Cambridge Prisms: Global Mental Health www.cambridge.org/gmh Psychotherapy training in postgraduate psychiatry training in Nigeria – Are we doing enough? Frances Nkechi Adiukwu1,2 Research Article Cite this article: Adiukwu FN, Adedapo OO, Ojeahere MI, Musami UB, Mahmood MY, Saidu Kakangi A, Salihu MO and Pinto da Costa M (2024) Psychotherapy training in postgraduate psychiatry training in Nigeria – Are we doing enough? Cambridge Prisms: Global Mental Health, 11, e41, 1–5 https://doi.org/10.1017/gmh.2024.32. Received: 25 March 2023 Revised: 19 February 2024 Accepted: 27 February 2024 Keywords: early career psychiatrists; psychotherapy training; psychiatry trainees; psychotherapy; Nigeria Corresponding author: Oluwadolapo Olujinmi Adedapo; Email: dradedapodolapo@gmail.com Margaret Isioma Ojeahere , Oluwadolapo Olujinmi Adedapo3 4 , Umar Baba Musami Mohammed Yusuf Mahmood Mumeen Olaitan Salihu 8 6 5,6 , Amina Saidu Kakangi , , 7 and Mariana Pinto da Costa , 9,10,11 1 Department of Mental Health, College of Health Sciences, University of Port Harcourt, Rivers State, Nigeria; 2Department of Neuropsychiatry, University of Port Harcourt Teaching Hospital, Rivers State, Nigeria; 3Assessment/Psychiatric Intensive Care Unit, Neuropsychiatric Hospital, Aro, Nigeria; 4Department of Psychiatry, Jos University Teaching Hospital, Jos, Nigeria; 5Mental Health Department, University of Maiduguri, Maiduguri, Nigeria; 6Federal Neuropsychiatric Hospital, Maiduguri, Nigeria; 7Mental Health Department, Federal Medical Centre Abuja, Nigeria; 8 Department of Behavioural Sciences, University of Ilorin Teaching Hospital, Ilorin, Nigeria; 9South London and Maudsley NHS Foundation Trust, London, UK; 10Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK and 11Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal Abstract Introduction: Nigeria, with an estimated 40 million people living with mental disorders, faces a critical shortage of psychiatrists to address the significant burden. Despite psychotherapy being integral to psychiatric training, it lacks structure, consistency and adequate supervision. This is alarming, particularly given the substantial demand for specialized psychotherapeutic support among those with mental illness. Methodology: A cross-sectional study utilised an online survey targeting early career psychiatrists recruited from the Early Career Psychiatrists section of the Association of Psychiatrists in Nigeria. Results: The questionnaire was distributed to 252 early career psychiatrists across Nigeria, with a 42.9% response rate, of which 50% were male, with 73.2% trainees and 26.8% early career psychiatrists. While 52.8% had received some psychotherapy training, only 2.8% were qualified psychotherapists. Notably, only 27.6% of those with psychotherapy training had over 100 hours of training. Factors such as receiving psychotherapy training during postgraduate training and having supervised psychotherapy training were found significant for having independent psychotherapy training. Conclusions: There is little emphasis on psychotherapy training in the postgraduate training in Nigeria. Those who had full training in psychotherapy were self-sponsored. Structured, supervised and mandatory psychotherapy within psychiatry training curriculum is recommended. Impact statement © The Author(s), 2024. Published by Cambridge University Press. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http:// creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited. Global best practices promote the training of psychiatry trainees in various techniques of psychotherapy and its incorporation into the training curriculum, hence the need to assess the extent and factors associated with the completion of psychotherapy training among early career psychiatrists (ECPs). Almost half of the ECPs in Nigeria had some form of psychotherapy training, however, only a few had full psychotherapy training. This study reveals the need for the inclusion of mandatory psychotherapy in the current psychiatry training curriculum, which will consequently improve psychiatric practice and decrease the treatment gap in mental healthcare. This inclusion will go a long way in improving the quality of holistic care delivered to mental health patients by ECPs. Introduction Nigeria is a low and middle-income country in West Africa with an estimated population of 40 million people living with mental disorders, which span across mild to severe forms (Lansana, 2017). Interventions to support people with mental disorders may require psychotherapy alone or in combination with other biomedical therapies (Madu, 2016). Despite the high prevalence of mental disorders, Nigeria has only about 250 Nigerian-trained and qualified psychiatrists, https://doi.org/10.1017/gmh.2024.32 Published online by Cambridge University Press 2 200 psychiatry trainees, and 319 licensed clinical psychologists (Bakare, 2021; Coker, 2022). As part of their clinical education, psychiatric trainees should be well-equipped with psychotherapeutic techniques. Psychotherapy is a useful therapeutic resource that, over time, has evolved and expanded, and is currently considered a mainstay of treatment for mental disorders (Locher et al., 2019). Although recent advances in biological psychiatry and neuroscience have put pharmacotherapy at the forefront giving it more clinical consideration, psychotherapy remains a widely accepted and evidence-based form of treatment for mental disorders (Tavakoli, 2014). Psychiatrists and psychiatry trainees have a critical role in the management of individuals with mental disorders, as they represent a significant part of mental healthcare providers capable of providing integrative pharmacotherapy and psychotherapy (Locher et al., 2019). Despite this proviso, a considerable number of psychiatrists seem to lack skills in specialized psychotherapeutic techniques and seem to shy away from conducting this form of intervention (Madu, 2016). According to the Specialist Training General Psychiatry curriculum of the National Postgraduate Medical College of Nigeria, the minimum duration of psychiatry training is 4 years. Successfully passing the primary examination qualifies a doctor to commence residency training. The junior residency training is expected to last a minimum of 24 months, and after passing the part 1 examination, trainees proceed to senior residency training for another 24 months, at the minimum. At the end of the senior residency training, the part 2 examinations are written, and successful trainees are awarded the College Fellowship in Psychiatry (FMCPsych). To qualify for the part 1 examination, a minimum of 6 months rotation in adult psychiatry, 3 months rotation in neurology, and 3 months in each of any 5 out of the 7 following core rotation areas is required: child psychiatry, psychiatry of later life, forensic psychiatry, community psychiatry, substance use psychiatry, emergency psychiatry and consultation-liaison psychiatry. During the senior residency training, the two outstanding core rotations are completed in 6 months, 3 months rotation in a subspecialty area apart from intended subspecialization, 3 months elective rotation and the remaining 12 months is expected to be in the area of intended subspecialization. Although the curriculum incorporates psychotherapy training during the postgraduate training, it does not include psychotherapy as one of the mandatory rotations and it is unclear how well this is supervised, considering the limited number of psychotherapists and psychologists within the country (NPMCN, 2018). Psychotherapy is mostly conducted by psychologists. Previously, concerns have been raised that psychiatrists who lack psychotherapeutic skills will be unable to offer appropriate care to the burgeoning number of individuals with mental disorders if all they continue to offer is pharmacotherapy (Holmes et al., 2007). In Nigeria, the National Postgraduate Medical College of Nigeria and the West Africa College of Physicians are the two recognized institutions that coordinate and superintend postgraduate medical education programs (Okonofua, 2018). Postgraduate psychiatry training has existed in Nigeria for over four decades. Nigeria has over 20 postgraduate psychiatry training centers with variations in the exposure to clinical psychotherapy training due to the absence of a consistent psychotherapy evaluation program beyond course modules. Psychotherapy was incorporated into the junior postgraduate psychiatry training in Nigeria, but the program does not address the exact duration of psychotherapy training within the first 24 months period for junior residency (NPMCN, 2018). https://doi.org/10.1017/gmh.2024.32 Published online by Cambridge University Press Frances Adiukwu et al. Little is known about psychotherapy training in Nigeria, leading to the dire need to assess the views and experiences of ECPs in Nigeria on their psychotherapy curriculum and training. To address this, this study aimed to investigate the access to, and experiences with, psychotherapy in the various training centers across Nigeria, namely: i) To determine the extent to which psychotherapy training is included in psychiatry training programs in Nigeria; ii) To determine the factors associated with the completion of psychotherapy training by psychiatric trainees in Nigeria. Methods This has been a cross-sectional study, part of a larger international study, the World Psychotherapy Survey. Study participants were ECPs recruited from the database (containing the names and contact details) of the ECP section of the Association of Psychiatrists in Nigeria (APN). In Nigeria, ECP is defined as psychiatry trainees (those currently undertaking residency training) and psychiatrists within 5 years post qualification from both postgraduate training colleges (National Postgraduate Medical College of Nigeria, Faculty of Psychiatry; West African College of Physicians, Faculty of Psychiatry). There is no age criteria in this definition. The questionnaire was distributed via email to ECPs between November 2021 and February 2022 through a google form. The questionnaire was developed for the World Psychotherapy Survey conducted by the Early Career Psychiatrists Section of the World Psychiatric Association (Eissazade et al., 2021; Rai et al., 2021; Belinati Loureiro et al., 2023; Kaya et al., 2023). The selfadministered questionnaire has 16 items covering three areas: i) socio-demographics, ii) psychotherapy training (types and modalities) and iii) satisfaction with psychotherapy training. Participation in the survey was voluntary, and all information was kept confidential. Data was transferred to the statistical package for social sciences version 20 (SPSS 20) for data analysis. Descriptive statistics were used to report the socio-demographics of the study participants, types and modalities of psychotherapy training received and training satisfaction. Non-parametric tests (chi-square and Fisher’s exact) were used to determine factors associated with the modalities of psychotherapy training. Results The survey was distributed to 252 members of the ECP section of the APN. One hundred and eight participants submitted the completed survey form, giving a response rate of 42.9%. Fifty percent of the participants were males and 50% were females. The majority, 56.7% (n = 59) of participants, were within the 36–45 years of age bracket. Among the professionals, psychiatry trainees accounted for 73.2% (n = 79), and the psychiatrists within their first 5 years after training for 26.8% (n = 29). Of the study participants, most (n = 86, 79.6%) reported awareness of the inclusion of psychotherapy training during the residency training program in Nigeria and most (n = 60, 71.4%) reported psychotherapy training as mandatory. More than half (n = 57, 52.8%) of participants had psychotherapy training, whether completed or partial (which is the case in the majority of the cases), during their residency training period (during junior residency training where it is included in their 3 Cambridge Prisms: Global Mental Health training curriculum), and only three (2.8%) completed psychotherapy training during residency (Table 1). Where psychotherapy training was available during the junior residency training program, it was fully funded by the participants in more than half (n = 61, 56.5%) of the cases. Psychotherapy training was given in theory in the majority of the cases, with Table 2. Details on the format of training n % 58 68.24 16 18.82 Practical psychotherapy 7 8.24 Theoretical teaching on psychotherapy and 1other 2 2.35 Practical psychotherapy training and 1 other 1 1.18 Theoretical teaching on psychotherapy and 2 others 1 1.18 Total 85 100 Cognitive behavioral therapy and 2 other types of techniques 26 31.33 Cognitive behavioral therapy and 3 other types of techniques 23 27.71 Cognitive behavioral therapy 10 12.05 Cognitive behavioral therapy, family therapy 9 10.84 5 6.02 How training was provided Theoretical teaching on psychotherapy Theoretical teaching on psychotherapy and practical psychotherapy training Table 1. Participants socio-demographics and psychotherapy training experience n % Gender Female 54 50 Male 54 50 Total 108 100 Age 29–35 41 39.4 36–45 59 56.7 46–54 4 3.9 Total 104 100 Types of psychotherapy techniques trained in Cognitive behavioral therapy and 4 other types of techniques Type of professional Psychiatry trainee 79 73.2 Family therapy 5 6.02 Adult psychiatrist 23 21.3 Cognitive behavioral therapy, psychodynamic 2 2.41 Child and adolescent psychiatrist 4 3.7 Family therapy, Interpersonal therapy 2 2.41 Community/consultation liaison psychiatry 1 0.9 Interpersonal therapy 1 1.2 NR 1 0.9 Total 83 100 108 100 Very satisfied 6 10.53 Satisfied 20 35.09 Neither satisfied nor dissatisfied 19 33.33 Dissatisfied 9 15.79 Total Awareness of the inclusion of psychotherapy training during postgraduate training No 22 20.4 Yes 86 79.6 Total 108 100 If yes Satisfaction with training Very dissatisfied 3 5.26 Total 57 100 Mandatory 60 71.4 Optional 24 28.6 Total 84 100 Fully by the trainee 61 56.5 Fully by the hospital/training institution 21 19.5 Psychotherapy supervision Fully by the government 15 13.9 Part by the trainee and part from other sources 10 9.3 Of the participants who received psychotherapy training, about one-third received supervision for their training. To these, training supervision was mandatory for only 48% (n = 14) of the participants. Training was mostly given in groups and lasted less than 50 hours in total (Table 3). Who funds psychotherapy training? NR Total 1 0.9 108 100 cognitive behavioral therapy being the most taught form of psychotherapy (Table 2). Have you had any psychotherapy training? No 51 47.2 Yes, currently training 54 50 Yes, completed training 3 2.8 108 100 Total NR: Not responded. https://doi.org/10.1017/gmh.2024.32 Published online by Cambridge University Press Factors associated with mandatory psychotherapy training Where psychotherapy training was mandatory, it also tended to have optional supervision (p = 0.027), which was funded by the participants (p = 0.002). Other factors such as the psychiatry specialty, type of psychotherapy training available, and whether 4 Frances Adiukwu et al. Table 3. Psychotherapy supervision Table 4. Factors associated with mandatory psychotherapy training n Mandatory psychotherapy training Optional psychotherapy training Theoretical 42 (70.0) 18 (30.0) Practical 7 (100.0) 0 Personal 0 0 12 (75.0) 4 (25.0) % Variables Psychotherapy training supervision available No 79 73.15 Yes 29 26.85 Total 108 100 Mandatory supervision 14 48.28 Theoretical/practical No 15 51.72 Personal/practical Total 29 100 In groups 11 37.93 Types of Psychotherapy available Individual 7 24.14 6 (66.7) 3 (33.3) Individual and in groups 11 37.93 Cognitive behavioral therapy (CBT) Total 29 100 Family therapy (FT) 4 (80.0) 1 (20.0) 1 (100.) 0 All three Total Interpersonal therapy (IT) Duration of training 50–100 h 7 24.14 <50 h 14 48.28 >100 h 8 27.59 Total 29 100 training was theoretical or practical did not have any association with the training being either mandatory or optional (Table 4). p Types of training Yes Format of supervision F 0 1(100.0) 2 (100.0) 0 63 23 CBT and FT 8 (61.5) 5 (38.5) 3 or more types 44 (75.9) 14 (24.1) 63 23 Total 6.715 0.243F 2.105 0.777F Nature of psychotherapy supervision Mandatory Optional Total 14 (51.9) 13 (48.1) 0 (0.0) 6 (100.0) 14 19 27 (57.4) 20 (42.6) 16 (100.0) 0(0.0) 5.40 0.027F* Nature of sponsorship Discussion Main findings Despite over half of the participants stating that psychotherapy training was included in their psychiatry postgraduate training and as a mandatory requirement, just about half received some form of psychotherapy training, and only 3% of the participants in Nigeria had full psychotherapy training. This might be a result of this mandatory training being self-funded as well as being theoretical in nature in the majority of the cases. Despite the relatively low number, all qualified psychotherapists undertook self-sponsored psychotherapy training. Mandatory psychotherapy training was associated with it being self-funded and mandatory supervision of the training. Despite this, the completion rate was poor, indicating that priority was not being given to psychotherapy training in Nigerian psychiatry postgraduate training. These findings also show a general dissatisfaction with the psychotherapy training received during the training period. Comparison with other literature There is generally less emphasis on psychotherapy training during postgraduate training in Nigeria than in other countries, as it is not mandatory in the curriculum (Jain et al., 2012). The findings from this study in Nigeria are consistent with the results from this survey in Nepal, where one-third of ECPs received psychotherapy training (Rai et al., 2021). The present study also observed that psychotherapy training varies in different training institutions and was not made mandatory, with low supervision https://doi.org/10.1017/gmh.2024.32 Published online by Cambridge University Press Fully self–sponsored Fully by training institution Fully by government 10(90.9) 1 (9.1) Partly by trainee and partly by other sources 6 (66.7) 3 (33.3) 1 (100.0) 0 60 24 Others Total 13.45 0.002F* F, Fisher’s exact test. rates. However, findings from this survey in Iran reported that almost all participants had mandatory psychotherapy training (Eissazade et al., 2021). While there are a lot of constraints in psychotherapy training during psychiatry training, which includes poor funding and supervision, over half of the respondents in Nigeria sponsored their own psychotherapy training. This is similar to the results from a psychotherapy survey conducted across Europe, where trainees reported self-funding for psychotherapy training (Giacco et al., 2012). Nonetheless, many participants in Nigeria considered that the payment for the psychotherapy training should not be done by the participants themselves and wished the current training be improved upon through full incorporation and implementation of a uniform, mandatory, well-supervised accredited psychotherapy curriculum during postgraduate training in line with global best practices. Evidence suggests that online psychotherapy training provides equal knowledge, competency and 5 Cambridge Prisms: Global Mental Health confidence in psychotherapy when compared with supervised training. This, therefore, may create an option for a cheaper form of training that can be undertaken by psychiatry trainees and ECPs in low- and middle-income countries (Bennett-Levy et al., 2020). Financial support. This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Implications of the findings for practice, policies and research Ethical approval. Ethical approval was obtained from the Ethics Review Committee of the University of Ilorin Teaching Hospital, Kwara State, Nigeria. While there are different psychotherapy modalities, psychotherapy training should focus on common models such as cognitive behavioral therapy, family therapy and interpersonal therapy as well as group and individual therapy techniques. In Nigeria, psychiatry trainees and ECPs undergoing psychotherapy training are exposed to the common models listed above where such training exists. There is a need for the current psychiatry postgraduate training curriculum to make psychotherapy training mandatory and ensure adequate supervision as a requirement for qualification as a psychiatrist. Increased attention should be given to psychotherapy training in the postgraduate psychiatry training program curriculum. This will improve psychiatric practice and decrease the treatment gap that exists in mental health care. Strengths and limitations This is the first study to investigate psychotherapy training in Nigeria; however, its limitations are the relatively low response rate and small sample size. This affects the power of the study and the reliability of the measures of associations used to determine factors affecting psychotherapy training. Conclusions Psychotherapy training offered during psychiatry postgraduate training, though present in the postgraduate curriculum, lacks structure and mandatory supervision and is not mandatory for qualification as a psychiatrist in Nigeria. ECPs are largely unsatisfied with the training and tend to seek further training outside of the postgraduate training. Despite this, very few are qualified psychotherapists. This highlights the need to improve the delivery of the training curriculum as it pertains to psychotherapy training so as to decrease the treatment gap in psychiatry present in Nigeria. Data availability statement. The data used to support the findings of this study are included within the article. Acknowledgements. The authors acknowledge the Early Career Psychiatrists Section of the World Psychiatric Association for the development of the survey instrument. Author contribution. All authors contributed to different aspects of this manuscript. M.P.d.C. conceived this study and its design and all authors were involved in data collection. Analysis and interpretation of data were performed and written by F.N.A., O.O.A., U.B.M. and M.Y.M. while the rest of the literature was written by F.N.A., M.I.O., A.S.K. and M.O.S. F.N.A., O.O.A., A.S.K. and M.P.d.C. edited the final manuscript. All authors agree to be accountable for all aspects of this manuscript. https://doi.org/10.1017/gmh.2024.32 Published online by Cambridge University Press Competing interest. The authors declare none. References Bakare M (2021) History of postgraduate psychiatry education and training in Nigeria. South African Journal of Psychiatry 3, 27. Belinati Loureiro V, Ratzke R, Nogueira Dutra JC, Mesadri Gewehr D, Cantilino A and Pinto da Costa M (2023) Psychotherapy training in Brazil: Experiences of psychiatric trainees and early career psychiatrists. Medicine 102(50), e35388. https://doi.org/10.1097/MD.0000000000035388. Bennett-Levy J, Hawkins R, Perry H, Mills, J (2020) Online cognitive behavioural therapy training for therapists: Outcomes, acceptability, and impact of support. Australian Psychologist 47, 174–182. https://doi.org/10.1111/j.17429544.2012.00089.x Coker T (2022) Nigeria’s Mental Health Crisis: A Mind-Boggling Burden on 40 Million Minds. Available at https://www.tchealthng.com/thoughtpieces/nigerias-mental-health-crisis-a-mind-boggling-burden-on-40-mil lion-minds (accessed 25 July 2023). Eissazade N, Shalbafan M, Eftekhar Ardebili M, et al. (2021), Psychotherapy training in Iran: A survey of Iranian early career psychiatrists and psychiatric trainees. Asia-Pacific Psychiatry 13(1). https://doi.org/10.1111/APPY.12434. Giacco D, Luciano M, Del Vecchio V, et al. (2012) A survey from the WPA early career psychiatrists council: What about training and practice of psychotherapy across Europe? European Psychiatry 27, 1. Holmes J, Mizen S and Jacobs C (2007) Psychotherapy training for psychiatrists: UK and global perspectives. International Review of Psychiatry 19, 93–100. Jain G, Mazhar MN, Uga A, et al. (2012) Systems-based aspects in the training of IMG or previously trained residents: Comparison of psychiatry residency training in the United States, Canada, the United Kingdom, India, and Nigeria. Academic Psychiatry 36, 307–315. Kaya H, Tasdelen R, Ayik B and Pinto da Costa M (2023) Psychotherapy training in Turkey: Experience of early career psychiatrists. Turkish Journal of Clinical Psychiatry 26, 84–90. Lansana G (2017) Mental illness invisible but devastating Africa Renewal. United Nations Africa Renewal. Available at https://www.un.org/africar enewal/magazine/december-2016-march-2017/mental-illness-invisibledevastating (accessed 13 May 2022). Locher C, Meier S and Gaab J (2019) Psychotherapy: A world of meanings. Frontiers in Psychology 10. https://doi.org/10.3389/FPSYG.2019.00460. Madu S (2016) Psychotherapy training in Nigeria. International Journal for Psychotherapy in Africa 1, 7–13. NPMCN (2018) Specialist Training Curriculum in General Psychiatry. National Postgraduate Medical College of Nigeria. Okonofua F (2018) Postgraduate medical education in Nigeria: Past, present and future. Tropical Journal of Obstetrics and Gynaecology 35, 1. Rai Y, Karki U and Pinto da Costa M (2021) Psychotherapy training in Nepal: Views of early career psychiatrists. BJPsych International 18(2). https://doi. org/10.1192/BJI.2020.50. Tavakoli S (2014) The place of psychotherapy in contemporary psychiatry. Iranian Journal of Psychiatry and Behavioral Sciences 8, 1.