The efficacy of training in dynamic psychotherapy

Training in dynamic psychotherapy is recognised as an important part of training in psychiatry for all mental health professionals. This importance is emphasised in the College guidelines for psychotherapy training as part of general professional training (Grant et al, 1993). That training, even at an introductory level, can benefit people in their general psychiatric work (Hughes & Halek, 1991). In their study, a one year course introducing psychodynamic principles to nurses resulted in significant changes in the nurses'


Training
in dynamic psychotherapy is recognised as an important part of training in psychiatry for all mental health professionals.This importance is emphasised in the College guidelines for psychotherapy training as part of general professional training (Grant et al, 1993).That training, even at an introductory level, can benefit people in their general psychiatric work (Hughes & Halek, 1991).In their study, a one year course introducing psychodynamic principles to nurses resulted in significant changes in the nurses' confidence, competence and understanding of their work-valuable assets in any psychiatric setting.
For many years, the Leicester psychotherapy service has provided training to a wide range of people working in different mental health settings.
Qf ^0,^^Is that no trainee reported any decreased skills.It is, of course, unlikely that a trainee would perceive a decrease in skills as a Findings result of any training experience, even a bad Out of 27 trainees.20 returned the completed on?: 'n our f*^3' We ^^^q uestionnaires.
There were nine doctors mdicaUÂ°ns of change, so scores of 3 (mostly registrars), six nurses (four 0â"¢*Â«****slight improvement) were not community psychiatric nurses, one ward CÂ°nsjd5efdf PÂ°sitivech^e.sister, and one clinical nurse specialist with UAdeflnlte **"* Â«mergedfrom the responses: the eating disorders team), three occupational ^lon^r one has spent in supervision, the therapists and two social workers.Most had Â«"Â»ter ^Perceived skills development.1 shows ^number of respondents scoring 4 or 5 (improvement or great improvement) across the range of variables when scores Number of years in supervision were stratified by length of time in Eight trainees had less than one year of supervision'.The trend overall is for an supervision in the department (seven of these improvement in skills the longer one has were doctors).Four had between one and two been in supervision.
However, this years of supervision and eight had more than relationship is not always a linear one.The two years.The longest period in supervision cohort with one to two year's experience of was seven years.
supervision seem less confident about their

The efficacy of training in dynamic psychotherapy
grasp of concepts such as transference and countertransference.
Given these atypical results for the middle cohort, it was not included in the statistical analysis, a single comparison being made between the 'less than one year's supervision' cohort with the 'greater than two year's supervision' cohort.The following changes achieved statistical significance (using Fisher's exact test) when these two cohorts were compared.

Other work changes
Trainees noted improvements in their overall job satisfaction and motivation at work even as a consequence of less than one year of training in dynamic psychotherapy.
For those trainees with more than two years of supervision, 75% noted improved job satisfaction with 100% feeling an improvement in their motivation at work (see Table 1).These results indicate that training in dynamic psychotherapy is a good influence on trainees' work.

Trainees' written comments
Most trainees added their own comments in addition to filling in the ratings for each question.Comments described their experi ences: of doing something new or different, e.g."I allow things to take their course and don't rush" of being able to apply their knowledge in specific areas, e.g."Importance of boundaries particularly useful when dealing with bulimic patients" of the learning process, e.g."I can contain my patients' anxiety to a much greater degree knowing there is meaning -anxiety does not occur in a vacuum".
The comments gave a sense of the wide variation in individuals' learning needs and styles and in their perception of the training attachment as a learning experience.

Comment
This study shows that trainees gain much from their training in dynamic psychotherapy.They report significant changes in their knowledge base, clinical practice and self awareness as clinicians.

The process of learning psychotherapy
The longer one has been in training and supervision, the greater is the perceived development of skills.However, within this picture, a number of interesting patterns emerge.Some skills develop at an early stage.The majority of trainees with less than one year's experience see an improvement in their understanding of patient's communications, of transference and of countertransference in the patient/therapist relationship.
They also see themselves as being more aware of understanding the patient's problems in dynamic terms.Other skills -management of patient's anxiety and boundary management, overall ability to work within the therapeutic relationship -take more time to develop.
In any developmental process, some things are learnt more quickly than others.It may be that the process of learning dynamic psychotherapy parallels the processes involved in learning a language.In the early stages, one learns to understand the language, its structure and meaning.It is only at a more advanced stage that the ability to use the language for oneself and with others develops.The skills which take time to develop may be related more to the management of the therapeutic process rather than the understanding alone.
Even considering individual skills, e.g.understanding of transference, development is not always a linear process and there seems to be a drop in confidence in the one to two year period (see Table 1).It is unlikely that the understanding gained in year one has been lost.It may be that 'understanding' of a concept occurs at many different levels.At an early stage, trainees may have a superficial understanding of 'transference'.With further training and experience they realise the complexity of the concept and are more aware of the limitations of their knowledge.Subsequently, a richer and more in depth understanding develops.Many theories of learning stress the active role of the learner in constructing personal understanding.Kolb (1983) outlined a learning cycle of four phases.
The first phase involves a 'concrete experience' in which the trainee gains basic tangible knowledge.This could come from starting therapy with a patient, learning some basic definitions.Next, there is a phase of 'observation and reflection' which may get under way as the trainees begins to discuss their case in supervision and listen to other trainees' experiences.Third, is a phase of 'forming abstract concepts and making generalisations' which takes time to achieve and is assisted through theoretical discussions in seminar and supervision groups.The fourth phase involves 'testing the implications of concepts in new situations'.This phase enables the trainees to apply their experience in day to day practice.

Professional differences
It was not possible to analyse differences across professional groups, as most of the doctors had less than one year's experience of supervision.It is likely that doctors will differ from other trainees.They are required to have psychotherapy training whereas the other trainees will have sought out the training opportunity.Doctors may also be wanting a different experience to other professionals, seeing psychotherapy training as part of their general psychiatric training.However, the results of this paper indicate that to consolidate their psychotherapy skills, a period of at least two year's supervision would be recommended, as is emphasised in the College guidelines (Grant et cd, 1993).

The impact of psychotherapy training on trainees' general work
Training takes time but the study indicates that it is time well spent.The beneficial effect of training on people's motivation to work and job satisfaction is clear from and will be of interest to managers.Specialist psychotherapy departments have always seen training as an important part of their role and this study underlines the effectiveness of this function.Purchasers too have an interest in training and will find it helpful to have demonstration of its value.
Our questionnaire has only touched on what is a huge area concerning the learning process itself.It would be valuable to look in more depth at the learning process over time, perhaps with a more refined instrument.It would also be of interest to focus further on just how training in dynamic psychotherapy might inform a trainee's work in other areas of psychiatry.

Table 1 .
Respondents scoring 4 or 5 (improvement or great improvement) for questionnaire variables when stratified by length of time

in supervision < 1 year <l-2 years < 2 years
Table had no previous training in psychotherapy.