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The Royal College of Psychiatrists Improving the lives of people with mental illness


Background to psychotherapy

Psychotherapy is unique amongst the subspecialties in psychiatry in not being defined by a patient population in terms of age or diagnosis. I think this embodies the integral relationship psychotherapy has with all of psychiatry; it permeates all of the subspecialties in the form of the relationship with the patient that is the foundation of all psychiatric practice.

A psychiatrist who decides to train as a psychotherapist will leave mainstream psychiatry but will be required to remain engaged with it. The psychiatrist needs the psychotherapist and the psychotherapist needs the psychiatrist. The medical psychotherapist informs and helps to develop psychiatry to help to make it the discipline it aspires to be, integrating biological, psychological and social perspectives on an equal footing.

The medical psychotherapist brings their medical and psychiatric training as a foundation for an approach to psychotherapy which is informed by working with the body, with risk, with responsibility and with colleagues.

All psychotherapy involves sitting in a room with a person or people in mental pain and psychological confusion, conflict and distress and trying to make sense of what is going on. There are many different models of therapy to suit all sorts of personality, some structured, problem solving and logical; others more intuitive and exploratory and suited to those prepared to wait for thoughts and understanding to emerge. It is possible to work with individuals or with couples, families, groups, therapeutic communities or with organisations therapeutically.

An interest in teaching, training and research will be essential for a doctor wanting to become a psychotherapist as these functions are fundamental, in different measures, for all medical psychotherapists. A curiosity about the mind and a doubt that we have arrived at a satisfactory understanding of the mind will be an enormous asset in a profession which is constantly changing but which contains diverse and passionate advocacy for widely different ways of understanding the problems of being human.

Improving access is the shibboleth of psychotherapy and access to psychotherapy can only be improved by attracting doctors with an open mind into psychotherapy.

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Personal perspective

I think of psychotherapy as a craft which combines art and science. At the risk of this being sent to Pseuds Corner in Private Eye, psychotherapy is the poetry to the prose of psychiatry. Without psychotherapy, psychiatry would be very impoverished. Psychotherapy was why I came into psychiatry.

I chose to train as a psychoanalytic psychotherapist because it suits my perception that  people are universally similar and infinitely different from one another. In medical school I first encountered psychotherapy in family therapy in a child and adolescent unit where I spent an elective. It has taken me some years to realise that I chose this elective because I was interested in exploring my own origins and family which is what drew me towards psychotherapy.

I have been working as a consultant psychiatrist in psychotherapy for twelve years in a busy and thriving psychotherapy service in Leeds and I do not stop feeling that it is a privilege to be in the position of listening to my patients’ stories. However, I do not want to ignore the darker side of the work because people seeking psychotherapy are in mental pain and trauma and destructiveness in human relationships are a leitmotif of my day.

Many forms of therapy now exist and compete with one another for the prize of being the most effective, but what all therapies have in common is the interest in the value of using the mind to attempt to understand and help another mind.

Dodo Bird

Despite the competition between therapies, therapists in whatever model recognise what it takes to become a good therapist. If I was asked what makes a good therapist, working in whatever model of therapy, I would say that it is a person willing to reflect on themselves. This is what we hope for our patients, that they might be able to reflect on themselves, to come to be able to reflect on their own minds, to develop a mind of their own, and the therapist has to be able to model this in their willingness to reflect on themselves.

At the heart of psychotherapeutic practise is the creation and the development of a space to think. There are many demands in life which internally and externally threaten the space to think and reflect on the self.

My cartoon of the ‘Do Do Bird’ shows a rather beleaguered bird attacked by multiple competing demands and my caption the ‘Do Do Bird became extinct because it had no space to think’ captures a central concern that a space to think is not a luxury, it is crucial to the survival of the species known as a psychiatrist.

Dr James Johnston

Consultant Psychiatrist in Psychotherapy, Leeds

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