A guide to support trainee’s success in the psychotherapy written case submission

Abstract

Objective

Many trainees find the Psychotherapy Written Case (PWC) requirement of the Royal Australian and New Zealand College of Psychiatrists training program challenging. The skills developed and assessed through this experience are critical to the competencies expected of a psychiatrist. However, the process of psychodynamic psychotherapy is often dramatically different from the expectations associated with early clinical placements in acute psychiatric settings. To support trainees in achieving success in the PWC, a guide to the written report was developed based on a review of existing resources and various stakeholder perspectives.

Conclusions

The submission should reflect a training case rather than an idealised or fictionalised story attempting to demonstrate the therapist’s competence. The PWC submission must meet the requirements of a general psychiatric report and provide a considered reflection on the experience of the novice therapist.

Passing the Psychotherapy Written Case (PWC) is a mandatory requirement of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) training program. Successful completion of the case involves a trainee seeing a patient for at least 40 weekly sessions of psychodynamic psychotherapy under the guidance of an accredited supervisor and then submitting a case report summarising the psychological assessment, progress of therapy, and reflections on the case experience. The PWC submission allows trainees to develop skills in professional report writing and sophisticated formulation. ¹ However, historically the psychotherapy case requirements have been described as a ‘daunting task’ ² by trainees, and in the 2016 RANZCP Admission to Fellowship survey, only half of the respondents agreed that their training in psychotherapies had been satisfactory. ³

The pass rate for the PWC has hovered around 70% for many years. Our experience is that many trainees initially struggle to understand the requirements of the case report submission. Over the period 2021–2022, almost 90% of unsuccessful cases did not meet the standard across multiple marking domains, and more than 50% of unsuccessful cases had deficits across four or more of the eight marking domains. ⁴ The PWC submission may be challenging for trainees as the process of psychodynamic therapy and preparation of detailed reports differ dramatically from the experiences and expectations of early clinical placements in acute psychiatric settings. Much of their training focuses on crisis and risk management and the biological aspects of psychiatry,^5,6 particularly early in the training pathway. As a result, trainees may feel comfortable to describe their case presentation, but have more difficulty in thinking about, understanding, and working through psychodynamic models of care as it relates to their specific case. However, psychodynamic thinking remains a critical orientation in psychiatry, underpinning guiding assumptions such as early life experiences influencing later struggles, unconscious processes’ role in day-to-day life, and doctor-patient interaction. ⁷ Skills in psychodynamic thinking remain helpful in assessing and treating a wide range of psychiatric presentations, making this an important skill to develop in trainees.

The PWC submission also assesses professional written communication. It is the only assessment of report writing skills in the current iteration of the RANZCP training program. Although report writing is a core competency expectation of psychiatrists, many trainees have limited opportunities to develop comprehensive formulations with patients ⁸ and prepare similar reports. ¹ Several Branch Training Committees (BTCs) make a de-identified case history library of past successful submissions available to trainees. These will reflect the broad range of passing standard and there may be challenges associated with using another trainee’s case as a template to capture the unique narrative of each long case experience.

The PWC is a unique assessment that requires considerable time and effort. While undertaking the minimum 40 hourly sessions, trainees receive supervision (preferably weekly), engage in formal case-based discussions, maintain detailed process notes, and read texts and papers to inform their understanding of relevant theoretical frameworks. ⁹ However, competing training and life commitments mean that some trainees struggle to adequately complete these tasks during therapy progress. In addition, writing the report following therapy completion requires synthesising large amounts of observed and inferred information to develop a coherent self-reflective narrative of the patient and therapy grounded in a specified therapy model. Given these demands, it is unsurprising that some trainees find the PWC report submission daunting.

Our experience is that accredited RANZCP psychotherapy written case supervisors are often more confident in supervising the therapy than supporting the case write-up. The expectations of the report, extensively detailed in the Policy and Procedure, ¹⁰ encompass features of a general psychiatric assessment report going beyond the expectations of a psychoanalytic case report. Furthermore, the size of the submission report (8000–10,000 words) means it is unfeasible for other training supports, such as Directors of Training, to provide feedback on reports before submission. The Queensland experience suggests it takes between three and 10 h to provide individualised feedback to a trainee to guide their successful re-admission of a failed PWC.

To address the challenges experienced by trainees in preparing the PWC submission report, Post-Graduate Training in Psychiatry (Queensland, PGT-QLD) developed a report template. This paper describes the template’s development and shares the resource for the benefit of trainees and their supervisors.

Methods

Various stakeholders collaborated to develop the template with the core team including Directors of Training, accredited members of the Faculty of Psychotherapy, and a Stage 2 trainee completing the PWC. The relevant RANZCP policy and forms guided the generation of the template’s structure, with the initial content subsequently elaborated based on resources on the RANZCP website and other sources (see Table 1). Experience and resources developed through assisting trainees respond to feedback in the re-submission process of unsuccessful cases was used to further inform the content (see Table 2). The guidance was iteratively developed with input from each co-author and then revised following consultation with trainee representatives and the Queensland BTC.

Table 1.

Resources informing the initial development of the psychotherapy written case submission guidance

Source	Resource	Relevance
		Structure	Content
Australasian psychiatry	Formulation in psychiatry – a guide to developing competence 11		X
Psychscene	Avoiding pitfalls in the RANZCP psychotherapy case 12		X
	How to write a psychotherapy case – RANZCP 13	X	X
Qld psychiatry training	Passing the psychotherapy written case 14		X
RANZCP LearnIT	Trainee support webinar series: Navigating the psychotherapy written case 15		X
	Training program – Psychotherapy written case 16	X	X
RANZCP website	Developmental descriptors 17		X
	Guide to psychotherapy training 9		X
	Observed clinical activity (OCA) formulation guidelines 18		X
	Psychotherapy written case – Congress 2022 4		X
	Psychotherapy written case marking sheet 19	X	X
	Psychotherapy written case policy and procedure 10	X	X
	The psychotherapy case in the RANZCP 2012 CBFP 20		X
The psychotherapies	Psychological formulation in the assessment interview 21		X
www.psychtraining.org	Memo about finalising the PWC 22		X

Note. PWC = Psychotherapy Written Case (PWC)

Table 2.

PWC submission guidance: Sections, key points, and key resources

Section	Key points	Key/suggested resources
General overview	Adhere to the submission guidelines concerning de-identification and formatting	PWC case marking sheet 1
		PWC policy and procedure 2
	Proofreading is essential	Professional services or digital tools such as Grammarly.com
	It is a training case, not a model case; acknowledge mistakes and be vulnerable	-
Introduction	Single paragraph introducing the context and purpose of the report	-
Assessment	Develop a coherent narrative using the standard headings of a psychiatric assessment report	Kaplan and Saddock’s synopsis of psychiatry 12th edition 3
Mental state examination	Must be detailed and accurate, including consideration of relevant negatives	The psychiatric mental status examination 4
Initial formulation	Should flow logically from the assessment and cannot include new information	Psychoanalytic case formulation 5
	Not purely a psychodynamic formulation	Formulation in psychiatry – a guide to developing competence 6
Risk assessment	Consider risk issues broadly and ensure relevance to the case	Prevention-oriented risk formulation 7
Diagnosis	Diagnosis and differential diagnoses must adhere to a recognised diagnostic system and be justified by the assessment	That is, DSM5 8 or ICD-11 9
	Consider personality factors
Management plan	Specify and justify the intended model of psychodynamic therapy	Consider evidence and guidance specific to the chosen therapy model
	Is the proposed therapy preferable to alternative treatment approaches?	RANZCP clinical practice guidelines*
	Consider biological, psychological, and social aspects of treatment
Progress	Tell an honest and engaging story with a focus on the therapist-patient relationship	Process and supervision notes to identify disjunctions, interventions, and transference considerations
	Explore the termination phase in adequate detail
Re-formulation	Demonstrate the depth of understanding you developed throughout the therapy	See ‘Initial formulation’
	Not purely a psychodynamic formulation
Supervision	Reflect critically on your experience of supervision with honesty and vulnerability	-
Communication/Liaison	Described interaction with key stakeholders, including care arrangements post-termination	-
Discussion	Critically reflect on the therapy experience: what would you do differently, and how will the experience impact your practice	-
References	Use referencing software	For example, Endnote/Mendeley/Zotero

Note. PWC = Psychotherapy Written Case (PWC)

Results

The final psychotherapy written case submission guide matched the PWC’s recommended structure and formatting requirements (Supplementary File 1, see Table 2 for an overview). In addition, content guidance and additional resources (where relevant) were detailed.^23–28 Queensland trainees have already provided positive feedback on the usefulness of the guidance in supporting the drafting of PWC submissions.

Discussion and conclusion

It is anticipated that the PWC report guidance will make writing up the PWC case submission less daunting for trainees. Initial feedback from stakeholders, including trainees and supervisors, has been positive. Hopefully, this resource will improve the success rate of PWC submissions in Queensland. Early feedback suggests this is the case.

Supplemental Material

Supplemental Material - A guide to support trainee’s success in the psychotherapy written case submission

Supplemental Material for A guide to support trainee’s success in the psychotherapy written case submission by Korinne Northwood, Nicola Warren, Jimsie Cutbush, and Stephen Parker in Australasian Psychiatry.