Psychotherapy in Contemporary Psychiatric Practice

Barriers to Mental Health care in Canada Identified by Healthcare Providers: A Scoping Review

The mental health treatment gap remains wide across the world despite mental illness being a significant cause of disability globally. Both end-user and healthcare provider perspectives are critical to understanding barriers to mental healthcare and developing interventions. However, the views of providers are relatively understudied. In this review, we synthesized findings from current literature regarding providers' perspectives on barriers to mental healthcare in Canada. We searched Medline, PsycINFO, Embase, and CINAHL for eligible Canadian studies published since 2000. Analysis and quality assessment were conducted on the included studies. Of 4,773 reports screened, 29 moderate-high quality studies were reviewed. Five themes of barriers emerged: health systems availability and complexity (reported in 72% of the studies), work conditions (55%), training/education (52%), patient accessibility (41%), and identity-based sensitivity (17%). Common barriers included lack of resources, fragmented services, and gaps in continuing education. Interestingly, clinicians often cited confusion in determining the ideal service for patients due to an overwhelming number of potential services without clear descriptions. These five domains of barriers present a synthesized review of areas of improvement for mental healthcare spanning both patients and clinicians. Canadian mental health systems face a need to improve capacity, clinician training, and in particular service navigability and collaboration.

An appraisal of psychotherapy training during psychiatry residency program in India: A national survey

Background

The need for psychotherapy training (PT) has been recognized worldwide and is considered an integral component of postgraduate psychiatry training. Our study aims to assess the quality of PT received by psychiatrists during their postgraduate studies and its impact on their current practice.

Aim

To evaluate the quality of PT and its effect on the current psychiatry practice.

Methodology

An anonymous web-based survey was conducted on registered psychiatrists practicing in India to evaluate the level and quality of PT received during their postgraduate studies.

Results

The survey indicates that PT was included in the postgraduate psychiatry curriculum (73.8%). However, more than 50% of responders reported no separate posting, evaluation, logbook, or guidelines related to PT. Most (95.4%) psychiatrists think their PT could have been better. PT was satisfying in medical colleges in terms of inclusion in the curriculum (7.70, P = .021), psychotherapy rotations (16.48, P = <0.001), supervision of sessions (14.80, P = 0.001), lectures on psychotherapy (10.13, P = 0.006), periodic psychotherapy meet/forum (19.35, P = <0.001), maintenance of psychotherapy logbook/records (7.65, P = 0.022), institutional or departmental guideline related to PT (20.55, P = <0.001), and overall quality of PT (22.05, P = .005 and 31.81, P = <.001). Time constraint is the most common (49.9%) barrier in delivering psychotherapy.

Conclusion

PT is not well organized, consistent, and uniform in psychiatry training; there is a prevailing sense of inadequacy and dissatisfaction among the country's psychiatrists with a perceived need to improve and learn PT.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

www.psychopap.com : améliorer l’accès à la psychothérapie par le transfert des connaissances aux patients et aux futurs thérapeutes

La psychothérapie est un traitement efficace pour plusieurs troubles mentaux. Elle est, toutefois, peu accessible pour différentes raisons, dont son coût, la façon de l’offrir et la disponibilité locale des thérapeutes. Par ailleurs, l’accès à la formation en psychothérapie pour les futurs thérapeutes peut être compliqué par différents facteurs incluant le manque de ressources adaptées à différents contextes de pratique et la difficulté à obtenir une supervision. Dans ce contexte, un site web offrant des documents d’autothérapie aux patients, des miniguides de formation dans différents types de psychothérapies basées sur des données probantes, des suggestions d’articles et livres phares, des capsules vidéo expliquant les principes sous-tendant différents modèles théoriques et démontrant des techniques de psychothérapie, pourrait bénéficier autant aux patients qu’aux psychothérapeutes débutants.

L’Hôpital en santé mentale Albert-Prévost (HSMAP), impliqué dès ses origines dans la formation et la pratique de la psychothérapie, conçoit un tel outil pour célébrer son centenaire, le site www.psychopap.com. Le présent article propose de décrire la genèse et le déploiement de ce projet de transmission de connaissances en psychothérapie en décrivant d’abord le contexte et l’implication des membres de l’HSMAP dans l’enseignement de la psychothérapie puis une brève recension des écrits concernant l’autothérapie pour les troubles mentaux, l’utilisation des ordinateurs/Internet pour l’enseignement de la psychothérapie et comment ces données ont été appliquées dans la création de www.psychopap.com.

European Psychiatric Association policy paper on ethical aspects in communication with patients and their families

BACKGROUND

Establishing a valid communication is not only a basic clinical need to be met but also a relevant ethical commitment.

METHODS

On the basis of the relevant literature, ethical issues arising from specific, important situations in clinical practice were identified.

RESULTS

The main ethical problems regarding communication about the disorder, both in general and in relation to prodromal stages, were described and discussed together with those regarding communication about voluntary and involuntary treatments, "dual roles" enacted in clinical practice, genetic counseling, and end-of-life conditions; on the basis of what emerged, ethically driven indications and suggestions were provided.

CONCLUSIONS

Several situations put the psychiatrist in front of relevant dilemmas and doubts which are no easy to face with; an ethically driven approach based upon the principle of the best interest of patients may support clinicians in their decisions.

Standalone DBT Group Skills Training Versus Standard (i.e. All Modes) DBT for Borderline Personality Disorder: A Natural Quasi-experiment in Routine Clinical Practice

We describe a naturally occurring, real-world comparison of outcomes following 6 months in standalone DBT skills training group for adults with Borderline Personality Disorder (BPD) without recent suicidal or severe self-harming behaviours and standard (i.e. all modes) DBT for BPD including patients with recent high-risk behaviours. 34 patients chose standalone skills over waiting for standard DBT and 54 were offered standard DBT. Dropout was higher for standalone skills than standard DBT (38.2% vs. 16.7%). No statistically or clinically significant differences were found among completers between conditions on borderline symptoms, general psychopathology, and suicide ideation. There was a moderate effect for standalone skills on hopelessness and emotion regulation difficulties which may have reflected non-equivalence of treatment groups. Significant methodological factors limit generalisability of findings which offer support for feasibility of standalone DBT skills as an effective alternative to waitlist for standard DBT for at least some patients with BPD in the community.

Impact of an educational workshop on psychiatrists' attitude towards psychosomatic medicine

BACKGROUND

Although psychosomatic medicine is not recognised as a medical specialisation globally, it has proven useful for treating many disorders in Germany. This paper reports on the impact of an educational workshop as a tool for raising awareness about psychosomatic medicine among international psychiatrists.

METHODS

Psychiatrists from eight different countries were educated on psychosomatic medicine and psychotherapy during a 90-min workshop using a video, a slide presentation and an innovative teaching format called 'speed coaching'. Learning outcomes were assessed by analysing questionnaires completed by the participants before and after the workshop.

RESULTS

Half of the participants who initially rejected the notion that psychosomatic medicine should be a specialisation on its own changed their minds in favour for it to be a separate discipline (p = 0.125). Awareness about which diseases and patients psychosomatic doctors deal with was increased. The intent for treatment of patients with eating disorders by a psychosomatic physician quadrupled among the participants (p = 0.004).

CONCLUSIONS

A brief educational intervention can influence psychiatrists' decisions to opt for approaches by doctors specialized in psychosomatics for certain disorders. Further studies may explore why psychiatrists agree or disagree that psychosomatic medicine should be a separate specialisation on its own.

Should all psychiatrists be skilled to practice psychotherapy?

Psychiatrists have a unique place in the spectrum of mental health services, as being able to integrate psychotherapy and pharmacotherapy in clinical practice. It is through psychotherapy training that a trainee gains optimal communicative skills and competence in establishing therapeutic alliance with a patient. It helps developing empathic understanding, which is very important for a good collaboration and enable understanding, diagnostic and treatment. It improves trainees’ own insight. All are these fundamental aspects of a biopsychosocial approach of psychiatry.

In many countries psychiatry trainees have a positive attitude towards psychotherapy during their training. Moreover, patients often prefer and adhere to combined psychotherapy and medication than split-care treatments. Research in psychotherapy provides ample evidence that these treatments are effective. The UEMS considers psychotherapy education as mandatory. EFPT advocates that all trainees must gain competence in at least one recognised form of psychotherapy and have a basic knowledge for other forms. Altogether, there is a consensus among all actors of mental health services that psychotherapy training is essential and should be improved. Yet, it is still far from being a priority in psychiatric training and is subdued by biological training and research, which is easier, faster and prevailing in training institutions. Also, psychotherapy training is found less affordable by trainees.

With collaboration from other organizations, EFPT aims to improve standards of psychiatry training, including psychotherapy. We present some initiatives led by UEMS, EPA, WPA and ECNP. Today's technology allows trainees to reach various psychotherapeutic training availabilities, including online tools (Webinar, MOOCs, online guidebooks) and international courses. It is advisable that training institutions devote more time on psychotherapy training and supervision, associations provide costly training availabilities or scholarships, encourage more scientific research on psychotherapeutics and take into account the progress of research in psychology and neuroscience [1–5].

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Should all psychiatrists be skilled to practice psychotherapy?

Psychiatrists have a unique place in the spectrum of mental health services, as being able to integrate psychotherapy and pharmacotherapy in clinical practice. It is through psychotherapy training that a trainee gains optimal communicative skills and competence in establishing therapeutic alliance with a patient. It helps developing empathic understanding, which is very important for a good collaboration and enable understanding, diagnostic and treatment. It improves trainees’ own insight. All are these fundamental aspects of a biopsychosocial approach of psychiatry.

In many countries psychiatry trainees have a positive attitude towards psychotherapy during their training. Moreover, patients often prefer and adhere to combined psychotherapy and medication than split-care treatments. Research in psychotherapy provides ample evidence that these treatments are effective. The UEMS considers psychotherapy education as mandatory. EFPT advocates that all trainees must gain competence in at least one recognized form of psychotherapy and have a basic knowledge for other forms. Altogether, there is a consensus among all actors of mental health services that psychotherapy training is essential and should be improved. Yet, it is still far from being a priority in psychiatric training and is subdued by biological training and research, which is easier, faster and prevailing in training institutions. Also, psychotherapy training is found less affordable by trainees.

With collaboration from other organizations, EFPT aims to improve standards of psychiatry training, including psychotherapy. We present some initiatives led by UEMS, EPA, WPA and ECNP. Today's technology allows trainees to reach various psychotherapeutic training availabilities, including online tools (Webinar, MOOCs, online guidebooks) and international courses. It is advisable that training institutions devote more time on psychotherapy training and supervision, associations provide costly training availabilities or scholarships, encourage more scientific research on psychotherapeutics and take into account the progress of research in psychology and neuroscience [1–5].

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Personal Therapy in Psychiatry Residency Training: A National Survey of Canadian Psychiatry Residents

OBJECTIVE

The authors collected nationally representative data on Canadian residents' experiences with and perspectives on personal psychotherapy in their psychiatric training.

METHODS

A 43-item questionnaire was distributed electronically to all current psychiatry residents in Canada (N = 839).

RESULTS

Four hundred residents from every program across Canada returned the survey (response rate 47.7%). The prevalence of personal therapy at any time was 55.3%, with 42.8% receiving personal therapy during residency. Of residents who undertook personal psychotherapy, 59.3% engaged in weekly therapy, 74.1% received psychodynamic psychotherapy, and 81.5% participated in long-term therapy (>1 year). Personal growth, self-understanding, and professional development were the most common reasons for engaging in personal therapy; however, one-third of residents did so to alleviate symptoms of depression, anxiety, or other mental health concerns. Time was the most important factor impeding residents from personal therapy; only 8.8% found stigma to act as a barrier. The vast majority of residents rated their experience with personal therapy as having a positive or very positive impact on their personal life (84.8%) and overall development as psychiatrists (81.8%). For 64% of respondents, personal therapy had an important or very important role in psychiatry residency training. Residents who received personal therapy rated themselves as better able to understand what happens moment by moment during therapy sessions, detect and deal with patients' emotional reactions, and constructively use their personal reactions to patients.

CONCLUSION

Interest in personal therapy remains strong among psychiatry trainees in Canada. Residents who engaged in psychotherapy endorsed greater confidence in psychotherapy and rated their psychotherapy skills more favorably than those who had never been in the patient role, supporting the view of personal therapy as an important adjunct to psychotherapy training during residency.