The dual training is five years in length and on satisfactory completion will lead to the award of two Certificates of Completion of Training (CCT) in Medical Psychotherapy and General Psychiatry, recognised by the General Medical Council if the trainee is appointed to the two dual training sub-specialties in an appointment committee simultaneously. The Training Programme Directors for General Adult psychiatry and psychotherapy are available are on school structure page. The two Training Programme Directors take joint responsibility for the running of the dual training scheme as a whole. The dual trainee will at all times be allocated an educational supervisor (trainer) who is a trained Consultant Medical Psychotherapist and an educational supervisor (trainer) who is a Consultant General Psychiatrist. There are three strands to the training programme over the five years. One strand is a full higher training in General Psychiatry, the second strand is a full higher training in Medical Psychotherapy and the third strand is in integrating these two sub-specialty trainings in the applications of psychotherapy in different psychiatric settings. The following model of dual training developed in the Peninsula outlines each year of the five year programme in which gaining a wide range of experience of placements across the geographical area of the scheme is balanced with the importance of allowing sufficient time to take on long term psychotherapeutic work. The underlying principle of exposing the trainee to both General Psychiatry and Medical Psychotherapy from the outset of training concurrently is to foster a ‘training dialogue’ for both trainee and trainers between the two sub-specialties and their different paradigms of mind.
In the first year the trainee will be offered General Psychiatry training and preparation for starting their psychotherapy training which will include starting Personal Analysis where the trainee has chosen to specialise in Psychoanalytic Psychotherapy. In the second year three days per week will be spent in general adult psychiatry and two days in psychotherapy. In the third year the trainee will spend two days in adult psychiatry and three in psychotherapy. During the second and third year trainees will be offered opportunities to develop their thinking and skills in applying psychotherapeutic ideas to psychiatric practice. In the fourth year a full time placement in psychotherapy and the Personality Disorder service will be offered and in the fifth year a specialist psychotherapeutically oriented placement will be offered in keeping with the trainee’s career plans.
The basic plan of each one year training post is:
- Eight clinical sessions with the principal Consultant Trainer, except in the second and third years where the training is integrated.
- One special interest session, which may be with the Consultant Trainer or with another Consultant. The special interest sessions will be arranged after discussion with the Programme Director.
- One research session supervised by a member of the Academic Department or a supervisor approved by the Programme Director.
The training scheme is based around main centres in Bodmin, Redruth, Exeter, Plymouth, Barnstaple and Torbay. Each centre has its own on-call arrangements. Specialty trainees on the scheme are employed by one of three NHS Trusts: Cornwall Partnership Foundation NHS Trust, Devon Partnership Trust and Livewell Southwest Community Interest Company (A Social Enterprise). The Regional Postgraduate Dean is Professor Martin Beaman.
Allocation of posts is made by the Programme Director in the light of discussions with individual Specialty Trainees, initially directly after appointment and then a few months prior to each rotation point in July of each year. Specialty Trainees are strongly encouraged to meet with the Consultant trainers for their preferred placements prior to the final allocation. Placements will be made tailored to particular trainees interests where possible. However is also the case that placements may change in the course of training and not all of those currently available will continue to be so at the time the trainee is approaching that stage of training.
There are 16 posts on the rotation. Four NTN’s exist in Old Age Psychiatry, eleven in Adult Psychiatry and one in Medical Psychotherapy. Of the sixteen posts, four are allocated to Cornwall Partnership Trust, four to Livewell Southwest and eight to Devon Partnership Trust.
Throughout his/her tenure, each Specialty Registrar is entitled to one session per week for research as part of the core training programme in psychiatry and this does not constitute study leave. Specialty Trainees are entitled to additional study leave and one half day for special interest to be planned between trainee and trainer. The Specialty Trainees are also encouraged to meet monthly for informal support and specific educational activities.
The Programme Director runs a regular training surgery in each locality and trainees are encouraged to make use of this facility. The scheme has a well-established ARCP (Annual Review Competency Progression) process which is highly regarded by trainees.
Outline Structure for the Five Year Training Period
The principle of proposing and ratifying each year of the Advanced Medical Psychotherapy Training Plan (see appendix A) year on year between the Trainee, the Training Programme Directors and the two Educational Supervisors will apply throughout the period of dual training, depending on the developing training needs of the trainee. The detail of where particular General Psychiatry placements take place is therefore omitted in the following outline with the principles underlying the training objectives for each year described. There are two Consultant Psychiatrists in Psychotherapy on the Peninsula Postgraduate Medical Education Psychotherapy training scheme, Dr Mizen Consultant Psychotherapist and Dr Darnley who is a Consultant Psychiatrist in Forensic Psychotherapy. It is anticipated that Dr Darnley will be able to offer placements to interested Trainees in the Medium Secure Unit at Langdon Hospital. General Psychiatry placements will be identified which do not necessarily include Educational supervisors with a special interest in psychotherapy but do include the Educational Supervisor actively in planning the placement and articulating the aims of the dual training before the trainee begins in their General Psychiatry placement.
Year 1 Specialty Training Year ST4
General Adult Psychiatry: Five days per week
The first year of training will be spent in General Adult Psychiatry. This post is more likely to be in a location outside Devon Partnership NHS Trust in order that the trainee can gain the broadest Adult Psychiatry experience before the commitments of their psychotherapy training begin. During this year the trainee will meet with the Psychotherapy training programme director to discuss their psychotherapeutic interests and career plans. If their Psychotherapy training at CT 1-3 has substantial gaps they may attend the training programme in the Psychotherapy Department at Wonford House. If the trainee’s interest is in psychoanalytic psychotherapy as their primary modality they will be expected to start in Personal therapy during the course of this year.
The General Adult Psychiatry Educational Supervisor is the Consultant in this placement.
Year 2 Specialty Training Year ST5
General Adult Psychiatry: three days per week
Three days per week will continue to be spent in a General Adult Psychiatry setting which will be congruent with the trainee’s needs and developing interests. For example, this could be in an early intervention service, a crisis team, an in-patient team, liaison psychiatry, rehabilitation and recovery or a community team with a specialist area, such as assertive outreach.
Medical Psychotherapy: two days per week
Two days per week will be spent in the Generic Psychotherapy Service and outpatient Personality Disorder Service where the trainee will have an opportunity to see patients individually or in groups for three years. Clinical supervision of psychotherapy cases seen once weekly in more than one modality, including group analysis will begin in the second year and continue throughout training. Trainees will be expected to attend an appropriate training course in their primary therapy modality. The trainee will undertake assessments for psychotherapy.
Year 3 Specialty Training Year ST6
General Adult Psychiatry: two days per week
The General Adult Psychiatry will now begin to be orientated towards developing applied skills in different psychiatric settings. For example, the trainee could co-facilitate a reflective practice group in a community mental health team. The trainee would also join Medical Psychotherapy Consultations on behalf of other specialists seeking a medical psychotherapeutic opinion for complex psychiatric patients.
Medical Psychotherapy: three days per week
In the third year it will be anticipated that one of the two subsidiary models of therapy will be introduced alongside the adopted major modality of medical psychotherapy. The trainee will work within the generic psychotherapy service and the outpatient Personality Disorder Service.
Year 4 Specialty Training Year ST7
Medical Psychotherapy: five days per week
The trainee will undertake more intensive/challenging clinical cases under supervision and pursue appropriate experience in all three therapy modalities, e.g. psychoanalytic/systemic/cognitive behavioural or an agreed derivative therapy model of these three therapies such as Mentalisation Based Therapy or integrative models such as Cognitive Analytic Therapy. These cases will continue to be seen in the outpatient generic and Personality Disorder Services. In addition the trainee will be offered a placement in the Specialist Day Therapeutic Programme for people with Personality Disorder currently based at the Iris Centre in Exeter where they will have an opportunity to gain experience in the functioning and leadership of a therapeutic team as well as direct clinical experience of individual and group psychodynamic therapy and systemic work within this setting.
Year 5 Specialty Training Year ST8
Medical Psychotherapy in Psychiatry: five days
This final year of dual training is devoted to honing competence in psychotherapy and its applications in various settings of psychiatry. The aim in this final year of dual training is for the trainee to begin to consolidate the integration of their psychiatric and psychotherapeutic experience that has been developing over the previous four years and to consolidate their emerging as a psychotherapeutic psychiatrist in mental health services. This experience may for example be gained in one of a number of inpatient therapeutic settings such as the proposed Tier 4 Inpatient Personality Disorder service, the Medium Secure Unit led by Dr Darnley at Langdon hospital or the Haldon Unit specialising in eating disorders.
The trainee’s placements and Advanced Training Plan (see Appendix A) will, in the latter part of the training, have come to reflect particular areas of special interest and career aspiration as far as possible with placements agreed in collaboration with Educational Supervisors and the Medical Psychotherapy and General Psychiatry Training Programme Directors.
Trainees undertaking psychoanalytic training undergo their own personal analytic experience. This is for their personal and emotional development and the development of an understanding of the impact of the work with severe psychiatric disturbance, and in particular the emotional challenges of working across different settings with potentially very different ways of thinking about patients.
Psychoanalytic psychotherapy is required throughout the training period with a psychoanalyst or a psychoanalytic psychotherapist registered with the British Psychoanalytic Council and agreed with the Medical Psychotherapy Training Programme Director. The trainee may begin in a once weekly therapy and increase the frequency as they develop through the training but also in keeping with the requirements of the formal psychotherapy training they undertake. This may include three four or five times weekly therapy depending on the training. Some account will be taken of the time required to attend therapy during the working week, some will be in the trainee’s own time. It is expected that personal therapy would continue throughout the duration of training.
For trainees who choose to major in other models of therapy such as cognitive behavioural therapy, self-reflective personal development experience which would be considered congruent with the adopted main therapeutic modality training orientation would be required. The chosen path of self-reflective development would not preclude personal therapy.
Trainees in cognitive behavioural therapy or systemic therapy as their major modality who wish to undergo personal therapy would be supported subject to approval of the Training Therapist by the Training Programme Director.
The aim of the dual training programme is to help the trainee to become a medical psychotherapist and psychiatrist, who embraces and integrates their medical and psychiatric identity as a specialist psychotherapeutic psychiatrist. The general goals of professional attributes, risk, audit, teaching and supervision, clinical and service management, organisational change and clinical governance will form the backbone of this training programme as they do other advanced psychiatric training programmes.
The distinct theoretical and experiential aim of dual training is to integrate the knowledge and skills of two CCT trainings in both General Adult Psychiatry and Medical Psychotherapy in such a way that the future Consultant Psychiatrist in Psychotherapy is helped to inform their professional orientation to their Medical Psychotherapy role according to these two different sub-specialities and different paradigms of mind.
Trainees majoring in systemic psychotherapy will be expected to attend the Intermediate Course in systemic psychotherapy in Plymouth and the Masters course in systemic psychotherapy at Exeter University.
Trainees majoring in CBT will be expected to attend a high quality training Course in CBT such as the Oxford Course. This will need to include the application of CBT to a number of different psychological disorders as well as training in supervision.
Psychoanalytic trainees will be required to learn about the theoretical foundations of Psychoanalytic Psychotherapy as well as undertaking a clinical training which will lead to a qualification and a
registered Psychotherapist. Courses available in the South West include the two year MSc Course at Exeter University, the subsequent two year BPC qualifying course. There are also opportunities to develop this training into a Clinical Doctorate or a PhD through Exeter University with which the psychotherapy department and PD service have training and research links.
Alternatively the Trainee may choose to train with the Severnside Institute in Bristol or with Group Analysis South West.
The Training Programme Director in Medical Psychotherapy recommends that all psychoanalytic trainees consider and discuss the possibility of an external psychodynamic training with a training recognised by the British Psychoanalytic Council during their training in developmental discussion with their Medical Psychotherapy Educational Supervisor. The Dual Medical Psychotherapy and General Psychiatry Training Programme will aim to help the trainee to integrate any external psychoanalytic training with their development as an NHS Consultant if they are accepted and commence training within the CCT training period.
The trainee will be expected to carry out a minimum of 700 clinical hours in their adopted major model of psychotherapy and 100 clinical hours in two supplementary models of therapy. The three models in the Peninsula are chosen from psychoanalytic psychotherapy, cognitive behavioural therapy and systemic therapy. 100 hours of clinical practice in the chosen supplementary model of therapy and 100 hours of a third model is required which can include supervision. The Training Programme Director will decide with the trainee and Medical Psychotherapy Educational Supervisors what clinical experience and models of psychotherapy can contribute to the hours of experience required.
Work place based assessment of all psychotherapies will be undertaken, including the formative Structured Assessment of Psychotherapy Expertise (SAPE) during clinical supervision of therapy, Structured Assessment of Psychotherapy Assessment (SAPA) and a summative Psychotherapy Assessment of Clinical Expertise at the end of each therapy (PACE or Psychotherapy ACE). All these WPBAs are on line in the Royal College of Psychiatrists’ portfolio on line training website.
Trainees will observe assessments and be observed undertaking assessments in psychotherapy using the Structured Assessment of Psychotherapy Assessment (SAPA) to assess.
All trainees will be required to maintain reflective practice reports discussed in Educational Supervision of their psychotherapies and general psychiatry assessment feedback as part of self-reflective practice development in the Advanced Medical Psychotherapy Curriculum (2013).
The dual trainee will receive clinical supervision from practitioners both within the scheme in psychotherapy and also outside of the scheme as part of their external training. In the early stages of training (ST4, ST5) clinical supervision is from the Consultant Psychiatrist in Psychotherapy but will also be provided by adult psychotherapists and psychologists.
The clinical supervisors who supervise the clinical work within the scheme are invited to attend and contribute to the Peninsula Medical Psychotherapy Training Committee to facilitate the development of the Medical Psychotherapy Training Scheme.
Clinical supervisor’s reports will be requested on a once yearly basis around six months before the Annual Review of Competence Progression (ARCP).
These Clinical Supervision Reports will be used to inform the annual assessment of the trainee’s progress and development for the Annual Psychotherapy Appraisal between the Trainee, Medical Psychotherapy Educational Supervisor and Training Programme Director prior to and in preparation for the Annual Review of Competence Progression (ARCP).
The trainee will have experience of assessments of patients for psychotherapy and other psychological interventions, as well as seeing patients for assessment as part of the consultation process.
The trainee is required to have a minimum of 60 hours of assessments.
Joint assessments will be undertaken with Medical and other Psychotherapists with experience of different modalities, and mental health colleagues and medical and psychiatric colleagues as appropriate.
Trainees will observe assessments and be observed undertaking assessments in psychotherapy using the Structured Assessment of Psychotherapy Assessment (SAPA) to assess.
Trainees will be expected to develop skills in psychodynamic risk assessment both in forensic and non-forensic placements.
Medical Psychotherapy Consultation
In the first and second years of dual training (ST4 and ST5) the trainee will be offered psychoanalytic consultation on some of the psychiatric cases they see in their training placement psychiatric settings or on call within Educational and Clinical Supervision with a Consultant Psychiatrist in Medical Psychotherapy. This will take the form of a Balint group facilitated by a Consultant Psychiatrist in Psychotherapy with Advanced Psychiatry training peers in psychiatry and forensic psychotherapy who are on placement in the psychotherapy department.
From their third year onwards (ST6) the trainee will begin to participate in Medical Psychotherapy Consultation accompanying a Consultant Psychiatrist in Psychotherapy offering consultation on complex patients to other specialist colleagues working in psychiatry and to GPs and other professionals in primary care. In the fourth and fifth years (ST7 and ST8) the dual trainee will undertake their own supervised consultations.
Since clinical consultation is one of the most challenging aspects of the interface between the Medical Psychotherapist and their psychiatric colleagues, careful consideration will be given to the selection of cases and the supervision of this work.
The Medical Psychotherapy clinical consultation interface with other specialists represents the ‘coalface’ for the development of the trainee’s emergent psychotherapeutic and psychiatric identity. Medical Psychotherapy Consultation is therefore a crucial and central component of the dual training to become a Consultant Psychiatrist in Psychotherapy.
Work place based assessment (WPBA) of consultation will include cased based discussion (CBD) Structured Assessment of Psychotherapy Expertise (SAPE) and Assessment of Clinical Expertise (ACE). The work place based assessment (WPBA) Direct Observation of Non-Clinical Skills (DONCS) can be used for chairing professionals meetings or participating in a Care Programme Approach meeting.
Medical Psychotherapy Consultation in observing and seeing colleagues and their cases for consultation will offer a foundation for the development of observing reflective practice competence in others. One important role for the application of medical psychotherapy skills lies in developing reflective practice competence amongst colleagues.
Consultation and reflective practice supervision provided by a Consultant Psychiatrist in Psychotherapy will provide a foundation for dual trainees from ST6 onwards to bring consultations observed and seen and for some dual trainees to plan and establish running a reflective practice group in an acute psychiatric setting such as an in-patient ward or a crisis team. The dual trainee would not be expected to consult with colleagues within their General Psychiatry placement as this would place them in the dynamic of an internal consultancy position making this untenable.
The dual trainee will also maintain reflective practice reports discussed in Consultation and Reflective Practice Supervision of their consultation and reflective practice activity experience as part of self-reflective practice development in the Advanced Medical Psychotherapy Curriculum (2013).
Teaching and Supervision offered by the Dual Trainee
Throughout training the dual trainee will be actively involved in teaching, training and supervision. In the later part of training this will include the provision of clinical case supervision to Core Trainee Psychiatrists (CT1-CT3) and lectures to medical students at the Peninsula Medical School, and mental health professionals as well as teaching on the MRCPsych course. The trainee will develop and evaluate teaching materials and will be encouraged to undertake a Certificate in Medical Education.
The dual trainee will also have an opportunity to observe a Consultant Psychiatrist in Psychotherapy conduct a Balint group for Core Trainee Psychiatrists and will later in training (ST6 onwards) facilitate their own Balint group, for Core Trainees. The dual trainee is required to conduct work place based assessment of their Balint groups using the Balint group assessment (BGA) and formative assessment of their clinical supervisees using the Structured Assessment of Psychotherapy Expertise (SAPE).
The dual trainee will attend the PD and psychotherapy service clinical governance, business, management or other committee meetings during their placements. A clinical governance perspective on psychotherapy service delivery including the economic aspects of care systems will be incorporated throughout the programme.
The trainee will be expected to attend local and national management courses at points in their training which are relevant to their needs.
The trainee will be expected to familiarise themselves with the literature in relation to the evidence base and research in their respective sub-specialties. The methodological strengths and weaknesses of the relevant literature should be familiar.
The issues surrounding the evidence base and comparison between different models of psychotherapy should be familiar. The trainee should be aware of current psychotherapy outcome measures and their strengths and limitations and should be able to appraise the literature critically.
Exeter University has an active and progressive School of Psychology which has attracted large research grants in developing Cognitive Behavioural Treatments for Mood Disorders and Dialectical Behaviour Therapy for Emotionally Constricted Personality Disorder. The School of Psychology runs undergraduate courses in Psychology but also postgraduate courses in psychological therapies including MSc courses in Psychodynamic, Family Systemic and Cognitive Behavioural Therapies. There are also Clinical Doctorate and PhD courses. In addition the School of psychology has developed research links with the Trust, for example the Eating Disorders service has developed links with the School of Psychology to run a trial of DBT for patients with Eating Disorders. The School of Psychology has expressed a keen interest in developing links with the Specialist Personality Disorder Service to undertake similar studies. Links with the University are therefore through the clinical placements of MSc students in the psychotherapy service and developing Personality Disorder Service, through the provision of professional development opportunities in furthering psychotherapy training for Trust employees including the post holder if required and through research.
Specialty Trainees are encouraged to conduct research. Each Trust has modern library facilities and access to internet facilities.
The trainee will be expected to have an understanding of the audit cycle and carry out at three to four audit projects during their training in Medical Psychotherapy and General Psychiatry.
Specialty Trainee training is available on a flexible (i.e. part time) basis for doctors with good reasons. This applies to both men and women. Acceptable reasons include dependent relatives, whether adult or children, disability or ill health. This list is not exhaustive. Once a post is secured a Specialty Trainee may announce their desire to be a flexible trainee. Appointments to flexible training are made at interviews for full time training on a competitive basis. Less than full time training (LTFT) is possible with this integrated model of dual training, further information is available on the policies page.
Special Interest Sessions
Specialty Trainees are encouraged to make full use of their special interest sessions which may be used to pursue a higher qualification that is relevant to their training.
Training Programme Appraisal and Assessment
The trainee will have usually weekly contact with both their Educational Supervisors in Medical Psychotherapy and General Psychiatry to consider their developmental progress.
The Educational Supervisor role is to support the trainee as a mentor and to challenge as a colleague, enabling the trainee to reflect openly and robustly about their capacities and development. This process will be largely informal.
The more formal element of appraisal and assessment takes place in formative assessment throughout training in the work place based assessments (minimum of one a month) and in the annual summative assessment the ARCP panel (Annual Review of Competence Progression).
The ARCP panel for dual trainees will include both Training Programme Directors from General Psychiatry and Medical Psychotherapy.
The ARCP will be undertaken by the Peninsula Postgraduate School of Psychiatry informed by the reports of the Training Programme Directors, who are in turn informed by both Educational Supervisors in the preceding year’s General Psychiatry and Medical Psychotherapy placements.
A six monthly Medical Psychotherapy review of the Training Plan (see Appendix A) is undertaken with the dual trainee informed by the Clinical Supervisors’ reports and the Educational Supervisor’s Annual Report with the Medical Psychotherapy Training Programme Director. The review provides an opportunity for the dual trainee to raise concerns or highlight good practice relating to placements or the programme generally and for the Educational Supervisor to highlight good progress or areas of concern and plan appropriate support/teaching or remedial action. The review also helps the trainee to prepare their portfolio for the ARCP.
The Medical Psychotherapy component of the ARCP will be supplemented by the annual Clinical Supervisors’ reports and an Annual Psychotherapy Appraisal. This will be conducted prior to the ARCP (usually around April-May before the June ARCP).