MEDICAL PSYCHOTHERAPY. Advanced Psychiatric Training Competencies. Work Place Based Assessment Guide

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1 MEDICAL PSYCHOTHERAPY Advanced Psychiatric Training Competencies Work Place Based Assessment Guide Dr James Johnston Consultant Psychiatrist in Psychotherapy Chair Medical Psychotherapy FECC March

2 Advanced Training Competencies in Medical Psychotherapy WPBA Guide for Trainers and Trainees How to use this guide: The purpose of this guide is to assist clinical supervisors, trainers, other assessors and trainees in conducting the Workplace Based Assessments (WPBAs) required in advanced psychotherapy training from Specialty Training Year 4 (ST4) onwards. This WPBA guide applies to sole training for a certificate of completion of training (CCT) in medical psychotherapy and to the medical psychotherapy component of dual training with another psychiatric sub-specialty (dual CCT). Selected intended learning outcomes may be used for special interest placements in psychotherapy sought as part of training in other psychiatric sub-specialties. This guide covers selected intended learning outcome areas from the Psychotherapy Curriculum (2009) which can be assessed using work place based assessments. The most appropriate type of WPBA is suggested but assessors can use other assessment types if they are considered more suitable to the situation. The areas of ability which should be considered in the assessment are listed to help the assessor in drawing conclusions about competence. It should be noted that WPBAs are not the only way of assessing and recording psychotherapeutic development and competence in advanced training. The clinical supervisor reports of the trainee therapist are an important assessment tool completed at six month and one year intervals as part of the Annual Review of Competence Progression (ARCP). The applications of medical psychotherapeutic competencies in clinical supervisory and consultancy skills with other professionals apply across all the intended learning outcomes in psychotherapy. 2

3 See appendix 1 (page 14) for detailed recommendations of both the quantitative and qualitative requirements and methodology for using workplace based assessments in medical psychotherapy. 3

4 Intended learning outcome 1a The doctor will be able to perform specialist assessment of patients and document relevant history and examination of culturally diverse patients to include: Presenting or main complaint History of present illness Past medical and psychiatric history Systemic review Family history Developmental history ST4: CbD of a patient in an acute psychiatric assessment. ST5: ACE /CbD of a patient in an assessment for psychotherapy. ST6-ST8: ACE /CbD of a patient seen in consultation. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to obtain the history systematically and convey it as a narrative. Able to show the psychotherapeutic task in taking a psychiatric history. Able in situations of urgency to prioritise the information immediately needed and gather information in challenging and complicated situations. Able to perform psychotherapeutic assessments of socially and culturally diverse patients. Able to demonstrate the conscious, unconscious and behavioural aspects of development in both psychological health and psychiatric disorder. Able to gather the necessary information to inform decision making on whether to recommend and if so for which model of psychotherapy. Able to identify and assess psychopathology indirectly in the work of colleagues in consultations on patients not seen by the practitioner (1b). Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 4

5 Intended learning outcome 1b The doctor will be able to demonstrate knowledge of the principles of clinical supervision and skills in their practical application in offering clinical supervision and consultation to colleagues: NB: Competencies in clinical supervisory and consultancy skills apply across all the intended learning outcomes in medical psychotherapy. ST6-ST8: ACE /CbD of a patient seen in consultation. ST6-ST8: ACE/CbD/DOPS of a consultation with other professionals. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to identify and describe the psychotherapeutic task in the history presented by another professional. Able to identify and assess psychopathology indirectly in the patients of colleagues in supervision or case groups not seen by the practitioner. Able to communicate the emotional, behavioural and cognitive aspects of development in psychological health and psychiatric disorder. Able to apply knowledge and skills in deriving a formulation to inform management based solely on consultation with colleagues. Able to gather the information to decide an appropriate therapeutic recommendation to assist the management of the patient. Able to respond to the impact of the psychopathology of the patient on professionals to enhance their understanding. Able to apply consultancy knowledge and skills in urgent as well as planned consultation contexts. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 5

6 Intended learning outcome 2 The doctor will demonstrate the ability to construct formulations of patients problems that include appropriate differential diagnoses: ST4: mini ACE of a formulation on an assessed patient. ST5: repeat mini ACE of changing formulation with a patient. ST6-ST8: mini ACE/CbD/ACE of a formulation derived in ongoing therapy, completed therapy and consultation. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to describe the theoretical basis of psychotherapeutic formulation in each of the major modalities of psychotherapy. Able to construct a formulation which is coherent and well evidenced and while informed by relevant therapeutic theories is lucid to non specialists. Able to derive a formulation which deepens previous understanding of the psychopathology to enhance the range of possible interventions. Able to offer a comprehensive psychotherapeutic formulation of the patient s difficulties accessibly for the clinical use of other professionals. Able to use the formulation to decide on appropriate therapeutic recommendations to assist the care and management of the patient. Able to employ the formulation of the psychopathology of the patient to aid other professionals to enhance their emotional understanding. Able to apply formulation flexibly in reflective practice, supervision and consultation to accommodate the particular level of experience. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 6

7 Intended learning outcome 3 The doctor will demonstrate the ability to recommend relevant investigation and treatment in the context of the clinical management plan. This will include the ability to develop and document an investigation plan including psychological investigations and then construct a comprehensive treatment plan addressing biological, psychological and socio-cultural domains: ST4-ST5: CbD/ACE on patients seen in acute/community/other psychiatric settings. ST6-ST8: CbD/ACE of completed assessments derived in supervised consultation of complex patients presenting management challenges. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to convey the theoretical underpinnings of different approaches to psychological assessment as methods of psychological investigation. Able to integrate psychological assessment in a variety of clinical contexts which accommodates other primary approaches to management. Able to recommend relevant investigation and psychotherapeutic treatment in the context of an overall clinical management plan. Able to offer a tailored psychotherapeutic formulation for a broad range of disorders. Able to provide reasoned recommendations for choice of treatment informed by investigation to patients with confidence. Able towards the completion of advanced training to offer expertise in advising on and planning treatment for patients with specialised needs. Able to evaluate the outcomes of treatments already received or in progress and adjust management accordingly. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 7

8 Intended learning outcome 4 The doctor will demonstrate the ability to comprehensively assess and document a patient s potential for self harm or harm to others. This includes an assessment of risk and the ability to intervene effectively to minimise risk and implement prevention methods against self harm and harm to others. This will be displayed whenever appropriate, including in emergencies: ST4-ST5: mini ACE/CbD/ACE demonstrating risk assessment of patients seen in acute/community/other psychiatric settings. ST5-ST6: CbD/ACE/DOPS of risk assessments derived in supervised consultation of complex patients presenting challenges to care. ST6-ST8: CbD/ACE/DOPS/DONCS of leading multi-professional meetings as a component of consultation for high risk complex cases. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to undertake a detailed clinical assessment relevant to risk. Able to recognise the relationship between specific psychopathologies and risk, including the influence of personality disorder on illness. Able to recognise risk escalators such as drug and alcohol misuse and how these interact with the co-morbidity of the patient s psychopathology. Able to formulate a dynamic assessment of risk which incorporates a psychotherapeutic perspective of harm to self and/or other. Able to apply the principles of empathic understanding and a psychologically minded approach to risk assessment and management. Able to document the risk assessment in a detailed summary which includes risk planning integrated with a psychotherapeutic perspective. Able to provide support in crisis situations, in the aftermath of a death and to undertake critical incident reviews with sensitivity to participants. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 8

9 Intended learning outcome 5 (See appendices 1-4) The doctor will demonstrate the ability to conduct therapeutic interviews; that is to collect and use clinically relevant material. The doctor will also demonstrate the ability to conduct a range of individual, group and family therapies using accepted models and to integrate these psychotherapies into everyday treatment including biological and socio-cultural interventions: ST4-ST6: mini ACE/CbD/Psychotherapy ACE of patients commencing major model of psychotherapy (WPBAs Informed by SAPA and SAPE). ST5-ST8: mini ACE/CbD/ACE commencing in, ongoing and completing other models of psychotherapy (WPBAs Informed by SAPA and SAPE). ST6-ST8: mini ACE/CbD/ACE in ongoing and completed major model of psychotherapy (WPBAs Informed by SAPA and SAPE). Competencies: measured as below, meeting or above specified Specialty Training year standard Able to display and apply contemporary knowledge of psychological therapies relevant to the challenges of the clinical context. Able to show congruence with and deepening expertise in the chosen major model of psychotherapy with competence in two other models. Able to conduct a range of individual, group and family therapies using accepted models and to make appropriate recommendations for them. Able to integrate psychotherapies in everyday treatment, including biological and socio-cultural interventions. Able to plan psychotherapy on the basis of individual formulations predicting the probable patient impact and interactions of the treatment. Able to demonstrate awareness of the current evidence based guidelines and their range of application. Able to review the overall progress of a treatment accurately. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 9

10 Intended learning outcome 7 (See appendices 1-4) The doctor will demonstrate the ability to carry out specialist assessment and treatment of patients with chronic and severe mental disorders and to demonstrate effective management of these disease states: ST4-ST8: mini ACE/CbD/Psychotherapy ACE assessing for, commencing in, ongoing and ending psychotherapy (Informed by SAPA and SAPE). ST6-ST8: mini ACE/CbD/ACE/DOPS in consultation, reflective practice, formulation based case discussion, clinical supervision and other applications of psychotherapeutic thinking in other psychiatric settings. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to understand the psychological effects of chronic illness on intrapsychic and interpersonal relationships. Able to maintain and develop a professional alliance with highly disturbed patients over the long term. Able to help professionals from different backgrounds to understand and use psychotherapeutic ideas in managing very disturbed patients. Able to bear severe disturbance without resort to either unrealistic hope shown as therapeutic zeal or unrealistic cynicism as therapeutic nihilism. Able to provide psychotherapeutic assessment and specific therapeutic interventions tailored to chronic and complex mental disorders. Able to assist and guide other trainee and senior professionals in assessing and managing patients with severe and enduring mental illness. Able to contribute over time offering a psychotherapeutic perspective on multidisciplinary team work with severe and enduring mental illness. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 10

11 Intended learning outcomes 9 and 10 The doctor will demonstrate the ability to work effectively with colleagues (including team working) and develop appropriate leadership skills: ST4-ST8: DONCS/DOPS in chairing meetings, leading on organisational projects and processes, planning events and conferences, managing conflict at work, coping with change in the process of training and showing leadership development. ST4-ST8: Mini-PAT multi source colleague feedback with selection of workers consistent with developing stages of seniority. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to understand how a team works and develops effectively with knowledge of psychoanalytic, systemic and cognitive understanding. Able to manage autonomous projects and seek help appropriately. Able to understand the principles of change management and manage change in service structure and maintain focus on the primary task. Able to recognise and resolve dysfunction and conflict in teams. Able to facilitate the leadership other colleagues and challenge the performance of colleagues when standards seem to be compromised. Able to act as an external consultant to other teams showing skill in using different approaches tailored to the context and need. Able to demonstrate an understanding of organisational policy and practice at local and national level in the health and social care economy. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 11

12 Intended learning outcome 15 The doctor will demonstrate the ability to teach, assess and appraise: ST5-ST8: AoT/CP/JC/DOPS in relation to teaching, case presentation and journal clubs. ST4-ST8: DONCS/DOPS in setting up and running educational projects (for example a Balint group, a psychiatry summer school or other local or national educational events). ST4-ST8: CbD/DOPS in facilitation of a Balint or case based discussion group for undergraduates, foundation, core or advanced trainees. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to demonstrate an understanding of the basic principles of adult learning. Able to identify different learning styles and respond to them flexibly. Able to understand and offer the appropriate use of a variety of teaching strategies. Able to identify learning outcomes and evaluate teaching methods. Able to organise local and national educational events. Able to act use appropriate approved assessment methods and to be honest at all times when assessing performance. Able to give feedback in a timely and constructive manner and to demonstrate a professional attitude to teaching. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 12

13 Intended learning outcome 16 The doctor will demonstrate the ability to develop an understanding of research methodology and critical appraisal of the research literature: ST4-ST8: DONCS/DOPS in proposing and undertaking research. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to demonstrate an understanding of the research governance framework including local employer (NHS Trust/other) implications. Able to understand the work of research ethics committees and aware of the ethical implications of a proposed research study. Able to understand how to design and conduct a research study and identify sources of research funding. Able to demonstrate knowledge of the evidence base of psychotherapies and the limitations of this with recognition of the methodological issues. Able to write a research protocol and work collaboratively in research supervision. Able to prepare research for written publication and follow journal submission instructions and to present material at conferences. Able to understand the particular complexities of research and audit design and implementation in psychotherapeutic treatments. Able to carry out a thorough literature search, critically analyse existing knowledge, synthesise information and summarise relevant findings. Able to communicate clearly with other professionals and staff from other agencies about the importance of applying research in everyday practice. Able to translate research findings to everyday clinical practice, adopting the principles of practice based evidence at a service level. Able to appreciate the limitations and controversies within the relevant area of scientific literature. Able to appreciate the scientific unknowns in the relevant field of psychiatric practice. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 13

14 Intended learning outcome 18 The doctor will demonstrate the ability to develop the habits of lifelong learning: ST4-ST8: DONCS/DOPS in orientation to the local service setting for psychotherapy including the use of educational supervision, the use of regional, national and international resources for professional development and evidence of commitment to self reflective practice. Competencies: measured as below, meeting or above specified Specialty Training year standard Able to understand the opportunities for continuing professional development as a doctor, psychiatrist and as a psychotherapist. Able to recognise and use learning varied opportunities in ways which are commensurate with stage of professional development and need. Able to maintain familiarity with the clinical literature relevant to the major model of psychotherapy and more generally. Able to show a professional commitment to development through courses and conferences. Able to show a personal commitment to development through personal therapy or seeking other model congruent self reflective practice. Able to use the self reflective practice to try to address conscious and unconscious limitations to effective clinical practice, (e.g: prejudice). Able to use a personal development plan to ensure that clinical work is adequately supported through supervision and experiential learning. Below Meets Above Competency text descriptions What areas of practice are especially good? What areas of practice require further development? What was the agreed action on further development? 14

15 Appendix 1 Recommendations for medical psychotherapy workplace based assessments Assessment of Clinical Expertise (ACE) 2 satisfactory ACEs each ST year: these can be for assessment of assessment skills or ongoing or completed clinical cases. The Medical Psychotherapy Faculty Education and Curriculum Committee has developed two forms which are intended to facilitate an ACE assessment of clinical work: supervised assessment of psychotherapy expertise, SAPE (appendix 2, page ) and the assessment for treatment: supervised assessment of psychotherapy assessment, SAPA (appendix 3, page ). The SAPE and SAPA are specialty specific and allow a much more precise assessment of the skills needed in these situations. SAPE was developed from clinical peer evaluation and SAPA was developed from Skills for Health Psychotherapy Competencies. (See Psychotherapy Assessments on Royal College of Psychiatrists website). Case Based Discussion (CbD) 3 or 4 CBDs depending on ST year - these forms can be for ongoing clinical work (SAPE) but can also be used to assess assessment competency (SAPA). A mixture of the others WPBAs as appropriate to the competencies being measured: e.g. teaching, management skills, case presentations, supervision. There should therefore by the end of the training period be a minimum of 6 satisfactory ACEs with a significant proportion being of completed treatments and assessments in the main psychotherapeutic modality. All therapeutic modalities must have at least 1 CBD WPBA. The following are illustrations of ways in which WPBAs might be completed using the portfolio on line on the Royal College of Psychiatrists website forms: WPBA of Assessment Skills in Psychotherapy Either a: CbD: take process assessment notes to your supervisor who will complete the relevant SAPA to inform scoring of the CbD form. Or b: ACE. Complete a Psychotherapy ACE form (see appendix 2 below) for appropriate level during your training. 15

16 If appropriate to modality the Psychotherapy ACE can be done in two ways: Either: With an indirect observation of an assessment session (audio tape, video) or direct observation by the assessor sitting in the assessment Or: Direct observation or taping of the assessment may not receive consent from the patient or direct and indirect observation may not be considered appropriate for psychoanalytic psychotherapy assessment. In this latter instance it is proposed that: a) The ACE may be based on reading a transcript of the process note account of a completed assessment that the trainee presents to the supervisor who scores the psychoanalytic supervised assessment of psychotherapy assessment (SAPA). b) The trainee then takes the completed SAPA and presents a summary of the recent assessment with the written clinical supervisor s report to another trained specialist in the model of therapy. The second assessor carries out the ACE with the trainee and scores an on-line ACE form. WPBAs in ongoing and completed clinical cases Ongoing therapy CbD: for any therapeutic modality during a supervision session with your clinical supervisor, when presenting process notes/tapes to them, the supervisor would rate this presentation using the SAPE ST4-6 form (supervisor s assessment of psychotherapy expertise) and then score the on-line CbD form. For a CBT ACE of ongoing therapy: your supervisor or another CBT therapist will rate a full session either live or from a recorded session using a SAPE to inform the scoring of the on-line ACE form. 16

17 For a systemic ACE of ongoing therapy: a SAPE will be completed from the trainee s work with the couple or family after it has been observed by the family therapy supervisor, either live (behind the screen) or from a recorded session. This will be used to inform the scoring of the on-line ACE form. For a mini-ace of ongoing therapy: live observation or a segment of a recorded session (10-20mins) illustrating a specific competency (e.g. agenda setting in a CBT session or deriving and presenting a psychodynamic formulation) will be rated by the clinical supervisor to inform the completion of a mini-ace. Completed therapy For a Psychotherapy ACE on a completed clinical case in any modality: to complete an ACE, you will need to present a written account of the case (500 words) and the 2 SAPEs from this case to a specialist in the therapy. This assessor will discuss the case with the trainee to score an ACE on clinical competencies for treatment. (See appendix 2). For psychoanalytic psychotherapy the 2 SAPEs will be scored by your clinical supervisor on your clinical work presented half way through treatment and at the end of treatment. For CBT and systemic therapy one or both of these SAPEs can also come from direct observation (live or recorded) of ongoing therapy sessions as above. Other WPBAs Consultation on complex cases with colleagues: Direct Observation of Procedural Skills: DOPS form. Assessment of teaching: AoT form. Journal Club presentation: JC form. Case presentations: CP form. Managing, chairing committees, other leadership activity: DONCS. Multi-Source Feedback (MSF) is obtained using the Mini Peer Assessment Tool: Mini-PAT which is an assessment made by a cohort of workers across the domains of Good Medical Practice guidance (GMC); suggested minimum 1 mini PAT per year. 17

18 To summarise: at each ST year the trainee should aim to have completed at least 12 WPBAs by the time of the ARCP. Depending on year of ST training and the time devoted to psychotherapy (for example, in dual training with another psychiatry sub-specialty) WPBAs in each year should include: 1 round of Mini-PAT. 8 clinical WPBAs, including 3/4 CBDs, 2 ACES with SAPES, 1/2 ACE/CBD using SAPA, 1 DOPS of a consultation (ST6-ST8). 3 non clinical WPBAs: AOT, JC, CP, DONCS. 18

19 Appendix 2 Psychotherapy ACE Procedure In order to complete a psychotherapy ACE candidates will be required to undertake the following. 1. Complete a psychotherapy case in a recognised modality of treatment under supervision with a supervisor designated by the scheme organiser or psychotherapy tutor. 2. Obtain two satisfactorily completed Supervisors Assessment of Psychotherapy Expertise (SAPE) forms from their supervisor one completed during and one completed after completion of the therapy. 3. Prepare a brief 500 word summary of the case. 4. Present the SAPE, and the summary to an assessor and discuss aspects of the case with the assessor in an oral presentation which should focus on aspects such as case selection, techniques specific to the chosen modality, difficulties in treatment and achievements in treatment, termination and evaluation of outcome. Instructions to assessor The trainee should be allowed a reasonable period of time to present the case they have treated in a narrative fashion. Once they have completed their presentation you should take up aspects of the case particularly focusing on areas where you are unclear how the case was conducted as well as areas where the trainee showed particular skill and good clinical judgement. You should direct questioning towards completion of the mark sheet reproduced below. On line completion of the ACE can be used in addition to this for the trainee s e portfolio of workplace based assessments. 19

20 Mark sheet for psychotherapy ACE Name of trainee Name of assessor. Name of supervisor Trainees must provide evidence of a SAPE with competencies satisfactorily achieved. Has this been done? Yes/No Trainees must provide a description (in up to 500 words) of the therapy undertaken. Has this been done? Yes/No What type of therapy was reported?. What was the duration of the reported therapy?... In the discussion of the therapy how do you rate the following? Poor Work to be done Attitude towards patient and development of an empathic relationship Understanding of the rationale of treatment and ability to provide a working formulation Establishing a frame for treatment and noticing challenges to this Use of therapeutic techniques and monitoring the impact of these Management of the ending of treatment Use of supervision Quality of written summary in conveying key points Satisfactory Good Unable to rate 20

21 Comments Overall would you rate the psychotherapy competencies of this trainee as Unsatisfactory / Satisfactory 21

22 Appendix 3 SAPE (Assessment of Psychotherapy Expertise) Instructions: Supervisor to consider each aspect in turn. Circle the one option that corresponds most closely to your experience of the trainee s performance. Total the scores for each column and enter the total score opposite. 1.Attitude towards patient 2 Understand rationale of treatment 3. Provide working formulation of patient s difficulties 4. Develop empathic and responsive relationship with patient 5. Establishing frame for treatment 6. Use of therapeutic techniques Unacceptable (score: 1) Derogatory, intrusive or disrespectful Cannot explain rationale of treatment Minimal understanding of what formulation is or no attempt to produce one Little or no sense of patient s feelings or perspective Behaves as if in another setting entirely, eg. talking with a mate; leading an interrogation. Actions in sessions bear no relation to patient s needs 7. Monitor impact of therapy Repeatedly unable to recognise positive or negative effects when these occur 8. Ending treatment Abandons patient without warning, or is unable to let patient go. 9. Use of supervision Misses several sessions without explanation or is very cynical. 10. Documentation. Records (notes and/or letters) are seriously incomplete, inaccurate or misleading Much work to be done (score: 2) Often makes unjustified assumptions Confused about key differences between therapeutic approaches Formulation is attempted but significantly incomplete or inaccurate Working relationship is limited by lack of rapport, interest or understanding Repeatedly fails to protect setting, keep to time or confuses patient by behaviour towards them Attempts at intervention are often clumsy or inappropriate Limited insight into how patient is being affected by the therapeutic sessions and attendant risks Little attention is paid to impact of ending, whether planned or patient leaves early. Guarded and uninvolved or too dominant in discussion. Fails to grasp what is being conveyed. Records omit key events in treatment; summary excessively generalised or uninformative Borderline (score: 3) Satisfactory (score: 4) Accomplished (score: 5 or 6) Some difficulties in appreciating patient s position. Still unsure of how therapy would help patient Formulation lacks at least one important component. Relationship is often sound but also lapses through therapist s uneven attunement. Occasionally fails to maintain setting appropriately. Interventions vary considerably in execution and success Evident blind spots in assessments of impact on patient Ending is considered, but perfunctorily or at unsuitable moments in the treatment Shows capacity to use supervision but this remains inconsistent. Records are often competent but incomplete Respectful and nonjudgmental Correctly explains basic principles of approach Adequate account of predisposition to, precipitation and maintenance of problems Earns patient s trust and confidence from ability to listen and appreciate their feelings Manages setting, time, and personal boundaries consistently Well chosen interventions are usually carried out thoughtfully and competently Describes impact of therapy on patient comprehensively and accurately Patient is prepared for ending of treatment and its consequences are anticipated Attends regularly, participates honestly and openly in discussion, uses advice received. Record of treatment sessions is focused and clear; final summary /letter apt and comprehensive Informed by realistic but positive view of patient s potential Recognises how recommended actions lead to therapeutic change Formulation is cogent, personalised and theoretically sound Developed capacity to feel and imagine events from patient s perspective. Optimises working collaboration by adjusting approach to patient Interventions are sensitively timed and phrased and linked to positive change Aware of interrelationship between different aspects of change during treatment Patient helped to continue to develop after cessation of treatment Allies sensitivity with creativity in reflections about the therapy Records resembles those of a more experienced therapist 22

23 Appendix 4 Supervisor s Assessment of Psychoanalytic Assessment (SAPA). Psychotherapy ST4-8 Stage of training ST4 ST5 ST6 ST7 ST8 Competency assessed Psychoanalytic Assessment Instructions: Supervisor to consider each aspect in turn. Circle the one option that corresponds most closely to your experience of the trainee s performance. Meets standard for ST4 completion Meets standard for ST5 completion Meets standard for ST6 completion 1. Awareness of indications, contraindications and risks of psychodynamic assessment and therapy 2. Awareness of alternative treatment outcomes 3. Ability to balance a sustained analytic attitude with a need to gather information 4. Ability to recognise and evaluate conscious and unconscious material 5. Ability to make appropriate interventions and interpretations 6. Ability to recognise and evaluate transference phenomena 7. Ability to recognise and use countertransference phenomena 8. Ability to evaluate patient s external resources for supporting treatment 9. Ability to evaluate patient s internal capacity to use treatment. 10. Provide working formulation of patient s difficulties Able to provide a clear rationale for these and their impact on the assessment outcome Awareness of a range of alternative treatments Awareness of need for balance between analytic attitude and information seeking Awareness of both conscious and unconscious communication Consistently applies a range of interventions linked to treatment rationale Demonstrates a developed capacity to feel and imagine events from the patient s perspective. Aware of impact of transference on assessment Awareness of emotional impact of the patient s material on the therapist. Aware of impact of this on assessment Able to provide a clear rationale for the evaluation of external resources and identify them Able to provide a clear rationale for how capacity to use treatment might impact on the assessment outcome Formulation is cogent, personalised and theoretically sound Understand the link between these and assessment outcome across a range of disorders and complexities of presentation Able to consider alternatives for a range of disorders and complexities of presentation Capacity to sustain analytic attitude in face of pressure to abandon it. Able to identify conscious and unconscious communication across a range of disorders and complexities of presentation Interventions are sensitively timed and phrased and linked to sessional content Use of understanding of transference is sensitively timed in response to sessional content Countertransference understanding is applied in a sensitive, appropriately timed way in response to sessional content Able to use identification of external resources in feedback to patient about future treatment(s) Able to identify patient s capacity to use treatment and use this sensitively in feedback about future treatment(s) Formulation is consistently coherent, comprehensive and individually tailored Uses theory to guide assessment in a flexible and sophisticated manner and recognises its limitations Able to balance risks and benefits of alternative treatments in a sophisticated balanced way Capacity to sustain analytic attitude and capacity to flexibly move between this and information gathering in response to sessional material Able to identify and use conscious and unconscious communication from the patient in a flexible and responsive manner Interventions are skilfully applied in a highly flexible and responsive manner Transference based interventions are skilfully applied in a highly flexible and responsive manner Countertransference interventions are skilfully applied in a highly flexible and responsive manner Able to identify impact of external resources across a wide range of treatment settings. Able to use this in formulation in a sophisticated way Able to identify patient s capacity to use treatment in a range of settings. Use this as part of feedback to patient and in formulation Formulation integrates the full range of available information into a narrative unique to the patient Based on this assessment, how would you rate the Trainee s performance at this stage of training? Below expectations satisfactory better than expected

24 Appendix 5 Glossary Several WPBA tools have been developed for use in psychiatry: Assessment of Clinical Expertise (ACE) The assessor observes a whole new patient encounter in order to be able to assess the trainee's ability to take a full history and mental state examination and arrive at a diagnosis and management plan. Mini-Assessed Clinical Encounter (mini-ace) The assessor observes part of a patient interaction, for example history taking or negotiating a treatment plan, and rates the trainee's performance. Case-based Discussion (CbD) The trainee selects two sets of notes of patients they have recently seen and the assessor picks one to discuss. The discussion will allow demonstration of clinical decision-making and the application of clinical knowledge. Case Presentation (CP) This tool can be used when trainees give clinical presentations and involves assessment of domains such as presentation skills and interpretation of evidence. Journal Club Presentation (JCP) This can be used when trainees present a journal article and covers domains such as analysis and critique and answering questions. Directly Observed Procedural Skills (DOPS) This has more limited use in psychiatry compared to other areas of medicine but can used in situations such as administering ECT. 24

25 Mini-Peer Assessment Tool (mini-pat) It allows co-workers to assess the trainee's attitudes and behaviours and ability to work well with colleagues. Assessment of Teaching (AoT) This is a new tool that is being developed after feedback from the pilot programme. It allows an assessment to be made of teaching skills and may relate to a lecture, tutorial or small group teaching session that a trainee leads. Directly Observed Non Clinical Skills (DONCS) This is a tool for assessing competence in non clinical areas such as leadership and management, for example it could be used for appraising committee work. Dr James Johnston Consultant Psychiatrist in Psychotherapy Chair Medical Psychotherapy FECC March