of a 6-month dedicated psychotherapy post. This offers a greater intensity of exposure to psychotherapy training. Allowing for other educational activities, study and annual leave, we estimate a dedicated 6-month post will offer approximately 500 hours of training. One would expect that this large amount of time spent in a dedicated placement would allow an increased exposure to therapy training experiences. However, there can be logistical problems if a therapy group is not starting and finishing parallel with the trainee's rotations and there is often time spent initially acclimatising to the post. In addition, the short duration of a 6-month post will not allow more in-depth therapeutic work, for example along psychodynamic lines.

A third model of psychotherapy training is that it is delivered along a half-day release basis. Such a scheme has been in operation in Exeter for several years and has attracted favourable comments from College approval visits. We suggest it as a possible model for other training schemes.

Details of the Exeter psychotherapy training half-day release scheme

The training programme is organised on a 2-year programme cycle and provides specific training and clinical experience in cognitive—behavioural therapy (CBT) and cognitive—analytic therapy (CAT) together with a comprehensive seminar programme (see fig. 1). Trainees completing the first 2-years can gain further experience during an elective third year, particularly in psychodynamic, group and family therapy.

Fig 1. Training programme (CAT, cognitive—analytical therapy; CBT, cognitive—behavioral therapy).

Training takes place on Thursday afternoons in the psychotherapy department of the psychiatric hospital. All trainees are expected to attend and their clinical timetables reflect this. Ward work is covered by non-training grade psychiatrists and general practitioner trainees. In theory the training should be ‘bleep-free’, but this does not always happen in practice. The training is convened by the consultant psychiatrist in psychotherapy, who reviews the trainees' progress annually using the College log book. Trainees join the programme in the September, following appointment, and are allocated to one of the two supervision groups, A or B.

Each year's programme starts with an introduction covering the curriculum for the MRCPsych exam (Royal College of Psychiatrists, 2001), the College training guidelines (Royal College of Psychiatrists, 1993) and an outline of the different approaches to therapy.

After the introductory sessions, the remainder of the autumn term is used to deliver theoretical and skills-based training in CAT and CBT in small groups of three to four trainees. Group A studies CAT in the first year and CBT in the second. Group B studies CBT in the first and CAT in the second. The trainers are experienced and accredited psychotherapists within their particular model. Theoretical underpinning and therapeutic skills are introduced during extended 3-hour tutorials.

Supervision continues on a weekly basis during the rest of the academic year. Patients are selected from the psychotherapy department waiting-list as suitable training cases and discussed with the supervisor in advance. Trainees are expected to see two cases consecutively within the year.

Groups A and B combine for the seminar programme that commences in January and runs throughout the spring and summer terms for 1.5 hours weekly. The programme is delivered by psychotherapists accredited and working within the theoretical model taught. Psychodynamic, group analytic and systemic approaches are covered in detail. There is also an introduction to other therapies such as client-centred and gestalt. Trainees are encouraged to read relevant papers and texts in advance for discussion within the seminar. Key concepts in psychodynamic and systemic therapy are discussed in respect of specific psychotherapeutic and general psychiatric practice and extensive use is made of case discussion.

The third year is optional. Trainees are encouraged to choose from a variety of psychotherapeutic opportunities including co-leading out-patient psychotherapy groups, acting as co-therapists in family therapy or taking on an individual patient for longer-term dynamic therapy under weekly supervision.

Throughout the training programme trainees are encouraged to attend the Balint type group run by a member of the psychotherapy department. Trainees wishing to pursue individual therapy are given every encouragement in finding a suitable therapist but this is not a compulsory part of the training.

On the face of it, the half-day release model offers substantially less time in psychotherapy training than the dedicated 6-month post. However, 275 hours are spent in total over the 2-year scheme on theoretical and practical training. Should trainees opt for an elective third year allowing more in-depth longer-term work, this adds approximately 120 more hours to the training, bringing it up to approximately 400 hours in total. This compares favourably with the 500 hours estimated for a dedicated 6-month psychotherapy post. In addition, there is opportunity for longer-term, more in-depth therapeutic work, given the extended time period of the training.

A great strength of the half-day release model is that it ensures that all trainees achieve basic clinical competence in psychotherapy, whereas a dedicated psychotherapy post may not be available for all trainees or only attract those who are psychotherapeutically-minded. In our scheme the elective third year allows trainees to choose whether or not to continue beyond basic training in psychotherapy. Around half of trainees in recent years have opted to do this.

Improving psychotherapy training

The best way to provide psychotherapy training has to be decided locally by each scheme organiser or tutor in consultation with local trainees and will depend on geography and available resources, particularly personnel. Whatever approach is taken, designated and protected time for training is essential.

It helps if trainees are assertive. Shortcomings in local provision can be raised through the local training committee and are more likely to be resolved if the trainees themselves make suggestions about how this could be done. Trainees should not, however, be left to organise their own training!

Tutors and scheme organisers will usually need the help of a suitably experienced specialist colleague to ensure that psychotherapy training is organised effectively. Ideally this will be a consultant psychotherapist. Alternatives might be a psychiatrist with designated responsibility for psychotherapy training or a senior clinical psychologist. Whether the coordinator of training is a psychotherapist, psychiatrist or psychologist, he or she will need to have an understanding of the needs of trainees, clear objectives for training and an ability to negotiate with the clinical tutor, consultant psychiatrist and managers. Experience in the south-west of England suggests that the organiser will need two sessions per week to set up and maintain an effective training programme.

The College guidelines for psychotherapy training are currently being revised and will in future set explicit and achievable standards. What is less clear, however, is what will happen if these standards are not met. Historically, the College, through its approval panel visits, has been reluctant to withdraw training approval from schemes despite inadequate psychotherapy training. Other sanctions that have been discussed include limitation of training approval, for example to 18 months or 2 years instead of the customary 3 or 4 years, or the possibility that completion of psychotherapy training might become a prerequisite for registration for College membership, as is the case with child psychiatry/learning disability.

The widespread shortcomings of psychotherapy training are well documented and might be said to represent our profession's traditional ambivalence towards psychological treatments. The situation is further impaired by a national shortage of consultant psychotherapists. The Department of Health, however, has emphasised the importance of psychotherapy within mental health services and the revised College guidelines for psychotherapy training should help to ensure that psychiatrists of the future are adequately equipped in this respect. Trainees and trainers will need to work together to ensure that successful training actually takes place.