Psychotherapy training wheels

To the Editor

As an incoming psychotherapy educator in Northern Sydney, I read with great interest the recent correspondence between Jureidini (2012) and Harari (2013) on the place of psychodynamic thought, both in psychiatry in general, and more specifically in a busy psychiatric emergency setting. Ultimately, both seem to be making very similar statements about the importance of psychodynamic principles in general practice, and very sensibly invoking the old pillars of empathy, reflection and broader formulation as the containers within which general psychiatric practice becomes meaningful.

In this regard, Jureidini’s (2012) invocation of minimalism is an interesting choice. Minimalism is of course an artistic movement that revolves around removal of the unnecessary and paring back to only the essential components, and it (like psychotherapy) is not without controversy. For minimalism to work, there must be a degree of conceptual familiarity (and ideally historical context) on the part of the viewer – a painting consisting solely of a black canvas square may simultaneously be a bold statement in artistic self-definition to the cognoscenti, and a meaningless waste of canvas to the less artistically inclined. Similarly, if you are psychodynamically fluent, even a brief interaction can be elegant and meaningful, be it the starting point for a more detailed exploration, as in Harari’s article (2013), or a thoughtful limited intervention within a practically constrained frame, as Jureidini originally described. However, without the psychodynamic thought that informs that interaction, the brief emergency psychiatry admission becomes a confusing blank canvas that addresses safety and (perhaps) diagnosis, but leaves meaning and narrative in the hands of the patient.

In this context, it is worth pausing to note that Jureidini’s (2012) story starts with a baffled trainee, and to consider where such minimalism fits into psychiatric training. We practice in an era where medication is a dominant force, and where there are reasonably clear indications that, over decades, the pendulum has swung from over-reliance on psychodynamic theory (Paris, 2005) to over-reliance on medication (Rosenbluth et al., 2012). Training reflects this, such that it is now possible to complete the training provided by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) without much attention to psychodynamic thought – although the formal training structure can certainly support excellence in this regard, the nature of implementation on the ground is variable. Generalist training requires the delivery of only 150 h of psychotherapy (70 in basic training, 80 in advanced training), which is approximately 1.5% of training time over a period of 5 years. Further, the practicalities of case examination mean that we assess the trainee’s ability to tell a story about therapy rather than actually conduct it. Additionally, psychodynamic theory could hardly be said to be a major focus of written examination, and the psychotherapies are relegated to a handful of entries in the new competency-based system. Advanced training in the psychotherapies, although excellent, attracts only a minority of trainees. Psychological treatment (of any modality) is often implemented patchily in the public sector, and although some registrars will be lucky enough to land in a centre of excellence or be exposed to an inspiring practitioner, most training experience is in the medical model, with psychology as something that happens somewhere else and is done by someone else. Psychiatrists for whom psychodynamic experience was mandatory are moving towards retirement, and with that we risk the knowledge base that informs such interventions draining gradually from the system.

The net result is that the vast majority of practical experience in RANZCP training is exactly the sort of psychodynamic minimalism described by Jureidini (2012). It may be an understandable clinical compromise in a complex environment, but when we consider it as a dominant training experience, it is appropriate to ask whether it is adequate or comprehensive. There is a de facto statement inherent in framing psychological thought up as something to fit in between service requirements, rather than an integrated part of practice for every patient, and although both Jureidini and Harari (2013) are clearly practising elegantly and striving to avoid this pitfall, the balance between psychological experience and biomedical experience in training is certainly questionable. To formulate in a sophisticated way or implement a brief psychotherapeutic interaction well, you need to be comfortable and fluent with the relevant concepts, and this takes substantive training and experience, rather than simply intermittent exposure to an expert who knows what they are doing. If you were to start and finish teaching art history with minimalism, your students could be forgiven for developing a dim view of the exercise, and if psychotherapy in training settings is too minimalistic, that will have consequences for the profession as a whole.