How Trainee Factors May Affect Treatment Efficacy in Psychodynamic Psychotherapy

Rebecca Bennett

Abstract

This opinion piece aims to explore the impact of trainee factors on the treatment efficacy of psychotherapy, specifically focusing on the Psychotherapy Long Case (PLC) requirement in Core Psychiatry Training in the UK. The aim of the PLC is to develop trainees’ competence in delivering long-term psychotherapeutic interventions and to provide them with essential skills for a career as a Psychiatrist. However, several trainee factors, detailed within this article, may affect treatment outcomes.

The article explores therapeutic alliance as a fundamental factor for positive treatment outcomes, emphasising trust, empathy, understanding and collaboration. However, negative attitudes and barriers to completing the PLC, such as difficulty finding a supervisor and patient dropout rates, may negatively influence the efficacy of therapy. Trainees’ limited preparation and experience in psychodynamic psychotherapy, along with variable supervision, can affect treatment outcomes.  Furthermore, the target number of sessions required by the PLC may affect the dynamic within the sessions and the nature of patient selection, to fit with trainee timelines, may mean some unsuitable clients are recruited. The implications of these challenges on treatment efficacy are discussed throughout the paper. The article concludes by highlighting the mutual benefits of trainee-led cases for both trainees and clients, including learning opportunities, quick access to therapy, and personal growth. Overall, this article underscores the importance of considering trainee factors in psychotherapy and highlights potential areas for improvement to enhance treatment outcomes. The author approaches this critique from the position of a trainee who has recently completed the PLC and has experienced some of the challenges first-hand.

Introduction

According to a survey conducted by the Office for National Statistics (ONS) in England, it was found that approximately 1 in 4 adults (24%) were diagnosed with at least one mental illness in 2019 [1]. This equates to around 12.1 million adults in the UK. The actual prevalence of mental illness in the UK may be higher than this, as it is based on self-reported data that may not fully capture all cases, especially those with limited insight into their condition.

Mental health conditions in the NHS are typically treated through a range of different services and approaches, depending on the nature and severity of the condition. Often talking therapies are recommended as a first-line treatment and in 2008 the UK government implemented a program called Improving Access to Psychological Therapies (IAPT) to improve access to evidence-based talking therapies for people with common mental health problems, such as depression and anxiety. According to the most recent data, over 1.6 million people accessed psychological therapies through the IAPT program in 2019/2020 [2]. Those with more complex conditions may require more in-depth therapy, provided by Tier 4 NHS psychotherapy services.

The Royal College of Psychiatrists recommends several forms of psychological therapy for the treatment of mental health conditions including Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT), Psychodynamic /Psychoanalytic Psychotherapy, Family therapy, Eye Movement Desensitisation and Reprocessing (EMDR), and Dialectical Behavioural Therapy (DBT) to name a few. The choice of therapy is generally based on the nature and severity of the condition to be treated, as well as the preference of the patient and the availability and skills of the therapist.

Psychiatry Training in the United Kingdom

Budding psychiatrists within the UK complete a rigorous training pathway to become a Consultant. To be eligible for Core Psychiatry Training, individuals must have completed two years of Foundation Training following a medical degree and hold full registration with the General Medical Council. During the three-year Core Psychiatry Training program, trainees are required to complete rotations in various psychiatric specialties, such as adult, child, and forensic psychiatry. They must also complete a range of appraisals, including workplace-based assessments, written exams, and a portfolio of evidence of their competence [3]. Trainees must also engage in a psychotherapy long case (PLC) as part of their Core Training Program. The long psychotherapy case is a structured psychotherapeutic intervention that trainees undertake with a patient over an extended period, typically 6-12 months, under the supervision of a qualified psychotherapist. The goal of this training requirement is to develop the trainee’s competence in delivering long-term psychotherapeutic interventions as well as gaining the ability to understand the perspective of other people, effective listening, handling challenging interactions in a clinical setting, learning how to set appropriate boundaries and developing problem-solving abilities, some would argue essential skills for a career as a Psychiatrist. As well as completing a long piece of work with a patient, trainees must also complete a short case, typically 12-20 sessions with a patient in a different modality.

Psychodynamic Psychotherapy therefore is a typical therapeutic modality that is appropriate for a trainee’s long-case given its suitability for 6-12 months of engagement, availability of supervisors familiar with this approach and known efficacy of the treatment [4]. A survey of 598 psychiatric trainees showed that 80% of trainees were undertaking or had undertaken the PLC in a psychodynamic or psychoanalytic modality.

Although the trainee psychotherapist requires extensive theoretical knowledge, the work of therapy has a practical element, and it is important to be able to merge the two aspects in a balanced manner. A key part of psychotherapy training is therefore putting the theoretical knowledge into practice, and indeed the Royal College of Psychiatrists states that “treating patients is the only reliable way to acquire skills in delivering psychotherapies” [5,6,7]. However, we must be mindful that to become truly proficient in delivering such therapy to clients takes many years of training and trainees are unlikely to be competent in these skills after tackling only a handful of cases. 

Psychodynamic Psychotherapy

This therapeutic approach is based on the theory that unconscious mental processes, outside of the individual’s awareness, play a significant role in psychological disturbance. These unconscious processes are inferred through careful consideration of material such as the person’s free and uncensored speech, their actions, and their dreams.  It is important, therefore, that the therapist-patient relationship can provide a safe and supportive enough environment for the patient to feel able to discuss and consider their experiences.

There have been extensive studies on common factors which lead to positive treatment outcomes [8,9]. These include therapist factors including experience and competence, treatment adherence, client factors and positive therapeutic alliance to name a few. These issues are not exclusive to trainees, however, they may hold particular relevance, as will be explained below.

1 Therapist Factors

Therapist experience, competence, and therapeutic style have been associated with better psychotherapy outcomes [8]. The concept of the therapist as an expert and a guide is a common one. It is reasonable to assume therefore that the trainee therapist’s therapeutic skills and competence can affect the outcome of psychotherapy. Trainees who have received adequate training and practice in evidence-based psychotherapy techniques are more likely to provide effective treatment [10]. However, often the preparation for completion of a PLC is minimal and often this is the trainee‘s first experience of Psychodynamic Psychotherapy. Most will not have shadowed any sessions before initiation and only 13% of those surveyed in the Royal College Psychotherapy report had undertaken personal therapy whilst completing their PLC, where they would learn first-hand how psychotherapy should be conducted. Furthermore, the level and quality of supervision that a trainee therapist receives from their supervisor can affect the outcome of psychotherapy. Research has shown that trainees who receive more frequent and high-quality supervision are more likely to provide effective treatment [11]. Trainees have reported difficulties in finding an appropriate supervisor; quality and effectiveness of supervision may also be variable.

2 Treatment Dosage

As discussed, the PLC should be conducted over a period of 6-12 months. The RCPsych specifies that there should be a minimum of 20 sessions and, due to difficulties with regards to accessing patient records, should end when a trainee rotates away from the Trust. Having a fixed number of psychotherapy sessions can influence the patient dynamic in several ways. Firstly, it may create a sense of urgency or time pressure for the patient, leading them to feel the need to address their concerns quickly within the limited sessions. This can impact the depth and pace of exploration in therapy. Additionally, knowing that there is a set number of sessions can trigger anxiety or concerns about the progress made or the ability to resolve complex issues within the allocated time frame. Moreover, the fixed session structure can impact the therapeutic relationship. Patients may feel more inclined to focus on specific symptoms or immediate challenges rather than engaging in deeper self-exploration or addressing underlying issues. This can affect the overall therapeutic process and the potential for long-term growth and change. On the other hand, the fixed number of sessions can also foster a sense of structure and accountability for both the patient and therapist. It can encourage the patient to actively participate and make the most of the available sessions. Additionally, it may help the therapist in structuring the treatment plan and maintaining a focused approach.

The termination of the therapeutic relationship is another crucial aspect of Psychodynamic Psychotherapy. The client and therapist work together to prepare for termination and ensure that the client is prepared to move forward without the support of the therapist. As part of the PLC, the Royal College of Psychiatrists stipulates a minimum of 20 sessions with usually a time limit at the end of Core Training. This may mean the trainee is forced to terminate therapy for the client earlier than would be recommended for the patient. As a result, in some circumstances, the patient and therapist may maintain a sense of stagnation with interactions remaining at the superficial level for protracted periods of time. This may stem from a shared recognition that engaging in a more profound exploration would require a considerably longer duration than 20 sessions. Consequently, there exists a hesitancy to delve too deeply into sensitive matters due to apprehensions about opening substantial avenues of exploration, only to subsequently truncate them.

3 Treatment Adherence

Adherence to treatment, in that a patient regularly attends scheduled sessions, has been linked to achieving positive results from psychotherapeutic interventions [12]. Conversely, missed sessions can create feelings of resentment or mistrust between the therapist and the client, particularly if the therapist is unattuned to the significance of missed sessions. This may lead to the client feeling judged or criticised by the therapist for missing the session. These negative feelings can erode the trust and rapport that has been established in previous sessions. One may argue that this resentment may be more apparent when the therapist is a trainee whose career progression rests on the completion of a certain number of sessions. As completing a PLC is a key tenet to Core Psychiatry Training Competencies, those who are not able to complete this task by the end of core training are unable to progress in line with their peers. The Royal College of Psychiatry Survey on psychotherapy competencies found that 228 trainees (38%) showed a negative attitude towards needing to complete the PLC with 50.3% experiencing barriers to completing the PLC which included patients dropping out of therapy as being a notable factor [13].

As mentioned previously, while it can be beneficial to explore the significance of a missed session for the client, the trainee’s focus on meeting targets may overshadow their understanding of the true implications and thereby hindering the potential progress that could be made during the work.

Literature suggests that alongside exploring the underlying reasons for the missed sessions, such as anxiety or avoidance, and developing strategies to address these issues, the therapist may also need to be flexible with scheduling to a certain extent, to accommodate the client’s needs and ensure that therapy remains accessible. However, opportunities for undertaking these psychotherapy experiences and the related supervision are expected to be made available within normal duties at the mental health service where the trainee is employed. This may mean, due to the needs of the service as part of the trainee’s role in the National Health Service, flexibility is limited.

4 Client factors

Various client factors, such as motivation, insight, and social support, have been linked to positive psychotherapy outcomes [5]. However, due to the time-restricted nature of completion of a PLC, it may be difficult to find a suitable patient. Almost 10% of those surveyed by the Royal College of Psychiatrists had no support in finding a patient, resulting in severe delays in starting their case and subsequent negative perceptions of the PLC as mentioned previously. On some occasions, it may be that a client who is not entirely suitable for a trainee case is chosen out of desperation by both supervisors and trainees.

5 Therapeutic alliance

Multiple studies have shown that the collaborative relationship between a client and therapist is fundamental to the success of Psychodynamic Psychotherapy [12,14]. The alliance involves several key elements, such as trust, empathy, understanding, collaboration, and awareness of transference and countertransference. Establishing a strong therapeutic alliance is crucial in creating a safe and supportive environment for patients to explore their thoughts, feelings, and behaviours [15]. It is hoped that the therapist, regardless of their trainee status will be able to empathise with and understand the client in order to aid this therapeutic alliance. However, there may be other factors at play which may negatively influence this relationship.

It may be that the compulsory nature of the PLC may have a negative impact on the therapeutic alliance. For one, it may affect the therapist’s emotional reaction to the client. For example, the trainee may be less sympathetic towards the patient’s needs or be inclined to adopt a more lenient approach, prioritising consistent attendance above all else.

Furthermore, it may have an impact on the power balance between therapist and client. Therapy is ideally a collaborative journey undertaken by both the therapist and the client. In other roles, the doctor has traditionally held a good proportion of the power in the consultation, however, the doctor may recognise that the client plays a pivotal role in shaping their future, and therefore this change of dynamic may feel unusual for the budding therapist.

The therapist must strike a balance between being supportive and maintaining appropriate boundaries. When the client feels safe and secure in the therapeutic relationship, they are more likely to open up and make use of the therapy. Often, although the patient will be aware that the therapist is a trainee, they may not understand what that entails and are unlikely to know the details of the trainee’s work life and other responsibilities and work requirements outside of therapy. They may not be aware the trainee works elsewhere, needing to travel to the location to complete the therapy, or that they work nights or weekends in another service as part of their day job. This can mean the trainee holds resentment towards the client if they were to not show up for a session, despite the fact the client would not necessarily be aware of the importance of the session to the trainee.

“…it puts tremendous pressure on trainees who are fearful of their ARCP outcomes. Myself and colleagues frequently came in on nights and annual leave to see our patients who did not always turn up.” [13]

However, this may be an element of therapy which is not specific to trainees. In fact, a patient may never know what is going on in a therapist’s life. One could argue that there are many reasons for a patient not to attend an appointment, such as to communicate how difficult they are finding the sessions.  If a trainee were to get overly fixated on the number of sessions achieved, they may not be able to tune into the true meaning of the lack of attendance and therefore may not be able to fully support and guide their client effectively.

It is of course the aim of such cases to be mutually beneficial for both the trainee and the client, with both parties gaining valuable insights, growth, and progress on their respective paths. For the trainee, it offers a valuable opportunity for learning and skill development as they work with clients, apply therapeutic techniques, and hone their clinical abilities. Supervision and guidance from experienced professionals help trainees receive feedback, learn from their mistakes, and improve their therapeutic aptitude. Moreover, engaging in therapy with clients encourages self-reflection and personal growth, enabling trainees to uncover their own biases, strengths, and areas for improvement. It also contributes to the formation of their professional identity as trainee psychiatrists, helping them understand their theoretical orientation, ethical standards, and therapeutic style. For the client, trainees bring a fresh perspective and innovative ideas to therapy, which can be particularly advantageous for clients who have felt stuck or have not found success with previous therapists. Due to the need to allocate training cases in a timely manner, a patient can often receive psychotherapy quicker and avoid lengthy waiting lists for qualified therapists if they opt to see a trainee.  Furthermore, trainees are often empathetic and invested in their clients’ well-being, providing a supportive and non-judgmental space for clients to explore their thoughts, feelings, and concerns.

Discussion

This article has hoped to highlight how trainee factors may influence the treatment efficacy of psychotherapy as part of the PLC within Core Psychiatry Training. It is worth noting, however, that there are benefits to the client from taking part in a trainee-led case. As mentioned, the waiting list for tier-4 psychotherapy provision is often very long due to pressures on the service. If the patient is suitable, allowing a trainee to lead their case will often mean that they may be able to bypass long waiting lists. It may also result in patients, who do not fully meet the criteria of referral to secondary psychotherapy services but are too complex for primary care, being able to be seen by a therapist under robust supervision.

With appropriate supervision, the trainee should be able to recognise and understand difficulties the client may have in engaging with therapy and be able to challenge these, to facilitate a strong therapeutic relationship, therefore the fact the therapist is a trainee should not adversely affect this part of therapy.

Despite the negative comments included here, the Royal College of Psychiatry survey showed most trainees (80%) felt the completion of the PLC benefitted their training, and significantly increased trainees’ self-rated competence in a range of domains, including empathy, managing boundaries, listening skills, managing difficult clinical interactions, and formulation skills. In addition, trainees felt that the PLC improves resilience and that working psychotherapeutically adds to their enjoyment of work, thereby increasing retention in psychiatry training.

Perhaps it would be more beneficial to assign a trainee a less complex case. The UK government’s IAPT scheme aims to enhance access to psychological therapies, primarily targeting patients with mild to moderate mental health difficulties. Severe mental health conditions or complex psychological disorders fall outside the scope of this scheme. In such cases, patients are typically referred to specialised mental health services, such as Tier 4 services, for appropriate care. For the PLC, it is customary for patients to undergo assessment and be deemed suitable for Tier 4 services, under the care of a psychiatrist. By including IAPT patients as part of the PLC, not only would simpler pathologies be addressed, but it would also expand access to a broader range of patients who might otherwise miss out on such valuable therapeutic experiences.

The crucial question at hand is how else can a trainee acquire valuable experience in this significant aspect of Psychiatry? Watching videos or reading literature would be unlikely to provide the trainee with a true understanding of the complex emotional dynamics experienced in therapy. A possible alternative suggestion is that acquiring the essential psychotherapy competencies may be better achieved through the process of shadowing experienced psychotherapists, rather than being the primary therapist themselves. However, having a trainee observe a psychotherapy session may further affect the therapeutic alliance as well as creating a more uneven power dynamic between the multiple therapists and the client.  Another option would be for the trainee to undergo therapy themselves. By engaging in therapy, trainees would gain first-hand experience of being in the client’s position, fostering empathy and enhancing their ability to connect with and understand their clients on a deeper level. Therapy also offers trainees a safe space to explore their own emotions, beliefs, and experiences, leading to greater self-awareness and self-reflection. This process allows them to identify and address any personal issues or biases that may impact their work in psychiatry. Moreover, undergoing therapy can provide trainees with valuable tools and coping strategies to manage the emotional demands of their profession effectively. By prioritising their own mental health and well-being, trainees would be better equipped to provide competent and compassionate care to their patients.

As discussed, having a fixed amount of psychotherapy sessions can influence the patient dynamic in several ways. While a fixed amount of psychotherapy sessions can provide a clear framework for therapy, it is essential for both the patient and therapist to be mindful of the potential impact on the therapeutic process and adapt accordingly to ensure meaningful progress is made. The question then could be asked, should trainees be focused more on the quality of the work undertaken rather than a fixed number of sessions? Would the supervisor be best placed to determine whether a trainee has achieved a reasonable understanding of the therapeutic modality, sufficient for their level of training? This would remove the fixation with box ticking and switch the focus towards true understanding.

It would be insightful to gather feedback from patients who have received treatment from a trainee to identify any potential negative experiences they may have encountered. However, it may be difficult to determine if their treatment could have been more efficacious had it been completed by a more experienced clinician. Gathering qualitative data enables us to explore and investigate whether the effectiveness of psychotherapy is influenced by the presence of a trainee therapist or if the therapeutic process creates a mutually beneficial symbiotic relationship for both the trainee and the client.

Overall, this article has aimed to underscore the importance of considering trainee factors in psychotherapy. To truly understand the impact of these factors, however, more research should be conducted to enable further improvement and to enhance treatment outcomes within the context of Psychotherapy competencies within Core Psychiatry Training in the UK.

References

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About the authors

Dr Rebecca Bennett is a Core Trainee (CT3) in Psychiatry, working at Nottinghamshire Healthcare NHS Foundation Trust.