Non-school training in psychotherapy: problems and perspectives.

INTRODUCTION

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Psychotherapies are therapeutic approaches that through words seek to restore emotional health, modify inappropriate behaviors or alleviate mental symptoms(1). It has been estimated that there are around 500 psychotherapies today(2), each one has its own efficacy managing a given mental symptom. While one group has shown efficacy in clinical trials(3), another group has not shown this virtue or has not been studied(4,5). The American Psychological Association has listed psychotherapies with proven clinical evidence. The absence of a psychotherapy on this list does not mean that it is useless, but rather that there is currently no evidence to support its use(6). The effectiveness of psychotherapy depends on the knowledge, experience and skills of the therapist(7), so it is vital that professionals performing this role are properly trained.(4)

 

Psychiatrists receive psychotherapeutic training during their medical residency(8,9). The goal is for residents to learn how to combine psychopharmacology and psychotherapy in order treat mental health problems(10). In this context, however, different international reports indicate that teaching psychotherapy in psychiatry residencies has decreased(8,11,12), due to the greater emphasis placed on the biological aspects of psychiatry(13,14). This is evidenced by the fact that teaching psychotherapy has become an elective course or is only studied in the last years of residency(15). There has been an attempt to counterbalance this situation by opening fellowships or other university programs that offer psychotherapy for psychiatrists and mental health professionals who are interested in this area.(11)

 

In Peru, teaching psychotherapy in psychiatry medical residency is compulsory but has also been reported to be scarce(16,17). Residents report having few theoretical classes or psychotherapy practice. More than half of them have mentioned that they are not very satisfied or are dissatisfied with their tuition. Therefore, to “add psychotherapy courses” is the second most frequent recommendation made by students to improve their residency training(16). Additionally, postgraduate university programs in psychotherapy as specialization programs, master’s degrees and doctorates are scarce(18). This context leads psychiatry residents and psychiatrists interested in improving their skills in this area, to pursue unschooled education.

 

Unschooled training in psychotherapy is defined as the teaching of this treatment outside of university clinical settings and university education regulations. This training takes place in private mental health centers that offer assistance services and training in psychotherapy. The programs work autonomously(19), and without the supervision of educational regulatory agencies(20), so the admission, teaching, evaluation and certification processes are those provided by the centers themselves(18). This has led to the existence of several forms of training and psychotherapy certification. That is why it has been indicated that while the teaching and practice of medicine follow accepted and regulated paths, the route is very different from the one usually followed to be a psychotherapist.(21,22)

 

Unschooled training in psychotherapy is quite widespread in Peru, and probably exists in every country where psychotherapy is practiced. In Peru, unschooled training has grown dramatically in recent years, due to the high demand for training and the lack of university programs(18). Although the educational quality of these programs has not been evaluated, the fact that the teaching does not take place in university clinical settings can make optimal training difficult. This considers the high clinical and teaching resources necessary in the training of health professionals. Furthermore, the practice of psychotherapy, endorsed only by the certification that these programs provide, could lead to professional and ethical problems.

 

Considering that psychotherapy is a valuable tool in the treatment of mental health problems(23), it is essential to consider including a training modality for this discipline, other than the one existent in universities today. The present study describes the characteristics of unschooled training in psychotherapy in Peru, and addresses its potential problems when confronted with the current regulations of higher education and the professional practice of medicine in Peru(24). Although the analysis is based on the Peruvian context, its application to the reality of other countries is plausible since unschooled training in psychotherapy exists elsewhere and the study and practice of medicine is fairly standardized between countries.

 

Training in psychotherapy in psychiatry

Although teaching psychotherapy varies according to the objectives of each psychiatry program(25), it is always regulated by university standards. The academic processes of admission, teaching and assessment are carried out under the regulations of the medical residency; and the psychiatrist certification given to residents upon completion of their training allows them to provide clinical psychotherapy. Psychotherapy training is performed in teaching hospitals and is assessed by psychiatric services users, continues during the three to four years that the residency lasts(26), and is supervised by professors who assess the academic development of the residents.(26)

 

Teaching psychotherapy in the residency is complex due to the high number of psychotherapies available and the relatively short time available to teach them(27,28). For this reason, many programs have focused on teaching only evidence-based psychotherapies(29). Thus, in the United States, the Accreditation Council on Graduate Medical Education suggests teaching support therapy, psychodynamic therapy, and cognitive-behavioral therapy(30); and in Canada, the Royal College of Physicians and Surgeons proposes training in these same psychotherapies, and additionally in behavioral therapy, dialectical-behavioral therapy, and interpersonal therapy, among others(31,32). Some residency programs also include other evidence-based psychotherapies(33). This teaching model allows for the development of an eclectic approach in residents, rather than rigidly privileging a single form of psychotherapy.(34)

An alternative model of psychotherapy teaching is that of “common factors”(35-37). This model is based on findings that show that most psychotherapies share a set of similar factors that explain positive changes, while specific aspects of each psychotherapy have little or no effect on recovery(38,39). Common factors include: patient characteristics, the Hawthorne effect, hopeful and positive expectations, the therapeutic alliance, therapist characteristics and behavior, and the impact of extra-therapeutic events(40). In institutions where this model is applied, residents are trained in the development of skills related to common factors in the first two years of the residency, to later be trained in the specific aspects of each psychotherap.(40,41)

 

Psychotherapy training is gradual in the introduction of content and training time(10,42). Residents learn the more “basic” psychotherapy approaches during the firsts years, and then reach more complex ones(40). For example, at McMaster University (Canada), residents are introduced to concepts such as emotion-based psychotherapy during the early years of the residency, to accquire listening and empathy skills, and understanding of emotions; to then move on to cognitive behavioral and psychodynamic therapy(40,43). On the other hand, the time dedicated to practice increases as the years go by, and these activities are allowed to be carried out with greater autonomy(44). The resident eventually acquires sufficient clinical experience at the end of training.

 

Teaching psychotherapy during residency is offered in different modalities. These include theoretical classes, seminars and supervised practices(10,45). Clinical supervision, a cornerstone of psychotherapist training, allows not only to assess residents, but also to assess the clinical progress of patients(28,44). Residency offers the option for teachers with different therapeutic approaches to train residents, which contributes to the conceptual enrichment of their training(19,44). Residents’ personal therapy is no longer a mandatory requirement(10). However, a group of residents performs it for the benefits they find it has on a personal and professional level(46,47). The synergistic effects of these activities leads to psychiatry residents acquiring high psychotherapy skills.

 

Unschooled psychotherapy training

Unschooled psychotherapy training varies widely between programs; however, based on two characteristic factors, we can summarize its main functional aspects:

 

a) Admission

Out-of-school programs admit students with different educational backgrounds. They include health professionals: medicine (psychiatry), psychology, nursing and social service(20), but also college seniors, professionals from areas that are not related to health and people without a professional degree. Although psychotherapy training for different health professionals is a valid option(20), training students or people with no healthcare related profession could be questionable, since they could lack basic clinical fundamentals (eg clinical interview) that would allow them to acquire tools related to mental health. Therefore, the admission system for unschooled programs in psychotherapy is quite flexible and is opposing to university programs that require a bachelor’s degree, knowledge tests etc.

 

b) Teaching

Psychotherapy currents

Although several out-of-school programs provide training on evidence-based psychotherapies, some of them also teach psychotherapies that lack scientific evidence. This leads to students being trained in psychotherapies that are only theories of knowledge about a certain mental health problem, but clinically ineffective(2,48). In these cases, psychotherapy is approached rigidly and is learned dogmatically, which leads to the denial of any need to study it scientifically in order to critically assess its real effectiveness. This has important ethical consequences, since in medicine it is incorrect to apply an ineffective intervention to a person, as well as not to report the real clinical benefit of the therapy prior to treatment.

Clinical field

Most unschooled programs lack the clinical field that allows patient assessment. This is due to the fact that they take place in private centers and not in teaching hospitals, thus patients may prefer not to participate in academic activities. The result is a lack of clinical supervision, clinical discussions, and patient follow-up. Instead, clinical practice is developed almost exclusively through role-playing, and most of the hours in the program are spent on theoretical classes. This makes learning difficult, since psychotherapy is learned essentially through clinical practice and observation of professionals providing the actual treatment(28,44,49), while reading guidebooks or attending seminars contributes very little to a proper training.(50,51)

 

Duration

Study time may not ensure optimal training. Although the programs are offered in different modalities and have different lengths, its main “Specialization” programs have an average duration of two hours per week for 10 to 20 months (one or two academic years). Thus, the total training time (80 or 160 hours) is quite condensed in order to acquire a new skill, when compared to the time required to obtain a master’s degree in Peru, which is 350 hours(24). Condensed training means that teaching focuses on aspects directly related to the studied psychotherapy, while little attention is paid to essential aspects such as its theoretical foundations, humanism, and the development of personal skills.(52)

 

c) Assessment

Assessment allows examining whether the student has achieved the required skills(53). In general, it is suggested to assess a student periodically to provide constant suggestions (additive skills); and carry out a final examination to determine the level reached (summative competencies)(54). This is usually done by recording the practical sessions(29), and using scales to obtain an objective score of the level reached(55-57). These assessments are difficult to carry out in unschooled programs, since as mentioned, clinical practices do not usually take place in these courses. Thus, student assessment is limited to only evaluating the theoretical aspects of psychotherapy. In other cases, practical assessment is left to the instructor’s judgment, who defines whether the student has acquired the skills due to their development in the course(19), but without examining them in real clinical scenarios.

 

d) Certification

At the end of the training, the different institutions issue a certificate in the students name and not “In the Name of the Nation” as all university diplomas in Peru. This is due to the absence of legal regulations that empower them to train professionals(24). Hence, the diplomas only certify the completion of their studies, but do not authorize the professional practice of psychotherapy. This deserves to be specified since many centers state that it is possible to practice psychotherapy after having completed the courses. Some centers also suggest that their graduates apply to international associations linked to the studied psychotherapy. However, despite the high criteria that must be met to join several of these institutions, they do not grant legal value for professional practice either.

 

DISCUSSION

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Psychiatry residency is the academic setting that should train future psychiatrists in psychotherapy (10,45). However, the limited psychotherapy training in some psychiatry residences and the limited offer of postgraduate psychotherapy program, as the case in Peru, leads to the study of it outside schools. Theoretically, we consider that this type of study is valid, these programs can train health professionals in psychotherapy in the same way that many associations, professional associations and hospitals offer training courses. However, it is the academic and professional scope of these trainings that should be valued since these programs do not have the academic resources or the legal value to replace university training.

 

The idea that unschooled training in psychotherapy involves formal learning and leads professional practice of psychotherapy is quite widespread. The high number of professionals who demand this service and the growing number of centers dedicated to meeting this demand, proves the preceding idea. This idea may have arisen due to the benefit obtained by the institutions offering these courses and by the professionals who study there. These institutions would benefit from a greater demand of their programs and courses by supporting the idea that their training allows the practice of psychotherapy. Students would benefit by obtaining a “psychotherapist degree”, without having to complete university studies that would require more resources. Thus, the benefit of promoting and accepting the idea that you can undergo psychotherapy training and become certified through unschooled studies would explain the high acceptance of these trainings.

 

However, psychotherapy training provided in psychiatric residencies differs significantly from unschooled programs. In the first case, only residents have access to training in psychotherapy, teaching is carried out in teaching hospitals including patient assessment, evaluation processes are based on university standards, and a psychiatrist certification empowers the professional practice of psychotherapy. The second case on the other hand, allows people with different basic training to take these courses which are not carried out in proper clinical-teaching environments, assessment is carried out by the instructor, and the certification they provide has no legal value for their professional practice.

 

The practice of psychotherapy on the basis of unschooled training may involve professional and ethical problems. Psychiatrists can practice psychotherapy by virtue of the license granted by their psychiatry degree. However, the practice of unschooled psychotherapy would imply an professional and ethical responsibility of letting patients know about the study method followed and its clinical efficacy. Otherwise, patients may believe that the professional in charge was trained for this treatment throughout medical studies with methods that have a proven clinical efficacy. Users have the right to know this, since the clinical effect of non-evidence-based psychotherapies is unknown; and psychotherapies in general, when not properly used, can cause unwanted effects.(58-60)

 

Problems related to unschooled training in psychotherapy have been reported for 50 years in Peru. Reynaldo Alarcón reported in 1975 that psychologists who offered psychotherapy had only received short-term courses in centers that granted certificates not comparable to a university degree. This is because psychotherapy was not offered as a specialization in psychology(61). In addition, he reported that many psychiatrists acted as psychotherapists without having had training in psychotherapy. In addition, the Peruvian Society of Psychotherapy was created, as a way to recognize this activity, but it did not have the legal powers to regulate its exercise(61). These training and certification doings, from the 1970s have not changed today. However, the rules that run university education and the practice of medicine have been strengthened, creating dilemmas in the present.

 

Peru has regulated university education and professional activity in recent years. University education is regulated by Law No. 30220 (University Law), which was created by the National Superintendence of Higher University Education in order to supervise the quality of higher education and register the degrees and certificates of graduating professionals(24). The professional practice of medicine is regulated by the Medical College of Peru, which records the university studies of doctors and entitles them to the profession they studied(62). Currently, both institutions do not recognize psychotherapy unschooled psychotherapy studies, since the institutions where this kind of training is available are not recognized as higher education institutions. This means that, in a strict sense, doctors who have received unschooled training cannot be licensed or recognized as psychotherapists.

 

This is mainly the result of the little attention that teaching, and certification of psychotherapy has received in Peru. In the 21st century, psychotherapy is probably the only accepted clinical treatment that can be learned outside of university settings. This is due to the fact that its teaching has not migrated from unschooled practice to school practice, as other areas did(63). In addition, a system that certifies the professional exercise of this activity has not been created , for example a “professional college” that registers, regulates and supervises its practice. This situation has led to confusion, mainly generated by those who claim to be qualified in this kind of treatment without proper preparation or certification.

 

In this context, we believe that the teaching of psychotherapy should be strengthened at the university level. Studies show that psychiatric residents have high interests in learning and practicing psychotherapy(34,64). However, this interest contrasts with a decrease in teaching this subject during psychiatry residency(8). These programs need to assess residents’ perception of their training in psychotherapy, which allows them to make the necessary changes for improvement. In addition, other university graduate programs must meet the demand for psychotherapy training. Although university studies do not guarantee excellent academic training, they do certify that education and certification are carried out under official standards.

 

This review has a limitation due to that it presents the weaknesses found in psychotherapy training psychiatric and breaks it down in two categories. Thus, it is difficult to affirm that the different unschooled training programs share the same characteristics, in the same way that it is difficult to affirm that psychotherapy tuition is the same in all psychiatry residencies. However, we consider that unschooled training has the aforementioned characteristics due to its two characteristic factors. Psychiatry research should study the extension of unschooled training, the achievement of academic competencies and the the education quality of graduates. Thus, it is necessary to assess the feasibility of unschooled training along with the existing academic and professional laws in each country.

 

In conclusion, unschooled psychotherapy training is a valid training option, however, its academic and professional scope should be further assessed, since this approach may not have the necessary academic resources and does not have the legal value to replace university studies. Current regulations for university education and professional licensing in medicine in Peru, do not support psychotherapy studies or certification obtained through unschooled training. It is necessary to strengthen psychotherapy training in psychiatry residencies and to open postgraduate university programs so that psychotherapy study and certification can follow universally accepted professional licensing and training channels. These observations do not intend to be conclusive in any aspect, but seek to open discussion and dialogue to improve psychotherapy training.

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