(Edward Boyne spoke with Bill Shannon following his participation in the ‘Exploration Through Dialogue’ panel at the IAHIP conference held in the Royal Marine Hotel on 18 October 2013.)
Ed: I wonder if you enjoyed the recent IAHIP conference? It was quite a landmark and ambitious event and it was the second time that IAHIP had organised such a conference.
Bill: I enjoyed the conference very much and was delighted to have been invited. After the panel session to which I contributed, I managed to attend some of the workshops which were very interesting and worthwhile.
Ed: You are originally from County Clare and worked for a long time as a GP in Cork starting in 1969.
Bill: Yes, following graduation from UCC Medical School in 1965 I set about training to become a GP by completing three years in hospital posts prior to spending a final fourth year as a GP registrar at the University of Edinburgh.
Ed: And you have just completed your term of office as President of the Irish College of General Practitioners (ICGP). You were the first Professor of General Practice in Ireland at the Royal College of Surgeons in 1987. In 2008 you were appointed Foundation Director of Education in the new Graduate entry Medical School at the University of Limerick. From the beginning of your career I understand you have advocated non-drug approaches to psychological issues at primary care level. In many ways you were far ahead of your time in Ireland!
Bill: The role of psychotherapy in primary care has been an interest of mine for many years. It was obvious to me as a medical practitioner for almost 40 years that other approaches and skills were needed apart from, or in conjunction with, the orthodox medical model as early in my practice I realised emotionally distressed patients need and deserve more than a prescription for medication. Unfortunately, many GPs don’t have the necessary skills or resources in terms of time to deal properly with complex mental health issues. I have known several cases where psychotherapeutic intervention has made all the difference and enormously improved the quality of life of patients. One story emerged in my own practice when a lady, recently engaged to a caring loving man, disclosed to me how terrified she was about any pending sexual intimacy. This was as a result of her history of being sexually abused as a child. I referred her to a psychotherapist and she gradually overcame her fear and proceeded with the marriage.
Ed: I know when you were in charge of General Practice training in the Royal College of Surgeons in the late 1980s you had the opportunity to appoint a new Director of the General Practice Training Course. GP education is vital if we are to see change. Equally important in this are the backgrounds and attitudes of those who are the GP trainers. You chose a psychotherapist and not a doctor for the post. This was unprecedented in Ireland before or since. Did you get into hot water for that decision?
Bill: Initially yes, because up to that time all Course Directors of GP training were themselves fully qualified GPs and members of the Irish or Royal College of General Practitioners. One interesting fall-out from that decision came about a year later when that particular psychotherapist was invited to resource several workshops for his fellow GP trainers from other universities. They wanted to learn more about the world of psychotherapy and how it might help to expand their own consulting skills with their patients!
Ed: At a certain point you decided to undertake training for yourself in psychotherapy. What made you take that path and how was it for you as an experience?
Bill: In 1985 I was introduced to a German psychotherapist, Maria Huss, who was then practising in Cork. I invited her to run some introductory sessions on psychotherapy for my GP trainees and was so impressed by her approach that I signed up myself for her training course. I believe I was the only GP to do so but I greatly enjoyed the experience and tried my best to incorporate any ‘lessons’ learned into my medical practice. It certainly helped to make me a better observer and listener in the process of consultation.
Ed: That brings me on to ask you about the whole area of psychotherapy training in Ireland currently. You have recently been appointed as Chair of the Tivoli Institute Academic Council. As a senior member of the medical profession and as a medical educator what are your views about psychotherapy training today?
Bill: I’m new to the field to some extent but there can be an advantage in that I can bring a fresh perspective and honesty. I think one of the key issues for the psychotherapy profession is the question of standards and accreditation of training. The standards need to be high enough and be seen to be high enough in order to command the respect of other professions including my own, the respect of the Government, and especially certain influential senior civil servants, etc. And it’s not just about training courses or training colleges. Every practitioner is affected if training standards are such that they let the profession down in the public eye. It could also affect referrals and the business side of psychotherapy practice on every level. The perception of training is important.
Ed: Do you see parallels with your own area of training in medicine?
Bill: I do certainly. For example, all medical school graduates must spend a minimum of four years in a post-graduate training scheme before being eligible for registration on the GP specialist register of the Medical Council. I see no reason not to expect psychotherapy trainees to spend a similar length of time in post-graduate training before being eligible for registration as a fully-fledged psychotherapist.
It’s obvious to me that there is a major problem for the psychotherapy profession in this area of training standards. This is due to the variability of standards and the confusion surrounding that.
Ed: Do you mean that the profession’s training standards are too low and are seen to be too low?
Bill: That’s exactly how I see it and I’m not alone. It’s important to state at the outset that the Irish Council for Psychotherapy’s (ICP) standards are quite acceptable, at least for now and the foreseeable future. I know that the ICP includes IAHIP as an organisation that upholds the highest standards. There is also a strong connection with the European Association for Psychotherapy.
I note that the ICP requires that only graduates or their equivalent can enter psychotherapy training. That is very important and it ensures inter alia that only entrants in their mid-20s start training. I understand that there is a requirement by ICP for a four-year programme of specialised post-graduate training. That is also very important, as is the strong emphasis on personal development and personal process. The recently published QQI (Quality and Qualifications Ireland) standards, which I know you were involved in drafting, state that training should take place at Master’s level.
Ed: Do you think these standards are well-enough known in the wider community?
Bill: The ICP does not appear to publicise its standards strongly enough. In the absence of having such standards widely circulated in the public domain and regarded as the norm, it is no surprise that other health care professionals are sometimes confused when trying to select a therapist for one of their patients or clients.
Ed: In relation to what you say around confusion, alongside the ICP, as you know there are other professional bodies. For example, a larger organisation, the IACP (Irish Association for Counselling and Psychotherapy), now also lays claim to speak for psychotherapy. Training standards there are certainly different. There is no requirement for graduate entry to courses. There are training courses recognised by this organisation which are allowed to accept and do accept school- leavers; eighteen-year olds training to become psychotherapists.
Bill: That is not ideal.
Ed: The IACP once had a long-standing rule which precluded those below 23 years of age from entering recognised psychotherapy training courses, but that rule has recently been dropped. The length of recognised training can be two years which is obviously problematic. There is hardly any personal therapy requirement. The IACP has done some very valuable work over many years. Maybe its standards need updating to remove the confusion you speak of. What would be your advice?
Bill: Well as you know, several Irish Medical Schools have set up four- year graduate entry courses. The ages of students at entry ranges from 23 to 39 which means that many of our students enter medical school with a broad range of life experience in addition to their primary degree. I am convinced this is already producing better and more rounded doctors. On this basis I would urge the leaders of the psychotherapy profession to study this model rather than expecting much younger people, including school-leavers, to be ready for a demanding career as a psychotherapist at the age of 19, 20 or 21 years.
Ed: It’s clear you fear that poor or uneven standards can bring the entire profession into disrepute. Is it not the case that the psychotherapy profession has, from the beginning, not had a great reputation among other professions?
Bill: That is probably so, but all the more reason to show concern for a consistently high standard now and to publicise that standard well and properly. The general public need guidance. Other related professions such as medicine are entitled to be challenging and critical. The high standard is already there in regard to ICP and is in operation. It needs to be asserted regularly and clearly.
There are some excellent practitioners and some excellent trainings which operate to a high level. My point is they deserve better support and a proper context in which to operate. At the moment what we have is confusion and a mixed message to say the least.
Ed: How pressing is this in terms of current political and other policy developments in Ireland?
Bill: At the end of the day the failure of the psychotherapy profession to establish itself would mean that the patient or potential client is poorly served. It would result in fewer properly qualified psychotherapists on the ground where they are needed most, in primary care and analogous settings.
We may well see a version of Universal Health Insurance in this country before long. It is already Government policy. Tivoli hosted a seminar on the subject in November 2012 to which I contributed. The psychotherapy profession must establish itself enough to be taken seriously in relation to this new system of payment for medical and psychological services. Training standards are going to be crucial in this respect, in terms of being taken seriously and in terms of ceasing to be a kind of ‘Cinderella’ profession. It comes down to vision and leadership and time is short, but it can be done.
Ed: Thank you Bill for those inspiring and challenging comments.
Edward Boyne is Director of Training at the Tivoli Institute and is secretary of the IAHIP accreditation committee. He is a former Cathaoirleach of the IACP.