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Newsletter - Royal College of Psychiatrists

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					Newsletter

Winter 2009

Psychotherapy Faculty; Royal
College of Psychiatrists

Message from the Chair

Continuing economic difficulties are posing several challenges for medical
psychotherapists. There are additional personal burdens for patients and
prospective patients. There are threats, actual or looming, to what it may
be possible for us to provide on behalf of the NHS. And there is a strategic
need to respond to changing circumstances through a more economically
informed defence of clinical services. I shall outline some of the things the
executive is currently doing in response. One has been to commission a
strategic review of the economic implications of providing intensive
treatments for people with personality disorders. This is intended to lead
to advice on how future arrangements for ‘Payment by Results’ can ensure
provision psychological therapies for people with complex needs on the
basis of cost as well as clinical effectiveness.

In the meantime, it will be important to protect facilities that are already
valued. I had recently used the College email list to enquire about any
instances of service commissioners changing funding arrangements for
psychotherapy services and implicating Improving Access to Psychological
Therapies as a reason for this. I am not convinced that the response to
date is an accurate reflection of what is happening. Even without a change
in government, it is evident that future funding arrangements for IAPT are
likely to change, increasing pressure on the system as a whole. It remains
important that the executive are aware of significant changes in
commissioning patterns. Rumour is of limited help, but if services you are
responsible for are being directly affected, please ensure we are aware of
this.

I commented in the last newsletter about glaring deficiencies in the
proposals for the future regulation of psychotherapists through the HPC as
these went out for consultation. The faculty is continuing to pursue the
steps that would be necessary for any psychiatrist who has extensive
training in psychotherapy to have this recognised in future within their
registration with the GMC. Relevant discussions are at an early stage and
I hope to report in more detail early in the New Year.

At the same time, a further twist of governmental regulation has been
revealing itself. The Care Quality Commission is instituting a regime of
independent registration of premises used for certain kinds of health and
social care. This is likely to be expensive and unwieldy. It is also selective
in its targets, in a way that threatens to disadvantage faculty members
practising psychotherapy privately. In brief, psychotherapists whose
practice is already regulated because they are doctors, look likely to be
subjected to this additional tier of regulation. However, the majority of
psychotherapists, who will remain personally free of statutory professional
regulation for some time yet, look likely to be exempt from this attempt to
regulate the premises and service they are responsible for as well! Watch
this space.

Taking all the above and more into account, I confess to simple
incomprehension at how, alongside the evident need to ensure that
patients receive help with a minimum of fuss and best use of available
funds, the drive to divert energies and resources into measuring,
monitoring and regulating at every level just goes on gathering
momentum. There may be a modern fable waiting to be written in this –
I’m sure the newsletter editor would be receptive to contributions.

Lastly, I’ll share my acute concern over the sacking of David Nutt by the
government as an independent scientific advisor. It is unclear at the time
of writing what the eventual upshot of the affair will be. If past events are
anything to go by, politicians may well change their views with the tides
and shifting opportunities. However, it seems significant that the basis of
the opposition’s initial criticism of the government was not that they had
failed to respect an advisor’s right to represent the views of his expert
committee, but that they did not remove him soon enough. These glints of
a hardening authoritarianism across the political classes come in the wake
of attempts to use revisions of mental health legislation to restrict the
freedoms of professionals and patients alike that can’t have escaped any
psychiatrist. The alliances between professional groups, representatives of
service users and mental health charities that formed then seem likely to
be finding new functions in the near future.

Next April’s residential meeting in Cambridge should be an antidote for
any feelings of oppression. Details are enclosed. It is an opportunity to
think, feel and associate as freely as we wish. But other needs can’t be
ignored entirely. Please do not forget that signed nominations for vacant
places on the executive, and for the chair, need to be received either at
the College by Tuesday 20th April 2010, or by hand in Cambridge by the
start of the Annual General Meeting on Thursday 22nd April. Choose well.
There will be much for them to do.

                                                                 Chris Mace
Editors note

Of late the ground, upon which we consider the confidentiality of our
therapeutic conversations with patients, has shifted. In June 2009 following a
ruling in the Appeal Court, the Chief Medial Officer, Sir Liam Donaldson
highlighted what he described as the dangers of keeping informal medical
records separate from the main official patient record and stated that clinical
colleagues and records staff must be able to access all parts of the clinical
record.

The GMC also has issued new guidance on confidentiality for doctors which is
thorough in its recommendations to all doctors, espousing the principle that
sharing information within clinical teams is good practice. Supplementary
guidance is available on the disclosure of specific types of information such as
information about communicable diseases or concerns about patients to the
DVLA, but no specific guidance is offered as yet to doctors working as
psychotherapists where confidentially is, in some instances as fundamental to
the clinical work as an autoclave might be to a surgeon, albeit that this is a
somewhat loaded analogy.

The issue may more pressing for some therapists than others, systemic
therapists may routinely work in teams for example and CBT therapists may
routinely record sessions for supervision purposes. For those therapies where
the relationship with the therapist is itself the therapeutic tool and where the
most personal disclosures of fantasy life and personal experience are likely to
be made, the developing ethos regarding confidentiality in the public sector
begins to present problems which may impact upon the therapeutic work
itself.

The guidance provided by registering bodies such as the British
Psychoanalytic Council (BPC) and United Kingdom Council for
Psychotherapists (UKCP) confirms that the rules of confidentiality, applying to
psychoanalytic psychotherapists for example, go well beyond medical
confidentiality or that which applies to psychiatrists, being a prerequisite for
the focus on unconscious activity and effective therapeutic work. This
demands strict standards of confidentiality on all written records. A distinction
is made by the BPC between „records‟ which provide a basic set of data and
„notes‟ which are kept for the purpose of clarifying the therapists own thinking
with no intention that this would be used as a communication about or with the
patient. Such „notes‟ may be of educational value to the therapist when used
for supervision and are recorded in a way which does not identify the patient.

The discrepancy between the two cultures within which many of us practice is
widening and likely to continue to do so with the development of electronic
patient records within mental health services.

National electronic records may not be an immediate concern, but many
Mental Health Trusts are shifting to electronic patient records which replace
paper records. New electronic records systems permit varying levels of
access to records on a „need to know‟ basis by professionals across the
whole service. Managers administering such systems may see little difference
between the relationship a patient has with their therapist and that with their
care co-ordinator. Sarah Robertson has negotiated the boundaries of
confidentiality at Springfield Hospital in South London where an electronic
records system, RIO has been introduced and writes of her experience here.

Over and above these considerations about the medical records another
framework is required when considering the status of process notes. Until
recently The College had not expressed a view about the inclusion of process
notes in the medical record, in discussion with members of the faculty,
agreeing that the most appropriate solution was that process notes be kept
separate from the clinical record for use purely in supervision and considered
part of the therapists CPD notes. It appeared that the GMC and Department
of Health had also not really considered this issue. This position has been
complicated by the Chief Medical Officer‟s recent directive which was made
without awareness that this raises a problem with CPD notes. The College
recognises that further guidance is needed and the matter has been referred
for consideration by the GMC.

We will make that guidance available in a future issue of the newsletter. In this
issue we will summarise the current guidance on the confidentiality of process
notes as provided by the Faculty Process Notes Working Party.

                                                                     Sue Mizen

                                                         susanmizen@nhs.net
Report on the development of a protocol for process notes.
January 2008

A provisional statement on the status of process notes based on the principle
of treating them as CPD notes is as follows:


The Royal College of Psychiatrists
Statement on the status of process notes

   1. Process notes, which include treatments of individuals, groups and
      families, are part of a psychiatrist‟s training and CPD documents.

   2. The records should be anonymised or, in the case of group or family
      records, the names should be abbreviated.

   3. All clinically relevant information should be recorded as part of the
      general medical record.

   4. The rules for destruction are those applying to training/CPD and
      general medical records respectively.

   5. Training and CPD notes have no function beyond completion of the
      training or CPD activity and should be destroyed at that point.

   6. A record of the completion of the training or CPD activity should be
      retained.

   7. While training or CPD is continuing, relevant notes should be kept in a
      separate and secure situation, not with clinical notes.

   8. Members of the Royal College of Psychiatrists should be aware that
      CPD notes are only disclosable on receipt of a court order.

   9. General medical notes are disclosable under the Access to The Data
      protection Act.

   10. Members should note that if they receive a court order they can ask to
       discuss the request and its content with the Judge before disclosure.



With thanks to Dr Jim Wilson and Dr Rob Hale
Process notes working party
Rio and Confidentiality.


Our department of psychotherapy offers assessment and treatment along
psychodynamic lines. We have been using RIO for just over 2 years. RIO is
intended to reduce paperwork, and, more importantly, to ensure that all
relevant clinicians have access to clinical information from different parts of
the service. We think this laudable ambition has created an unanticipated
problem for our service.

Before the introduction of RIO on dictating an assessment report, a copy
remained in the department providing basic information for patient‟s therapist.
A copy would go to the referring team for the hospital file if the referral was
from within the Trust. If the referral was from outside the hospital a letter
would go to the referrer, a copy being sent to the patient unless they had said
they did not wish one. A written note would be made in the patient‟s paper
records during the assessment process and on starting treatment.

On Rio there is potential for many people within the Trust to access patients‟
electronic notes on a „need to know‟ basis. Although this process is audited
this is done retrospectively and so inappropriate access is only picked up after
the event. We are worried this makes the confidential nature of the setting
less safe. A safe setting for psychotherapy is paramount to the process of
assessment and the development of the therapeutic alliance both from the
external point of view but also internally, in the patient‟s mind. It is essential
that a private space can be achieved so the patient feels safe to unfold in the
way he/she will and the therapist has space to think without unnecessary
anxiety about intrusions into the analytic frame. .

After much discussion we felt we could not offer this setting unless we did
more to protect the patient‟s confidentiality. We argued our case with the
information governance department for an increased safeguard and for our
assessments to be uploaded onto RIO and password protected. Only our
department, information governance and medical records department have
the password. If teams or clinicians want a copy of the assessment we send it
asking them not to upload it on to RIO.

At the same time we make a note in the progress notes on RIO about the
assessment and any concerns we have about the patient‟s management.
These progress notes are accessed on a need to know basis. This care about
confidentiality does not mean that we do not liaise with the referring team or
clinician. If there is concern about the patient from either the assessor or
team, we liaise with the team, and where there is a psychodynamic
understanding which the assessor thinks important for psychiatric
management this will be discussed with the CMHT clinicians.

This position is not without tensions, and some referring teams or clinicians
are not happy that they cannot access assessment reports routinely. “Why
are we different? Everyone has to protect the patients‟ confidentiality” There is
curiosity about what is behind the closed door, and sometimes a feeling that
we are withholding important information. We try not to enforce rigid rules but
to share information and work collaboratively with teams in whatever way
suits the individual patient.

Sometimes the CMHT consultants are not happy about our only uploading a
note of important points from the assessment onto RIO wanting to upload the
whole assessment. In this case we advise that they, as the responsible
consultant, upload what is important to their team having discussed it. Clearly
there may be important dynamics being enacted in the whole process and this
needs thinking about in the liaison consultation.

We try and manage the tension between disclosing too little, the treating team
not getting useful feedback and disclosing too much so the patient or therapist
are left feeling that their inner world is not safe, but open to an unknown
number of people, in a way that will have an adverse impact on assessment
and treatment.

This position is one that our particular department has chosen to adopt.
Neither within the department has there been complete agreement on this
approach, nor across the other departments of Psychotherapy within the
Trust. Three of the department‟s password protect assessments and one
does not arguing in favour of this on the basis of the impact password
protection has on relations with the CMHT and other teams.

Is the likelihood of confidentiality being breached greater with RIO than with
paper records? Patients can opt for additional protection if required, such as
electing to use a Pseudonym if they are concerned about being recognized on
RIO. They can also opt for restricted access to their records (although the
notes can still be accessed on a need to know basis).

It may be that we are being unreasonably anxious about this issue. After all,
for years we sent off reports for filing in the general files, and did not know
who might read them. Somehow, the electronic version seems more
vulnerable, more public, although in practice, there is no reason to suppose
that they are more likely to be read by those without the right to read them
than the paper account. Is this a persecutory anxiety stirred in us by the
potential of more unknown people being able to access the records causing
us to over restrict access to the psychotherapy record? Certainly, some
patients have felt very strongly about the electronic records and have felt
reassured to know of these precautions.

It would be interesting to hear from others whether they see this as an
important issue and how they are managing the tensions generated by the
electronic records system.

                                                      Sarah Robertson
      Consultant Psychiatrist in Psychotherapy and Programme Director
Working groups within the Psychotherapy
Faculty Exec.
Over the past two years the Faculty Executive has established four working
groups, responsible for carrying forward developments in the following areas:



SERVICE INNOVATION AND POLICY WORKING GROUP
In terms of activity over the past year the Service Innovation and Policy sub-
group has been heavy on the policy and light on the service innovation side of
the equation.

I have the role of writing responses on behalf of the Psychotherapy Faculty to
selected Department of Health and other national policy documents that are
sent for consultation to the College for comment.


Here are selected policies I have responded on:

      New Horizons: Towards a Shared Vision of Mental Health

      Consultation about Tier 4 Services for Personality Disorder in the
       South East („Shaping the Future‟)

      Common Assessment Framework for Health and Social Care services

      Care Quality Commission: Mental Health Strategy/Registration

      Medical Research Council:     Strategic Review of Mental Health and
       Wellbeing

      Marmot Review: Strategic Review of Health and Equalities in England
       Post 2010

      Consultation on Specialist Training in Psychiatry

      Royal College of Psychiatrists Survey on Suicide and Self Harm

      British Psychological Society: Psychological Health and Wellbeing, A
       New Ethos and a New Service Structure for Mental Health
Consultation in relation to policy documents is currently a reactive process but
one I‟d like to change to show a coherent Faculty opinion I can feel accurately
reflects the thinking and activity of members.

In terms of the lighter side of the equation, service innovation, drawing
together examples of service development from across the country from
medical psychotherapists would help me to inform and actively promote a
proactive Faculty voice which is not solely my own.

If you want to let me know about service developments and strategy in your
region or pass comments to me about new consultations I‟d welcome your
thoughts.

                                            James Johnston October 2009.
                                          James.Johnston@leedspft.nhs.uk




THE PUBLIC AND PROFESSIONAL EDUCATION WORKING
GROUP.


Our task is to gather together the current information in the college about
psychotherapy, (review, edit, update and remove redundant information,
rewrite as necessary and add more information that we think will be helpful).
The work we have done is being shared with the Executive and with the rest
of the Faculty through this newsletter and also through the faculty webpage.
Our second task is to ensure medical psychotherapists are available for
comment on relevant developments throughout the UK.

We also are represented on the Public Education Committee which Kevin
Healy and I attend on a regular basis. Kevin has made links with a school who
requested some information on suicide after one of their pupils committed
suicide and he is about to visit some of the teachers there.

We have allocated specific members of our work group to review specific
areas of the available material on the college website from the perspective of

1) Faculty members
2) College members outside of the faculty
3) Trainees and their needs
4) The public, including the views of service users and carers.

We are linking with the website editor Rex Haigh who is overhauling the
Faculty web page, and articles elsewhere on the College website so these are
given a greater profile. We would be grateful for your views of the new look
website.
The information sheet on „What is Psychotherapy‟ has been rewritten and
brought up to date and is available on the public information page of the
College website. If you Google „psychotherapy‟ it comes up number 2.

We are thinking of other things to include such as pod casts about the
different forms of psychotherapy or interviews with service users about their
experience of treatment. The idea would be to link these to the faculty web
page. We are also wondering about other ways to disseminate information
such as Twitter.

We would welcome your thought on what you would like to see more of and in
what form...

(Kevin Healy, Sally Mitchison, Jale Punter and myself Sarah Robertson).

                                             Sarah Robertson October 2009



EVIDENCE AND RESEARCH WORKING GROUP

The sub-group has begun deliberations about how it can best influence
psychotherapy research priorities and funding and welcomes comments from
Faculty members [to David Kingdon dgk@soton.ac.uk].

Over the past two decades, evidence for the effectiveness of psychotherapy
for most distressing and disabling mental conditions has been rapidly
accumulating. This has had positive effects on referral for and availability of
psychotherapy exemplified by their inclusion in NICE Guidelines and the
Government funding of the Improving Access to Psychological Treatments
programme.

However there remain uncharted areas
   much of the evidence demonstrates short-term effectiveness only
   substantial numbers of patients do not respond to first-line therapies
   evidence for some therapies which have been available on the NHS is
     limited to case series or expert opinion only
   targeting of therapies to individuals is based on crude and stigmatising
     indicators, usually diagnoses based on ICD10 or DSMIV categories,
     e.g. Personality Disorder, Depression, or Schizophrenia, or focusing
     on individual symptoms, e.g. depression or self-harm.
   systematic research into cultural adaptation of therapies is virtually
     non-existent
   there is little comparative evidence between therapies to inform choice
     by patients, professionals or commissioners

The evidence-base is extremely important in guiding individual practice and
influencing those compiling guidelines, e.g. NICE, those providing services,
e.g. NHS Trusts, and those commissioning them especially PCTs.
Consequently absence of convincing evidence of effect is leading to
disinvestment and closure of services. As the Psychotherapy Faculty aims to
advance the practice of psychotherapy, especially medical psychotherapy, it
therefore has a key interest in influencing the development of such evidence.
Such influence can be exerted through proposing topics for commissioning by
research funders especially National Institute of Health Research
programmes, e.g. Health Technology Assessment or Policy Research
Programme.

Possible priority areas
   Role of medical psychotherapist (MP)
         o E.g. through qualitative study of MPs, non-MPs, psychiatrists &
             patients.
   Psychological treatment for non-response or partial response to
      medication and first-line psychological therapy („Post-IAPT‟)
         o Phase 1: Independent matched controls/ Phase 2: RCT
         o Possible areas:
                 Depression with perfectionism: e.g. schema-based CBT
                    v. psychodynamic psychotherapy
                 Depression with dependency: e.g. CBT v. problem-
                    solving/skills-focused social work intervention
                 Borderline (including dual diagnosis with bipolar or
                    psychosis):
                         Dialectical Behaviour Therapy v Cognitive Analytic
                           Therapy or dynamic psychotherapy
                         Role, indications and cost-benefits of residential
                           placement
                 Psychosis & bipolar disorder:
                         Mindfulness/Acceptance & Commitment Therapy


                                                              David Kingdon




Member Support Working Group: Outline Terms of Reference

This group is working to develop terms of reference. The scope is 3 fold:

1 To provide strategic advice relating to workforce development, this to
include the developing role of the Consultant Psychiatrist in Psychotherapy,
workforce capacity and career framework.

2 To provide assistance for members of the Faculty who request support. This
is to be progressed through the development of a responsive network of
members who volunteer to provide support, advice or mentorship including
signposting.
3 To advocate for and facilitate a national provision of confidential, high
quality and accessible services for sick doctors.

If you are interested in contributing to any of these proposed developments
we would love to hear from you.

         (Tony Garelick, Mark Evans, Siobhan Murphy, Sarah Robertson.)

                                                                  Jan Birtle
                                           Contact: jan.birtle@bsmhft.nhs.uk




Correspondence

The summer newsletter has been followed by a flurry of correspondence on
the subject of revalidation and 360 degree appraisal. Several people
welcomed Sally Mitcheson‟s frank account of undertaking the Colleges 360
degree appraisal and added a few experiences of their own. These included
comments on how cumbersome this system was and doubts as to the validity
and reliability of this form of feedback on performance whilst a few examples
were provided instances where feedback resulted in change, possibly
improvement in practice. Instances in which an outlier who has an axe to
grind with the appraisee can significantly skew average scores. Other tools
were mentioned such as the Leadership Qualities Framework questionnaire
and RES 360 which can be completed online.

Concerning the question of whether to apply for revalidation some colleagues
have confirmed that they will not be doing so intending to continue on private
practice as psychotherapists or analysts and no longer practice as doctors.

This along with the CQC proposal for registration of premises which doctors
practice therapy in privately, a laborious which our non-medical colleagues
will not for now be expected to complete could result in a division in our
profession between those medical psychotherapists who chose to keep their
medical registration and practice psychotherapy in the NHS and those who
chose to give up their medical registration and practice privately. The loss of
the mixed culture of work in the public sector and private work which inform
one another would perhaps be to the detriment of all concerned.

With thanks to Dr Ray Haddock, Dr Mike Rigby and others whose agreement I
have not obtained to publish their contributions
                          Psychotherapy Faculty
                             Draft Programme
                      Annual Residential Conference

                        Cambridge, 22-23 April 2010

                      Art, Science and Psychotherapy


Thursday 22nd April

9.30am - 11.00am Prof Paul Fletcher: Brain Relationships in Psychosis

11.00am Tea

11.30am – 13.00 Gerald Wooster and Dave Bell; “Troilus and Cressida and
Hamlet”

13 – 1400 Lunch

14.00 – 15.30 David Kingdon; Title tbc

15.30 Tea

16.00 - 17.30 Richard Rusbridger; “Don Giovanni”

17.30pm - 18.30pm Psychotherapy Faculty AGM

19.30 Dinner and after dinner speaker:


Friday 23rd April

9.00 10.30am Jonathan Bird; “To sleep , perchance to dream”

10.30 – 11.00 Tea

11.00 – 12.30 Kevin Healey and Chris Mace

!2.30 - 13.30 Lunch

13.30 – 15.00 Jonathan Green; “Art Object as a mental state or Form and
mental state: an interpersonal approach”

15 00 – 15.30 Tea

!5..30 – 17.00 Don Campbell; “Gun Gangs and Gun Boy”

				
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