Hello and welcome back to the Thought Broadcast, the trainee focused podcast from Australasian psychiatry. Today's episode will return to the topic of the psychotherapy written case, an important but often daunting part of the training programme. This time, our focus will be on the written case submission component of the task. We hope to cover some key advice about approaching the write-up for any registrars who may be looking to fire up their laptops and start typing. My name is Michael Waiteman, and I am on the editorial committee of Australasian Psychiatry. Joining me as host today are two of our regular voices. Firstly, we have Fiona Wilkes, one of our associate trainee editors. Welcome, Fiona.

Thanks, Michael. Really nice to be here.

No worries. And we also have Michael Tarran, who is another of our associate trainee editors. Welcome, Michael.

Hello. Thanks, Michael. Good to be here.

Great to have you both. And today we are fortunate to be joined by not one but two special guests. We are speaking with two of the co-authors of a really useful paper published last year in Australasian Psychiatry entitled A Guide to Support Trainees Success in the Psychotherapy Written Case Submission. I would like to welcome the first author of that paper, Corinne Northwood. Welcome to the show, Corinne.

Thanks so much for having me, guys.

Our pleasure. And our second guest is Stephen Parker, the senior author of the same paper. Welcome, Stephen.

Thank you very much for having me as well. A pleasure to be here.

Wonderful. And I wonder if we could start by hearing a little bit about each of yourselves, Stephen and Corinne, and also perhaps your own experience of the psychotherapy long case as a registrar or even supervisor as well. Perhaps you could start, Corinne.

Yeah, so I'm an early career psychiatrist. I just finished my fellowship training in the middle of this year, so about a month and a bit ago. At the moment, I'm doing combined clinical and academic work, including teaching and research. And I have a real interest in ongoing teaching work supporting trainees and medical students who get into psychiatry. My experience of doing the psychotherapy written case as a registrar was part of how I came to be involved in the preparation of the paper. So I really enjoyed the therapeutic part of the whole process. My patient and I, I felt that we were really simpatico. And while we had a lot of challenges in the therapeutic process, it was such a privilege to be part of her life for you know for a therapeutic period of time. But the write-up was a lot more daunting. And I did what I think a lot of trainees are encouraged to do, which is start seeing your patient early because that can be a lengthy process and you might have false starts, but then leave some time to mature before you do the write-up, which actually means to procrastinate. But I was very lucky in that I had a period of time when I was working in a research register role with Professor Parker and a couple of other people with the postgraduate training for Queensland. And Stephen came to me with this idea that we should try to develop a template write-up. And because that was something that you know I had an immediate need for, I leapt on that, and that was how I came to be part of this whole process.

Fantastic. Well, we're really glad you did the write-up and we'll look forward to talking about it a bit more in a moment.

Stephen, how about yourself? Thanks, Michael. So I'm Stephen Parker. Um I work up in Queensland as well. I'm the director of research at Metro North Mental Health and also work cleverly with the early psychosis service here. My psychotherapy written case, that was a very long time ago. As you asked that, I was remembering going to the post office the day before it was due and mailing a very, very large envelope with several paper printed copies of my case to the college, desperately hanging onto my registered post slip with the hope and expectation that it would arrive in time. So it is a distant memory for me, but I certainly have a lot of memories about the value that I took from that for my training overall, and the sense it gave me of I guess how to actually take a history, how to write up a history, how to do a formulation, and realising the limitations of the day-to-day clinical work that we do in terms of the amount of time that we get to spend with a person and the richness that comes through from actually having that time to talk to someone and really hear their story and help them in thinking about that and pulling it together.

Yeah, I'm sure a lot of people would would share those sentiments as well. I certainly found it a very valuable experience myself as well, and hopefully that the assessment side of the task doesn't take away from those learnings, and hopefully things like this will make it a bit more enjoyable for people doing it.

So, in terms of putting that article together, and Corinne did such a fantastic job of leading that, and I think her being in the midst of writing a case while doing it was a really helpful place to be in, in terms of trying to remember what it's actually like and what to do. From my point of view, I was uh what a director of training in Queensland at the time, myself and Jim C. Cutbush, the director of postgraduate training in Queensland, were just so keen to find a better way to help trainees to make this task less daunting. And I think one of the things that we'd seen as directors of training, I certainly had helped it helped many people with the psychotherapy case even before I was in that role, was that the same problems seemed to come up again and again. And the hope with that paper was that putting down a structure and putting down some ideas would help people to know how to start and hopefully to start early and to have that be something they move through in a way that makes sense rather than feeling frightened of it. I think the hard thing with a psychotherapy written case is it's daunting for anyone. Like lots of people say, Oh, I'm gonna leave that till I'm in year three because I want to know more. Where you are in your journey of psychiatry is going to be daunting because it is so alien to what you're doing. The hope was to have some guidance to help people to think about the big picture, think about why this exists as a college assessment, but also to know this is what I need to do to get through this.

I've got to say, it's been such a lovely paper, and it's a paper that the the main reason I was keen to come on this podcast and talk to you guys about it is because of how wonderful it is and how much I I'm kicking myself that I didn't read it when I was preparing my psychoserapy longos, which is in Korea, you're talking about giving yourself a bit of time to mature between doing the therapy and then doing the write-up. I had a baby in between doing the therapy and doing the write-up. So I did a lot of procrastinating. And then when I got to the write-up, it was kind of doing it with while trying to juggle, being back at work with a small child and getting it done within the time. And I definitely didn't have a proper structure of how do I do it. I just had a pile of other ones that are people that have passed and went, oh yeah, so I guess this is what we do, structure it. But it's this massively daunting task that I was trying to juggle, which was then the first, the entire thing in all of my training in psychiatry that I have failed. So I am now waiting with baited breath to hear about the rewrite to see what happens. But if I don't, then I will definitely be looking at your paper for guidance for my third time around.

Oh, I'm sorry to hear about the the struggles you've had with it. And I think that's definitely something that I was very conscious of as a registrar too, was that lots of fellow registrars that I really looked up to and really admired and said it was such a difficult thing and such a difficult process and had had to do resubmissions and things like that. So but I think it can smell your fear. You have to go in with confidence, you know.

I don't know, and and structure, I think, about uh having read the paper about how to do it. You know, I was very I was I was like, I have a value PhD. How did I fail?

And it's a real challenge because most trainees pass, like even though it's daunting and terrifying, but not being successful often says nothing at all about you as a trainee and your capability. Like a lot of it comes down to what is this task about? What are they wanting from you? And what are you needing to do to get it over the line? I think that there's a lot of misunderstanding and myths about that that make it a real challenge.

Oh yeah. Have you properly understood the question and what they're asking? Because it is so alien, as you say, it's a very different type of writing.

And one group of trainees I see who really struggle with it, particularly the people who've got a real interest in psychodynamic psychotherapy. You know, people who are doing all of this reading, they're getting into these big ideas, they're getting into this language, and they write a document that is a beautiful psychotherapy case, but may not align with what the college is wanting with this assessment. And fundamentally, this is the only written case history now in the training program that people need to do. This is the only opportunity that the college has to look at can you document a mental state? Can you document a formulation? Do you know what the aspects of the history are and how to order them correctly? So, so much of what people are being assessed on in psychotherapy written case has nothing to do with psychotherapy. It has to do with that ability to pull together in a standardized way the expectations of a formal report. And part of it, I think I think it's a bit like getting prepared for writing a report for the court when you're eventually asked to do that, and thinking about the level of detail and thought that goes into doing that.

I would agree. I think some of it as a trainee, you really want to focus on, oh, you know, I've done a really good job as a therapist, I've seen my patient for 40 sessions, we've had, you know, lots of discussions about childhood experiences, but that's not actually what the guide, when you read the marking criteria, that's not what the marking criteria want from you. And I think we tried to emphasize that in the guide that it's more about your ability to prioritize a massive amount of clinical information, 40 sessions worth of clinical information, synthesizing it through a psychodynamic lens or using those psychodynamic principles which underpin much of that longitudinal therapeutic work, and then present it in a structured, coherent narrative. And I think the other thing that they really want to assess is trainee self-reflection. Though I suspect what you give them in terms of self-reflection in the psychotherapy-written case is highly curated, but but I think that's part of what they want as well, is your ability to say this is what I did, and this is what I could have done differently, and this is how things might have been different. Would you agree, Steven?

I would agree. It sounds like my day-to-day practice. All the things that I wished I'd done differently, or I wished I'd known, or if I'd done this, maybe this would have happened. You know, so I think again, it's not about at all demonstrating what a good therapist you are or what fantastic outcomes you achieved. It's about the learning that you had through this process that helped you to think about the patient in the room with you, and helped you to think about what you may take from that and do differently, having learnt through that experience. Which is so different to what we're doing every day for most of us in our day-to-day clinical work, an outpatient clinic or an inpatient board.

I wonder given what we're talking about here, if if we could ask you about what is the role of the supervisor in the write-up phase versus what is the role of the trainee and how the trainee will get help from the supervisor in this process.

My recollection from the marking criteria was that the the role of the supervisor is really just to ensure that fidelity of the case to their period of supervising during the therapy process. My experience as a trainee, my psychotherapy supervisor was excellent during the therapeutic process, but I think they have a lot of competing pressures and don't have the time or necessarily the ability because they don't mark the psychotherapy written case. So they're not really in a position to critically appraise the writer. So I didn't get a lot of intensive feedback from my psychotherapy supervisor about the writer. I think the main benefit that I had from my psychotherapy supervisor was I exploited the hell out of them during the therapy process by asking many of the questions from the psychotherapy write-up, like what other therapies might we have considered, or if I had done this kind of therapy, what do you think might have been the challenges? And then use that later on to incorporate. That was my experience anyway, but uh you know, my psychotherapy supervisor was wonderful, and I really, really appreciated their role, but I didn't see it as being that much focused on the write-up part.

You spoke earlier about uh leaving that time between doing the sessions and and doing the write-up, which can be two very separate things, and referred to that as maybe more procrastinating than maturing. From your experience, when would you recommend would be a good time to start the write-up?

Uh yeah, in hindsight, definitely during obviously that beautiful honeymoon period when you're like, oh yes, I've ticked off my psychotherapy, but I haven't written up the case. That was delicious time. But I actually think that if I had done a bit more formal write-up of the first half of so the initial assessment, the initial formulation, the planning contemporaneously with the early therapy, it would have been so much easier for me later not to confuse later information or try to foreshadow later information. And I think the other thing it would have done is focus my therapy a little bit more, which, even though that's not the focus of the psychotherapy write up about the success of the therapy itself. I think if I had done it then, I think it would have probably influenced how I followed my patient through. And so that would be definitely my advice. In terms of after the sessions are done and the last reformulation, I do wish that I'd done that a lot closer to the time. Maybe not contemporaneously, but certainly I wish I hadn't waited as long as I did. I think it just would have made it easier for me to hold on to the vibe, I guess.

Two years later with the toddler, also not a good time to start.

And look, I I think Corrine's yeah, the experience Corrine that you describe of you know, not a lot of involvement with the write-up is not uncommon. When you look at the regulations for psychotherapy written case, the supervisor is committing to support that write-up, not just to confirm the content is accurate, but to actually support throughout that. But it becomes very hard, you know, where a supervisor may no longer be actively supervising you if you've moved on to somewhere else or to a different service, and that distance is there can make it really tricky. I agree with Corinne's hindsight reflection of starting early. And if I was a trainee, I would be using those WVAs with a psychotherapy written case. You know, those write-ups that you have to do at those three time points, they are logical time points. The first discussion is where I would hopefully have written down my history using those categories from a textbook in the order they're meant to be in, my mental state as comprehensive as I can, my formulation, not perfect, but having it written and getting feedback on that. Similarly, at that midpoint, you know, having actually thought, where are we going? What's the story? What's the narrative of this therapy? What are the big events? And writing that down, and also writing the feedback I'm getting in that discussion as well, and as we move towards termination for that final discussion with the supervisor that has to be signed off, maybe even writing for that your reformulation, your ideas about that, your thoughts about termination. Because at that point, then by the time you've finished, you've already got a draft that's written, and you've already got a draft that your supervisor has been looking at and helping you with, and you will have had the chance to adapt that as you're working through it as well. It does get so hard as time goes on, and I think it gets harder and harder the longer it goes beyond the case, particularly with the reformulation, which is a real challenge because if you're spending all your time, as you're writing writing an amazing initial formulation, but that's all informed by all the stuff that's happened, the knowledge you've got, how do you then create something that shows your learning? It's very hard to disentangle many months or years after the fact.

Corinne, I think you're right as well, with that. If I'd done the intro stuff at the time, it would have given me a clearer picture in my head of who she was and where we were going. But I certainly felt at times like I was only really understanding what we'd done two years later when I was doing the write-up.

Yeah. Yeah. That's definitely a very sobering reflection that I had as well. That was, you know, oh gosh, if only I had known at the beginning what I know at the end, isn't that always the case though?

You list a number of quite useful resources in the article. Where should a trainee try to begin when they decide to commence the write-up?

That might be a question for Stephen overall. But for me, the Nancy McWilliams psychodynamic formulation textbook is beautiful. I borrowed it from the library and then I bought a copy, and I still really, really like it. And then I actually read quite a bit of work by Jonathan Shedler about any particular psychodynamic model, but just about psychotherapy in general. And I found those to be really inspiring and really helpful and just encouraging me to think about my patients in a different way. So those are the two main resources that I really used.

And look, I think there's nothing that you must read or you have to read, but I think that this piece of assessment and this clinical task becomes incredibly difficult if you're not reading. So yeah, you need to open a textbook that tells you what a comprehensive assessment looks like. What are the headings you need to do? Hopefully you've done that before you've seen the patient. You want to have read something that tells you about assessment for psychotherapy, you know, and suitability before you've gone to the room to do that so you know what you're looking for. Also, whatever model of therapy you're using, you need to have a basic textbook or a set of articles that you have read. Otherwise, it becomes so hard to try and pull it together. And certainly, I don't think you know anyone would go and do an appendisectomy without reading an anatomy textbook beforehand and going through that process. So these are the things that will really help you to feel less frightened and to feel more confident that you're doing it correctly. I agree. The Nancy McFilliam psychedelic case formulation book, it takes a Saturday morning to read and it's really nice and very light and gentle, and it is so helpful in thinking about what are the anchors for formulation that come out of your comprehensive assessment and what are the things you want to make sure you've asked about. I'd also get one of your textbooks for your mental state examination, and following that, there's a couple that the college recommends. Again, whatever you're doing, having one and using the order that are set out in that textbook and being comprehensive as you move through that. And similarly, you need to either have your DSM5 or your ICD and be looking at that as you do your diagnostic formulation, as you do your justification and using those words. You also need to be looking at that as you're writing your assessment to think, have I got the content in here that I mean? You know what? If you don't have the content, that's fine. You just say, these are the gaps, these are the things I missed, these are things that would have been helpful to know.

Yeah. I would say the other main resource that I use was the marking criteria. Which you'd be surprised. People don't look at them, but that's the thing that you're going to be assessed against.

So I didn't look at it. And yeah, in hindsight, that was so dumb. I should have looked at the button.

If you look at Corinne's article, I think the headings basically come off the marking criteria directly. And that's always been my strategy with any academic task is grab the marking criteria, use the headings, and make sure you address each one of the points that's there.

It sounds like that's uh that could be a common pitfall for trainees doing the psychotherapy case and case write-up. Are there any other really common errors or pitfalls that trainees should be aware of?

Oh there are many, many, many, many, Michael. But I think that I've done a lot of work with people who have been unsuccessful. And often the errors are when people have omitted key content because they're trying to make their case seem less complicated. And the hard thing is, most markers will have probably been seeing patients for 15, 20, maybe 30 years. They have these patterns in their mind. And I can read someone's case and I think, hold on, what about that first marriage? Where's that? Or this person had siblings, didn't they? Or someone's died. Like for some reason, if you spend enough time in people's stories, you this stuff comes intuitively. So hiding important things is always going to make it very hard for that case to hang together. Similarly, trying to look clever, trying to look like you really knew what you were doing, and went to a great therapist, is inevitably going to backfire because probably your markers are going to be a little bit more experienced than you are as well. But also often your markers aren't going to be a psychoanalyst, they're going to be a psychiatrist who has an interest. And you want to make sure that this case is a good psychiatric case, not just a good case report for a psychodynamic psychotherapy. I think the other thing that I would always try and do is in some way, I'm sure that you and your patient end up being likable by the time the case has been finished. You know, because it will come across very clearly if that negative counter-transference was incredibly strong and it will make it really hard for them. I can't take marks away from you, but geez, it makes it a much more difficult case to read.

Thanks, Stephen. Yes, always a good policy to get the marker to think positively of you. This has been a really interesting conversation, and we'd love to pick your brains a bit further, but we may need to take a pause here in the interest of time. We will continue the second part of this discussion on the psychotherapy case write-up in a separate episode. To both our guests, Corinne and Stephen. Thank you for joining us and providing us some really useful advice on the write-up. We'd also like to thank and acknowledge Mr. Kuma from the College, who gives us so much support in producing and editing the show. We are also thankful to Australasian Psychiatry for the opportunity to make these podcasts, as well as Sadhmy Prentice for our artwork and Shady Dave for our music. Thank you also to our listeners. Please subscribe to the Thought Broadcast and rate the podcast. That's all for now. We hope you will join us next time for part two of our discussion on the psychotherapy with the case report.