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The UCL Student Psychotherapy Scheme1
Jessica Yakeley
Introduction
Although motivations for choosing a career in medicine are varied and complex, most medical students start their clinical studies with a commitment to help and care for their patients, often accompanied by a genuine curiosity and openness towards illness and suffering. These attitudes, however, may become quickly challenged by their immersion in a medical culture which implicitly or explicitly discourages emotional attachments to patients and provides limited opportunities to get to know individual patients in any depth. Medical students often complain that their contacts with patients are brief and fragmented with few possibilities of following them through the course of their illness. This makes it difficult for students to gain understanding of how a patientās presenting illness relates to his or her personal history, particularly in its psychological and emotional aspects. Although initiatives at some medical schools, such as following a cancer patient for several months through their treatment (at University College London [UCL] this is called the Cancer Patient Pathways project), have gone some way towards addressing this, students nevertheless may be unprepared for the powerful emotional responses evoked in them by their contact with ill and sometimes dying patients, or patients who may be anxious, silent, hostile or uncooperative. Formal teaching forums within the curriculum in which these universal, but often ignored, affective responses in students can be acknowledged and talked about are lacking.
The UCL Student Psychotherapy Scheme (SPS), currently operating under the aegis of University College London School of Medicine from the Camden Psychodynamic Psychotherapy Service, Camden and Islington Foundation Trust, is a unique method of educating first-year clinical medical students about the doctor-patient relationship in which the teaching focuses on just such emotional and psychological issues. By seeing a carefully selected patient for weekly psychotherapy sessions for at least a year under the supervision of an experienced psychodynamic or psychoanalytic psychotherapist, the student has the experience not only of a long-term intensive contact with a patient, but of exposure to a range of emotional responses and non-verbal communications from the patient. Moreover, he or she will have a regular space, provided by the psychotherapy supervision, in which to learn how to reflect on and manage such emotions ā his or her own and the patientās ā in the best interests of both. Although student therapists will inevitably learn something about the theory and practice of psychodynamic psychotherapy, the main aim of the scheme is to introduce students to a psychodynamic way of thinking about the doctor-patient relationship and to a form of communication skills which will be useful for their future career as doctors, as well as introducing patients to this type of therapy.
I was a student at the then University College and Middlesex School of Medicine and participated in the SPS in the late 1980s supervised by Peter Shoenberg, who was running the scheme at this time. This experience had a lasting and formative influence on both my choice and course of career as a psychiatrist, and laid the foundations for my later training as a medical psychotherapist and psychoanalyst. Fifteen years later, my first consultant psychiatrist post in psychotherapy was back at University College Hospital running the scheme, as well as actively assessing patients, selecting and supervising the medical students, and researching the impact of the scheme (see Chapter 8). My own involvement in the scheme as organiser, educator, supervisor, researcher, and most fundamentally as participating medical student, continues to be a significant source of professional and personal inspiration and fulfilment. However, the real strength of the scheme, which ensures its continued success, lies in the dedication and commitment of both its participating medical students and its supervisors, who provide a valuable therapeutic experience for patients and a unique teaching opportunity, respectively.
History of the Student Psychotherapy Scheme
The Student Psychotherapy Scheme was founded in 1958 by Heinz Wolff and Dorothea Ball, medically qualified psychotherapists, and Roger Tredgold, a psychiatrist, in the Department of Psychological Medicine at University College Hospital (Ball and Wolff, 1963). Yet even before this, first-year clinical medical students attached to the department were encouraged to play an active part in its work and were the first to see newly referred psychiatric outpatients (Sturgeon, 1983). The student would spend an hour with the patient taking a history, and then present this to the consultant psychiatrist and the other medical students. Following this, the patient would be interviewed by the psychiatrist in the presence of the students, who could ask further questions to clarify the diagnosis and formulate management and treatment. On occasion, the psychiatrist would recommend that the patient have some further interviews to give them the opportunity to talk through some of their difficulties in more detail and it was not unusual for the medical student who had originally clerked the patient to volunteer to do this, and report back individually to the psychiatrist.
Two important issues gradually emerged from this informal arrangement which led to the inception of the scheme. The students found that as the patient spoke more about their difficulties, more covert problems emerged which suggested a possible need for psychotherapy, but this might mean waiting several months before a vacancy arose. The medical students who had been seeing patients and developing a relationship with them began to voice their concerns that this relationship had to be abruptly terminated, leaving the patient waiting for treatment. Some also complained that despite being taught a good deal about psychotherapy they were not allowed to see it in action, as sitting in on therapy sessions was contraindicated for the patient (Ball and Wolff, 1963). This led to a few enterprising and enthusiastic students being allowed to continue to see their patients weekly, so long as every session was reported back to the psychiatrist.
We can see here how these students had discovered two fundamental aspects of the doctor-patient relationship that were to become fundamental principles of the Student Psychotherapy Scheme in learning that:
1 The patientās presenting complaint or conscious understanding of their symptoms and difficulties might conceal less conscious factors which nevertheless play a critical part in the genesis and course of their illness.
2 The importance of continuity of care, which was linked to the concept of attachment. These students discovered that the patient did not want to see different doctors, but wanted to continue to see the person ā in this case the medical student ā with whom they had developed a trusting relationship; the students themselves also felt frustrated by having to hand the patient over to another person, without being involved in the subsequent course of their treatment and its outcome. Now students could see for themselves that their growing relationship with their patients facilitated the emergence of new information about the patients, throwing light on both the origins of the patientsā illnesses, as well as informing their treatment and prognosis.
Tredgold, Ball and Wolff were surprised at how sensitive the students were to the psychodynamic issues of the patient, and how quickly some of them picked up and used psychodynamic principles such as transference and countertransference in their interactions with patients. Although the number of students seeing patients in this way was initially small, knowledge of this unusual initiative gradually spread by word of mouth among the students and their peers, so that increasing numbers came forward to ask if they too could take on a patient for psychotherapy. This soon, however, raised a problem for the psychotherapists of finding enough time for the students to be supervised, and led to the suggestion that they should be supervised in groups.
Ball and Wolff (1963) describe the debate which this provoked. On the one hand, it was argued that individual supervision allowed for a confidential relationship to develop between the student and the supervisor, mirroring the one between the student and patient, where the studentās personal anxieties and conflicts could be discussed to some extent. On the other hand, not only was individual supervision more time-intensive, but supervision in a group of three or four students allowed students to share their initial anxieties about seeing a patient, as well as enabling students to experience differences between patients and therapeutic approaches through hearing how their fellow students each handled their own patients.
However, Sturgeon (1983) highlights the deeper anxieties and conflicts between the members of staff in the Department of Psychological Medicine exposed by the push towards group supervision. If group supervision were sanctioned and organised, it would require official acknowledgement and approval of the whole enterprise. Not all members of the department believed that students were capable of safely conducting psychotherapy in the best interest of the patient and therefore did not want to be associated with this practice. Serious concerns were expressed about the possibility of the patient breaking down, or even committing suicide whilst being treated by a student therapist, and parallel concerns were voiced about students whose own disturbance might be revealed by their participation in the scheme. Tredgold, as head of the department, decided to allow group supervision to go ahead, and for the scheme to become a formal teaching option for medical students at UCH, considering it to benefit patients and students. He thought that if a student were to break down it was better that this happened early on in his or her career under conditions of close supervision and support rather than years later when conditions might be less favourable and responsibilities greater. However, the concerns voiced by others in the department were not ignored and have influenced the way in which the scheme has developed over the years.
Group supervision allowed more students to see patients in the department at any one time. Another important change which consolidated the scheme as a formal entity was that some students began to ask whether they could see a patient who might be suitable for psychotherapy, but one whom they had not initially clerked (Sturgeon, 1983). A special medical student waiting list of patients was started which included referrals from the medical, surgical or obstetric and gynaecology teams where students might have seen them being interviewed during psychiatric liaison teaching, which was facilitated by UCH already having a strong tradition of teaching a psychosomatic approach to patients.
Following presentations about the scheme at the European Conference on Psychosomatic Research in 1976, the Psychosomatic Clinic in Heidelberg decided to set up a similar scheme (Sturgeon, 1983). A European Commission grant facilitated a joint project between the two centres to plan meetings, hold workshops with students and compare methods, culminating in Heidelberg University setting up its own scheme. This also stimulated UCH to revisit some of the controversies about its scheme, such as the selection of students, the nature of the supervision groups, and different styles of supervision. Medical students who had previously participated in the scheme were also invited back to the department to report how participation in the scheme had continued to influence their work after qualifying as doctors.
Since then, similar Student Psychotherapy Schemes have been set up in medical schools with varying degrees of success. For some years a scheme was run for a few students in the early 1990s in the Department of Psychotherapy at West Middlesex Hospital in London but ceased as it did not receive sufficient backing from the medical school (West, 2002). Another scheme operated in Oxford for a few years. Similarly, a scheme set up in the UniversitĆ© Vaudois in Lausanne, Switzerland ran for some years until its two supervisors left the department. Other medical schools have allowed students to see patients for shorter periods of supervised psychotherapy than on the UCL Student Psychotherapy Scheme, including a teaching initiative at St. Georgeās Hospital Medical School where all students were involved in a brief (5-week) weekly supervised psychotherapy of one of their patients during their psychiatry clerkship (Crisp, 1986), and since 1995 at the Department of Psychiatry in the University of Toronto in Canada, where medical students take on a patient for 4 months of weekly psychotherapy, while receiving group supervision from a faculty psychiatrist (Shapiro et al., 2009). The latter scheme was modelled after the UCH Student Psychotherapy Scheme and continues to operate today. In the UK, a similar scheme was set up in 1996 for medical students at Bristol University Medical School and continues to successfully operate and develop (see Chapter 4). More recently a Student Psychotherapy Scheme, also specifically modelled on the UCH scheme, has been initiated in the Department of Psychological Medicine in conjunction with the Institute of Psychiatry at Kingās College London University to enable medical students to see a patient for supervised psychotherapy as an extended Student Selected Component (SSC)2 for 9 to 12 months (Kingās College London, 2012). As the scheme grew in popularity some students actually began to choose to study at UCL in order to get on this scheme. By this time, however, demand far outweighed supply, and there were many students who ended up disappointed that they were not allocated to the scheme. Places were limited to 10 to 15 students per year, first by the finite number of supervisors available, and second by the limited number of suitable patients. This led to the introduction of a new process of selecting students by interviewing them, and student Balint groups were eventually offered as an alternative in 2004 (Shoenberg and Suckling, 2004; see Chapter 5) to accommodate the large numbers of students wanting to participate in this scheme.
Remarkably, the scheme has not only survived several mergers and expansions of the medical school, as well as structural iterations of the psychotherapy department in which it is delivered, but remains extremely popular and oversubscribed.
Organisation of the UCL Student Psychotherapy Scheme
The UCL Student Psychotherapy Scheme bridges two separate but linked institutions ā a medical school, part of University College London, and a department of psychotherapy, now part of a much larger NHS mental health foundation trust. The functioning of the scheme is therefore not solely confined to those directly involved in its organisation and delivery but also has to take account of its wider institutional settings.
Selection of students
Participation in the scheme is available as an optional educational activity to medical students in their first clinical year when they experience their first significant clinical contact with patients. Because of the schemeās long history, the medical school has always actively supported and promoted it as a worthwhile extra-curricular opportunity available to a minority of medical students. An introductory talk is given at the beginning of the first clinical year, during which we tell the students about the scheme, and also about the student Balint group scheme, their history, aims and practicalities, and what the students might expect to gain from the experience of participating. Students who have recently taken part in the scheme talk about their experience of seeing a patient as a student therapist under supervision, which powerfully conveys the intellectual stimulation, emotional intensity and responsibility that participating in the scheme confers. We then invite all interested students to put their names down if they wish to be interviewed for the scheme. This is in itself a test of their motivation, as many change their mind and decide not to be interviewed. We usually end up interviewing around 40 (out of a total year group of 350) students for the 10 to 15 places available on the scheme each year.
This interview assesses the studentās motivation to participate in the scheme and in a rather limited way gauges whether they have any psychological difficulties, such as a depressive illness or eating disorder, that would interfere with doing psychotherapy. We ascertain that students recognise the amount of time (3 to 4 hours per week) involved in making a commitment to doing this scheme and also that they are aware of the responsibility entailed in seeing a patient: the student who expresses anxiety about such a commitment may be more in touch with this than one who appears to be in denial. Previous experience of voluntary work with vulnerable individuals is always an asset. These students will not have had any clinical experience of psychiatry at this stage and we are not testing for prior knowledge of psychiatry, psychology or psychotherapy. We are, however, looking for students who appear enthusiastic, committed and conscientious, and also have some awareness of their limitations and potential vulnerabilities, without appearing too fragile.
Selection of patients
The patients have all been originally referred for psychotherapy by GPs, general psychiatrists or other mental health professionals. They are assessed by a senior memb...
