Discussion

This study adds substantially to the very limited literature detailing the peculiarities and challenges of training in intellectual disability psychiatry. ^{Reference Hollins1,Reference Graham, Herbert, Price and Williams2} One strong theme that emerged from our results was how trainees considered training in intellectual disability to be different from other psychiatric posts and the degree to which they were prepared for this. The reasons cited were related to both the specifics of the work and the structure of teams. It is well known that psychiatric disorders in intellectual disability may be more complex to diagnose, particularly owing to difficulties in effective communication. A further contrast with many other areas of psychiatry is the degree to which healing or restoration to full function or participation is possible. In intellectual disability psychiatry, the primary disability is often the intellectual impairment or associated developmental disorder, thus treatment of any mental illness may restore the patient's previous level of functioning and quality of life, but no further. Despite epilepsy management being a common role for the intellectual disability psychiatrist, ^{Reference Bowley and Kerr8} our findings suggest that many trainees felt apprehensive about their skills and confidence in this area.

Feelings of isolation were also highlighted. CLDTs in the area of the study are geographically spread out and based away from their mainstream psychiatric colleagues. Separation from peers has been noted as off-putting to foundation doctors, ^{Reference Welch, Bridge, Firth and Forrest9} but few studies explore feelings of isolation among psychiatry trainees ^{Reference Graham, Herbert, Price and Williams2} It has been noted previously that individuals who work with people with disabilities can feel stigmatised and isolated. ^{Reference Byrne10–Reference Afia, Hassiotis, Strydom and King12} Stigma by association is the process by which relatives, support staff, friends and associates feel stigmatised owing to their contact with a stigmatised group. ^{Reference Pryor, Reeder and Monroe13,Reference Parfene, Stewart and King14} This may also affect trainees working in this area and contribute to their feelings of isolation. We think that one reason the group was valued could be its ability both to reduce the feeling of isolation by bringing trainees together, and to mitigate some of the stigma felt by enabling the trainees to share difficult experiences. One could speculate that the group may have not just attenuated some potential negatives of the subspecialty training, but also contributed to the enjoyment and reward of it. If this were to be true, it would be interesting to study whether training schemes in areas with specialty-specific support or educational groups do better in relation to trainee retention or satisfaction than those without such structures.

It should be noted that despite the challenges, there was also a strong and pervasive feeling of positivity about training and working in intellectual disability psychiatry. Such experiences were startlingly absent in previous work, ^{Reference Graham, Herbert, Price and Williams2} but are important to note to reassure future recruits in the specialty. In particular, the trainees mentioned the term ‘rewarding’, a varied and complex concept. ^{Reference Weber15} The view that community-based intellectual disability psychiatry would be rewarding was predicted some 30 years ago, ^{Reference Bicknell16} although this is the first study as far as we are aware that affirms this view. Intellectual disability requires a particularly holistic approach, often not dissimilar to the approach of general practitioners (GPs). While there is an absence of published surveys or qualitative studies on what psychiatrists find rewarding, interpersonal relationships between doctor and patient have been found to be particularly satisfying for GPs. ^{Reference Fairhurst and May17} However, we are unaware of similar studies among psychiatrists. ^{Reference Lepnurm, Dobson, Backman and Keegan18}

Both focus groups discussed how consultant supervision and the support group were different, but mutually supportive and compatible. When surveyed, UK trainees report they are mostly happy with supervision and find it useful. ^{Reference Ho and McConville19} The Royal College of Psychiatrists recommends that supervision should enable ‘the development and assessment of clinical and personal skills under direct one-to-one supervision by an expert’ and should be ‘focused on discussion of individual training matters’. ²⁰ The hierarchical nature of consultant supervision is both valued by trainees ^{Reference Chur-Hansen and McLean21} and necessary for valid competency assessments, but this can be a potential barrier to seeking support in some areas, particularly revealing vulnerabilities to a supervisor who is also an assessor. Personal upset and secondary grief relating to patients is considered by some supervisors and supervisees to be a boundary breach in supervision. ^{Reference Chur-Hansen and McLean22} The trainee support group is set up without hierarchy and this may have contributed to reducing boundaries around discussing vulnerabilities. Honest discussion about how trainees were ‘coping’ was easier in the trainee support group than supervision, despite the College suggesting consultant supervision should include this. ²⁰ This study adds to previous work suggesting some mismatch between intent and what trainees feel comfortable discussing ^{Reference Chur-Hansen and McLean23} This space for honesty is a value of the group but it would be a concern if the availability of the trainee support group and its support acted as a colluder or barrier to honesty in consultant supervision.

Group peer support may be more beneficial than alternatives such as paired peer support. Several of the benefits described in both focus groups suggested similarities to Yalom's therapeutic factors: universality, altruism, guidance, imparting of information, cohesion, and existential factors. ^{Reference Yalom24} That senior trainees stayed in the group for up to 3 years may reinforce some of these factors, and their relative maturity and existing trust following a longer involvement in the group may provide additional support. ^{Reference Bandoli25} It also provides senior opinions, which have been found to be supportive when shared in other contexts. ^{Reference Dewar, Eagles, Klein, Gray and Alexander26} A common concern when leaderless groups are used for supervision is a loss of focus on the task and drifting into support and advice-giving. ^{Reference Counselman and Weber27,Reference Borders28} As the model presented here is primarily for support, and advice is part of that, the lack of leader is not a concern in this context, although the results did suggest that some participants would have liked a facilitator role in encouraging quieter members to contribute.

As this is an analysis of a single group and the findings have not been replicated elsewhere, it is difficult to generalise the utility of such groups to other areas. However, we think similar models of egalitarian peer support that require limited resources for setting up may have the potential to benefit trainees in other, smaller or more challenging, specialties.