History of psychotherapy training in Singapore

Like many countries in Asia, Singapore has its own system of postgraduate training and specialist accreditation in psychiatry. Psychiatry trainees are strongly encouraged, but not required, to receive supervision in psychotherapy with patients during the 6-year period of basic and advanced training since the inception of the Masters of Medicine in Psychiatry (MRCPsych equivalent) in 1985.

In the late 1980s and early 1990s psychotherapy supervision of trainees was provided by a handful of psychiatrists who were mostly trained in psychodynamic or cognitive—behavioural psychotherapy in the UK. Small groups of psychiatry trainees (senior house officers and registrar levels) met regularly in psychotherapy supervision groups at three main locations, namely the state psychiatric hospital, the university department of psychiatry and the private sector. Despite such initiatives a sizeable proportion of psychiatrists still did not have direct experience of being supervised for psychotherapy with patients.

A recent survey of mental health professionals in Singapore revealed that 47% had received supervision for psychotherapy with two or more patients over a minimum of 6 months at some point in time (further details available from the author upon request). Psychiatrists were more likely to be exposed to psychodynamic psychotherapy and cognitive—behavioural psychotherapy. Other mental health professionals such as social workers, psychologists and trained counsellors were more likely to be trained in systemic therapy, cognitive—behavioural therapy and client-centred therapy, respectively.

Gestation of a psychotherapy training programme

In 1997, a group of psychiatrists and clinical psychologists founded the Association of Group and Individual Psychotherapy out of a common interest to promote the practice, training and supervision of psychotherapy. The emphasis was on developing an informal network to encourage efforts towards such ends. Around the same time the Department of Psychological Medicine at the National University Hospital began to organise a psychotherapy training programme, focusing on two main areas:

1. (a) Submitting the rationale and curriculum of a structured psychotherapy training programme to the relevant university authority.

2. (b) Creating a regular forum for more experienced psychotherapy practitioners to meet, discuss and exchange ideas on psychotherapy training.

Although there was a steadily growing interest to develop a more formal psychotherapy training programme, various challenges were encountered at this stage. First, there were questions about the credibility of the proposed training programme. Second, there was a need to identify enough potential trainers and supervisors for such a course. Third, there was opposition from certain segments of the psychiatric community for understandable and less obvious reasons. Many of these issues were addressed by the timely visit of two psychotherapy experts from the UK.

In 1998 the Ministry of Health invited Dr Christopher Dare (Institute of Psychiatry, London) as a visiting expert to provide training and consultation in psychotherapy, mainly from a psychodynamic perspective, to all mental health professionals in Singapore. The programme for his visit included training workshops, case discussions and lectures for mental health professionals from diverse settings as well as group consultations and discussions on psychotherapy training for a smaller number of more experienced practitioners and teachers of psychotherapy. In the same year Professor Jan Scott (Cognitive Therapy Centre, Newcastle), who was sent by the Royal College of Psychiatrists as one of the external examiners for candidates of the Masters of Medicine in Psychiatry, met with the same core group of more experienced psychotherapy practitioners to discuss psychotherapy training.

One important contribution from these external visitors was in providing feedback to the Ministry of Health and the relevant university authorities on the significance and relevance of psychotherapy training as a part of the strategy to upgrade existing mental health services and postgraduate education in psychiatry in rapidly-developing Singapore. In addition, the visiting experts supported and facilitated interested psychiatrists from different sectors to work towards a common goal; gave valuable advice on matters pertaining to the training curriculum and process; and provided consultation on ways of addressing the potential challenges ahead. Issues raised included essential components of training programmes, conduct of supervision for trainees and selection and evaluation of trainees.

A working committee was formed after the curriculum and training programme (drafted by the author of this paper) was approved by the Senate of the National University of Singapore. The committee (comprising six psychiatrists and a clinical psychologist) was responsible for the Graduate Diploma in Psychotherapy in July 1999.

The result: the Graduate Diploma in Psychotherapy

The diploma is a 1-year part-time course that is divided into two phases:

1. (a) an initial 3-month module providing an introduction to individual psychotherapy, covering normal development; psychopathology; ethics of psychotherapy; indications and assessment for psychotherapy; effectiveness and limitations of psychotherapy; and the fundamentals of psychodynamic and cognitive—behavioural psychotherapy

2. (b) a subsequent 9-month practicum in either psychodynamic or cognitive—behavioural approach that involved group supervision of clinical work, case conferences, lectures, reading seminars, training workshops and written assignments.

Distinctive features of the course include the acceptance of both medical and non-medical professionals as trainees and supervisors; exposure of trainees to both psychodynamic and cognitive—behavioural approaches to psychotherapy before restricting practicum training to one approach; and involvement of international visiting experts as course consultants and trainers for supervisors and trainees. The primary goal of the course is to train mental health professionals to have basic competency in the use of time-limited psychotherapy with individuals who seek help from the organisations they are working with, using either the psychodynamic or cognitive—behavioural approach.

There were more applicants for the training programme than anticipated. Suitable candidates were selected on the basis of their prior clinical experience, ability to have access to patients and personal aptitude or qualities to conduct psychotherapy. Approximately half of the trainees had medical degrees. Eight supervisors (four supervising psychodynamic and four supervising cognitive—behavioural psychotherapy) provided supervision in small groups with two or three trainees each.

Concluding discussion

The Singapore experience has demonstrated that with careful preparation, some planning, flexibility and commitment to training it is possible for a local initiative to put together a structured psychotherapy training programme despite limited resources (e.g. availability of supervisors). Our story also highlights the valuable contributions from experienced psychotherapy trainers in the international community. It is encouraging to note that a significant number of psychiatrists who contributed actively were members of the Royal College of Psychiatrists and had in fact received psychotherapy training in the UK.

Because psychotherapy may still be regarded as a Western invention in some Asian societies, legitimising psychotherapy is important if any formal psychotherapy training programme is to find widespread support in the East. One way of doing so is described by Rhee (Reference Rhee1984) in his commentary of the Korean experience in which attempts were made to relate psychoanalysis to Eastern Taoist or Confucian philosophy. Kang (Reference Kang1990) has written a good account of the developments in the training of psychoanalytic psychotherapy in Korea. In his concluding remarks he pointed out the lack of a systematic and organised programme of psychotherapy training in Korea, despite impressive sustained efforts over the past 50 years.

The other way of giving legitimacy to psychotherapy training in Asia is by conducting it in a university setting. This approach was found to be particularly helpful in Singapore and is likely to find greater acceptance in societies in which the university is a respected educational institution.