Acad Psychiatry DOI 10.1007/s40596-015-0333-x
EMPIRICAL REPORT
Education in Psychopathology in Europe: Results from a Survey in 32 Countries Andrea Fiorillo 1 & Gaia Sampogna 1 & Valeria Del Vecchio 1 & Mario Luciano 1 & Alessandra Ambrosini 2 & Giovanni Stanghellini 3
Received: 25 September 2014 / Accepted: 12 March 2015 # Academic Psychiatry 2015
Abstract Objectives The aim of the present paper is to assess the current status of training on psychopathology in Europe and to identify the unmet needs of training on psychopathology. Methods An online survey was carried out during the period July–December 2013. Forty-one representatives of early career psychiatrists of their national associations were invited to participate. Each respondent was asked to provide the collective feedback of the association rather than that of any of its individual officer or member. Results Thirty-two associations returned the questionnaire out of the 41 contacted (response rate, 78 %). All respondents recognized psychopathology as a core component of training in psychiatry. According to respondents, the primary aims of psychopathology are (a) to assess psychiatric symptoms (47 %), (b) to understand patients’ abnormal experiences (33 %), and (c) to make nosographical diagnosis (20 %). A formal training course in psychopathology is available in 29 out of the 32 surveyed countries. In most countries, (a) there is not a defined number of hours dedicated to psychopathology, (b) teaching is mainly theoretical, and (c) a structured training on psychometric tools is missing. At the end of the training, about half of trainees is not satisfied with received training in psychopathology. Electronic supplementary material The online version of this article (doi:10.1007/s40596-015-0333-x) contains supplementary material, which is available to authorized users. * Andrea Fiorillo [email protected] 1
University of Naples SUN, Naples, Italy
2
G. d’Annunzio University, Chieti, Italy
3
D. Portales University, Santiago, Chile
Conclusions According to European early career psychiatrists, there is the need to rethink training in psychopathology, which should be at the heart of training in psychiatry and the key element of psychiatric practice. Education in psychopathology is affected by several unmet needs, such as lack of appropriate training in the use of psychometric instruments, lack of supervision, and lack of practical skills.
Keywords Professional development . Psychopathology . Career development . Medical education . Training More than one century after the seminal work of Karl Jaspers’ General Psychopathology, modern psychiatry is far from Jaspers’ emphasis on adequate concepts and methods for exploring the patient’s perspective [1]. Since the publication of diagnostic manuals, many psychiatrists confused operationalized criteria with handbooks of psychiatry and psychopathology and diagnostic criteria with the whole picture of the illnesses [2–4]. Consequently, a glossary of psychopathological knowledge, including in-depth descriptions of mental abnormal phenomena and syndromes [5], has simply been removed from psychiatric educational programs. Moreover, according to a recent review, the term “psychopathology” is now used in a trivial way, referring to the subject matter of psychiatry, instead of the discipline that studies the phenomena of mental disorders [6]. However, more recently, the importance for psychiatrists to have strong psychopathological bases has been repeatedly affirmed since psychopathology: (1) is the common language that allows psychiatrists to communicate each other, (2) represents the basis for diagnosis and classification of mental disorders, and (3) makes
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an indispensable contribution to understanding patients’ abnormal experiences [7]. Recently, the need to rediscover psychopathology has become even more cogent, following the changed target of psychiatry. In fact, when the target was “madness,” the alterations and deviations from the norm were quite obvious [8]. Today’s target of psychiatry is “mental health problems,” which are the result of different biological, social, and psychological forces, and whose psychopathological background is not always clear [9]. The risk is that psychiatry as a discipline may lose its own identity if a rigorous assessment of the patients’ subjectivity in psychiatric care is disregarded [10]. Recent changes have had an impact not only on clinical practice but also on the training in psychiatry. The need to go “back to fundamentals” was recently claimed by academicians [7, 11, 12], while trainees and early career psychiatrists consider “rediscovering psychopathology” as one of the top priorities for their own future and for that of their patients [13]. According to the “Charter on training of medical specialists in the EU: Requirements for the specialty of psychiatry” proposed by the European Union of Medical Specialists (UEMS) [14], educational programs during psychiatric residency should include a structured training (with lectures, seminars, etc.) on psychopathology and other disciplines, which represents the scientific bases of psychiatry. Many studies [15–19] and a recent review [20] on the application of the UEMS recommendations in the different European countries showed great variability, in particular as regards training in psychopathology. However, specific data on the current status of training and practice on psychopathology are not available. Taking into account these premises, we decided to carry out an online survey to assess the current status of training on psychopathology in Europe with the aim to identify the unmet needs of trainees and to suggest future challenges for psychiatrists.
by researchers and academicians who were experts in the field of education and psychopathology (AF and GS), which led to the final version of the questionnaire consisting of 29 items, subdivided in three sections: (a) knowledge of psychopathology, (b) training in psychopathology, and (c) unmet needs and future perspectives of training in psychopathology (Appendix 1). In the period July–September 2013, 41 European early career psychiatrists, representatives of their national associations, were invited to participate in an online survey through email invitation. According to the definition provided by the European Psychiatric Association [25] and the World Psychiatric Association [26], early career psychiatrists include trainees in psychiatry and specialists in psychiatry under 40 years of age and/or with less than 5 years of practice after specialty. Respondents were asked to consult other members of the association and to investigate with them the status of training in psychopathology in their own country. The final compiled questionnaire should have been approved by the members of the association and represents their official document. We asked to answer the sections “Knowledge of psychopathology” and “Unmet needs” after a careful discussion among the members of the association by e-mail exchange or at physical meetings. Answers were not weighted, but general trends were considered from the national representatives. Only one answer per country was accepted. Answers to the questions investigating the national standards (“Training in psychopathology”) were taken from national regulations/ laws on the organization of training in psychiatry. More than 1 month (or even more, if needed) was given before sending back the questionnaire. Items were analyzed by means and frequency counts as appropriate. All analyses were performed using the Statistical Package for Social Science software (SPSS), version 18.0 [27]. The Institutional Review Board (IRB) of the University of Naples SUN exempted the authors to obtain a formal IRB approval since this study does not involve human subjects.
Methods
Results
An ad hoc questionnaire was developed using the same methodology adopted for other surveys recently carried out by the early career psychiatrist networks of the World Psychiatric Association (WPA) and the European Psychiatric Association (EPA) [21–24]. In order to develop the questionnaire, several focus groups have been carried out within the EPA Early Career Psychiatrists Committee and the EPA section on Philosophy and Psychiatry. These focus groups took place twice during the EPA annual congresses in 2012 and 2013 and led to the development of the preliminary list of items. The content validity of this 34-item list was reviewed
Thirty-two countries (Azerbaijan, Albania, Austria, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, France, Germany, Italy, Latvia, Lithuania, Macedonia, Malta, Montenegro, Poland, Portugal, Romania, Russia, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, UK) returned the questionnaire, with a response rate of 78 %. Although psychopathology is the core part of psychiatric curricula according to 100 % of respondents, 12.5 % of them think that psychiatric practice can be done without a formal (theoretical and practical) training in psychopathology.
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Although European early career psychiatrists affirm that psychopathology is, and will continue to be, a core part of psychiatric curricula, and that more time should be devoted to psychopathology, 21 % of respondents believe that psychopathology “is not useful in clinical practice,” 25 % that it “is old-fashioned,” and 50 % that it “is not interesting for psychiatric practice.” Only 6 % of respondents declare to have “no time to dedicate to the study of psychopathology.” The most frequently adopted psychopathological approach is the clinical one (65 %; 21 countries), while the phenomenological approach is adopted in 22 % of the countries (n=7) and the descriptive approach in 18 % of countries (n=6). In two countries, this information is not available, while in one country, different approaches are adopted in the various regions. Of course, in some countries more than one approach is adopted (Table 1). Before starting residency in psychiatry, 75 % of respondents affirmed to have read general books on psychopathology and to know what psychopathology is. According to early career psychiatrists, the primary aims of psychopathology are to assess psychiatric symptoms (47 %), to understand abnormal experiences (33 %), and to make nosographical diagnosis (20 %). Karl Jaspers, Emil Kraepelin, and Kurt Schneider are listed as the most influential psychopathologists, followed by Eugene Bleuler, Sigmund Freud, and Philippe Pinel. The other psychopathologists mentioned by the respondents are Nancy Andreasen, Silvano Arieti, Arnaldo Ballerini, Simon BaronCohen, Bruno Callieri, Lorenzo Calvi, Victor Kandisky, Melanie Klein, Ernst Kretschmer, Jacques Lacan, and Michael Rutter. Table 1
Relevance of psychopathology for psychiatric clinical practice
Do you think psychopathology is (and should be) a core part of psychiatric curricula? Yes Do you think psychiatric practice could be done without a formal (theoretical and practical) training in psychopathology? Yes What is the main reason for you or your colleagues to not study psychopathology? Not interesting Old-fashioned Not useful in clinical practice Lack of time What is the most adopted psychopathological approach in your country?a Clinical approach Descriptive approach Phenomenological approach a
More than one answer was possible
Percent
(N)
100
(32)
12.5
(4)
50 25 19 6
(16) (8) (6) (2)
65 22 18
(21) (7) (6)
An official course in psychopathology is available during specialistic training in 29 out of the 32 surveyed countries (91 %) (Table 2) with no specification as regards the number of hours dedicated to education in psychopathology. Croatia, Estonia, and Austria do not include an official teaching in psychopathology in their specialistic curricula (Table 2). The most frequent teaching modalities are theoretical lessons (96 %). Discussion of clinical cases is routinely performed only in Azerbaijan, Poland, Russia, Serbia, Sweden, Switzerland, and UK (24 %). Workshops and role-plays are available in Germany, Lithuania, Serbia, and Sweden. Respondents from Albania and Macedonia did not provide this information. Respondents from ten countries (35 %) reported that an official training course on the use of psychopathological rating scales is available in their country, and respondents from 19 countries (73 %) reported to routinely use them in clinical practice, even without a formal training. The most frequently used ones include the Positive and Negative Syndrome Scale (PANSS), the Hamilton Depression Rating Scale (HAM-D), the MontgomeryAsberg Depression Rating Scale (MADRS), the Hamilton Anxiety Scale (HAM-A), the Brief Psychiatric Rating Scale (BPRS), the Structured Clinical Interview for DSM-IV Axis I Disordes (SCID-I), and the Young Mania Rating Scale (YMRS). At the end of residency, 48 % of respondents are not satisfied with the training they received in psychopathology. An expert in psychopathology, who takes the responsibility to supervise trainees on psychopathological methods, is available in 11 countries (Azerbaijan, Belgium, Germany, Macedonia, Montenegro, Poland, Romania, Russia, Serbia, Sweden, and Turkey; Table 2). The most important unmet needs identified by residents in psychiatry are time dedicated to supervision (90 %), time dedicated to study psychopathology (73 %), and opportunities to discuss patients’ psychopathological phenomena in clinical practice (57 %). Other unmet needs include lack of supervision, which is available only in 11 of the surveyed countries (35 %), and lack of training in the use of psychometric tools scales, which should become a compulsory part of residency courses for 100 % of respondents (Table 3).
Discussion To our knowledge, this is the first European survey on the current status of training in psychopathology at European level. In fact, we found no similar studies published in the last 20 years. The main findings of the survey are that: (1) psychopathology is recognized as a core part of psychiatric curricula, (2) the
Acad Psychiatry Table 2
Characteristics of training in psychopathology Is an official training course in psychopathology available in your country?
Azerbaijan
x
Albania Austria Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia France Germany Italy Latvia Lithuania Macedonia Malta
x
x x x x x x x
Montenegro Poland Portugal Romania Russia Serbia Slovenia Spain Sweden Switzerland Turkey Ukraine United Kingdom
x x x x x x x x x x x x x
Have you been formally trained in the use of psychopathological rating scales?
x x x x
Do you use psychopathological rating scales in routine practice?
Is there an expert Are you satisfied psychiatrist who is with training in responsible for psychopathology? training in psychopathology?
x
x
x x
x x
x x x
x
x x
x x x
x x
x
x x
x x x
Are you confident in using psychopathological methods in clinical practice?
x x x
x x
x
x
x x x
x x
x
x x x
x x x
x x
x x
x x x
x x x x x x
x x x x x x x x x
level of satisfaction with the received training is not high, (3) psychometric tools are used too often without an appropriate training, and (4) several unmet needs are identified. Our results are in line with the need to rediscover psychopathology, which has been recently proposed by different international bodies [13, 28] and individuals [29–31]. There are at least five reasons why psychopathology is still the core part of training curricula in psychiatry, one of them being the need to provide psychiatrists with a method enabling them to capture the subtle nuances of the patients’ experience that constitute the essentials of the “psychiatric object” [32]. In this
x x x
x x
x x
x x x x
x x x x x x
respect, the section on Philosophy and Psychiatry of the European Psychiatric Association (EPA) is running since 2013 a highly successful annual educational course that brings together many early career psychiatrists from Europe [33, 34]. Further educational activities, including the organization of scientific events and the production of books and educational modules for young psychiatrists, should be envisaged [35]. Yet, about 50 % respondents also affirm that psychopathology is not useful in clinical practice. This datum seems to be in contradiction with the previous one. One way to interpret this inconsistency is that early career psychiatrists are critical
Acad Psychiatry Table 3
Unmet needs of training in psychopathology
Training in the use of psychopathological rating scales Time free to dedicate to books and papers on psychopathology Availability of senior supervisors Discussion groups on psychopathology
Percent
(N)
100 73
(32) (22)
90 57
(27) (17)
More than one answer was possible
towards the education in psychopathology they received, rather than towards psychopathology itself. In fact, early career psychiatrists explicitly ask for an improvement of the quality of their educational opportunities [36], and a key issue we may argue is the need to couple theoretical psychopathological knowledge with practical clinical skills. In particular, more hours spent in clinical practice under the supervision of an expert in psychopathology (rather than ex cathedra theoretical lessons) could help fill this gap, reshaping teaching programs in psychopathology. Another possible explanation is that those who do not want to spend time with their patients are those who report that psychopathology is not useful in clinical practice, as it happens regarding psychotherapy [21]. Indeed, residents in psychiatry are not globally satisfied with training in psychopathology. In particular, the main problems include a scarce definition of training characteristics and the limited number of hours dedicated to this subject. Comparing our results with those from other surveys regarding the status of training in areas such as psychotherapy [21] and early prevention and intervention [22], we found a regrettably lower level of satisfaction with the training in psychopathology. This could be a consequence of the fact that current curricula are more oriented towards neuroscientific knowledge and technical skills [37, 38]. The dichotomizing debate about the very identity of psychiatry as a medical discipline, opposing supporters to psychiatry-as-a-biomedical science to backers of psychiatry-as-part-of-medical-humanities, does not help to find for psychopathology its proper place in psychiatric educational curricula [39]. In fact, psychopathology, being the science of human abnormal subjectivity, is a peculiar discipline characterized by an and-and agenda, meaning that it is based on two main complementary methodological approaches: explaining (searching for causes) and understanding (searching for meanings) [40]. Early career psychiatrists are probably aware of the different languages spoken in mental health research and practice and are telling us that the approach to mental disorders as provided in DSM-5 and ICD-10 is not useful to explore and make sense of the complexities of abnormal mental phenomena [41–45]. These results highlight the importance to enhance psychopathological knowledge and attitude for the
future generation of psychiatrists in order to regain a holistic view of the psychiatric patients [46–48]. A third important finding is the lack of an appropriate training in the use of psychopathological rating scales, although these instruments are routinely used in clinical practice by early career psychiatrists. It is likely that psychopathological rating scales are often confused with other psychometric tools, which are important for making reliable assessments, but do not explore the patients’ perspective, that is, their subjective experiences and personal meanings. The use of psychopathological rating scales is essential in psychiatric practice; the severity score on a scale should represent the translation of patient’s subjective symptoms into an objective statement [49]. Obviously, this deficiency will affect psychiatrists’ clinical and research work, not to mention their epistemological awareness of the limitations of the field of application and of the results obtained using rating scales. The fourth finding is the recognition of several unmet needs for the new generations of psychiatrists. Although psychopathology is recognized as the basis of the whole mental health practice [11, 12, 29], psychiatric educational programs have simply removed the magnificent thesaurus of psychopathological knowledge from training courses. In fact, from our survey, it emerged that key figures in XX Century psychopathology (e.g., Minkowski, Ey or Kretschmer) are only sporadically reported by European early career psychiatrists, who—on the contrary—list Emil Kraepelin (indeed a nosologist who provided a fine description of psychiatric syndromes, rather than a psychopathologist) and Sigmund Freud among the most influential psychopathologists, suggesting that they are not at all familiar with the core psychopathological European tradition [1]. This study has some limitations that need to be acknowledged. A first limitation was due to the fact that this was a purposely designed survey. However, the response rate was particularly high (78 %), compared to previous surveys carried out with the same methodology [21, 22], indicating that not only those interested in the field of psychopathology answered to the questionnaire. Moreover, this methodological choice will help comparisons with other surveys, with the aim to contribute to improve psychiatric education. Another limitation is that only one national representative of the ECP association in each country was invited to participate instead of all ECP members. This possible bias was overcome by inviting people to respond on behalf of their association and not on behalf of themselves, by consulting the other members of the association before providing their inputs. Moreover, this was the only way to obtain reliable data in a relatively short period of time, and reaching (almost) all early career psychiatrists in the different European countries would have been beyond the possibilities of a non-financed, voluntary study. In conclusion, European early career psychiatrists recognize that psychopathology is the core part of psychiatric
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curricula, but they report that received training is far from being satisfying. There is the need to give psychopathology the place it deserves in post-graduate psychiatric training, given its methodological rigor, the richness of its descriptions, and its contribution to make psychiatric diagnoses and to understand mental disorders. Implications for Educators • Early career psychiatrists explicitly ask for an improvement of the quality of their educational opportunities, reporting the need to couple theoretical psychopathological knowledge with practical clinical skills. In particular, more hours spent in clinical practice under the supervision of an expert in psychopathology, rather than only theoretical lessons could help fill this gap, reshaping teaching programs in psychopathology. • Although early career psychiatrists are not trained on the most frequently used psychometric tools, they tend to use them anyway in their routine practice. This deficiency will affect psychiatrists’ clinical and research work. • National and international bodies that are responsible for education in psychiatry should seriously reconsider the importance of psychopathology in training curricula, given its role in psychiatric diagnoses, understanding of mental disorders, and its capacity to rehumanize psychiatric practice.
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21. Disclosure The authors declare that they have no conflicts of interest concerning this article. 22.
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EMPIRICAL REPORT
Education in Psychopathology in Europe: Results from a Survey in 32 Countries Andrea Fiorillo 1 & Gaia Sampogna 1 & Valeria Del Vecchio 1 & Mario Luciano 1 & Alessandra Ambrosini 2 & Giovanni Stanghellini 3
Received: 25 September 2014 / Accepted: 12 March 2015 # Academic Psychiatry 2015
Abstract Objectives The aim of the present paper is to assess the current status of training on psychopathology in Europe and to identify the unmet needs of training on psychopathology. Methods An online survey was carried out during the period July–December 2013. Forty-one representatives of early career psychiatrists of their national associations were invited to participate. Each respondent was asked to provide the collective feedback of the association rather than that of any of its individual officer or member. Results Thirty-two associations returned the questionnaire out of the 41 contacted (response rate, 78 %). All respondents recognized psychopathology as a core component of training in psychiatry. According to respondents, the primary aims of psychopathology are (a) to assess psychiatric symptoms (47 %), (b) to understand patients’ abnormal experiences (33 %), and (c) to make nosographical diagnosis (20 %). A formal training course in psychopathology is available in 29 out of the 32 surveyed countries. In most countries, (a) there is not a defined number of hours dedicated to psychopathology, (b) teaching is mainly theoretical, and (c) a structured training on psychometric tools is missing. At the end of the training, about half of trainees is not satisfied with received training in psychopathology. Electronic supplementary material The online version of this article (doi:10.1007/s40596-015-0333-x) contains supplementary material, which is available to authorized users. * Andrea Fiorillo [email protected] 1
University of Naples SUN, Naples, Italy
2
G. d’Annunzio University, Chieti, Italy
3
D. Portales University, Santiago, Chile
Conclusions According to European early career psychiatrists, there is the need to rethink training in psychopathology, which should be at the heart of training in psychiatry and the key element of psychiatric practice. Education in psychopathology is affected by several unmet needs, such as lack of appropriate training in the use of psychometric instruments, lack of supervision, and lack of practical skills.
Keywords Professional development . Psychopathology . Career development . Medical education . Training More than one century after the seminal work of Karl Jaspers’ General Psychopathology, modern psychiatry is far from Jaspers’ emphasis on adequate concepts and methods for exploring the patient’s perspective [1]. Since the publication of diagnostic manuals, many psychiatrists confused operationalized criteria with handbooks of psychiatry and psychopathology and diagnostic criteria with the whole picture of the illnesses [2–4]. Consequently, a glossary of psychopathological knowledge, including in-depth descriptions of mental abnormal phenomena and syndromes [5], has simply been removed from psychiatric educational programs. Moreover, according to a recent review, the term “psychopathology” is now used in a trivial way, referring to the subject matter of psychiatry, instead of the discipline that studies the phenomena of mental disorders [6]. However, more recently, the importance for psychiatrists to have strong psychopathological bases has been repeatedly affirmed since psychopathology: (1) is the common language that allows psychiatrists to communicate each other, (2) represents the basis for diagnosis and classification of mental disorders, and (3) makes
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an indispensable contribution to understanding patients’ abnormal experiences [7]. Recently, the need to rediscover psychopathology has become even more cogent, following the changed target of psychiatry. In fact, when the target was “madness,” the alterations and deviations from the norm were quite obvious [8]. Today’s target of psychiatry is “mental health problems,” which are the result of different biological, social, and psychological forces, and whose psychopathological background is not always clear [9]. The risk is that psychiatry as a discipline may lose its own identity if a rigorous assessment of the patients’ subjectivity in psychiatric care is disregarded [10]. Recent changes have had an impact not only on clinical practice but also on the training in psychiatry. The need to go “back to fundamentals” was recently claimed by academicians [7, 11, 12], while trainees and early career psychiatrists consider “rediscovering psychopathology” as one of the top priorities for their own future and for that of their patients [13]. According to the “Charter on training of medical specialists in the EU: Requirements for the specialty of psychiatry” proposed by the European Union of Medical Specialists (UEMS) [14], educational programs during psychiatric residency should include a structured training (with lectures, seminars, etc.) on psychopathology and other disciplines, which represents the scientific bases of psychiatry. Many studies [15–19] and a recent review [20] on the application of the UEMS recommendations in the different European countries showed great variability, in particular as regards training in psychopathology. However, specific data on the current status of training and practice on psychopathology are not available. Taking into account these premises, we decided to carry out an online survey to assess the current status of training on psychopathology in Europe with the aim to identify the unmet needs of trainees and to suggest future challenges for psychiatrists.
by researchers and academicians who were experts in the field of education and psychopathology (AF and GS), which led to the final version of the questionnaire consisting of 29 items, subdivided in three sections: (a) knowledge of psychopathology, (b) training in psychopathology, and (c) unmet needs and future perspectives of training in psychopathology (Appendix 1). In the period July–September 2013, 41 European early career psychiatrists, representatives of their national associations, were invited to participate in an online survey through email invitation. According to the definition provided by the European Psychiatric Association [25] and the World Psychiatric Association [26], early career psychiatrists include trainees in psychiatry and specialists in psychiatry under 40 years of age and/or with less than 5 years of practice after specialty. Respondents were asked to consult other members of the association and to investigate with them the status of training in psychopathology in their own country. The final compiled questionnaire should have been approved by the members of the association and represents their official document. We asked to answer the sections “Knowledge of psychopathology” and “Unmet needs” after a careful discussion among the members of the association by e-mail exchange or at physical meetings. Answers were not weighted, but general trends were considered from the national representatives. Only one answer per country was accepted. Answers to the questions investigating the national standards (“Training in psychopathology”) were taken from national regulations/ laws on the organization of training in psychiatry. More than 1 month (or even more, if needed) was given before sending back the questionnaire. Items were analyzed by means and frequency counts as appropriate. All analyses were performed using the Statistical Package for Social Science software (SPSS), version 18.0 [27]. The Institutional Review Board (IRB) of the University of Naples SUN exempted the authors to obtain a formal IRB approval since this study does not involve human subjects.
Methods
Results
An ad hoc questionnaire was developed using the same methodology adopted for other surveys recently carried out by the early career psychiatrist networks of the World Psychiatric Association (WPA) and the European Psychiatric Association (EPA) [21–24]. In order to develop the questionnaire, several focus groups have been carried out within the EPA Early Career Psychiatrists Committee and the EPA section on Philosophy and Psychiatry. These focus groups took place twice during the EPA annual congresses in 2012 and 2013 and led to the development of the preliminary list of items. The content validity of this 34-item list was reviewed
Thirty-two countries (Azerbaijan, Albania, Austria, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, France, Germany, Italy, Latvia, Lithuania, Macedonia, Malta, Montenegro, Poland, Portugal, Romania, Russia, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, UK) returned the questionnaire, with a response rate of 78 %. Although psychopathology is the core part of psychiatric curricula according to 100 % of respondents, 12.5 % of them think that psychiatric practice can be done without a formal (theoretical and practical) training in psychopathology.
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Although European early career psychiatrists affirm that psychopathology is, and will continue to be, a core part of psychiatric curricula, and that more time should be devoted to psychopathology, 21 % of respondents believe that psychopathology “is not useful in clinical practice,” 25 % that it “is old-fashioned,” and 50 % that it “is not interesting for psychiatric practice.” Only 6 % of respondents declare to have “no time to dedicate to the study of psychopathology.” The most frequently adopted psychopathological approach is the clinical one (65 %; 21 countries), while the phenomenological approach is adopted in 22 % of the countries (n=7) and the descriptive approach in 18 % of countries (n=6). In two countries, this information is not available, while in one country, different approaches are adopted in the various regions. Of course, in some countries more than one approach is adopted (Table 1). Before starting residency in psychiatry, 75 % of respondents affirmed to have read general books on psychopathology and to know what psychopathology is. According to early career psychiatrists, the primary aims of psychopathology are to assess psychiatric symptoms (47 %), to understand abnormal experiences (33 %), and to make nosographical diagnosis (20 %). Karl Jaspers, Emil Kraepelin, and Kurt Schneider are listed as the most influential psychopathologists, followed by Eugene Bleuler, Sigmund Freud, and Philippe Pinel. The other psychopathologists mentioned by the respondents are Nancy Andreasen, Silvano Arieti, Arnaldo Ballerini, Simon BaronCohen, Bruno Callieri, Lorenzo Calvi, Victor Kandisky, Melanie Klein, Ernst Kretschmer, Jacques Lacan, and Michael Rutter. Table 1
Relevance of psychopathology for psychiatric clinical practice
Do you think psychopathology is (and should be) a core part of psychiatric curricula? Yes Do you think psychiatric practice could be done without a formal (theoretical and practical) training in psychopathology? Yes What is the main reason for you or your colleagues to not study psychopathology? Not interesting Old-fashioned Not useful in clinical practice Lack of time What is the most adopted psychopathological approach in your country?a Clinical approach Descriptive approach Phenomenological approach a
More than one answer was possible
Percent
(N)
100
(32)
12.5
(4)
50 25 19 6
(16) (8) (6) (2)
65 22 18
(21) (7) (6)
An official course in psychopathology is available during specialistic training in 29 out of the 32 surveyed countries (91 %) (Table 2) with no specification as regards the number of hours dedicated to education in psychopathology. Croatia, Estonia, and Austria do not include an official teaching in psychopathology in their specialistic curricula (Table 2). The most frequent teaching modalities are theoretical lessons (96 %). Discussion of clinical cases is routinely performed only in Azerbaijan, Poland, Russia, Serbia, Sweden, Switzerland, and UK (24 %). Workshops and role-plays are available in Germany, Lithuania, Serbia, and Sweden. Respondents from Albania and Macedonia did not provide this information. Respondents from ten countries (35 %) reported that an official training course on the use of psychopathological rating scales is available in their country, and respondents from 19 countries (73 %) reported to routinely use them in clinical practice, even without a formal training. The most frequently used ones include the Positive and Negative Syndrome Scale (PANSS), the Hamilton Depression Rating Scale (HAM-D), the MontgomeryAsberg Depression Rating Scale (MADRS), the Hamilton Anxiety Scale (HAM-A), the Brief Psychiatric Rating Scale (BPRS), the Structured Clinical Interview for DSM-IV Axis I Disordes (SCID-I), and the Young Mania Rating Scale (YMRS). At the end of residency, 48 % of respondents are not satisfied with the training they received in psychopathology. An expert in psychopathology, who takes the responsibility to supervise trainees on psychopathological methods, is available in 11 countries (Azerbaijan, Belgium, Germany, Macedonia, Montenegro, Poland, Romania, Russia, Serbia, Sweden, and Turkey; Table 2). The most important unmet needs identified by residents in psychiatry are time dedicated to supervision (90 %), time dedicated to study psychopathology (73 %), and opportunities to discuss patients’ psychopathological phenomena in clinical practice (57 %). Other unmet needs include lack of supervision, which is available only in 11 of the surveyed countries (35 %), and lack of training in the use of psychometric tools scales, which should become a compulsory part of residency courses for 100 % of respondents (Table 3).
Discussion To our knowledge, this is the first European survey on the current status of training in psychopathology at European level. In fact, we found no similar studies published in the last 20 years. The main findings of the survey are that: (1) psychopathology is recognized as a core part of psychiatric curricula, (2) the
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Characteristics of training in psychopathology Is an official training course in psychopathology available in your country?
Azerbaijan
x
Albania Austria Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia France Germany Italy Latvia Lithuania Macedonia Malta
x
x x x x x x x
Montenegro Poland Portugal Romania Russia Serbia Slovenia Spain Sweden Switzerland Turkey Ukraine United Kingdom
x x x x x x x x x x x x x
Have you been formally trained in the use of psychopathological rating scales?
x x x x
Do you use psychopathological rating scales in routine practice?
Is there an expert Are you satisfied psychiatrist who is with training in responsible for psychopathology? training in psychopathology?
x
x
x x
x x
x x x
x
x x
x x x
x x
x
x x
x x x
Are you confident in using psychopathological methods in clinical practice?
x x x
x x
x
x
x x x
x x
x
x x x
x x x
x x
x x
x x x
x x x x x x
x x x x x x x x x
level of satisfaction with the received training is not high, (3) psychometric tools are used too often without an appropriate training, and (4) several unmet needs are identified. Our results are in line with the need to rediscover psychopathology, which has been recently proposed by different international bodies [13, 28] and individuals [29–31]. There are at least five reasons why psychopathology is still the core part of training curricula in psychiatry, one of them being the need to provide psychiatrists with a method enabling them to capture the subtle nuances of the patients’ experience that constitute the essentials of the “psychiatric object” [32]. In this
x x x
x x
x x
x x x x
x x x x x x
respect, the section on Philosophy and Psychiatry of the European Psychiatric Association (EPA) is running since 2013 a highly successful annual educational course that brings together many early career psychiatrists from Europe [33, 34]. Further educational activities, including the organization of scientific events and the production of books and educational modules for young psychiatrists, should be envisaged [35]. Yet, about 50 % respondents also affirm that psychopathology is not useful in clinical practice. This datum seems to be in contradiction with the previous one. One way to interpret this inconsistency is that early career psychiatrists are critical
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Unmet needs of training in psychopathology
Training in the use of psychopathological rating scales Time free to dedicate to books and papers on psychopathology Availability of senior supervisors Discussion groups on psychopathology
Percent
(N)
100 73
(32) (22)
90 57
(27) (17)
More than one answer was possible
towards the education in psychopathology they received, rather than towards psychopathology itself. In fact, early career psychiatrists explicitly ask for an improvement of the quality of their educational opportunities [36], and a key issue we may argue is the need to couple theoretical psychopathological knowledge with practical clinical skills. In particular, more hours spent in clinical practice under the supervision of an expert in psychopathology (rather than ex cathedra theoretical lessons) could help fill this gap, reshaping teaching programs in psychopathology. Another possible explanation is that those who do not want to spend time with their patients are those who report that psychopathology is not useful in clinical practice, as it happens regarding psychotherapy [21]. Indeed, residents in psychiatry are not globally satisfied with training in psychopathology. In particular, the main problems include a scarce definition of training characteristics and the limited number of hours dedicated to this subject. Comparing our results with those from other surveys regarding the status of training in areas such as psychotherapy [21] and early prevention and intervention [22], we found a regrettably lower level of satisfaction with the training in psychopathology. This could be a consequence of the fact that current curricula are more oriented towards neuroscientific knowledge and technical skills [37, 38]. The dichotomizing debate about the very identity of psychiatry as a medical discipline, opposing supporters to psychiatry-as-a-biomedical science to backers of psychiatry-as-part-of-medical-humanities, does not help to find for psychopathology its proper place in psychiatric educational curricula [39]. In fact, psychopathology, being the science of human abnormal subjectivity, is a peculiar discipline characterized by an and-and agenda, meaning that it is based on two main complementary methodological approaches: explaining (searching for causes) and understanding (searching for meanings) [40]. Early career psychiatrists are probably aware of the different languages spoken in mental health research and practice and are telling us that the approach to mental disorders as provided in DSM-5 and ICD-10 is not useful to explore and make sense of the complexities of abnormal mental phenomena [41–45]. These results highlight the importance to enhance psychopathological knowledge and attitude for the
future generation of psychiatrists in order to regain a holistic view of the psychiatric patients [46–48]. A third important finding is the lack of an appropriate training in the use of psychopathological rating scales, although these instruments are routinely used in clinical practice by early career psychiatrists. It is likely that psychopathological rating scales are often confused with other psychometric tools, which are important for making reliable assessments, but do not explore the patients’ perspective, that is, their subjective experiences and personal meanings. The use of psychopathological rating scales is essential in psychiatric practice; the severity score on a scale should represent the translation of patient’s subjective symptoms into an objective statement [49]. Obviously, this deficiency will affect psychiatrists’ clinical and research work, not to mention their epistemological awareness of the limitations of the field of application and of the results obtained using rating scales. The fourth finding is the recognition of several unmet needs for the new generations of psychiatrists. Although psychopathology is recognized as the basis of the whole mental health practice [11, 12, 29], psychiatric educational programs have simply removed the magnificent thesaurus of psychopathological knowledge from training courses. In fact, from our survey, it emerged that key figures in XX Century psychopathology (e.g., Minkowski, Ey or Kretschmer) are only sporadically reported by European early career psychiatrists, who—on the contrary—list Emil Kraepelin (indeed a nosologist who provided a fine description of psychiatric syndromes, rather than a psychopathologist) and Sigmund Freud among the most influential psychopathologists, suggesting that they are not at all familiar with the core psychopathological European tradition [1]. This study has some limitations that need to be acknowledged. A first limitation was due to the fact that this was a purposely designed survey. However, the response rate was particularly high (78 %), compared to previous surveys carried out with the same methodology [21, 22], indicating that not only those interested in the field of psychopathology answered to the questionnaire. Moreover, this methodological choice will help comparisons with other surveys, with the aim to contribute to improve psychiatric education. Another limitation is that only one national representative of the ECP association in each country was invited to participate instead of all ECP members. This possible bias was overcome by inviting people to respond on behalf of their association and not on behalf of themselves, by consulting the other members of the association before providing their inputs. Moreover, this was the only way to obtain reliable data in a relatively short period of time, and reaching (almost) all early career psychiatrists in the different European countries would have been beyond the possibilities of a non-financed, voluntary study. In conclusion, European early career psychiatrists recognize that psychopathology is the core part of psychiatric
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curricula, but they report that received training is far from being satisfying. There is the need to give psychopathology the place it deserves in post-graduate psychiatric training, given its methodological rigor, the richness of its descriptions, and its contribution to make psychiatric diagnoses and to understand mental disorders. Implications for Educators • Early career psychiatrists explicitly ask for an improvement of the quality of their educational opportunities, reporting the need to couple theoretical psychopathological knowledge with practical clinical skills. In particular, more hours spent in clinical practice under the supervision of an expert in psychopathology, rather than only theoretical lessons could help fill this gap, reshaping teaching programs in psychopathology. • Although early career psychiatrists are not trained on the most frequently used psychometric tools, they tend to use them anyway in their routine practice. This deficiency will affect psychiatrists’ clinical and research work. • National and international bodies that are responsible for education in psychiatry should seriously reconsider the importance of psychopathology in training curricula, given its role in psychiatric diagnoses, understanding of mental disorders, and its capacity to rehumanize psychiatric practice.
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21. Disclosure The authors declare that they have no conflicts of interest concerning this article. 22.
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