What is “medical psychotherapy”, and what does the training entail?

How do you get into training?

Medical Psychotherapy (MP) is one of the specialties in higher training in psychiatry and the recruitment is through the same national process as any other specialty. The way things stand now, there are no plans to change it towards more speciality-specific recruitment, so the only way to increase your chances is by ensuring you rank as high as possible in the interview process.

How many posts are there?

Hardly any. Usually, around 8 nationally for August recruitment, less, if any, for February intake.

Most posts are dual training posts, as MP + General Adult Psychiatry or Forensic Psychiatry; there are two new dual posts MP + CAMHS

Each training region (“deanery”) has a set number of MP/dual posts, and they advertise new posts when the current STs in those posts CCT. So a post remains “taken” for at least 5 years for full-time training but usually more if trainees are doing part-time work or taking time out of training. Sometimes, new posts are added, but the number remains small.

Historical context

Historically (pre-pandemic), there were different interviews for all the specialties, with a station focused on “CV and portfolio”, where it was essential to show “commitment to speciality”. Therefore, it was the norm that CTs gathered extra psychotherapy experiences, such as psychotherapy training, placements, own therapy, etc. None of this makes it more likely that you will be successful at the ST interview now unless it can get you points on the ST application. Of course, it would help with your own development, but that’s another story.

Going further back in time, before the national interviews, there were regional interviews, and the specialty had a reputation of being highly selective. There were rumours (true or not) that applicants were asked at the interview who was their psychoanalyst and they could be advantaged or disadvantaged based on interpersonal dynamics.

Is it better or worse?

My personal preference is towards the system we had before the pandemic. It was national, so it was fair enough for everyone, but it focused on selecting trainees who were interested and committed to the specialty. The medical psychotherapy faculty tried on multiple occasions to change the recruitment system, but the preference at the RCPsych is towards a more generalist approach (I am speaking in my own name, not in the name of the Faculty or the RCPsych)

So, what can you do to increase your chances?

Look at the self-assessment scoring system for ST applications as early in core training as possible and aim to score high.

As it stands, the CASC result counts for 50% of the overall score, so aim to do well (this is not easy, I know…)

Practice the interview scenarios with as many highly experienced seniors as you can and with STs who sat the interview recently; over the last 6-7 recruitment rounds, the same two scenarios were repeated, so you can start with practising those before they are published and book some meetings between the publication of the scenarios and the actual interview, in case the scenarios change.

What do CTs usually miss out on?

Many CTs focus on passing exams and ARCPs and only look at the ST applications after they pass the CASC. At the ST application stage, everyone would have passed exams, so that won’t set you apart. Look at the scoring system well in advance to ensure you have enough time to complete as many extra activities as possible. Disappointingly, the points resulting from the self-assessment count way less than the interview and the CASC, but any extra point matters for such a highly competitive speciality

How is the training organised?

Well, it depends….

Major and minor

Clinically, you need to be trained in a main psychotherapeutic modality (most posts are in psychodynamic psychotherapy, 1 or 2 in CBT, so you need to check) and at least 2 others, mainly CBT and systemic, but there can be regional variation, including other modalities such as DBT, MBT, CAT, DIT, PIT, SCM, etc..

Weekly structure

There are huge regional variations. For start, you need to complete 3 years in MP. If single training (MP only), that’s straightforward. If you do dual, 3 years need to be in MP and 2 years in the other specialty, GA or Forensic or CAMHS; the last years should be ideally more integrated, or highly skilled.

In some regions, the training is integrated throughout (eg 3 days GA and 2 days MP weekly); in others, you do year long placements in one or the other. One thing to have in mind is that MP work tends to “overspill” so you will need at least 2 year continuous work in MP to complete long cases. I prefer 2 years GA/Forensic/CAMHS followed by 3 years MP, or the other way around, rather than integrated.

With integrated training, you will need to build both portfolios at the same time and it can get confusing and overwhelming.

If you prefer any of these, ask the TPD for details about the training before you list your preferences. But the posts being so limited, a less preferred option may be better than no opportunity.

Academic program

The training needs to include teaching in psychodynamic psychotherapy. This is organised differently in different regions, either as weekly teaching, a requirement to complete private psychoanalytic training (I expect to be reimbursed), or some form of teaching modules. I trained in West Midlands and we joined with Oxford. We had 3 modules yearly. Each module consisted of 8 teaching afternoons, including an experiential group (a sort of light analytic group) and seminars. Each module focused on a theme, such as Freud, Klein, “independents”, personality disorders, medically unexplained symptoms, etc. We had to read papers in preparation, which was very time-consuming.

Clinical work

Historically, the requirement was to complete 700 (or 800?) “therapy hours” in the main modality and 100 in each minor (usually CBT and systemic). This requirement changed to “competency specific” rather than hours, but many of the senior psychotherapists still use the training hours as guidance.

You need to gain experience in a variety of ways of working, such as individual therapy, group therapy, short (6 months), long (18 months-2 years), once weekly, twice weekly. You see why having at least a 2-year block in psychotherapy is important. Otherwise, it’s very hard to do long-term psychotherapy. Each case needs to be supervised weekly, and you need to have different supervisors from different professions.

You will need to have different arrangements for the “minors”. Some medical psychotherapists have additional training in other modalities so can supervise you, but you may need to have placements or arrangements with other teams. For example, I worked with a DBT team for a year and a half (or 2?), my colleagues joined a forensic team for MBT.

Some regions have flexibility in organising these extra experiences (or not much is in place and you may feel like fighting for training); others have clear training structures in place.

Own therapy

Having your own therapy is a requirement in all MP training posts but the frequency and duration varies. In some regions, it’s a requirement to have 5 times weekly analysis during the whole training (GA and MP included); the minimum required is 2 times weekly for the duration on MP training.

Some % of the costs are reimbursed (not sure if there is still some variation)

Training as a supervisor

As most medical psychotherapists will have a supervisory role as Consultants, you will need to train to supervise others. This usually happens in the last year, by supervising core trainees for their psychotherapy cases and throughout training by co-facilitating Balint groups.

Other aspects

As with any other higher training, you will need to gain other experiences, such as leadership, audit, QI, research, etc…

What are some of the benefits?

You get paid to train in psychotherapy and to have your own therapy, which is wonderful

More seriously, by training in a variety of psychotherapy modalities, supervised by a variety of professionals whilst having your own therapy at the same time gives you a different level of depth and understanding. Or at least I hope so…

Personally, I feel that I matured a lot during training and that my practice is way richer as a consequence.

Another benefit is that you are highly desirable when looking for jobs.

You get to work in services which care for people with complex difficulties, adding extra expertise in the area.

What are some of the challenges?

The training is long, 5 years, compared with 3 years in a single specialty. If you rush to become a Consultant, it may not be a good option for you.

You need to learn more during training and you may be spreading thinly over a vast number of areas of expertise; it’s quite hard to keep on top of all the developments in both psychiatry and psychotherapy. It’s easier to pick a “niche” and get to be an expert in that.

When I started, for a year I was the only ST in MP. Having moved to an area where I didn’t know anyone, it was quite a lonely experience. I had colleagues later on and then I joined the GA peer group, so I built relationships, but MP is a small specialty overall.

As a Consultant, again, it can be isolating, as you may not “belong” to any professional group. You end up being a bit different from most psychiatrists if you “psychologise” or “formulate” too much :)), but psychotherapists with different professional backgrounds tend to be reserved about medics as they don’t know how what medical psychotherapy actually is, as it’s such a rare specialty. Of course, it depends on the service where you end up working and on interpersonal skills and dynamics.

What are the career prospects after?

I’ll get back on the history lane again. Some years ago (maybe 10-15?), Consultants in MP were in a strange situations where they couldn’t find jobs. As it’s quite expensive to employ a MP to deliver therapy, when “the same job” could theoretically be delivered by profesionals with lower pay scales. The dual training was then introduced, replacing almost all the single options, to ensure that Consultants are employable at the end of training.

The situation changed after national surveys showed that having a “psychotherapy tutor” trained in MP significantly increased the likelihood that CTs completed their psychotherapy requirements. What followed was that Mental Health Trusts needed psychotherapy tutors, when the number of Consultants had been very low for a while. So over the last 5 years or so, Consultants with MP CCTed were highly sought after for these tutor posts.

The recommendation is that a tutor post includes working in a suitable psychotherapy service but this is only loosely followed. The jobs differ in different trusts, depending on local need and the candidate’s preferences.

Overall, Consultants with dual CCT including MP are highly sought after. However, the degree to which they are allowed to practice psychotherapy varies widely.

When I was approaching CCT, I had discussions with recruitment leads in 4 trusts. One trust said that they would be happy to have me for any of the available jobs, depending on recruitment, but none included any psychotherapy, and they were not going to make any changes to the JD. Another trust said that they had everything in place for trainees’ training and supervision but they needed a tutor with MP training to tick the boxes (the communication was not as direct, I am summarising the undertones). Another trust needed a dual CCT to work in a PD service, to allow risk management and prescription. I asked if I could have some psychotherapy work alongside that and the AMD bluntly said “we will not be paying you for that”. Another trust offered a list of vacancies and were happy to create a JD collating some of the clinical work where they needed cover with psychotherapy and tutor work. You can guess which one was my preferred option, even if it involves commuting….

Other colleagues from my generation work in services such as “complex needs” (=PD services), or other combinations or roles involving teaching and training. The roles vary a lot.

So overall, you are likely to be highly desirable but it may take a while and some work to end up with a job that fully matches your interests.

Isn't easier to do psychotherapy training with a training organisation or CESR?

Private training

If you really want to do MP and can’t get a place, another option to gain extra psychotherapy experience is through a private training organisation. You can access training in various modalities, depending on location, fees, training structure, preference and affinities. However, you will be required to have “training cases” which may be trickier if you are not in MP training. However, it should be possible to organise as “special interest” when you are in higher training, or is SPA time as a Consultant.

You can access good quality training and enrich your clinical work, adding to your expertise. However, if you were to apply to an NHS post requiring CCT in MP, the private training would not tick the box (but you will have a chance if there was no candidate with CCT in MP)

You could use the expertise you gained for private work if you followed that route.

And your usual practice will definitely benefit from the extra psychotherapy experience gained.

Some of the STs or Consultants in MP choose to gain extra private training, mostly psychoanalytic.

CESR route

Like in any other specialty, you will need to meet the curricula competencies and to gain evidence. It can be more tricky than other specialties as you will need to deliver psychotherapy, which may be hard to organise in a non-psychotherapy post. It has been done so it is possible. Some trusts may employ SAS psychiatrists with a CESR route planned. Dr Nandini Chakraborthi wrote a very useful book about the CESR route.

Good luck whatever you decide!

Please add any questions you may have, this post is editable and I can update it.