Supervision of the Beginning Therapist: Privileges and Problems

Most of the trainee psychotherapists providing treatment within the National Health Service setting are psychiatrists in training. The Royal College of Psychiatrists recommends that supervised experience in psychotherapy should be gained by all trainees during their general professional training in preparation for the Membership examination. Short-term dynamic psychotherapy is commonly offered as an economical treatment approach for psychiatric patients within the public sector provision. The conflict between attitudes rewarded in medical training and the qualities needed for the practice of psychotherapy creates problems for the trainees which emerge in supervision. Experience of supervising beginning therapists, the privileges and the problems, and countertransference issues are discussed. A framework for supervision is outlined.     

Psychotherapist and expansion of awareness

The author emphasizes the therapist's well-integrated and matured personality as the crucial element for being a good psychotherapist; therefore, it is essential for a psychotherapist to make ceaseless efforts regarding his own personality growth with his ongoing therapeutic experiences. Nevertheless, nowadays students are apt to satisfy themselves with or cling to the theories and techniques of psychotherapy, neglecting their own personality growth. The author attributes such a tendency, on the one hand, to the contemporary thought of 'technology first and convenience first', on the other, to the current system of medical education which is extremely faithful to scientism. He warns that concepts or theories sometimes serve as a barrier in one's mind and falsify the reality. He reiterates the importance of the therapist's own maturity and expansion of awareness. In this context, the author recommends Zen meditation or Theravada meditation as one of the advanced courses of training for psychotherapists. He elucidates a way of promoting one's awareness in Zen meditation and what the ultimate state of "no-self" of Zen should be, based on his own experience of Zen practices.     

The Poet and the Psychotherapist: In Gratitude for the Life and Work of Seamus Heaney (1939–2013)

In this paper, I explore the question whether the inclusion in clinical training of a more observational and research‐based approach focused on evidence of outcome, as advocated by Knox (2013), risks eroding the subjective experience which is at the heart of the analytic encounter. I suggest that psychotherapists have always had to maintain a dual perspective of objective observer and experiencing subject. I compare the duality of the psychotherapist and the duality of the poet, using the poetry of Seamus Heaney for illustration purposes. I refer to themes and values shared by psychotherapy and Heaney's poetry, which make this comparison especially apposite. I refer to Heaney's poetry to illustrate that the maintenance of objectivity need not be at the expense of subjectivity and that the tension between the two perspectives makes for creativity. I also refer to certain of Heaney's poems for their educational value in expressing eloquently certain key concepts and aims of psychoanalytic psychotherapy. I liken Heaney's inclusiveness and non‐sectarianism to Knox's willingness to include within clinical trainings and practice an approach which seeks out and learns from research in other related disciplines.     

Balint Groups for Foundation and GP Trainees

Balint groups are increasingly offered to doctors in training, both to give support to the doctors and to develop a deeper empathic understanding of their patients, the family and the clinical team. We describe Balint groups; the history of such groups and current applications. Using material from groups we ran over a three-year period, we consider practical and theoretical aspects of setting up short-term, contemporary Balint groups for doctors working in four-month psychiatric placements as part of their foundation or GP training in medicine. Current medical and psychiatric practice is gradually moving away from the dyadic doctor–patient relationship, with the use of wider team members and family as an integral part of patient care. In addition to the doctor–patient dyad traditionally explored in a Balint group we consider ways in which group analytic ideas have an important role to play. We consider that group analytic concepts enhance the Balint groups and add to the experience of those leading the groups. We describe how these can be used to illuminate unconscious factors within Balint and supervision groups. We use clinical vignettes to demonstrate some of our experiences, using both group analytic and Balint ideas.     

The problem of integrating biological and psychodynamic views in psychotherapeutic training of physicians

A clinical seminar was arranged for the purpose of examining the special problems of doctors undergoing supplementary training in psychotherapy. Diagnostic and therapeutic problems analyzed during the seminar could be attributed to a one-sided overemphasis of either somatic or psychodynamic findings. The physician tends to administer only pharmacotherapy for illness of supposed organic origin, and only psychotherapy for disorders of supposed psychological origin. Yet most of mental diseases require a synthesis of both biological and psychological procedures. There is no special psychotherapeutic technique, which distinguishes the medical psychotherapist but the ability to integrate psychological and somatic perspectives of the patient.     

Psychotherapeutic training in an institutional setting

Many child and adolescent psychotherapists are asked to work in specialized institutions (where the children are either interns or externs), with children presenting behaviour problems, learning difficulties, mental handicap or important psychosocial problems. They learn through diverse treatment forms, or parent accompaniment during the child's treatment (bifocal or conjoint treatment more or less regular therapeutic sessions with both parents and children, etc.). The treatment of children within an institution makes the treatment modalities and technique more complicated. The psychotherapist must have a perfect knowledge of the specific environment of the child, and keep in mind the desires and requests of the direction and the people who work directly with the child (teachers, specialized teachers, etc.). How can the problems brought up by the rivalry between the institution and the psychotherapist be canalized: length of therapy, merits (how did the pedagogical intervention help, recognition of a specific action or of work done in conjunction with the educative action)? If these facts are not recognized, the treatment will often be interrupted and the psychotherapist may be excluded from the institution. This will be avoided by ensuring further training of the therapist.     

Psychotherapy in the General Practice Surgery: Working With and Without a Secure Therapeutic Frame

Many general practices employ psychotherapists and counsellors. Some GPs have also had personal therapy and may have training in counselling or various therapies. Where different approaches are used, conflicts and rivalries can arise. This paper describes a flexible model which has helped one practice negotiate these issues. The model permits several levels of work: from opportunistic counselling in ordinary GP surgeries, to formal 'secure-frame' psychotherapy. The model allows patients and practitioners to sculpt their own experiences of counselling and therapy from a variety of approaches, and allows us to combine therapeutic work with medical practice.     

Breathlessness and psychiatric morbidity in chronic bronchitis and emphysema: a study of psychotherapeutic management

This paper describes a study of the outcome of psychotherapy with patients disabled by chronic obstructive airways disease giving rise to dyspnoea. Forty-three men and 22 women with severe COAD were randomly allocated for 8 weeks to one of three types of psychotherapy or to an untreated control group, and were followed up six months later. The group treated by a medical nurse without training in psychotherapy experienced sustained relief of dyspnoea but tended to undergo less psychodynamic change; psychiatric symptoms were reduced in those receiving supportive, but not analytical, psychotherapy. The psychosomatic mechanisms involved and the implications for medical and nursing practice and for liaison psychotherapy are discussed.     

Health behaviors of psychotherapists

Examined the health behaviors practiced by psychotherapists (N = 86) themselves and the extent to which they focus on these behaviors with their clients during the course of psychotherapy. The specific health behaviors investigated were dietary habits, physical exercise, relaxation practices, sleeping, alcohol consumption, and smoking. Results indicate that psychotherapists are at this time actively engaged in both evaluating and making recommendations to their clients in the areas of diet, physical exercise, and relaxation practice. In addition, 51% of those who participated in this study evaluate health practices of their clients and make recommendations with regard to their physical health. While only 47% agreed that it is important for the psychotherapist to assess the typical client's physical health status, 72% of this group frequently inquire about chronic illness during an intake session.     

Informal Sources of Supervision in Clinical Training

Although formal, assigned supervision is a potent source of learning and guidance for psychotherapy trainees, many beginning psychotherapists use other, informal sources of supervision or consultation for advice and support. Results of an online survey of beginning trainees (N = 146) indicate that other than their formally assigned supervisor, trainees most often consult with colleagues in their program, their own psychotherapist, and their significant other; that they're most likely to seek these other sources of help when they're feeling stuck or feel they've made a clinical mistake; that they do so because they need extra reassurance and suggestions; that they feel the advice given from these sources is helpful; and that they don't especially regret sharing this information. Several case examples are used to illustrate these points. Discussing clinical material with informal sources is, apparently, a great deal more common than typically acknowledged, and as such, has implications for training programs (including discussions of ethics) and formal supervision.     

Quantum change and psychotherapy

Deep change in psychotherapy more typically comes slowly rather than suddenly, but this difference between therapeutic change and quantum change may be one of perspective rather than substance. Psychotherapy may be understood as a kind of mindfulness practice similar to working with koans in that the client presents a life dilemma incapable of rational solution. While quantum change cannot be engineered, the psychotherapist can create an environment conducive to such transformation by producing true presence and modeling calm, concerned, sustained attention to the dilemma that precipitated treatment. Psychotherapists who also maintain a sense of their work as a high art and a way of being, and who in consequence cultivate their own emotional and spiritual development, may be more likely to create such an environment.     

北京地区民营口腔医疗机构资源配置及诊疗服务开展现况

目的 调查北京地区民营口腔医疗机构资源配置及诊疗服务开展现况。方法 2018年对北京地区10%分层随机抽样的民营口腔医疗机构（综合治疗台≥2台）进行现场调研,对各项调研指标进行分类汇总、分析。结果 北京地区专科民营口腔医疗机构牙科综合治疗台和口腔医师数量多集中在4~6台/人次,日均门诊量集中在1~5人次/d,医疗总量多集中在100~499万元/年;非专科民营口腔医疗机构科综合治疗台和口腔医师数量多≤3台/人次,日均门诊量多＜1人次/d,医疗总量多＜50万元/年。民营口腔医疗机构的口腔医师多为大专学历,初级职称;护士多≤3人次,医护比多集中在1:1~2:1。三级、二级、民营口腔医疗机构在设备资源配置及口腔各专业诊疗技术开展方面存在一定的差异。结论 合理配置口腔医疗资源,明确功能定位,不断壮大民营口腔医疗机构人才队伍,促进民营口腔医疗机构医疗服务及质量的持续改进。     

Ethics, patient rights and staff attitudes in Shanghai's psychiatric hospitals

ABSTRACT: BACKGROUND: Adherence to ethical principles in clinical research and practice is becoming topical issue in China, where the prevalence of mental illness is rising, but treatment facilities remain underdeveloped. This paper reports on a study aiming to understand the ethical knowledge and attitudes of Chinese mental health professionals in relation to the process of diagnosis and treatment, informed consent, and privacy protection in clinical trials. METHODS: A self-administered survey was completed by 1110 medical staff recruited from Shanghai's 22 psychiatric hospitals. Simple random selection methods were used to identify target individuals from the computerized registry of staff. RESULTS: The final sample for analysis consisted 1094 medical staff (including 523 doctors, 542 nurses, 8 pharmacologists and 21 other staff). The majority reported that their medical institutions had not established an Ethics Committee (87.8%) and agreed that Ethics Committees should be set up in their institutions (72.9%). Approximately half (52%) had not received systematic education in ethics, and almost all (89.1%) of the staff thought it was necessary. Nearly all participants (90.0%) knew the Shanghai Mental Health Regulations which was the first local regulations relating to mental health in China, but only 11% and 16.6% respectively knew of the Nuremberg Code and the Declaration of Helsinki. About half (51.8%) thought that the guardian should make the decision as to whether the patient participated in clinical trials or not. CONCLUSIONS: The study indicates that most psychiatric hospitals in Shanghai have no Medical Ethics Committee. More than half the medical staff had not received systematic education and training in medical ethics and they have insufficient knowledge of the ethical issues related to clinical practice and trials. Training in ethics is recommended for medical staff during their training and as ongoing professional development.     

Choosing psychotherapy as a career: why did we cross that road?

This article addresses the question "Why do people become psychotherapists?" via two approaches. The first involves an examination of the empirical and clinical literature on motivations and influences common to most psychotherapists. The second approach explores multiple pathways to becoming a psychotherapist by considering distinct gender-linked career trajectories. We identify 12 oft-noted themes in the literature on therapists' career paths (e.g., cultural marginalization, a psychologically minded way of understanding self and others) and link these to the narratives of the eight authors in this issue. Finally, we discuss ways in which understanding career motivations may be useful for therapists in their practice.     

Treatment in combined medical psychiatry units: an integrative model

Approximately 14 medical psychiatry units have opened over the last 15 years due to the recognition of the frequent concurrence of medical and psychiatric illnesses. This article discusses the clinical problems encountered when medical care and psychiatric care are integrated and their impact on medical and nursing staff. Group therapy programs on medical psychiatry units may enhance psychiatric treatment and help maintain a psychiatric focus by both patients and staff, despite the patients' significant medical problems. Medical psychiatric units must adopt an integrative model of care that includes all disciplines involved on the units if they are to meet their goal of providing effective medical and psychiatric care.     

Evaluation of student performance in psychotherapy

In 1970, the APA's Psychotherapy Curriculum and Consultation Committee on Psychotherapy Training recommended that the faculty of training programs should formulate and publish explicit criteria by which the student's practice of psychotherapy can be evaluated. An informal survey of advanced clinical psychology graduate students (N = 17) of an APA-approved program indicated that during their first year of psychotherapy training, 77% of the students either did not know the criteria used to evaluate their performance as psychotherapists or thought that the evaluation was based on the professor's personal biases. The issue of using client outcome vs. competence in explicitly specified therapeutic skills as evaluative criteria was discussed. A combination of both criteria was recommended for implementation in training programs.     

Effects of a community mental health service on the practice and attitudes of general practitioners.

Recent years have seen closer links developing between general practitioners and mental health specialists. A study was undertaken in Manchester to determine the effects of a new community mental health service on the practice and attitudes of general practitioners. Ten doctors had access to the community based psychiatric team over a three year period while another 10 doctors continued to use hospital services. Those with access to the team were significantly more satisfied with the specialist support services, and were more likely to give high priority to community psychiatric nurses and psychiatric social workers working as part of a primary health care team than those without access to the service. Those with access were more willing than those without access to share with psychiatrists the care of patients with chronic neurotic disorders. The community mental health team was considered particularly helpful in reducing the burden posed by patients with neurotic and psychosocial problems, but this resulted in the general practitioners doing less counselling themselves. The study did not find that the new service had an effect on the general practitioners' ability to detect or manage psychiatric illness.     

MIDWIVES,FOSTER‐MOTHERS,STEPMOTHERS? CLINICAL PSYCHOLOGISTS TEACHING JUNIOR DOCTORS PSYCHOTHERAPY

ABSTRACT Teaching junior doctors psychotherapy is a difficult task. This paper charts the progress of clinical psychologists setting out on this task, initially finding it impossible, but thinking and working together to develop creative, working groups in which the junior doctors and group leaders learned and developed.
We detail how we run the teaching groups and what it is like to be a member of such a group. We consider the costs and benefits of clinical psychologists teaching junior doctors and the differing cultures of psychiatry, psychology and psychotherapy. We discuss institutional and group defences which create obstacles to learning. We propose a training model based on maternal containment as opposed to pseudo-paternal identifications. Containment of anxiety appears to be necessary for the creation and maintenance of a safe space for junior doctors to learn about psychotherapy.     

The Training Value of the Psychodynamic Psychotherapy Long Case: A Psychiatry Trainee's Perspective

In order to fully satisfy eligibility criteria for membership of the Royal College of Psychiatrists, trainees must demonstrate satisfactory attainment of competencies in psychotherapy. Evidence required includes a Psychotherapy ‘ACE’ (assessment of clinical expertise) and completion of two psychotherapy cases in two modalities. With training posts in the Yorkshire deanery becoming European Working Time Directive compliant, a trainee gains less experience in their actual clinical post. Therefore, what benefit could a trainee derive from further time away from their posts in order to gain experience in a subspecialty that very few of us will pursue long‐term? I have conducted a 40‐week period of psychodynamic psychotherapy. I also received weekly supervision sessions with an experienced therapist. I will reflect on my positive experiences completing a psychodynamic long case and describe how the skills I have developed are transferable to most aspects of practice. The role of the psychiatrist within the NHS is continually being redefined. The Department of Health's New Ways of Working initiative may result in fleeting patient contact, which may not be conducive to in‐depth psychodynamic work. I would suggest that, at this uncertain time, psychiatrists might wish to push for further involvement with psychotherapy. The first step in this process is to ensure that all psychiatric trainees are adequately trained in psychotherapy. Efforts should be made to ensure that, as working hours become more unpredictable, psychiatric trainees are afforded protected time slots in order to complete psychotherapy training.