Supercharge Your Psychotherapy Case Training – Tips to Pass RANZCP Psychotherapy Long Case

WHAT IS THE IMPORTANCE OF PSYCHOTHERAPY?

Psychoanalysis, starting with the theory that not all of our behaviours are under our conscious control and exploring the unconscious can help to improve human functioning, did not fix everyone. But it’s one of the first interventions that seemed to have lasting positive impacts in its patients, and these gains were dramatic, and permanent.

In the last fifty years there have been several pharmaceutical revolutions, and many conditions that were previously thought untreatable now show miraculous improvements. But there are still several patients who do not respond to medications. 15% of the general population have personality disorders. 30% of depressed patients do not respond to medications. Loneliness, the commonest mental illness, still does not have a DSM classification, nor an evidence-based treatment for its approach.

This does not mean that the panacea for all mankind is psychoanalysis. What it does mean is that there are some patients for whom it could be life-changing. Including it is part of the armamentarium for the modern psychiatrist greatly increases the possibility that you may have something to offer the patient.

I realise the logic of this implies learning about how to do leucotomies and insulin coma regimens. You’ll probably have to find someone else to teach you about those interventions, but what I can help with is psychodynamic psychotherapy.

WHAT IS IT I DO?

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) requires all trainees to complete a 40 session long term psychotherapy case, for which a psychodynamic intervention is used.

When I did my long term case, I found it incredibly daunting as there was a large amount of knowledge that I simply did not have, and I quickly found myself wondering what I was doing with my patients.

It was in the process of supervision and learning from several very clever people that I discovered what psychotherapy was all about – about learning a different style of interacting with patients that was a great deal more intensive. It was about learning new skills that heightened my capacity for diagnostic assessments, even when not providing psychotherapy.

It was about understanding people – and understanding myself – at a much more fundamental level, for the purposes of improving patient functioning. Most importantly, it was about having fun, because knowing what you’re doing and becoming better at something is a great deal of fun.

(By the way, it’s called “Psychodynamic” because Freud’s supervisor when he was a first-year medical student was inspired by the concept of thermodynamics to put forward the theory that living organisms are also energy systems, governed by the principle of energy conservation – hence “psychic energy”, “repressed impulses”, “drives”, etc. Psychoanalysis means the same thing.)

With that in mind, I provide case supervision that will fulfil your college requirements, but I also provide a course of introductory psychodynamic theory to help navigate the large amount of material that there is out there.

I start from talking about attachment and mentalisation and choosing people for psychotherapy, then into the fundamental skills in the practice of psychotherapy – the frame, boundaries, free associations, transference, resistance, and so on. Key elements that lead to improving your diagnostic skills then follow, with talking about formulation, key object relations, interpersonal triangles and defense mechanisms. We’ll then go on to an overview of some of the prominent models that have arisen in psychotherapy – from self psychology to the conversational model, Klein to Kernberg. The didactic course closes with more detail regarding formulation, particularly on personality disorders and some case studies.

Here is the online course I developed based on these principles to help you pass the RANZCP Psychotherapy case.

However, much of the learning is from listening to how your colleagues manage their cases, and exploring your own cases. Don’t worry if you don’t have a case yet – in fact, I recommend joining before getting a case, as it will take time to accumulate the theory and you’ll feel more confident before starting on a case. The course is designed as a “drop-in” open frame, so participants have access to all the course material from the start, but can turn up for sessions as they wish.

HOW TO CHOOSE A PSYCHOTHERAPY CASE?

I’d be remiss if I didn’t give some advice regarding psychotherapy case selection – the expanded version of this is on the website, but the first key thing is to be wary of the enthusiastic referrer. They may be well-meaning, but they may also have a very difficult patient who would completely overwhelm someone new to therapy.

There are three questions: Who should have therapy, who does well in therapy, and who does not do well in therapy.

The question for “who should have therapy” is answered either with “everyone”, for the Jungian “cleanse the world of the unconscious” acolytes, or those patients for whom a condition with a suspected unconscious psychological contributor is present. These can be hard to identify without actually going ahead with psychotherapy, but look for personality disordered patients (particularly clusters B and C), those who are depressed but with reactive affects (although, importantly, not the other atypical features), and those who wish to know more about themselves. It is this last category who do function well in psychotherapy, as part of the features of successful patients include the psychologically minded (Other features are the presence of at least one meaningful relationship, a lack of risk factors, strong motivation, a circumscribed problem, and evidence of prior achievement in their area of weakness).

WHICH PATIENTS WOULD BENEFIT?

Those who do not have a capacity for introspection are likely to be difficult to engage, as well as those with chronic substance use, serious suicide attempts, and gross self-destructive “acting out” behaviours. The process of psychodynamic psychotherapy usually involves the patient becoming worse as the unconscious gets exposed before they get better – it is for this reason that interventions like Dialectical Behavior Therapy were created, to provide patients with more supportive skills to enable them to tolerate the invasiveness of psychoanalysis.

Now it is very difficult to be aware of all of these factors, as well as the practical aspects such as whether you’ll be able to tolerate seeing your patient for almost a year on a weekly basis (not a minor consideration!) For this reason, I recommend that any patient who is considered for psychotherapy be only offered an assessment phase of 4 sessions – advise the patient that this is to determine what is a suitable intervention for them after this time. You may determine that the patient is well enough and does not require psychotherapy. You may determine that the patient has serious risk issues and is likely to do worse with psychotherapy. You may determine that the patient would be a suitable candidate for psychotherapy, but there is a poor fit between yourself and the patient and they may do better with another therapist.

Use the assessment phase to formulate the patient and work out what the goals of therapy are, what their psychological mindedness and defensive profile is, and to attempt a reasonable projection of what the next 40 sessions will bring. This will give good material to discuss with your supervisor – as well as provide you with the first 2000 words of your case write-up!

For the RANZCP Psychotherapy long case training, consider the Psychodynamic Psychotherapy Course developed by Dr Neil Jeyasingam. 

This online course is a compilation of engaging  videos where Dr. Jeyasingam takes you through 14 guided presentations that span  a period of 2+ hours.

It provides a brief overview of fundamental psychodynamic concepts, as well as models of psychotherapy and how to formulate. The principles, context, and applications of psychotherapy will be covered, giving you the opportunity to master this skill in short engaging videos.