Psychotherapy and trainees Current practice, its perceived importance and the question of lay counsellors

consistently emphasised the importance of psychotherapy training for trainees (Royal Medico-Psychological Association, 1971; Grant et al, 1993). Previous studies have compared these recommendations with the realities of practice and this survey records the experi ences of a large group of trainees in Ireland, in order to establish current trends and allow comparison with these studies. It also explores the relationship between psychotherapy experi ence and a number of other training para meters. Recent years have seen a growth in nonmedical counsellors, driven by the health ser vices' attraction to their lower costs (relative to medically-trained personnel) and by perceptions about medical counsellors among general practi tioners (Mutale, 1995). Attitudes of trainees to non-medical psychotherapists, who may nor may not be members of the interdisciplinary team, are presented.

Current practice, its perceived importance and the question of lay counsellors

Peter Byrne and David Meagher
The value ana efficacy of psychotherapy is currently being debated both within (Gabbard et aÃ¯,1997) and outside the profession. One commentator has spoken of psychotherapy's populist synonym 'counselling', as the "valium of this era", where counselling "does not cause the same clouding of consciousness as drugs, but its side-effects are twice as bad" (Dalrymple, 1996).
Royal College of Psychiatrists' guidelines have consistently emphasised the importance of psychotherapy training for trainees (Royal Medico-Psychological Association, 1971;Grant et al, 1993). Previous studies have compared these recommendations with the realities of practice and this survey records the experi ences of a large group of trainees in Ireland, in order to establish current trends and allow comparison with these studies. It also explores the relationship between psychotherapy experi ence and a number of other training para meters.
Recent years have seen a growth in nonmedical counsellors, driven by the health ser vices' attraction to their lower costs (relative to medically-trained personnel) and by perceptions about medical counsellors among general practi tioners (Mutale, 1995). Attitudes of trainees to non-medical psychotherapists, who may nor may not be members of the interdisciplinary team, are presented.

The study
A questionnaire was administered to all psychia tric trainees in the Eastern region of Ireland and yielded 138 completed replies, a response rate of 80.2%. The details and demographics of respon dents are recorded elsewhere (Meagher et al 1997). One section asked trainees a number of specific questions about their experiences of psychotherapy training and their general views in this area.

Current practice
Trainees were asked if they had received any formal training in the assessment of patients for psychotherapy (see Table 1). Trainees also indicated if they had treated patients under supervision using any of a number of treatments (Table 2).
Trainees who had practised psychotherapy (any modality) were compared to those who had not (see Table 3). Trainees who had undertaken psychotherapy indicated for how long each month they had access to a supervisor. For dynamic psychotherapy, 43 trainees had a mean 2.52 hours supervision monthly. Others were group psychotherapy (n=19) 2.27 hours; cogni tive-behavioural therapy (n=23) 2.17 hours; and family therapy (n=17) 2.35 hours.
This information identified a third group who had received supervision in accordance with College guidelines, that is, experience of each modality, with minimum time allocations, for example one hour supervision each week for dynamic therapy (Grant et ai, 1993). Six trainees met these requirements (see Table 3).

Value of psychotherapy
In the context of overall training, psychotherapy training was rated as Very relevant1 57%, 'relevant' 41%, with 2% 'irrelevant'. Trainees were also asked whether they thought a trained psychotherapy supervisor should be available to all trainees: 129 (99%) replied yes.
All trainees were asked if they were satisfied with their training in a number of key areas, including the three psychotherapeutic modalities listed in Table 4. Those who had had direct experience of psychotherapy were significantly more satisfied with this training ( Table 5).

Suitability of psychotherapists
Trainees were asked to indicate (yes or no) the suitability of the following persons to conduct psychotherapy: psychiatrist, clinical psycholo gist, social worker, general practitioner (GP) and lay counsellor. They were presented in that order, without any accompanying explanations. Sixteen trainees deemed all five suitable. They were less likely to have had any psychotherapy training (5/16 had this experience), but this trend was not significant. There was no relation ship between the total number of categories chosen and psychotherapy experience.
Eighteen trainees considered that only a psychiatrist could practise psychotherapy with eight stating that a clinical psychologist (i.e. psychologist alone) could do so. Only one of these eight trainees had experience of psychotherapy training. Forty-eight trainees, who did not in clude any other group, approved both profes sionals. The subtotal, 74 (68.9%), was compared to the remainder in relation to the presence of  psychotherapeutic experience. Although they were more likely to have had this experience, this trend was not significant (P=0.1). Seventy-six respondents (57.1%) judged the GP as a suitable person to practise psychother apy, 98 (73.7%) stated that any, or all of four other persons were suitable except the social worker, with 111 (83.5%) stating that any or all of the four other persons were suitable except the lay counsellor. These trainees showed the same distribution of experience in years and in training as the wider group. Thirty-three indi cated approval for the social worker, with 22 for the lay counsellor.

Comment
This study reports the views of a large group of trainees, and explores these views in the context of other areas of experience and opinion. In addition to the limitations of any questionnaire-based study, our results must also be seen in the context of a high proportion of trainees who had not yet attained MRCPsych (see Table 2). There may be a perception among trainees that psychotherapy is part of higher training, that is something to pursue after attaining MRCPsych. In practice the majority of teaching time for pre-membership trainees is exam orientated.

Current practice
Less than half of those questioned reported that they had direct experience of psychotherapy. Less than one-third had had formal training in the assessment of patients for psychotherapy. This group did not represent a group new to psychiatry, with an average of 3.05 years training. Table 2 compares the stated experi ences with previous studies, and our figures compare poorly with these. From our survey it would appear that in Ireland a substantial proportion of psychiatrists in training have no practical psychotherapeutic input into that training. Where training is provided, the amount of supervision falls short of College guidelines in all but a few cases.

Value of psychotherapy
When asked to rate the importance of psy chotherapy, the vast majority reported this training to be either relevant or highly relevant. The proposition that a supervisor be provided for all trainees was accepted almost unanimously.
In a previous study by Castle et al (1994), trainees rated training opportunities as 'poor' in psychodynamic therapy (28%), cognitive-beha vioural therapy (46%) and family therapy (38%). These ratings are important in that they repre sent the highest dissatisfaction ratings (with one exception, management of violence) in a survey of 137 MRCPsych Part II candidates (Castle et al 1994). In Table 2, we present even higher dissatisfaction rates, and these figures may be directly related to the deficits in training we have described. Trainees judge this training important and the lack of opportunities is seen as a weakness of their training. Our findings also support the hypothesis that deficits in training are related to supply of opportunities and super visors, rather than low demand from trainee psychiatrists.
American psychiatry has experienced the decline of psychotherapy as the dominant feature of psychiatric training. Wallerstein (1991) charted the decline over 50 years in psychotherapy teaching (as a percentage of total teaching time in an average Residency pro gramme) from 50 to 2.5%. Bradbury et al (1996) found the majority of psychiatrists recog nised the need for and efficacy of psychotherapy. We confirm this finding in identifying psychiatric trainees who consider psychotherapy important, and when they receive training and supervision are significantly more satisfied with both this specific aspect of training and their training in general.
Our findings also challenge the stereotype of the psychotherapeutically orientated trainee as female and someone who does not develop other interests. They have passed exams, researched and published, and are significantly more computer literate than their untrained peers. In this respect, those who complete any psy chotherapy training, but especially those who have met College guidelines, could be described as role models for all psychiatrists in training.

Suitability of psychotherapists
Trends were less obvious in this area. A minority of trainees regarded psychiatrists alone as suitable therapists, over half stated that only psychiatrists and/or psychologists were appro priate here and a similar number included the GP. No parameters could separate out these two groups.
Social workers and lay counsellors were fre quently absent from this suitability list, with high numbers of trainees (74 and 84% respec tively) believing that these persons were not suitable therapists. Again, no parameters could separate out these groups. With regard to social workers, one explanation could be the confusion in trainees' minds between psychiatric social workers and community care social workers. Under recent Irish legislation, the latter group may come into conflict with psychiatrists over child care issues (O'Boyle. 1996, personal com munication). In a recent survey of counselling in one district, none of the team's five social workers saw themselves as providing counselling to their patients (Arnott et al 1996).
Lay counsellors are unacceptable to a majority of respondents. This opinion was independent of psychotherapy experience, and could not be attributed to a 'sour grapes' attitude (we're not trained to do it, so why should they do it?) among trainees. At one level their concerns are shared by GPs in Ireland, whose recent guidelines (O'Carroll & O'Riordan, 1996) record reserva tions about the supervision and professional indemnity of lay counsellors. Interestingly in the UK, general practices which have formal links with mental health services, are more likely to employ a lay counsellor (Mutale et al, 1995).

Conclusions
Low numbers of trainees gained any experience and supervision times were below guidelines, with only a small minority meeting College guidelines. Trainees were unhappy with their current opportunities in this area. Favourable findings were that any training was associated with higher satisfaction levels, and well-rounded trainees. Respondents valued psychotherapy highly despite lower levels of training than previously published studies. The majority believed psychiatrists, psychologists and GPs to be suitable psychotherapists, but voiced reserva tions about non-medical counsellors.