Increasing the risk to patients

The capacity to engage psychologically with patients in distress is the basis of therapeutic care. If we do not have clear internal frameworks about psychological functioning to guide us in this work and confidence that developing this understanding is a key part of treatment, we profoundly reduce our capacity to provide meaningful care for our patients. There is a strong evidence-based demand from the suicide prevention community for psychiatric services to move away from tick-box engagement with patients towards dynamic clinical formulation and therapeutic engagement. Research has demonstrated the limits of risk assessment tools as predictors of risk and shown that this type of clinical contact can inflame those in distress. By contrast, a containing clinical encounter which seeks to understand and make sense of the distress based on a biopsychosocial formulation significantly reduces the risk of further self-harm.^{Reference Kapur, Steeg, Haigh, Bergen, Hawton and Ness10}

Concrete management of the patient population, resulting in the ‘revolving door’

Clinicians and teams carry out multiple assessments of patients’ presenting symptoms and risk, and discharge from wards or clinical teams may be planned once these issues seem less acute, only for the patient to be repeatedly re-referred as the underlying issues have not been addressed. The sheer weight of referrals can mean that teams have no time to carry out more comprehensive formulation-based assessments to understand the underlying factors driving the presentation to services at this time. There is a common feeling that consultants spend much of their time ‘firefighting’ and are overwhelmed with workload pressures, with no time to think more psychologically about their patients. In the longer term, this is unlikely to lead to effective use of clinical resources.

Without formulation, by which we mean biopsychosocial formulation, we fail our patients. We start to see them as diagnoses, assessable through the use of questionnaires, interviews based on symptom-gathering and tick boxes. We lose the ‘thick description’ that makes our specialty what it is. Why has this person become depressed now? What is the link between the loss of their daughter 8 years ago, their son leaving home and their symptoms? How is their expression and communication of distress affected by their early history of abandonment, abuse, parental neglect? We need to ask ourselves who would want to be a psychiatrist if we strip away the meanings and connections in the stories our patients bring us.

This is particularly important for complex patients with particularly complicated social backgrounds and comorbidities. This group of patients is most reliant on professionals holding the different aspects of their problems in mind, rather than splitting them off into different professional groupings or a range of specialist teams for different symptoms. This includes medically unexplained symptoms and factitious disorders, complex trauma and personality disorders, complex eating disorders, and comorbid conditions alongside psychotic disorders, which are increasingly common in routine psychiatric practice. The most complex patients are the ones that most need professionals who are able to hold their biological, psychological and social needs in mind at the same time. Psychiatrists are the only profession trained to do this, and in fact historically this was a core part of our role. This very complex group forms an increasing part of consultant psychiatrists’ workload.

Increasing workload pressures, difficulty in retaining staff and increasing specialisation of psychiatric teams have all contributed to real challenges in providing continuity of care to our patients. This can present significant challenges, as patients may experience multiple short-term relationships with different clinical teams, which may repeat experiences of disrupted attachments, a bewildering array of opinions and advice, and loss of caring relationships they can rely on. The importance of communication and effective case formulation involving our patients and their carers and loved ones, with care based on a holistic and shared understanding of their difficulties, is of even greater importance when working under these conditions if care itself is not to become fragmented.

Making psychiatry less attractive to medical students

Interest in the psychological is an important part of what draws trainees into our specialty.^{Reference Goldenberg, Williams and Spollen11} ‘Choose Psychiatry’,¹² the College's campaign aiming to encourage more medical students and doctors to specialise in psychiatry, includes establishing medical student psychotherapy experience and Balint groups within medical schools across the UK, which evidence has shown are major draws into psychiatry. Students who participate in a psychotherapy scheme (in which they are involved in delivering weekly psychotherapy for a patient under supervision, as part of learning about emotional aspects of the doctor–patient relationship) are significantly more likely to choose psychiatry as a career, even those who were not previously interested in psychiatry.^{Reference Yakeley, Shoenberg and Heady13} Doctors thinking of joining the specialty still think of psychiatrists as mostly listening and talking to their patients towards developing a deeper understanding of their difficulties and histories. We lose this at our peril.

Deskilling our trainees in formulation

Significant progress has been made in recent years to reinforce the place of psychological training within core training, with all trainees now required to participate in a Balint group and treat a minimum of two psychotherapy cases. The Balint group is intended to embed reflective practice as an essential component of a psychiatrist's working life, deepening clinical understanding, enabling processing of the emotional impact of the work and supporting team functioning.

The psychological part of the biopsychosocial model of psychiatry is not, however, just about becoming reflective practitioners¹⁴ and learning how to deliver different forms of psychotherapy. It is also about developing a biopsychosocial formulation as the basis of clinical care for all patients presenting to mental health services.

Loss of the long case in the examination for membership of the Royal College of Psychiatrists means that a key driver for developing case formulation skills has been removed. Although trainees are expected to formulate in a biopsychosocial way, anecdotally it is evident that this skill is becoming a lost art in UK psychiatry. In case presentations and academic meetings, it is now common to see trainees and senior colleagues move from the presentation of a patient's history to differential diagnosis, with no reference to a biopsychosocial formulation beforehand. It is as if the gathering of information is in the service of eliciting symptoms as part of a checklist and then rushing to a model or psychiatry in which a diagnosis is made and treatment prescribed. In taking a psychiatric history, we are privileged in the richness of the material we hear, full of meaning about someone's life. Yet it seems that trainees are no longer trained to use the information gleaned about their patients’ early development, relationship and attachment patterns, losses, and traumatic and other formative experiences.

A comprehensive case formulation is what enables us to understand our patients’ presentations and the challenges routinely faced in everyday psychiatry. The psychological component of a biopsychosocial approach supports an attitude of open curiosity about the person in need of mental health services, their emotions and thoughts, and the experiences and relationships most significant to them. It can also shed invaluable light on someone's vulnerability to psychiatric breakdown, what their symptoms may mean, the psychological and relational factors that may support or inhibit recovery, treatment non-compliance, and the reasons underpinning risky and self-destructive behaviours. The practice of psychiatry is a complex task; we need a fully biopsychosocial approach that seeks to understand the underlying issues behind our patient's presentations, in order to provide care on a truly holistic, meaning-making, relational and person-centred basis.

We are facing considerable challenges with recruitment and retention of the workforce within psychiatry. Although most specialisms within psychiatry have vacancies in higher training posts, fill rates for dual training in medical psychotherapy aligned with adult psychiatry are 100%. These posts are oversubscribed, strongly suggesting that trainees wish to develop into psychotherapeutically informed practitioners able to apply these skills across a wide range of psychiatric settings.

Deskilling consultants in formulation

If we don't train our workforce in comprehensive case formulation, we produce consultants who similarly lack these skills. There is no reason to think that such skills are no longer necessary in psychiatric practice – psychopharmacology and brain science have not cured mental illness. Psychological models offer vital ways to understand why our patients break down in the manner they do, the potential triggers for this, the relationship templates learned in early life, which may become manifest in the relationships created with clinical teams, and psychological aspects of treatment resistance – all of which may present management challenges in everyday psychiatry and hence require understanding in the service of providing compassionate clinical care and effective management planning.

Recommending psychological treatments

As psychiatrists, we are generally much less aware of advances in psychological approaches than we are of those in pharmacological approaches. Yet arguably the majority of advances in the past 30 years have been in the former. Many psychiatrists treat psychological interventions as black boxes in which they have little expertise or understanding and refer for (effectively) a second opinion rather than accurately ‘prescribing’ a psychological intervention. There is a good case for psychiatrists being as knowledgeable about psychological interventions as they are about pharmacological interventions. For example, when a patient presents with post-traumatic stress disorder, a psychiatrist would consider prescribing an antidepressant and consider referral for psychological treatment of some sort. This tends to lead to an additional assessment, and to dissatisfaction, as patients are encouraged to think of the psychological treatment as belonging ‘somewhere else’. A better way would be for the psychiatrist to feel confident to engage in an active discussion with the patient about psychological treatments which may help, having built a shared formulation of their difficulties and understanding of their most pressing concerns. Interventions such as trauma-based cognitive–behavioural therapy, eye movement desensitisation and reprocessing therapy, or psychodynamic psychotherapy could then be recommended as part of a comprehensive package of care in which psychological interventions and pharmacological interventions are managed in one place. Why should psychiatrists be less aware of the evidence for psychological treatments than that for pharmacological or physical treatments?

Providing psychological treatments

We train psychiatrists to be competent to deliver psychological treatments. A few (other than medical psychotherapists) continue to do this as consultants, but it is often difficult to timetable this into job plans. Trusts tend to see psychological treatments as best provided by other professions. We think this is because of the shifting perception of what psychiatrists do – assessing, diagnosing, prescribing, applying the Mental Health Act, and managing and holding responsibility for risk. This diminishes our role and the breadth of our training to function as psychologically informed practitioners. Colleagues who can deliver psychological interventions are enthusiastic about being able to do so. It is a mistake to assume that psychiatrists will not deliver expert psychological treatments. We have let this slip.

Psychological research

There has been an explosion in research in both novel and established methods of psychological treatment. In stark contrast to pharmacological research, these novel methods are producing positive results in areas for which there was previously little or no treatment, for example, personality disorder. Moreover, there is a wealth of cross-disciplinary studies linking research in psychological therapies to related fields such as neuroscience, experimental psychology and developmental research.^{Reference Holmes, Ghaderi, Harmer, Ramchandani, Cuijpers and Morrison15} Are most psychiatrists aware of this? It is hard to say, but a cursory glance at the schedule for the 2022 RCPsych International Congress will tell you that the extraordinary developments in psychological and psychotherapeutic approaches are having difficulty reaching the surface. A brief survey of the conference programme identifies 32 sessions on pharmacological and neuroscientific topics (mostly symposia composed of three or four sessions); 13 broadly socially focused sessions, on subjects such as the aftermath of Covid, inequality, the social determinants of mental illness and the impact of social media; and a number of sessions that don't fit into biological, psychological or social categories, such as risk assessment and phenomenology. However, there were only seven sessions on psychological approaches and understanding. There was not, as far as we could find, a single session on developments in psychological treatments. Does this accurately represent progress in practice and how we how we think about psychiatry?