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Introduction
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10.1093/med/9780199608386.003.0001
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Introduction

Medical psychotherapy: what is it?

(See Introduction General adult psychiatry: medical psychotherapies, applications, and research in Chapter 12, pp. [link][link].)

Medical psychotherapy is one of the six psychiatry higher specialties approved by the General Medical Council (GMC) for specialist registration. Specialists in medical psychotherapy work with others to assess, manage, and treat people with mental health difficulties, using talking therapies and applied psychotherapeutic techniques in supervision, consultation, and reflective practice. Although the professional title medical psychotherapist is commonly used, consultant psychiatrist in psychotherapy, consultant psychiatrist in medical psychotherapy, and consultant medical psychotherapist are titles also used by psychiatrists trained as psychotherapists with a Certificate of Completion of Training (CCT) in medical psychotherapy.

Medical psychotherapy is a small medical specialty, with around 50 higher trainees nationally at any one time, and around 140 consultant medical psychotherapists (RCPsych survey 2015), many of whom are in less than full-time National Health Service (NHS) consultant medical psychotherapy posts. Currently, medical psychotherapy training involves 3 years in core psychiatry training, followed by a further 3 years of higher specialty training for a single CCT in medical psychotherapy alone, or 5 years for a dual CCT in medical psychotherapy and another psychiatric specialty. Accredited dual training programmes for medical psychotherapy and forensic psychiatry (forensic psychotherapy) were initiated nationally in 1999, and dual training programmes for medical psychotherapy and general adult psychiatry have become increasingly popular in the past decade and are now offered by most deaneries in the United Kingdom (UK). All higher psychotherapy trainees are required to achieve competencies in the three major modalities of psychoanalytic psychotherapy, cognitive behavioural psychotherapy (CBT), and family (systemic) therapy, and to choose one in which to ‘major’ or specialize. This is usually psychoanalytic psychotherapy, although a few trainees may choose cognitive behavioural therapy as their major modality (see Introduction Training in medical psychotherapy in Chapter 12, pp. [link][link]).

History of medical psychotherapy

How did psychotherapy emerge as a separate specialty within psychiatry? Until the First World War, psychiatry in the UK was primarily concerned with the treatment of mentally ill patients within large mental hospitals or asylums. At the beginning of the last century, Ernest Jones, a psychiatrist, became interested in psychotherapy and psychoanalysis, travelled to Vienna to work with Freud, and, in 1924, founded the Institute of Psychoanalysis in London. During the First World War and the presentation of many of its survivors with shell shock, there was increasing interest in neurotic, or non-psychotic, disorders. This led to the founding of the Tavistock Clinic and the Cassel Hospital in London, both institutions that were interested in investigating and developing psychoanalytic ideas. During the Second World War, this interest continued and developed into group and therapeutic community treatments, stimulated by the work of psychiatrists such as Wilfred Bion, Tom Main, and Siegmund Heinrich Foulkes. In 1948, the NHS was formed; some institutions, such as the Cassel Hospital, the Portman Clinic, and the Tavistock Clinic, all elected to become part of the NHS, whereas the Institute of Psychoanalysis chose to remain independent. Psychoanalytic therapy, both in the private sector and within the NHS, remained predominantly based in London, although a few outposts began to form in cities such as Edinburgh, Leeds, and Newcastle, and a few training organizations were founded outside of London such as the Scottish Institute of Human Relations.

Meanwhile, medical doctors treating psychiatric patients were still known as physicians in psychological medicine, and psychiatry was seen as a branch of medicine and neurology. It was not until 1971 that the Royal College of Psychiatrists was founded, and, in 1975, psychotherapy was recognized by the then Department of Health and Social Security as a separate specialty within psychiatry, along with general psychiatry, child and adolescent psychiatry, forensic psychiatry, and psychiatry of mental handicap (now psychiatry of intellectual disability). The Joint Committee on Higher Psychiatric Training (JCHPT) was established in the 1970s to oversee the higher training programmes in each of the psychiatric specialties. The number of higher training posts in psychotherapy increased over the 1980s and 1990s to its current level and has remained relatively stable, despite several changes in the commissioning and delivery of postgraduate medical education since then. The number of consultant posts in medical psychotherapy also increased to reach a peak of almost 100 full-time equivalent posts nationally in 2006 but has subsequently reduced to its current levels, and remains under threat of further reduction with the recent decommissioning of psychoanalytic psychotherapy services and the perception that all psychological treatments can be as effectively delivered by less expensive, non-medically trained therapists.

Medical psychotherapy in the NHS has been predominantly psychoanalytic in orientation and, until recently, has been delivered in psychotherapy departments underpinned by psychoanalytic principles, based in psychiatric (or sometimes medical) hospitals or, more recently, mental health trusts, and led by consultant medical psychotherapists. These psychotherapy departments remained relatively separate from departments of psychology, which tended to be based in universities and other academic institutions, and which trained psychologists in behavioural and cognitive, rather than psychoanalytic, models. Moreover, a close inter-relationship existed between psychotherapy in the NHS and the private sector, particularly in matters of training. Until a little over a decade ago, almost all medical psychotherapists were additionally trained in psychoanalysis or in psychoanalytic psychotherapy at private training institutions such as the Institute of Psychoanalysis, the (then) British Association of Psychotherapists and the Scottish Institute of Human Relations, and the North of England Association for Psychoanalytic Psychotherapists.

In recent years, with an increasing emphasis on commissioning only ‘evidence-based’ treatments, CBT and other briefer forms of therapy more successfully demonstrating their clinical effectiveness in empirical studies than psychoanalytic psychotherapy, and the growth of alternative government-funded psychological therapy services such as Improving Access to Psychological Therapies (IAPT) in primary care, traditional psychotherapy departments with a more long-term psychodynamic focus have been under threat. Some, such as the therapeutic community, the Henderson Hospital, have been forced to close altogether, whilst others have been reduced in size and decentralized, encouraged to move into community mental health teams (CMHTs) and to provide a range of briefer therapies, including CBT, and to use outcome measures on a regular basis. Others have been reconfigured into specific services for more complex conditions such as personality disorders or medically unexplained symptoms, rather than continuing to treat patients with a range of problems, including anxiety, depression, and less well-defined difficulties in their lives and relationships, who are increasingly being seen within primary care. Not surprisingly, these changes have created anxieties and tensions, resulting in more psychoanalytic psychotherapists leaving their NHS work to go into full-time private practice, and concerns about the future of psychoanalytic psychotherapy within the public sector.

Why medical psychotherapy?

Psychotherapy today, both within the NHS and in the private and voluntary sectors, encompasses a vast field offering numerous different therapeutic treatment modalities, practised by a multidisciplinary workforce with different core professional backgrounds and varying levels of specialist psychotherapy training. Moreover, the boundary between counselling and psychotherapy is not clear-cut; the development of psychotherapeutic competencies may be thought of as incorporating increasing levels of complexity, depth, and expertise, from a basic psychotherapeutic stance and supportive attitude that all practitioners in mental health should demonstrate to the sophisticated knowledge and application of theories and techniques of the trained psychotherapist. However, the idea of levels may be too simplistic; some might argue that supportive therapy is the most difficult and requires the most training, and there are many experienced and gifted counsellors who offer a carefully thought-out integration of different therapeutic approaches appropriately tailored to the needs of the individual.

Within the multi-professional psychotherapy workforce, medically trained psychotherapists comprise only a small minority. Most talking therapies available within the NHS are now delivered by clinical psychologists and therapists from other core disciplines, including nursing, social work, and child psychotherapy. However, the tripartite training and qualifications as doctor, psychiatrist, and specialist psychotherapist (whether psychoanalytic, cognitive behavioural, or systemic) place the medical psychotherapist in a distinctive position of bridging the gap between two of the dominant paradigms in the care of the mentally ill—the physical paradigm and the psychological paradigm. As a medical doctor, the medical psychotherapist is trained to understand the structure and function of the body and brain; to take a systematic approach to assessment, formulation, and treatment; and to take on responsibility and leadership roles. As a psychiatrist, the medical psychotherapist has an extensive biopsychosocial training in the assessment, formulation, and treatment of mental disorders; has undergone psychotherapy training in at least three different therapeutic modalities, and is expert in at least one; and takes a developmental perspective on mental life which affords integration of past with present in planning the patient’s pathway and care process. The medical psychotherapist is therefore able to integrate physical and psychological perspectives and offer a bridge between psychiatry, psychotherapy, general practice, and allied mental health professions, championing the development of a psychotherapeutic psychiatry and ensuring that high-quality, therapeutically informed services are maintained. By being a doctor of body, brain, and mind, the medical psychotherapist is conversant with the latest research in neuroscience and treatment efficacy, yet remains aware of the central therapeutic value of relationships and, as such, is able to offer a range of approaches and therapeutic interventions that produce effective and meaningful outcomes for patients and their families.

What does the medical psychotherapist do?

The consultant in medical psychotherapy holds an essential role in both the clinical and training spheres within mental health, as well as being active within management, leadership, academia, and research.

  • Clinical—this is manifest in both direct and indirect contributions to their organizations:

    • Direct clinical role: undertaking assessments and delivering treatment (therapy) for individuals with severe and/or complex psychopathology, e.g. personality disorder, dual diagnosis, medically unexplained symptoms, eating disorders

    • Indirect clinical role: interventions in helping mental health providers to support staff teams and professionals from different disciplines through supervision, consultation, and reflective practice.

  • Training (see Introduction Psychotherapeutic medicine: thinking cradle to grave in Chapter 1, pp. [link][link])—within medicine and psychiatry, the medical psychotherapist promotes therapeutic professional development from medical school through foundation, core, advanced, and post-membership years for psychiatrists in mental health:

    • Medical psychotherapists are leading the development of medical school psychotherapy schemes and Balint groups for medical students across the UK, in which the exposure of medical students to reflection on their relationship with patients enhances their interpersonal insight and skills for their future as doctors and contributes to a more therapeutically aware medical workforce.

    • Consultant psychiatrists in medical psychotherapy also have an essential role in ensuring that the curriculum requirements for postgraduate psychotherapy training in core and advanced psychiatry are met. Within psychiatry, trainees are required to demonstrate competency in psychotherapy during their core psychiatry training, and are expected to continue to develop these competencies as they progress through advanced psychiatry training. The crucial role of the consultant psychiatrist in psychotherapy in leading psychotherapy training in psychiatry was evidenced in the first Royal College of Psychiatrists’ Medical Psychotherapy survey of psychotherapy training in psychiatry in 2012, which showed that the College curriculum was more likely to be fulfilled if the Psychotherapy Tutor possessed a medical psychotherapy CCT. The GMC undertook a quality assurance review of medical psychotherapy in 2012, and their findings replicated those of the Medical Psychotherapy survey, which led to an action plan, including the requirement that all core psychotherapy training in psychiatry should be led by a consultant psychiatrist in psychotherapy. This medical psychotherapy leadership role was incorporated in the core curriculum in March 2015.

    • Medical psychotherapists also contribute to the continuing professional development (CPD) of consultant psychiatrists and other professionals in health, social care, criminal justice, education, and other fields through teaching, supervision, consultation,and reflective practice.

  • Management and leadership:

    • Designing and delivering effective psychological therapy services that will be commissioned in the current evidence-based rationed health economy

    • Ensuring robust clinical governance frameworks for psychological therapy services regarding safety, quality, and effectiveness of services

    • Developing and maintaining psychological, social, and cultural health in institutions

    • Promoting public understanding of mental health.

  • Academic and research:

    • Promoting practice-based evidence: evidencing the effectiveness of treatment services via the meaningful monitoring of therapeutic outcomes and patient experience

    • Promoting evidence-based practice: knowing and disseminating the evidence base for the effectiveness of psychological therapies

    • Involvement in formal research projects both quantitative, e.g. empirical studies of treatment effectiveness, and qualitative, e.g. studies of patient experience of treatment

    • Links with other research fields, e.g. attachment, neuroscience, infant and child development

    • Developing and refining research paradigms to address the complexity of psychotherapeutic experience.

Layout of the handbook

The book comprises 12 main chapters, each divided into sections. The first chapter introduces medical psychotherapy as a distinct psychiatric specialty and describes the development and nurturance of a psychotherapeutic attitude within medicine and psychiatry in all stages of a doctor’s career from medical student to senior clinician.

The next four chapters comprehensively cover both the generic and specific principles of the medical psychotherapy modalities that we have chosen as being most representative of those delivered within mental health services in the UK. Chapter 2 starts with an overview of the theoretical and philosophical debates regarding the proliferation of different models of psychotherapy within the field and is followed by separate sections for each psychotherapy modality, describing their theoretical frameworks, concepts, trainings, and research evidence. Chapter 3 details the general therapeutic competencies that are needed across all of the modalities, focusing on the development of the therapeutic alliance and engaging the patient, handling emotions, dealing with breaks and endings, assessing and managing risk, and using clinical supervision. Chapter 4 covers the many different aspects of assessment in psychotherapy, with particular focus on the two main modalities of psychodynamic treatment and CBT, and includes guidance on how to assess patient suitability, choosing the most appropriate and available psychotherapy, how to complete a psychotherapeutic formulation, and what constitutes a consultation in psychotherapy. Chapter 5 mirrors Chapter 2 in consisting of sections for each specific psychotherapy modality, describing the different components of treatment: the key techniques and competencies, how these specific interventions effect change, the clinical populations treated, and two clinical vignettes, the first describing the treatment of a more straightforward case and the second detailing a more complex case. All of the clinical examples in the book are based on real cases, but the details are sufficiently disguised and altered to protect patient confidentiality.

Chapter 6 gives an account of human life through a psychodynamic lens, from a developmental view of the lifespan from infancy to old age; through the lived experience of interpersonal relationships, gender, sexuality, ethnicity, and culture; to an exploration of the disruptions and traumas that may puncture and alter our existence in fundamental ways. Although this chapter exposes the psychoanalytic bias of its editors, it also reveals universal life themes and challenges the boundary between what might be considered normal and what might be considered pathological within the wide and diverse spectrum of human experience.

Although, in general, we espouse a more dimensional than categorical approach to psychiatric nosology, Chapters 7 and 8 are organized according to diagnostic categories in line with contemporary psychiatric classifications of mental disorders. Diagnostic terms and criteria are those of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), with additional reference to International Classification of Diseases (ICD)-10 when indicated. Chapter 7 describes the main psychotherapeutic approaches and interventions used in the full range of mental conditions, developmental disorders, and intellectual disabilities encountered within psychiatric practice, and promotes an integrative approach that reflects a true implementation of the biopsychosocial model. The important topic of personality disorder has been allowed a chapter to itself in Chapter 8; this not only allows space to describe the wealth of exciting advances in the understanding of the aetiology of these conditions which have informed the development of more effective treatments for disorders which many believed were untreatable, but also this is because we believe medical psychotherapists are uniquely qualified to treat people with personality disorders, for whom a therapeutic approach encompassing considerations of body, mind, emotions, behaviours and relationships with self and other is critical.

Chapters 9, 10, and 11 cover topics that are relevant to all clinical practice and demonstrate the value of a psychotherapeutic perspective. Key issues regarding the ethics and boundaries of medical and psychiatric care, including legal and moral considerations, are explored in Chapter 9. Chapter 10 describes the application of psychotherapeutic principles and services within the wider health care system, focusing on management, teaching and consultation, organizational dynamics, and, most importantly, the meaningful involvement of patients and service users in the planning and delivery of services. Chapter 11 summarizes the historical and current findings and trends in the rapidly advancing field of psychotherapy research and its links with neuroscience, now encompassing a substantive body of empirical studies that demonstrate the treatment efficacy of specific therapeutic interventions and the neurobiological correlates of mechanisms of psychic change.

Finally, Chapter 12 explores the relationship between medical psychotherapy and the other specialties and trainings within psychiatry, from general adult psychiatry to the smaller psychiatric sub-specialties of child and adolescent, forensic, intellectual disability, old age, addictions, liaison, and rehabilitation and social psychiatry. Each section in this chapter addresses the clinical applications, research evidence, and trainings involved in the psychotherapeutic interventions within each respective psychiatric specialty, revealing the central role that medical psychotherapy plays within the discipline of psychiatry.

As with other books in the Oxford Specialist Handbooks in Psychiatry series, we have tried to keep the text concise and to the point (as much as is possible for psychotherapists!), highlighting key facts and topics, sometimes at the expense of fuller detail and discussion. This is because the series consists of handbooks for clinicians that promote brevity and ease of reference, rather than comprehensive textbooks. Referencing has therefore been kept to a minimum and has been replaced by recommended reading lists at the end of each section or chapter. Because there is some overlap between different parts of the book, topics are cross-referenced within all of the chapters and their sections.

Recommended reading

General Medical Council. Small Specialties Thematic Review: Quality Assurance Report for Medical Psychotherapy 2011–2012. Available at: Introduction http://www.gmc-uk.org/Medical_psychotherapy%97report%97FINAL.pdf_51696150.pdf.

Pedder J (1996). Psychotherapy in the British National Health Service: a short history. Free Associations 6(1): 14–27.Find this resource:

    Royal College of Psychiatrists (2006). Council Report CR139: Role of the Consultant Psychiatrist in Psychotherapy, Royal College of Psychiatrists: London.Find this resource:

      Royal College of Psychiatrists and Royal College of General Practitioners (2008). College Report CR151: Psychological Therapies in Psychiatry and Primary Care (2008). Royal College of Psychiatrists: London.Find this resource:

        Psychotherapeutic medicine: thinking cradle to grave

        The cradle and the grave that the reader is invited to think about in the title refer both to the history and personal development of the patient and to the professional development of the doctor. In relation to the patient, the cradle and the grave represent the developmental extremes of life and the depth of potential disturbance arising from these extremes. The doctor is, of course, being human, also exposed to the same cradle to grave extremes of potential disturbance. The cradle signifies primitive developmental states of mind, and the grave signifies the gravity of facing death or mourning loss and the anxiety about death which can arise out of unbearable states of mind. In psychiatry, the cradle signifies confronting the sometimes devastating impact of primitive emotional disturbance and the anxieties that surround the grave emanating from the risk of death.

        Socrates observed that the unexamined life is not worth living. It might be said that the unexamined mind is borne from the feeling that life is not worth living. The vicissitudes of living contribute to, and maintain, mental pain. The doctor who approaches the person in physical pain will recall the medical phrase ‘on examination.’ The reflective doctor approaching another in mental pain will also consider their own emotional responses, so that the examined mind becomes a reflexive process which includes the doctor’s examination and use of their responses to understand the patient.

        Psychotherapeutic medicine involves a therapeutic attitude which validates the emotional experience of the doctor as a source of learning about the emotional experience of the person who presents to them. A therapeutic attitude would not be a state of peace and calm, because it reflects engagement in the challenges of being alive; it involves feelings across the human range and being involved in the problems of being human. If a therapeutic attitude is idealized as seeking a state of stillness, contemplation, and self-reflection in a meditative state, then the ordinary struggle of being alive is missed. Live emotional contact with the person beyond the presenting problem includes emotional contact for the doctor with their own mind, and this is the aim of the self-reflective practice intended learning outcome (‘ILO-19’) which was included in the core curriculum of training for all psychiatrists in 2014. The inclusion of self-reflective practice is one of the strategic aims of the Medical Psychotherapy Faculty Education and Curriculum Committee, embodied in its Thinking Cradle to Grave strategy which aims toward the development of psychotherapeutic medicine and psychiatry (Johnston 2015). An idea central to this aim is that being a doctor involves emotional work for the doctor in order to remain engaged with the emotional life of the patient, and this requires recognized and protected space for self-reflective practice.

        Because a therapeutic attitude is integral to the development of the doctor, this self-reflective capacity needs to be nurtured at medical school (the cradle) and to continue to be developed throughout the doctor’s career, all the way to retirement (the grave). As a spiral curriculum of emotional work, there can be a developing therapeutic attitude as the leitmotif of the core human threads of illness, disease, and dying is encountered and explored at a different developmental level from undergraduate to postgraduate levels.

        Undergraduate therapeutic attitude

        The emotional demands on a medical student may be in holding on to the recollection of what they brought with them in their vocation to train as a doctor, retaining a sense of the whole person’s humanity, rather than ‘the abdomen in bed eight.’ The past in the present for the emerging doctor would be in recalling the ordinary uncertainties in the midst of extraordinary technical knowledge.

        Postgraduate therapeutic attitude

        In the postgraduate years, the student learns to become a doctor, and the struggle in this early phase of development will be in beginning to consciously and unconsciously sift positive and negative identifications between different mentors, as the student finds a professional mind of their own. The doctor who does not seek refuge in a scientific attitude or pursue the medical carapace of defensive practice, but is prepared to remain open to therapeutic risk in emotional terms and interested in meeting each patient as an individual, would be showing signs of emotional resilience and the possibility of growth.

        In the early years as a consultant psychiatrist, the doctor grapples with their place as a leader, as well as learning to bear responsibility, risk, and uncertainty with patients, relinquishing reliance on systems of certainty from training and seniors. In the later years, the emotional demands of maintaining and developing creative interest in the work without despair and cynicism, which are not associated with the patient but, more commonly, the employing institution and management, are features of resilience in the mature consultant psychiatrist. Mature ambivalence and therapeutic literacy in a consultant psychiatrist may be revealed in their openness to continuing to learn from their work and remaining, in some way, still passionate about what they do, whilst cognizant of the limitations of what they personally can bear.

        Medical psychotherapeutic attitude

        One of the contributions of medical psychotherapists is to try to embody a therapeutic attitude in their institutions in their contacts with colleagues and managers. Their struggles in doing so within their context will, in their self-reflective practice, include trying to work to maintain an open mind. A closed mind is one in which curiosity is inhibited or deadened and reflection paralysed, otherwise known as ‘burnout’. An open mind, in which curiosity remains possible and a cynical state of mind does not overwhelm a balanced outlook, can be very hard to maintain. Potent leadership does not deny, but recognizes, the challenges of fear and demoralization in systems in which there is increasing pressure to reduce resources, particularly where economic limitations take priority over cognizance of emotional limitations.

        The three Rs

        The three Rs for psychiatry, thinking in cradle to grave terms, are recruitment, renewal, and revalidation. A therapeutic attitude is pivotal to success in the three Rs, paradoxically by accommodating failure.

        Recruitment

        For psychiatry to attract doctors, it has to become more therapeutically minded. Psychiatry is not the place to begin; the beginning is in the other specialties of medicine and surgery, when the student first encounters patients. In the Royal College of Psychiatrists Medical Student Psychotherapy Schemes, the aim of introducing Balint groups (see Introduction Balint groups in Chapter 10, pp. [link][link]) across all UK medical schools is being established, before psychiatry placements are undertaken by students. The aim is to develop psychotherapeutic medicine, and some of these student doctors may, as a side effect of this reflective practice, choose a career in psychiatry. The paradoxical failure here is that, whilst the schemes may not always be successful in recruiting doctors to psychiatry, more therapeutically minded doctors beyond psychiatry will be helped to develop.

        Renewal

        For those medical students who are inspired to become psychiatrists because they enjoy reflection and want to develop a psychotherapeutic attitude to patients, a renewal of psychotherapeutic psychiatry is vital to ensure it retains therapeutically minded psychiatrists. The paradoxical failure in this instance would be that, in the success of recruitment to psychiatry of therapeutically minded psychiatrists, psychotherapeutic psychiatry itself has failed to develop, and disillusioned new recruits leave, with a professional ratchet effect of loss further inhibiting renewal. Failure to mitigate this loss for psychiatry could foster a wake-up call for psychotherapeutic renewal to retain the therapeutically minded doctors.

        Revalidation

        The CPD of psychiatrists reflects their role as parental figures in training, who carry the culture for trainees. Their willingness to engage in developing their therapeutic attitude to psychiatry, for example, in participating in consultant psychiatrist Balint groups, would embody the need to feed the parents, in order to ensure recognition of the needs for a therapeutic feed in those who succeed them. Failure to accommodate the therapeutic grave for the seniors could help to write the obituary for the therapeutic cradle for the students and trainees who are the next generation of psychiatrists.

        Psychotherapeutic psychiatry

        The development of psychotherapeutic psychiatry involves recognition that the majority of people suffering from mental illness, personality disorder, mental pain, or mental deadness will not see medical psychotherapists, but many will see psychiatrists. A robust medical psychotherapeutic training that parallels and equals the potency of biological training is necessary for all psychiatrists, because it is necessary for all of their patients. This is not to suggest that all psychiatrists need to train as medical psychotherapists. We suggest that, for psychiatrists (and all mental health professionals) to be able to develop and maintain a capacity to bear and think with people suffering extreme mental disturbance, they need to sustain a clinical routine of protecting reflective space in which to examine their own emotions in response to the people who come to them.

        The future of medical psychotherapy

        Following the 2013 GMC requirement for medical psychotherapy leadership in core psychotherapy training schemes filtering through the zeitgeist, there are signs across the UK that some deaneries and local education training boards are appointing consultant psychiatrists in psychotherapy for the sole purpose of fulfilling the psychotherapy training for core psychiatry trainees. A strategic tension lies in the appointment of medical psychotherapy CCT holders solely to deliver psychotherapy training without a clinical context. The acceptance of this would, over time, erode the specialty of medical psychotherapy, as, without a clinical infrastructure, the delivery of psychotherapy training would take place in a psychiatric vacuum. This is not an adaptive response to extinction anxiety.

        The GMC requirement that all medical psychotherapists and non-medical psychotherapists are in active practice is a welcome support to ensure that those who train psychiatrists practise what they teach. It is vital to maintain and develop psychotherapeutic psychiatry clinically, since, without this clinical context, psychotherapy training for psychiatrists becomes a marginal activity which defeats its purpose by reinforcing the peripheral position of psychotherapy in psychiatry as an activity fit for purpose solely in the Ivory Tower. Without psychotherapy, the profession of psychiatry is impoverished; the disappearance of medical psychotherapy would reinforce a prejudicial view of psychiatry as offering a reductionist medical model narrowly defined as being heavy on biology, but light on the social, cultural, and the psychotherapeutic.

        However, psychotherapy inevitably evokes ambivalence in psychiatry, as it does in individuals, because it involves emotional work and making contact with painful realities. Giving a place for affective subjectivity in developing psychotherapeutic medicine challenges the professional pressure towards a reductive medical model by including the feelings of the doctor about their relationship with their patients. Medical psychotherapists represent this discomforting position within psychiatry, subverting the attraction towards a settled view of a patient in medical terms which disavows the ordinarily human perspective. The loss of a meaningful medical psychotherapy contribution in the robust clinical development of psychotherapeutic psychiatry would therefore contribute to the demise of psychiatry as a profession. Turning a blind eye to the cradle of thought in early development could lead to a grave risk of losing the therapeutic heart of psychiatry.

        Recommended reading

        General Medical Council. Small Specialties Thematic Review: Quality Assurance Report for Medical Psychotherapy 2011–2012. Available at: Introduction http://www.gmc-uk.org/Medical_psychotherapy%97report%97FINAL.pdf_51696150.pdf.

        Hinshelwood R (2004). Suffering Insanity: Psychoanalytic Essays on Psychosis. Routledge: Hove and New York.Find this resource:

          Johnston J (2015). Thinking Cradle to Grave: Developing Psychotherapeutic Medicine and Psychiatry, iteration XIV. Therapeutic Education Strategy of the Royal College of Psychiatrists Medical Psychotherapy Faculty Education and Curriculum Committee. Introduction https://www.rcpsych.ac.uk/pdf/Thinking%20Cradle%20to%20Grave%20final%20iteration%20XIV%2016th%20July%202015.pdf.

          Main T (1989). Some medical defences against involvement with patients. In: John J, ed. The Ailment and Other Psychoanalytic Essays. Free Association Books: London.Find this resource:

            Shoenberg P and Yakeley J (eds) (2014). Learning about Emotions in Illness. The Role of Psychotherapeutic Teaching in Medical Education. Routledge: London.Find this resource: