Thinking Cradle to Grave

Thinking Cradle to Grave

Developing Psychotherapeutic psychiatry

A Meeting of Minds: In Dialogue with Human Distress and Disturbance; Patients, Doctors and the NHS

Friday 19

April 2013

Joint conference with the Royal College of General Practitioners

Thinking Cradle to Grave

A Lifelong Therapeutic Education Strategy in Medicine

Abstract

Thinking Cradle to Grave

The Medical Psychotherapy Faculty Education and Curriculum Committee therapeutic education strategy Thinking Cradle to Grave(developing psychotherapeutic psychiatry)

is grounded in a philosophy of medical practice evidenced by the UK Psychotherapy in Psychiatry Survey 2012 and the GMC quality assurance review of medical psychotherapy in 2012.

The philosophy behind Thinking Cradle to Grave is that the development and

maintenance of a therapeutic attitude in medical practice requires a robust and sustained model of therapeutically orientated educational experiences which begin at medical school and continue throughout the career of the doctor.

The primary task of the Medical Psychotherapy FECC in the Royal College of Psychiatrists is to develop high quality training in psychotherapeutic psychiatry.

The cross fertilisation of psychiatry and psychotherapy requires a cross fertilisation in the world of medicine more broadly and in the development of doctors who will not become psychiatrists. The relationship between psychotherapy and psychiatry is a relationship between two paradigms which offer clinical synergy in the care of patients. This echoes the relationship between psychotherapy and medicine which offers synergy in mind and body in the care of patients.

The Thinking Cradle to Grave strategy mirrors in the therapeutic development of the doctor the path of human development from cradle to grave.

The uncertainty of the cradle and looking to the future is brought into sharp relief by the certainty of the grave and memories of the past, reflecting on life from beginning to end. The human helplessness of the infant is brought into a lifelong relationship in medicine in the emotional impact of morbidity and death, reflected in psychiatry by twinned concerns surrounding primitive disturbed states of mind and risk.

The therapeutic attitude of the developing doctor requires lifelong attention and structures which support the inevitable anxieties and disturbance which are evoked in their work and which require a regular rhythm of recognition. Without such a rhythm of recognition, the human experience can be subsumed by the task, the doctor becoming oblivious.

The professional who becomes oblivious echoes an oblivion that is a common complaint about the caregivers of the past and about the NHS in the present.

Thinking Cradle to Grave

The cradle and the grave the reader is invited to think about in the title refer both to the development of the patient and the development of the doctor. In relation to the patient the cradle and the grave represent the developmental extremes of life and the depth of mental disturbance arising from these extremes.

Thecradlesignifies primitive developmental states of mind and thegravesignifies the gravity of facing death or mourning loss and the risk of death that is the pervasive anxiety arising from unbearable states of mind.

In relation to the development of the doctor the cradle and the grave represent personal life experiences and the lifelong learning trajectory of education, continuing professional development and revalidation.

In psychiatry the cradlesignifies confronting the sometimes devastating impact of primitive emotional disturbance and the anxieties and aggression that surround the

grave emanating from the risk of death. To be or not to be: is that the question?

The ontological questionto be or not to beis posed to the UK doctor with an interest in psychotherapy considering psychiatry training: do they train to be a psychotherapist and not to be a psychiatrist?

The dilemma in contemporary psychiatry training for psychotherapeutically minded doctors is that medical psychotherapy has increasingly become a separate discipline from mainstream psychiatry.

TheThinking Cradle to Gravetherapeutic education strategy challenges this to be or not to be training question. It proposes an alternative: the development of the

psychotherapeutic psychiatrist who questions not only their patients but themselves in relation to their patients.

The development of psychotherapeutic psychiatry involves recognition that the majority of people suffering from mental illness, personality disorder, mental pain or mental deadness will not see medical psychotherapists but many are likely to see psychiatrists. A robust psychotherapeutic training that parallels and equals the strength of biological training is necessary for those psychiatrists because it is necessary for their patients. For psychiatrists (and all mental health professionals) to be able to develop and maintain a capacity to bear and think with people suffering extreme mental disturbance they need to sustain a clinical routine of protecting reflective space in which to examine their own emotions in response to the people who come to them.

Developing psychotherapeutic psychiatry

Developing psychotherapeutic psychiatry may address those who are undecided about a career in psychiatry, early in psychiatric training or still therapeutically receptive in their mature development. Influence across the generations is vital to making a difference for future generations of psychiatrists and patients.

The difference made to the psychiatric profession could be in improving recruitment to psychiatry, securing greater retention of psychiatry trainees in psychiatry and enriching the revalidation of psychiatrists who embrace therapeutic development as part of their clinical practice.

The therapeutic education strategy aims to foster a therapeutic attitude of mind in the heartland of mainstream psychiatry so that psychotherapy begins to lose its peripheral position so it is less an activity of others called medical psychotherapists, adult

psychotherapists or clinical psychologists and more a therapeutic way of thinking about their patients psychiatrists see to be vital in their identity as a psychiatrist.

Why train psychiatrists in psychotherapy?

If psychiatrists aspire to think therapeutically but will not ‘do psychotherapy’ why train them in psychotherapy?

This question was posed in the UK Psychotherapy Survey (September 2012) which evaluated the core psychotherapy training of psychiatrists in the United Kingdom. A question posed by a psychologist working as Psychotherapy Tutor for a core psychiatry scheme, it is a question based on the premise that psychotherapy training for

psychiatrists is aimed at the delivery of psychotherapy as an intervention.

The aim of psychotherapy training for psychiatrists is not to train the majority of them to be psychotherapists but to train them to be psychotherapeutic psychiatrists. The UK Psychotherapy Survey revealed that psychiatrists trained as medical psychotherapists are five times more likely to fulfil the core psychotherapy curriculum as Psychotherapy Tutor. The Consultant Psychiatrist in Psychotherapy is needed to lead training of psychiatrists but this training is only meaningful in the context of a clinical service in which psychotherapeutic psychiatry can be seen to be relevant throughout psychiatry. The notion that psychotherapy is a peripheral activity undertaken only by those trained as psychotherapists reinforces the split of psychotherapy from psychiatry.

All of the following educational interventions in the therapeutic education strategy focus on integrating a therapeutic attitude in the development of reflective medical

practitioners.

Whether or not a foundation doctor decides on a career in psychiatry it is important that the profession of psychiatry does not deter therapeutically minded medical practitioners. A central contention of theThinking Cradle to Grave therapeutic education strategy is that psychotherapeutic experience at undergraduate and early postgraduate levels will influence doctors with an interest in the mind.

It is a ‘no brainer’ that neuroscience will be enough to attract some doctors to psychiatry but for others who are in two minds based on a concern that psychiatry lacks the human touch, evidence that psychotherapeutic psychiatry is alive and flourishing will be an important recruitment ‘pull’ factor.

Developing a therapeutic model of mind

The theme underlying the therapeutic education strategy is that the doctor who specialises in psychiatry needs a model of mind which can help to contain and understand the disturbing feelings psychiatric work with some patients evokes in professionals.

The phenomenology of psychiatry is not in itself sufficient to contain the disturbance evoked in the psychiatrist and where difficult patients evoke difficult feelings the person behind the well observed problem is not seen, a blind eye being turned to the internal world of meaning of the person.

Thinking cradle to grave places the development of self reflective capacity in the practitioner at the heart of therapeutic work.

Summary of strategic interventions from theThinking Cradle to Gravestrategy Curriculum amendments proposed to the GMC

Core psychiatry curriculum

Following presentation of theThinking Cradle to Grave ideas on developing

psychotherapeutic psychiatry in the College Curriculum and Assessment Committee a working group has been established to develop psychotherapeutic amendments in the core psychiatry curriculum in relation to developing reflective practice as a training leitmotif as a learning outcome and a thematic developmental process in core psychiatry training.

Advanced medical psychotherapy curriculum

Because of the inhibiting therapeutic impact of an unexamined mind in the professional in relation to the examined mind of their patients, amendments to mandate personal reflective development in the advanced medical psychotherapy training level curriculum have been proposed. The amendments include a strengthened statement regarding

model congruent self reflective developmentin a new Intended Learning Outcome: Self Reflective Practice. These amendments to the curriculum will be proposed to the GMC in April 2013.

Advanced general adult psychiatry curriculum

Amendments which strengthen elements of therapeutic exposure in the advanced curricula beginning in the advanced general adult psychiatry sub-specialty curriculum in relation to Balint groups and long therapy cases within the Intended Learning Outcome Reflective Practice are being proposed to the GMC in January 2013.

Advanced or higher medical psychotherapy dual and single CCT training

Dual training in medical psychotherapy with general adult psychiatry was ratified by the GMC in January 2012.The dual training is five years in length and can be in a concurrent integrated CCT or sequential CCT model.

Sequential dual training predates the introduction of integrated dual training in medical psychotherapy and general adult psychiatry in 2007. What is novel is the integrated or concurrent CCT model of dual training in medical psychotherapy and general adult psychiatry in parallel, underscoring the philosophical template of a bilateral

developmental relationship fostering an internal dialogue in the trainee between the two different paradigms of mind experienced in training in psychiatry and psychotherapy in the same working week.

UK Psychotherapy Survey 2012

The UK Psychotherapy Survey report was published in September 2012. The survey evaluated delivery of the core psychotherapy curriculum in the UK and had a response rate of over 80%.

The statistically significant finding is that the psychotherapy curriculum is five times more likely to be fulfilled when the Psychotherapy Tutor is a Consultant Psychiatrist in Medical Psychotherapy.

The UK Psychotherapy Survey also addressed the attitude of the Schools of Psychiatry to dual training in medical psychotherapy which received unanimous support.

The recommendations arising from the UK Psychotherapy Survey are:

1. Consultant Psychiatrists in Psychotherapy should lead the coordination and educational governance of all core psychotherapy training in psychiatry as Psychotherapy Tutors.

2. The aims of core and advanced psychotherapy training need to be linked

developmentally focusing on training which is a better fit for trainee capacity and is fit for the purpose of the work of psychiatry.

3. Multidisciplinary participation in core and advanced medical psychotherapy training should be formally developed, organised and led by Consultant Psychiatrists in Medical Psychotherapy.

GMC Review of Medical Psychotherapy

The General Medical Council has undertaken a QA review in 2011-2012 of Medical Psychotherapy as one of three smaller medical specialties which incorporated the findings of the UK Psychotherapy Survey including follow up questions addressing the contributions of different professions to psychotherapy training in psychiatry. The GMC report on the Review of Medical Psychotherapy was published in December 2012. This report will outline the deanery requirements, recommendations and underlines good practice in psychotherapy training including emphasis on the leadership role for Medical Psychotherapy in developing psychotherapeutic psychiatry. An action plan following the report’s recommendations will be published in April 2013.

Medical Psychotherapy in Psychiatry Summer Schools and Recruitment

A medical psychotherapy contribution in Psychiatry Summer Schools for sixth formers and medical students interested in psychiatry has been developed in 2011 and 2012.

Drawing from Life(psychoanalytic pictures of psychiatry) is on the RCPsych website for student associates. Running reflective practice groups for medical students as a vehicle to think about psychotherapeutic psychiatry have been effective. The GMC have

endorsed this Medical Psychotherapy FECC contribution to recruitment in their QA report on medical psychotherapy.

Oxford University Press Handbook of Medical Psychotherapy

An OUP Specialist Handbook of Medical Psychotherapy is being edited for publication in 2014. The lead editor is Dr James Johnston with associate editors Dr Gwen Adshead and Dr Stirling Moorey. The book is a compendium of contemporary medical psychotherapy written by medical psychotherapists, medical psychotherapy trainees and other

professions as an evidence based reference guide on a range of psychotherapies. The book is aimed at foundation trainees, core and advanced psychiatry trainees and general practitioners in training.

Medical Psychotherapy Faculty and Royal College of General Practitioner Conference

The Chair of the Medical Psychotherapy FECC presented the Thinking Cradle to Grave

strategy for developing and sustaining psychotherapeutic psychiatry at the annual faculty conference in Stratford upon Avon in April 2013.

A message in the presentation was a clinical caveat linked with the GMC QA medical psychotherapy training review requirement for medical psychotherapy leadership in core psychiatry psychotherapy training.

Balint Groups

Balint groups are established or are being developed for the following levels of medical practitioners:

 Undergraduate: to be offered beyond psychiatry placement years.

 Foundation years one and two: established for psychiatry F1 and F2 in Yorkshire 2011.

 Foundation years one and two: to be extended to include non psychiatry

placements in the new broad based foundation training (Psychiatry, Child Health, Internal Medicine and General Practice).

 Core psychiatry training years: to be extended from mandatory first year to span CT1 to CT3.

 Advanced psychiatry training years: ST4 to CCT.

 Consultant Psychiatrist: established in Yorkshire in 2008 offered to all psychiatry sub-specialties.

Medical Psychotherapy Faculty Website

The Medical Psychotherapy Faculty part of the site updated to clarify the aims of psychotherapy training:

 What is the purpose Balint groups? What are the requirements?

 What is the aim of a longer term therapy case? What are the requirements?  What is the aim of the shorter therapy case? What are the requirements?

 Clarify work place based assessment guidance for psychotherapy: formative and summative.

 Structured Assessment of Psychotherapy Expertise (SAPE); who can complete this formative WPBA?

 Psychotherapy Assessment of Clinical Expertise (PACE); who can complete this summative WPBA?

RCPsych and RCGP joint Council Report on Psychological Therapies in Psychiatry and Primary Care

Medical Psychotherapy Faculty and Royal College of General Practitioners joint scoping group to update the Council Report (CR151) as part of the Medical Psychotherapy Faculty Strategy.

T

HE

B

RICK

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OTHER

The psychoanalyst and psychiatrist Henri Rey (1912-2000) referred to the Maudsley psychiatric hospital as the ‘brick mother’. I think this description of the psychiatric hospital captures both the regressive longing to be contained in a very concrete sense, to be held even in the arms of a brick mother to protect against the fear of breakdown. In another sense the obliviousness in care giving that so often permeates the narrative of such patients is echoed in the impervious nature of that which now holds them, the painful evidence of limitations in the institution echoing the oblivion in their history.

T

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RADLE

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RAVE

The cradle grave sadly allows no space for life and development.

Defining and developing space for reflection is central to the Thinking Cradle to Grave education strategy.

The loss of space to think is reflected in the manic defence signified by the Do Do Bird below: the dominant conscious ‘do do or die’ defence which is preoccupied with risk to the patient replaced frequently by a ‘do do or disciplinary’ defence which is preoccupied by a risk to the professional.

The professional risk is of the exposure to the shame of negligence and judgement, which is transfused through the organisation into the veins of clinicians.

T

HE

D

O

D

O

B

IRD

The ontological angst of the mental health professional; to be is to be (Sartre), to do is to be (Nietsche) or do be do be do (Sinatra).

L

EARNING TO

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ISTEN

The aim of psychotherapy training in psychiatry is to learn to listen. The capacity to listen to the patient is proportional to the professional’s capacity to listen to their experience of the patient.

F

ROM

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REUD TO

F

RED

Speaking the language of psychotherapy in psychiatry requires translation of complex psychoanalytic ideas into accessible language, translating Freud into Fred.

The apparent disappearance of Freud in psychiatry may be because his ideas remain more relevant in the crisis situation of psychiatry (both acute and chronic crises) than is recognised.

Reports of the death of Freud may be exaggerated when it comes to finding appropriate help.

T

HINKING

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RADLE TO

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RAVE

The basis of the cradle to grave strategy is the psychoanalytic recognition of the early infant experience and its repetition throughout later life, particularly reflected in risk related anxieties which evoke disturbance in self and other.

The notion of cathexis or taking in the experience of the other is linked with Bion’s concept of reverie and the container contained relationship.

R

EVERIE

Bion’s container contained concept (1962). The unconscious process of working through unthinkable feelings.

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NTROJECTIVE

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DENTIFICATION

Taking in or cathecting the patient. Holding the other in mind involves emotional working through of pain and conflict.

W

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IN THE

C

OUNTERTRANSFERENCE

The first is a fictional therapist calledThe Psychic Warrior for whom reflecting on himself is central to working through.

The second isBorderline Professional Disorderin which a frozen inability to remember (obliviousness) echoes early oblivion.

The cartoon series shown in the conference are available from the Royal College of Psychiatrists through Roseanne BrakeRBrake@rcpsych.ac.uk