Thinking Cradle to Grave - Royal College of Psychiatrists Johnston.pdf · The Thinking Cradle to...
Transcript of Thinking Cradle to Grave - Royal College of Psychiatrists Johnston.pdf · The Thinking Cradle to...
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Thinking Cradle to Grave
Developing Psychotherapeutic psychiatry
A Meeting of Minds: In Dialogue with Human Distress and Disturbance;
Patients, Doctors and the NHS
Friday 19th April 2013
Medical Psychotherapy Faculty
Joint conference with the Royal College of General Practitioners
Dr James Johnston MA FRCPsych Chair, RCPsych Medical Psychotherapy FECC
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Thinking Cradle to Grave
A Lifelong Therapeutic Education Strategy in Medicine
Abstract
Thinking Cradle to Grave
The Medical Psychotherapy Faculty Education and Curriculum Committee therapeuticeducation strategy Thinking Cradle to Grave (developing psychotherapeutic psychiatry)is grounded in a philosophy of medical practice evidenced by the UK Psychotherapy inPsychiatry Survey 2012 and the GMC quality assurance review of medical psychotherapyin 2012.
The philosophy behind Thinking Cradle to Grave is that the development andmaintenance of a therapeutic attitude in medical practice requires a robust and sustainedmodel of therapeutically orientated educational experiences which begin at medicalschool and continue throughout the career of the doctor.
The primary task of the Medical Psychotherapy FECC in the Royal College of Psychiatristsis to develop high quality training in psychotherapeutic psychiatry.
The cross fertilisation of psychiatry and psychotherapy requires a cross fertilisation in theworld of medicine more broadly and in the development of doctors who will not becomepsychiatrists. The relationship between psychotherapy and psychiatry is a relationshipbetween two paradigms which offer clinical synergy in the care of patients. This echoesthe relationship between psychotherapy and medicine which offers synergy in mind andbody in the care of patients.
The Thinking Cradle to Grave strategy mirrors in the therapeutic development of thedoctor 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 thecertainty 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 inthe emotional impact of morbidity and death, reflected in psychiatry by twinned concernssurrounding primitive disturbed states of mind and risk.
The therapeutic attitude of the developing doctor requires lifelong attention andstructures which support the inevitable anxieties and disturbance which are evoked intheir work and which require a regular rhythm of recognition. Without such a rhythm ofrecognition, the human experience can be subsumed by the task, the doctor becomingoblivious.
The professional who becomes oblivious echoes an oblivion that is a common complaintabout the caregivers of the past and about the NHS in the present.
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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.
The cradle signifies primitive developmental states of mind and the grave signifies 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 cradle signifies 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 question to be or not to be is 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.
The Thinking Cradle to Grave therapeutic 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.
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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 the Thinking 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.
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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.
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Summary of strategic interventions from the Thinking Cradle to Grave strategy
Curriculum amendments proposed to the GMC
Core psychiatry curriculum
Following presentation of the Thinking 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 development in 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.
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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.
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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.
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THE BRICK MOTHER
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.
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THE CRADLE GRAVE
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.
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THE DO DO BIRD
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).
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LEARNING TO LISTEN
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.
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FROM FREUD TO FRED
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.
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THINKING CRADLE TO GRAVE
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.
REVERIE
Bion’s container contained concept (1962). The unconscious process of working through
unthinkable feelings.
INTROJECTIVE IDENTIFICATION
Taking in or cathecting the patient. Holding the other in mind involves emotional working
through of pain and conflict.
WORKING THROUGH (OR NOT) IN THE COUNTERTRANSFERENCE
Two cartoons sequences showing narrative arcs of working thorough and not working
through in the countertransference follow.
The first is a fictional therapist called The Psychic Warrior for whom reflecting on
himself is central to working through.
The second is Borderline Professional Disorder in 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 Brake [email protected]