Hello and welcome back to the Thought Broadcast, the trainee-focused podcast from Australasian Psychiatry. This episode is the second and final part of a discussion on the Psychotherapy Written Case Report. My name is Michael Waitman, and together with my colleagues from Australasian Psychiatry Fiona Wilkes and Michael Tarran, we have been talking to Corinne Northwood and Stephen Parker. Corrine and Stephen are two authors of a really useful guide on how to approach the psychotherapy written case report. If you haven't listened to the first part of this episode, we discuss some general advice for approaching the write-up. This second part of the episode will now focus in more detail on each of the sections typically seen in the report. I will hand over to Fiona to kick us off.

From my perspective, I think the introduction should read as a very nice summary synthesis of the case situation for your patient and give the reader that quick overview of where we're at and and why we're starting here. I think it can be a nice place to add a little bit of that the humanness of your patient because often, as Stephen was saying before, our clinical work is very much a 55-year-old man presenting with suicidal ideation in the context of alcohol misuse, you know, and there's not a lot of it's just quite perfunctory in a way. And I think having a nice summary statement that gives a little bit more of the flavour of the person without being too over the top is a really nice way to start.

Yeah, and look, I've got my own stylistic thoughts about this, and some people disagree, you know, but I I kind of think taking that four sentences at the very start of your document to orient your reader to what is it that you're doing here? And it's not just presenting the case of a patient. What you're actually doing is documenting your experience as a trainee psychiatrist undertaking psychonoic psychotherapy for the first time and the learning you had through that. So for me, that introductory paragraph is kind of flagging this is what this report's about. It's about a patient, but it's also about me within that therapy dyad and what I've learned to my reflections on that as well. And I think it's a useful way to make sure your reader knows what you're doing because you're not just describing a case, you're doing something quite different to that. Um, but also to help keep in your own mind why am I doing this? What is this about? Which isn't about writing up great therapy or showing how good a therapist you'd be.

So, really setting the scene and giving a picture of the patient and a little bit of yourself and that diad, as you say.

I remember Stephen and I having this discussion when I was writing up my case that I didn't do that latter part, including the sort of summary of the purpose of the report, but I know that that's something that that could be very useful.

You're right. I do get the feeling that different people have different opinions on that bit, don't they? About how much do you talk about yourself early on, although of course later on that's such a big part of it, curated fashion. Talking about the assessment section, how does that differ to an assessment that we might do in other settings for a trainee if we're doing like you know, a normal assessment of someone in the clinic? How is the assessment section in the write-up different?

Yeah. I think the difference is that the content in the assessment section focuses on a number of things that while they may be touched on in a normal comprehensive psychiatric assessment, you sort of going into a lot more detail on early life events, family of origin, key stages in psychological development, on defense mechanisms. So some of it is on the things that the patient has shared, but again, things that the that the reviewer, the uh trainee has identified. So it's a focus on all of these things rather than just on symptoms. So you're not just talking about their depressive symptoms or their neurovegetative symptoms or their their things like that. You're thinking about ego strength, thinking about defenses, and I think that that's what makes it quite different to an otherwise full psychiatric assessment. And the other thing I think is that the psychiatric assessment can often be really focused on reaching some kind of diagnosis, and I didn't see the assessment part of the psychotherapy written case necessarily about diagnosis, but more about understanding the person and their situation. That was how I approached it.

Yeah, and I agree, Corinne, that we're qualified. I mean, I think the headings are the same, it is at its core a comprehensive psychiatric assessment. The headings are exactly what you would expect to see in that if that's done appropriately. It's the level of detail and comprehensiveness that makes it different. And one of the challenges for a trainee is you get so much detail. If you've done an assessment over four hours, yeah, you've got all of this stuff. How do you work out what's in and what's out? So certainly you need something under each heading, and you need to have the important things there and visible so there is a degree of prioritization. It's not everything because then you will have written 10,000 words for your assessment and have nothing left for the actual report. But you do need to make sure that the things that are going to be your anchors for formulation come across in that assessment very clearly. And I also agree with Karim, like it's not about getting to the right diagnosis, but you know what, you have to have enough in there to justify a diagnostic formulation because the work we do it should be about understanding the person we're working with, not just putting a label on that correctly, but you do need to be able to take a history and demonstrate a mental state exam that is sufficient to support whatever provisional diagnosis you have and the differentials that are there. And also remembering the diagnostic frameworks, whether that's TSM or ICD, have you got all that stuff in there as well to make those decisions? And we don't always do that, but it's such a helpful thing to do once a week to pull out DSM and just look at are the criteria here or not. But for this case, yes, you must be making sure that you have within the assessment the content that's needed to inform that diagnosis, but also the content that makes sense in terms of the formulation.

One way that I would maybe break down that is you know, if you're thinking in the assessment section, family history, and there's a family history of, say, an uncle who died by suicide. I think in a normal psychiatric assessment, you might just say uncle had passed away by suicide at this age. But for the psychotherapy-written case, you would want more of a reflection from the patient. You know, how did they feel about that event? Were they angry and distressed that they'd lost their favourite uncle, or were they in a position where they were saying, Oh, but he was in a lot of pain psychically? So I understand, you know, you can see how when you're doing a psychotherapy case, having more of that reflection from the person about the meaning of events in their life is more important than just documenting all of these things happened at this age at this time.

Because that all then feeds into the initial formulation anyway, doesn't it? Exactly. How did that affect them and and what does it mean? So, how what do we put in the initial formulation? What goes into that?

I think initially very little psychodynamic theory, or only in very broad strokes. So you want a a wide range of ideology about the patient, about their emotional and psychological development. So everything that you might think of, Eric Sononian stages, you know, maybe a little bit of a dash of this and a sprinkle of that. And that's my perception, anyway. You want to try to make that initial formulation to sort of say, here's the information that I have about the patient, and without adhering to any specific ideology, here's some different ways of thinking about this person and what's going on with them. Because that gives you the opportunity at the end to narrow your formulation to the therapeutic modality that you chose. That's my suggestions, anyway. I mean, it makes sense, doesn't it? That's it.

And I got told similar, like, don't mention any terms for the first one, just be but you still want an understanding of them, just don't get sidetracked as I did later by various other things. Like, what's your understanding of the patient at the time? What about the management plan then? What should we be including and how is that different from a normal management plan and an admission note or something for a patient?

The management plan should include a little bit about you know, suitability, feasibility, accessibility, because you're talking about an intensive program of therapy. So that has to be part of your management plan. You know, how feasible is it for this patient in terms of their risks, for example, that they're going to be able to come to these sessions? How suitable are they? You know, that kind of thing has to be considered. The other thing that I think is a bit different is obviously a little bit more of a focus on the psychological aspect of it being it's a psychotherapy case, but don't forget your biological and your social aspect. But in the psychological, think about things like managing transference for a patient or managing risks at termination for a patient that are psychodynamic risks, because that shows the assessor that when you're considering your management, you're approaching it as a psychodynamic management, not just I'm gonna get 40 sessions out of this person and then send them back to their GP.

And look, I I agree with everything Corinne said, like it really is a comprehensive bio, psychosocial, cultural formulation. And the management should also be biological, psychological, social, and cultural in the elements that are considered. I think that it's not necessary to have a whole pile of psychodelic terminology sitting in that formulation, but you know what, you should have enough sitting there in terms of ideas that when you go to write your justification of psychodelic psychotherapy, and hopefully the justification of the particular model of psychotherapy that you're going to apply for the person you're working with, that there are the things that you can draw from the formulation that you can then link to that therapy, you know, the focus of that therapy and the elements that are there. So definitely having it sit together and come together as well. Also, not forgetting that psychodynamic psychotherapy may not be the first-line treatment for whatever condition the person's presenting with. So having a justification for that, which doesn't have to be hard, but thinking about the person in front of you, thinking about the evidence, why is this what you're proposing? And why is that something that may be preferable to another mode of psychotherapy or pharmacological therapy option? But I think it's really worthwhile to do because this is the things that hopefully we learn to think about intuitively, and we should be able to verbalize, yeah, why do we do what we're doing? Why this rather than that? You know, and kind of having that defensible approach to our practice and using the evidence, and remembering the evidence isn't just the research studies, the evidence is clinical experience, the evidence is listening to patients and their preferences as well.

In the clinical progress write-up, do you have advice about how on earth you we can condense 40 or more sessions into quite a small bit of word count?

See, this is why I think that some of that contemporaneous writing is useful and some of it is not. I think if you're trying to write your 40 session progress section while you're seeing your patient for 40 sessions, you're gonna get really swept up in a whole lot of little things. But look, you have to be judicious. I suspect that a lot of what happens is trying to be very concrete about a clear process of dealing with one issue or one, you know, having a narrative thread that makes a lot of sense and goes from beginning to end. I'm not saying that that's not what happens in therapy, but we all I think can acknowledge there are lots of little bylines. And I don't think there's anything wrong with including a little bit of, you know, side quest, as long as later on you're going to use that in your reformulation. And I think that's the big ticket for how to decide what goes in there is the reformulation is to build on the initial formulation while it now including the therapeutic model you've chosen and the information you gathered during those 40 sessions that influenced why you're reformulating this patient. Oh, I observed, I got this new information about their childhood. I observed these defenses in action. They struggled with this part of the therapeutic process. That's why I'm reformulating, and that's what you're going to put in your clinical progress section to get you to the reformulation at the end.

I really love Corinne your focus on the those significant events or you know, revelations, or for me, if I had to do this as a trainee, I'd do the same thing I do when I do a formulation. I'd grab a piece of A3 paper, I would draw a dot, and then a line across it, and then I would think about those 40 sessions and think, what are the big things that have happened in this journey? What are the things that you know surprised me that I didn't expect? What are the things that made me feel uncomfortable as a trainee therapist? What are the things that I learnt that I didn't know that I wished I'd known earlier on? And mapping those events again as the anchors for the narrative you bring, because they will be the events that hopefully will help you in your reformulation to demonstrate how you've understood this person better. But it will also help in that prioritization, you know, because if you wrote 40 sessions, you could be writing forever. And that prioritization really comes down to the narrative. And I think this is one thing where yes, you can write a lot of the progress stuff as you're going and session notes and things like that, but sitting back afterwards, after the fact, taking a bit of time to take in a whole will help you get that picture. And knowing that you may need to do it a couple of times to get it right and to work out what's really there in terms of building a narrative that makes sense. I think the other thing is you want your reader to stay awake and not fall asleep. So if you can have it as something that is living, you know, that brings the patient to life, that brings you as a training therapist to life, your marker's probably going to be much more sympathetic as they go through this to if it's this kind of perfunctory, this happened, then that happened, and then I did this intervention, then this happened, you know, because you've got to weave that narrative.

I definitely did too much of that in in my first one, and looking back at it, it's like, oh no, this is there was far too much of that. I did this, and then and my then when I had someone else look at it up, it was like, no, no. Do you need to show them, not tell them, you know, and pull it back, pull it back.

Yeah, and I think for me, the easiest anchors would always be, when did I get it wrong? When did it just go really badly? And what was going on? How did they react? What did I do? What did I learn from that? Yeah, because those disjunctions are often those most powerful aspects of that therapy journey, anyway.

Yeah, that's true, isn't it? It's that the rupture repair, the conflict is part of what makes therapy so effective and so challenging.

So, how do you then pull it all into the reformulation?

So I I definitely think what you want to add in is you know some of your your academic reading or clinical reading around the psychotherapeutic model you used. But also you've got to get that information that you gathered during the session. So your reformulation is an opportunity for you to demonstrate that you didn't just write the patient off at the beginning of the whole process and say, Well, this is who they are. You understood more about them through providing their therapy, and then make sure to give some examples of that. You know, why did the patient, as Stephen was saying, have this big thing that went so wrong? How does that make you reformulate their initial presentation? How does that make you think about their ego strength and things like that? So starting to pull that to show the examiner that you you learned something about the patient from the sessions, and that's helped you to see the patient in a different light.

I also think it helps to do the reformulation close to when you're actually finishing the therapy, you know, and definitely don't try and do the reformulation before you've done your initial formulation properly, because that will make it almost impossible. But as Corinne pointed out, like it's thinking about how has that therapy enriched your understanding of this person? What are the insights that you've developed through this 40 hours of sitting together, or more than 40 hours? What did you learn? And often that is the revelations, the things that someone tells you. Often is things emerge and things start to make a lot more sense. Often you realize a whole pile of strength and resilience that a person had that you know wasn't apparent at the beginning. So it's kind of thinking about how that therapy's helped you to understand this person better, and potentially also how that therapy has impacted this person as well. But I think you are part of that in the reformulation as a therapist, because it is a psychodynamic case. And I know I say I said the write-up's not a psychodynamic case, but the reformulation is about how did that psychodynamic psychotherapy enhance your understanding? And people have different stylistic things. I wouldn't be directly referencing psychodynamic literature, but yes, I would be using concepts and terms there, provided that they align with the named model of therapy that that I've said that I'm doing.

That's the trick, isn't it? So we then go on to the discussion, because the reformulation leads into that a bit, but also there are other things that we add. So what do we add and how would you structure it?

I like to see the discussion as the point where the where you, as the trainee, get to do some self-reflection of how the process may have changed you and changed your approach to this kind of patient or to therapy in general. And I think the thing that can be very important in the discussion is to be a bit critical of yourself and to identify the things that you would do differently next time. I suspect that sometimes we feel very vulnerable about saying, oh, I stuffed up, and my patient and I actually had a bit of difficulty connecting, or the termination didn't go well, and the patient abruptly discontinued her sessions, or or something along those lines. But that's a real opportunity for you to share with the reviewer that you have reflected on on your part in the process, because as Stephen was saying, there are two people, it's a dance, and so your reformulation talks about the patient and the discussion talks about you, and to say, I struggled with termination with this patient. What does that say about me? I found challenging my patient in order to stimulate change was really hard because I was so worried that they would stop coming and I was at session 32. You know, things like that, maybe phrase that slightly differently, but you know, things like that I think are what the discussion section is for to show your ability to reflect and talk about how you might do things differently in the future in your general practice or your psychotherapy practice.

Yeah, I I agree, and I think you've got the third person in this therapy as well, which is your supervisor. And a key part of that discussion is your ability to critically reflect and looking at the marking criteria, you know, this is something the colleagues want you to be able to do, to think critically. So think about the therapy. Was this the right therapy for this patient? If you deviated from the framework of the mode of therapy you'd intend to do, why did you do that? Why was that okay? What does that say about that therapy? Was there another therapy that you thought might have been more relevant to them in retrospect than what you chose to do? In terms of the supervisor, what worked, what didn't work, what happened? There might be service issues, you know. So I can remember seeing my psychotherapy patient having to apologize that my mobile phone was on because there was no one at the couple of the emergency department. And that stuff there may come into that as well. Maybe all. Also terminating at 40 sessions when you felt the work wasn't done. Very rarely will the work be done, but why did you that have to happen? May have happened because your service commits to support people for 40 sessions. May have happened because you needed to change your service for your training reasons. So thinking about those practical aspects as well and what that might mean, what that was like for you, what that might have been like for the patient as well. So I think there's so much that you can fit into that, but the key is to be honest, not to say psychonomic psychotherapy is so wonderful, I'm going to be an analyst and it's going to be great. This is my future. Because that's just going to come across as contrived and disingenuous. Like for most people, it's a really challenging exercise. And there are things that you learn about yourself, there are things that you learn about psychiatry, and hopefully things that will impact your practice regardless of where you go.

This is relating to the discussion. Would you also bring in potentially false starts? Because one of the biggest reflections I had on doing the 40 sessions was the difficulty in finding someone who I would get along with for 40 sessions who I felt I could develop that kind of relationship with. Is that something that you would bring into the discussion?

I don't know that I would bring in any of my previous experience into the case. I think that might muddy the waters a little bit. What would you advise, Stephen?

I probably wouldn't bring that in beyond acknowledging my own anxiety about the case and my own anxiety about holding the patient in the case. So it may be relevant to say, you know, that one of the things that you were conscious of was how anxious you were for the patient to stay in the therapy and what that meant and how that may have impacted your approach, your willingness to undertake interventions within therapy. I can remember when I did my psychotherapy case, I think I said nothing for 20 weeks. Like I was just too frightened to say anything. I just sat back. I wrote in my case about that, about how you know I felt so anxious about what if I got it wrong? And um, you know, the work that I did with my supervisor to build my confidence around it being okay to get it wrong.

With the write up with talking about supervision and the other one of the marking criteria of consultation liaison communication, sorry, where do you personally put that?

Is that their own little separate sections at the end and what do you put in, or is it I would include them as separate sections, but I agree with Stephen that some of the supervision stuff may come into your discussion, but there's certainly a dedicated heading that you can discuss supervision and your experiences, positive and negative. If you had group supervision, you can talk about what it was like hearing other people share the stories of their cases and whether that influenced how you approach your patient, or whether you crime and supervision made you feel less anxious with the patient, or as Stephen said, challenging the patient more as a result of feeling contained by your supervisor. And then for consultation liaison, I think that that some of that may not be super relevant depending on your patient's circumstances, but always, you know, GP handover or what happens when your patient finishes therapy, that's part of your communication and liaison. If you had to talk to their family because you were concerned about an acute deterioration or anything like that, so that's where you would handle those things. And I think separate headings are appropriate for those topics.

But I think your supervisor also needs to be alive in your case progress. Again, they are a part of this. They are a part of UK's progress. So, you know, it or what it never goes well if they don't appear at all in that. But agree, there should be a separate section, and there are many ways to do it.

Thank you. I mean, there's a whole lot more that we could certainly talk about, but unfortunately we're just about out of time. So I'd like to take this opportunity to both our guests, Corinne and Stephen. Thank you so much for joining us and giving us your thoughts and wisdom on this really important training topic, and certainly echo what Fiona said at the start. If had an opportunity to read the guide when I was doing my case support, that would have made life um so much easier.

I think Stephen and I are both really glad to hear that people find it useful. And that was certainly what we wanted out of it was to provide a little bit of support for something that's very daunting. So thank you for that feedback.

That's really thank you for having us today. No, that that's our pleasure. And and thank you to Fiona and Michael as well for joining me as host today.

Yeah, thanks everyone. It's been lovely chatting.

Thank you. I'll uh I'll be listening to this podcast and reading that article again and again as I write my uh my psychotherapy case. So thank you.

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 Sidoni Prentice for our artwork and Shady Dave for our music. We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors. We always love getting feedback or suggestions for further episodes, including any volunteers who might be interested in being a guest. Please get in touch by email at the thoughtbroadcast.org. That's all for now. My name is Michael Waiteman. Thanks for listening. We'll catch you next time.