Discussion

The main finding of this study was that only one-third of the ECPs in Nepal had received psychotherapy training. This figure might be much lower if we only count colleagues who trained in Nepal, since many respondents trained abroad (particularly in India), with good exposure to psychotherapy training. These shortfalls in psychotherapy training programmes have been highlighted in other countries as well.^{Reference Gargot, Dondé and Arnaoutoglou1,Reference Grover, Sahoo and Srinivas6} In the European psychotherapy survey, less than 50% of the trainees had received psychotherapy training.^{Reference Gargot, Dondé and Arnaoutoglou1} One possible explanation is that psychotherapy training is affected by the lack of availability of skilled psychotherapists who can train ECPs. Higher training in psychotherapy is not available, and training centres do not have protected time for psychotherapy training.

It is essential to legitimise psychotherapy for successful implementation of formal psychotherapy training programmes in Asian countries as psychotherapy is considered a Western concept.^{Reference Ang7} In Nepal, a major hindrance to psychotherapy practice was patients’ preference for traditional healing, difficulty in accessing therapy, cultural and language barriers, and non-availability of locally adapted tools.^{Reference Halder, Mahato, Naeem and Kingdon8} In Thailand, barriers to psychotherapy training identified by ECPs were time constraints, lack of supervisors and absence of incentives for psychotherapy practice.^{Reference Charernhoon and Phanasathit9} Providing psychotherapy training in university settings, relating psychoanalysis to Eastern Taoist philosophy (in Singapore) or to Confucian philosophy (in Korea) was particularly helpful for widespread support to implement psychotherapy training programmes.^{Reference Ang7} Therefore, local and cultural adaption of psychotherapies may be required for successful implementation in practice. It is challenging to bridge this learning gap, given the competing demands of mental health services and few formally trained supervisors in psychotherapy. It is imperative to establish a close liaison and collaboration with other professionals, such as clinical psychologists, to initiate and develop innovative training opportunities. Emphasis on the training can be ensured by allocating protected time specifically for psychotherapy training and supervision.

In this survey, more than two-thirds of ECPs in Nepal reported that psychotherapy is a part of psychiatry training and is mandatory. However, four-fifths reported that that training focused mainly on the theoretical aspects. This may be one of the reasons for the lack of competencies in psychotherapy. CBT was the predominant therapy ECPs had experience of in Nepal. Similarly, a recent survey in India demonstrated that training in different types of psychotherapy, such as psychodynamic psychotherapies, rational emotive therapy and dialectical behaviour therapy, was inadequate or low.^{Reference Grover, Sahoo and Srinivas6} A possible explanation is that CBT is the most supervised of therapeutic modalities in most Asian countries^{Reference Alfonso, Sutanto and Zakaria10} and training in other modalities is not as readily available and accessible.

One of the most important aspects of psychotherapy training is the supervision of psychotherapy cases. Our study found that two-thirds of those who had access to psychotherapy training received supervision. Half of them reported that the supervision was optional, and the duration was less than 50 h. The Indian Psychiatric Society (IPS) Task Force Guidelines on postgraduate psychiatry training have mandated that each trainee achieves a minimum of 50 h of supervised psychotherapy and submits one therapy case for evaluation as part of final year assessment.^{Reference Issac, Murthy and Sidana11} For those who had undergone psychotherapy training, about 50% reported that they were satisfied with it.

Importantly, most ECPs in Nepal considered that psychotherapy should be included in psychiatry training, and it was encouraging to find that ECPs in Nepal were highly motivated for psychotherapy training. Most ECPs would like to pursue further training in CBT, family therapy and interpersonal therapy. Psychodrama and dialectical behaviour therapy received the lowest interest, possibly a reflection that training in these modalities is difficult to access. These findings suggest that the postgraduate training curriculum might need to be updated and implemented to prioritise structured psychotherapy training with adequate supervision and thus enhance the training experience. Access to online training resources in different modalities of psychotherapy¹² can be a feasible short-term option in the Nepalese context to address these unmet training needs of ECPs.

It is difficult to establish whether this study is a true representation of all ECPs’ experiences (as the response rate was 53.7%) and the questionnaire did not ask about the place and year of training/work, to ensure that the responses were anonymous. Future research could be complemented by directly contacting the training programmes in each institution. It would be important to further explore the reasons for satisfaction or dissatisfaction, which was beyond the scope of this questionnaire. We also did not explore who does the psychotherapy supervision, or the frequency and quality of supervision, and these factors warrant exploration in further research.

Psychotherapeutic treatment can be made more accessible to patients by providing psychotherapy training to psychiatric trainees. Despite being challenging, training in psychotherapy will benefit upcoming young psychiatrists, improve patient care and enhance the specialty.