Damian Sendler: Europe’s biggest medical specialty is psychiatry. However, despite attempts to bring about uniformity, training in psychiatry throughout Europe continues to be very disparate. After establishing a charter of standards for psychiatric training in 2000, the Union Européenne des Médecins Spécialistes (UEMS) followed it up with a European Framework for Competencies in Psychiatry in 2009, and a European Framework for Competencies in Psychiatry in 2010. Despite this, they have not been applied across the European Union. On the one hand, the cultural disparities across nations with respect to how mental health treatment is seen and built on, and on the other, the cultural differences between individuals throughout Europe in all states, are discussed in this study, which is divided into three sections. The importance of psychotherapy is emphasized throughout the text. What was formerly considered to be the cornerstone of psychiatry as a medical profession seems to have become a neglected field of study. It is necessary to evaluate the patient with mental health difficulties in his cultural setting, but it is also important to assess him in his familial environment. Training should be designed to enable trainees to gain the knowledge and skills necessary to become well-equipped professionals. This is the subject of the final paragraph, in which trainees consider their current position and early career psychiatrists reflect on their training to determine whether what they learned corresponds to what they need in their current working environment. A common standard for training and certification is required across Europe, not only for the benefit of the profession of psychiatrists, but also for the protection of patients and their families. To better serve its users, UEMS is advising them to collaborate with the Council of National Psychiatric Associations (NPAs) within the European Psychiatric Association (EPA), as well as training programs and early career psychiatrists, to discuss with them what standards should be implemented in all European countries and how a European board examination could ensure professional quality of psychiatrists across the continent.
Damian Jacob Sendler: When it comes to the European Union (EU), one of the most essential issues is harmonisation of training. The rationale for this is entrenched in the EU’s fundamental principles of freedom of movement of products, money, services, and labor. As a result, there is a pressing need for professional credentials to be recognized by their peers. For the safety of patients and the security of professionals, a process of standardisation in training programs, competence evaluation, and quality assessment must be implemented while maintaining sensitivity to existing cultural variety in order to ensure their protection.
Dr. Sendler: In addition to the issue of harmonisation, there is the pressing problem in many European countries of inadequate recruitment of medical graduates into psychiatry, which has resulted in a shortfall in the number of medical graduates required to maintain an adequate medical labor force in mental health facilities.
Damian Sendler
Mayer et al. [1] undertook a thorough search of the literature in order to identify primary information that assessed the variety of training across Europe. As a result of their search, the authors discovered just six original publications that fit their search criteria, four of which were about survey data, as a result of their search. They also selected and described six published postgraduate courses that they had found and published. Based on this information, the authors came to the conclusion that there is a significant disparity in training experience throughout Europe, which will provide a hurdle to the objective of harmonisation in the future. They advised that curriculum be made more widely available and uniformly standardised, and that an agreed-upon evaluation mechanism be established that leads to the certification of “Fellow of the European Board of Psychiatry” be established.
This is unfortunate, but not unexpected given what we know about medical education scholarship, which shows that published research seldom tackles concerns of efficacy [2], and the lack of information about trainee psychiatrists’ educational experiences in Europe. As Jan Illing [3] noted, acceptable types of evidence may be obtained from sources other than those available in the conventional scientific literature, which is important to keep in mind while teaching at medical schools. Acceptable approaches may include the qualitative, as well as the narrative, among other things. Experts’ narrative knowledge based on their experience and expertise based on their practice, particularly when tested by triangulation, may therefore be considered credible kinds of proof.
According to Mayer et al., their review tackles the subject of harmonisation, but it does not answer the question of what the harmonisation should concentrate on. There is little use in every European country providing psychiatrists in training with the same experience if that experience does not result in the production of physicians who can function successfully in order to deliver the treatments that mentally ill people in Europe need.
The purpose of this guideline paper is to expand on the work of Mayer et al. [1] by investigating the topic of a uniform European standard for training in psychiatry from a variety of viewpoints, including the following:
Lastly, we will employ a conceptual framework derived from the field of organizational science to investigate why efforts to harmonize training have been unsuccessful, and we will draw conclusions from this to formulate recommendations that may be more effective than those that have been implemented thus far. We will use this to argue for greater inclusivity in the discussions surrounding the harmonization and improvement of training standards and procedures.
Damian Jacob Sendler
This guideline document is intended for those who are most directly involved: trainees and instructors. We want to contact national and worldwide professional organizations that are responsible for the creation and assessment of training programs in a more indirect manner.
The guideline will take into account a variety of forms of evidence, including that generated from experts by experience and that derived from expert practitioners in the area, in accordance with Illing’s [3] directive to employ diverse sources of evidence.
Damian Jacob Markiewicz Sendler: The European Economic Community was established in 1957 as a result of the signing of the Treaty of Rome (EEC). It established a single market among its member countries, allowing for the free movement of people, services, products, and money among them. The reciprocal recognition of professional degrees was a necessary precondition for the free movement of professionals in the European Economic Community. Since 1975, member nations of the European Community (EEC) have been compelled to recognize each other’s basic and specialty medical degrees. This provision was codified in Council Directive 93/16/EEC [4], which came into effect on April 5, 1993. In accordance with the Directive, member states are required to recognize basic medical credentials obtained in other member states. Additionally, the Directive mandated that basic medical training should be completed within six years.
Europe’s Union of Medical Specialists (UEMS, unofficially known as the European Union of Medical Specialists) was established in 1958 by professional organizations of medical specialists from across the European Community. With its support for the European Union’s idea of free movement of medical experts, the United Medical Specialists of Europe (UEMS) aims to provide high-quality training, continued medical education and professional development, and high-quality practice across all disciplines. It rapidly got engaged in programs aimed at enhancing the overall quality of life. As a culmination of this effort, the Charter on the Training of Medical Specialists in the European Community was published in October 1993 [5] and became effective. A condition of this Charter is that physicians get the training that was deemed essential to prepare them for the appropriate level of specialized practice in any member state. The criteria were broken down into six sections. The first five are general requirements for all programs of specialist training, while the remaining five are specific to each program. The so-called Chapter Six, which is prepared by the UEMS Board of the speciality in question, outlines the quality requirements that must be met in order to train in that specific specialty.
The University of Maryland Medical System Board of Psychiatry was formed in 1992. In April 2000 [6, the Board of Psychiatric issued the psychiatry specialist training chapter of the Charter, which was written by the American Academy of Neurology]. It is specified in this chapter how long psychiatric specialist training should last, how it should be organized, what it should cover, and how it should be monitored for quality. Briefly summarized, the chapter specifies that training should last a minimum of 5 years; trainees should rotate between clinical services and treat a variety of psychiatric disorders during their training; trainees should have experience in general adult psychiatry, old age psychiatry, substance misuse psychiatry, developmental psychiatry, as well as supervised experience in psychotherapy; and there should be established internal quality assurance systems within training institutions.
[7] Despite the considerable work that went into the development of UEMS criteria, their influence was limited by the fact that they were advisory in nature, the paucity of resources available to the Board of Psychiatry, and the wide range of mental health services offered across Europe. Research conducted in the years following the publication of Chapter Six of the UEMS Charter on Training Institutions and Trainees revealed that only the bare minimum requirements of the EEC Directive were consistently met, and that there was a significant variation in the content and structure of training delivered across Europe, as well as in the methods used to assess training outcomes and to ensure training quality [8–10]. The fact that people have differing perspectives on what is meant by mental health services as well as inequalities in how mental health services are delivered is particularly concerning [11].
Damien Sendler: In order to address these concerns of inconsistency, the UEMS Board of Psychiatry took the next step and developed curricular guidelines. On the basis of a European consensus declaration on the fundamental skills of a psychiatrist [12], this was to be implemented. The European Framework for Competencies in Psychiatry (EFCP) [13] was published in 2009 following an iterative development process that included key stakeholders such as psychiatric educators, national psychiatric associations, psychiatrists in training, and people who use mental health services as well as their families and caregivers. A high degree of participation in the creation of the EFCP by professionals with practical experience (trainees, users, and caretakers) increases the validity of the content of the EFCP as a statement of what the European Specialist Psychiatrist should be able to achieve by the conclusion of training.
There are currently no official statistics available to describe the effect of the EFCP. On the basis of anecdotal data, it seems that several national psychiatric training programs have been developed in order to achieve the goals of the EFCP. The EFCP seems to have had the same uneven influence on training as the UEMS Charter, based on the evidence available thus far.
Even though the variation in different aspects of training is a source of concern in and of itself [11], the greater concern is the possibility that this will manifest itself as variation in the quality of psychiatric practice.
In a particular society, psychiatry training is embedded in the mental health services that are available, and these services are embedded in the national and regional cultures of that society. As a result of their concern about what they termed “national conditions,” those who wrote the EFCP purposefully avoided developing an educational curriculum based on the capabilities outlined in the framework. They defer to local governments for the specifics of such matters. The fact that a curriculum is supposed to outline the techniques of learning and growth within a certain training program suggests that it may be heavily impacted by national circumstances.
There is a great deal of variation in the way mental health services are delivered across Europe. A combined number of psychiatric beds per 100,000 people in Europe ranges from 185 in Malta to 8 in Italy, according to the World Health Organization (WHO), as of 2014 [15]. Admission rates to inpatient units per 100.000 inhabitants vary from 1.301 in Romania and 1.240 in Germany to 87 in Albania, with Romania having the highest rate at 1.301 and Germany at 1.240. According to the World Health Organization, the number of outpatient visits per 100,000 people ranges from 28.2 in Slovakia and 26.1 in Finland to 1.08 in Albania and 1.07 in the United Kingdom.
The makeup of the workforce exhibits a similar degree of variety. The number of psychiatrists per 100,000 population ranges from 30 per 100,000 in Switzerland and 26 in Finland to 3 in Albania and 1 in Turkey, with Switzerland having the highest rate at 30 per 100,000.
The number of nurses who work in mental health care varies from country to country, ranging from 163 nurses per 100,000 people in Finland to 3 nurses per 100,000 people in Greece 7.
Because of the heterogeneity in the structure of the mental health workforce, it is likely that various professions will take on different types of work throughout Europe, which will in turn impact the content of postgraduate training in mental health care.
Europe is a diverse continent with a diverse range of cultures and sub-cultures, which has seen a significant inflow of even more cultures from all over the world in recent decades. It is likely that these cultural variations will have as much of an influence on how medicine and psychiatry are practiced in various nations as differences in the makeup of the mental health workforce. They also emphasize the significance of obtaining expertise in cultural psychiatric practice. Professionals are able to travel freely within the European Union, at least in theory. However, if the standards for the specialization are significantly different from those in the hosting nation, governments might request extra requirements such as appropriate language skills in the hosting country and further training in the host country.
There are some disparities between the cultures of psychiatric practice in different parts of Europe when the practice is analyzed. A long-standing tradition exists in several nations that psychiatry and psychoanalysis are synonymous. On the other hand, the influence of psychoanalysis on psychiatry has all but evaporated in several areas. Thus, there are conflicts among the many international, regional, state-level, and national psychiatric organisations, which represent the various schools of thought in neurobiology and psychoanalysis. In certain cases, this may result in political and governmental authorities exercising influence over curriculum as well as registration and board exams.
Central and Eastern European nations have a long history of political regimes in which psychiatry was connected with “discretely eliminating from society” politically problematic persons. This legacy may be traced back many decades. At the same time, psychiatry was the most despised area of health care, with a long history of institutionalization, inadequate finances, and outdated conditions, making it the least popular choice. The issue of stigma and prejudice towards those who suffer from mental illnesses continues to be a major concern, despite the fact that the environment has changed considerably.
The north-western region of Europe is now characterized by a strong empirically driven psychiatry, a research-driven medical profession that has gained prominence in universities, in society, and in the political arenas.
The result is that one is confronted with a continent that has wildly disparate “psychiatry,” which makes establishing Europe-wide standards a difficult undertaking. Although it would be inappropriate to enforce a single model throughout Europe, an agreement on principles that are shared by everyone may serve as a foundation that could then be supplemented with local values and habits within agreed limitations. However, in order to determine how the certification should be modified when a registered psychiatrist transfers from one area of the continent to another, it will be necessary to investigate the cultural variations in more depth in each location.
Individuals have various cultural identities in addition to their core cultural identity, which are influenced by a variety of circumstances such as their professional background, location of training, and place of employment. These identities will have an impact on how you seek treatment and how you perceive the world. All of our identities are tied to the cultural framework that we bring with us. Some of these characteristics may be more difficult to give up than others. In the context of migration or not, acculturation is a complicated time of adjustment to new ideas, attitudes, and behaviors that occurs as a result of direct or indirect interaction with other cultures. Acculturation may take place with or without migration. Individuals move for a variety of reasons, both within and across nations. Even within cultural groupings, there are differences, and physicians must be aware of these differences in order to provide effective treatment. Individuals may suffer cultural mourning as a consequence of their losses as a result of migration [17, 18]). Individuals may suffer cultural conflict as a result of differing cultural values within the same family or across cultures. Cultural conflict has been connected to willful self-harm among South Asian girls in the United Kingdom [19]. It is characterized as an emotional response [21] and is an experience that some migrants may have after arriving in a new country [20].
Psychiatric training is primarily concerned with preparing residents to be effective clinicians in their fields. It is critical to take cultural factors into account throughout training in order to produce physicians who are culturally competent. Good clinical practice, on the other hand, is about being competent with all patients, regardless of their cultural background. In order to be culturally competent, one must exhibit cultural sensitivity as well as knowledge of other cultures, empathy for others and the ability to provide culturally acceptable interactions. One must also be conscious of one’s own cultural strengths and shortcomings. The cultural formulation must include the individual’s cultural identity, their beliefs and values, their symptoms in their cultural context, their relationship with the environment, factors that reinforce their symptoms, distress as a result of the problems, their explanations for the distress, whether the doctor and the patient have a shared understanding of the problems and a shared plan for addressing the problems, the quality and nature of the interaction, and the nature and quality of the interaction with the doctor. This is the most important part of the training. However, it is also crucial for therapists to be conscious of their own cultural history and to understand if they are mono-cultural, bicultural, or multicultural in nature. It’s also important for them to be conscious of the signals they get from different cultural groups and how these messages influence their therapeutic practice. Personal qualities, such as the ability to recognize and explore one’s own strengths and flaws, are essential in therapy. They should be highly conscious of the worldview that they are promoting. It is also important to verify whether the pattern is similar to or differs from that of the patient at each visit. Trainees must be educated not to be color blind, but rather to be conscious of the parallels and variances between their own cultural beliefs and those of their patients.
Each family system has its own culture on a “micro-level,” or on a smaller scale. During the course of training to become effective therapists, it is imperative that students learn to consider the environment and family context.
For example, our families, as our earliest socializing agents, may serve as a site for both better understanding the origins of mental disorders and as a resource to help us grow as individuals. However, according to scientific epistemology, the term “family” refers to a systemic and network unit. There are several meanings of the term “family,” including family healthy functioning and dysfunctioning [21]. Even within a society, conceptions of family differ based on cultural and social groups. As civilizations grow more enriched with various cultures, their conventional notions of family are being challenged. An essential component of modern psychiatric treatment is the use of evidence-based biopsychosocial formulations to diagnose and treat mental diseases and issues. In that activity, we unavoidably come into contact with families. Among the questions we ask are regarding family histories of medical and mental conditions, high-risk behaviors (such as suicide, addiction, eating disorders, etc.), and the use of social media by patients and family members, to name a few examples. As a result, we need family assistance as well as communication abilities. In the diagnosis and treatment of people suffering from mental illnesses, there is a significant distinction between treating them as individuals and treating them as members of broader social (familial) groups. When it comes to family and systemic practice, the EFCP categorizes supporting competences under essential competencies that relate to treatment, communication, and the prevention of mental illness.
In a room where a psychiatric examination is taking place, dealing with more than one individual at the same time is a difficult job to do. For a psychiatrist working in clinical practice, there is a fundamental need for interviewing and intervention skills in order to interact and assist not just with one but often with a group of persons that are surrounding the patient. Family interviewing abilities do not imply the practice of family psychotherapy in any way. It refers to the ability to foster quick family contact, a brief greeting, or a 10-minute encounter, all of which contribute to the development of alliance. Family interventions, such as psychoeducational family intervention, family consultation, family education, family support, advocacy, and self-help groups [22], are important for the training of competent clinicians. Systemic family and network therapy are also important for the training of competent clinicians.
Additionally, the competent clinician must have had training in psychotherapy as part of their program [1, 23] so that they are able to interact with the patient and his or her immediate surroundings in a psychotherapeutic manner [1, 23, 24].
