Metamorphosis of  Association to College

The fortieth anniversary of the Royal College of Psychiatrists (RCPsych) is an appropriate time to reflect on the past.  The Royal Medico-Psychological Association (RMPA) was not moribund in 1972 but its functions were limited.  It had regional divisions in the UK and Ireland and two specialist sections (mental handicap and child psychiatry).  It had one of the best psychiatric journals in the world. The RMPA had little input into teaching, research or academic psychiatry and had no examination to become a member.There was inadequate training for junior psychiatrists in the1950’s or 1960’s, except at the Institute of Psychiatry in London as well as some in Edinburgh and Dublin.  Much education was “sitting by Nellie”:  watching and copying the behaviour of a Consultant, for whom a trainee was working as a registrar in a mental hospital.  They were fortunate if the first psychiatrist they worked for was enthusiastic, competent, knowledgeable and a good role model.

In the 1950’s and 1960’s Government departments still took much of their psychiatric advice from the Psychological Medicine Committee of the Royal College of Physicians (RCP). This consisted of Consultant Psychiatrists who had passed the MRCP examination. When a proposal to turn the RMPA into a College was first mooted, this committee was against it. At a later date they changed their views and supported the idea of the new College. This was a major change as many academic psychiatrists thought the RMPA was no more than a club for Medical Superintendants.

The first records of the RMPA considering becoming a College occurred in the 1950’s when it was occasionally discussed at Council meetings, but no action was taken. A pressure group (the Society for Clinical Psychiatrists: originally founded to replace Physician Superintendants with Consultants) raised the matter at the RMPA’s Annual General Meeting in1964, when a proposal that the RMPA should petition to become a College was passed by 150 votes to 9. Their earlier postal ballot had shown that 75% of the membership favoured this development.

Before 1970 there had been little attempt by University teaching departments to provide input (apart from some lectures) into the education of junior psychiatrists in mental hospitals and other isolated units.  Many trainees in psychiatry were unhappy about the proposed new College as they believed little would be done about their professional education and development. They expected the proposed new examination for membership would be modelled on the examinations of the other Royal Colleges. They feared it would be difficult to pass, with fees for the examination going to the College coffers for the other purposes than education and training. This led to the formation of another pressure group, the Association of Psychiatrists in Training (APIT), with 600 members who pressed for education and training to be included in the new Charter and for the examination to be scrapped and replaced by continuous assessment/monitoring. APIT was very active from 1968 to 1972 and were able to insert the responsibility for Education and Training into the proposed new Charter. At the time of the inception of the College, they recommended that all its members should boycott the new examination.

Following two years of acrimonious debates about the future College, there was an election of Officers and Council. Two- thirds of the Council were new, as were most of the Officers.There were representatives from all regions and specialities, with equal numbers of Fellows and Members. There were two Affiliate members, one a trainee (who was rapidly co-opted to Council).  Following alterations to the original proposed Charter, the College was allowed a small role for Inceptors (the constitutional name for trainees) for an experimental ten-year period. Junior psychiatrists in training posts were rapidly co-opted on to virtually all committees, though initially there was no official role for them. The new College played the rules according to the game rather than the other way round. The trainee was co-opted as a “non-voting participant observer”, appointed from an invented special subcommittee of the Education Committee with trainees from all regions and specialities. The introduction of trainees into all College activities was successful and led to a review of the Charter to make trainees an integral part of the College. This innovation was later followed by other Colleges.

In its first twenty years the College was defining its roles. The Officers were concerned with developing satisfactory training schemes.Three areas concerned the Officers:

1. developing a new examination (the MRCPsych)
2. establishing a system of inspection and accreditation of all training schemes, which was started by the first Deans
3. ensuring a place for trainees in all College structures.

The new examination proved less formidable than originally feared, and those who had passed a DPM were exempted from all parts, except the final viva, and the majority passed this. Although few people sat the first examination, nine out of the 10 passed and several hundred sat the next ones. 

The College had also been given the responsibility to inspect and approve training posts.The Dean started the overview of training posts with teams in all regions inspecting the posts in other Regions. A convenor visited all posts with two colleagues. After a short time it became mandatory that one of these was a trainee (a Senior Registrar who had passed the MRCPsych). 

There were few adequate training schemes that could be accepted for the following five years and the majority were only accredited for one year. This changed as pressure from the new College led to amalgamations into bigger training schemes and eventually into Regional ones. Trainees started to rotate between units with the opportunity to work with a different range of consultants and academic staff so that they would acquire their own style of working from the best people. The inspections were successful since the College had the power to cease recognising posts if there was an inadequate educational input, such as no lectures, no other teaching, no library facilities, no Clinical Tutor nor any relationship with the Postgraduate Dean. There was also the development of a new and acceptable examination.

There was a need for more staff to deal with these new responsibilities and four staff in three rented rooms in 1972 soon became inadequate. A new headquarters was obtained in Belgrave Square, which was enlarged in 1985 to house the growing Publications Department and a new Research Unit. These later expanded leading to the need to lease further premises. The College now has 200 paid staff housed in Belgrave Square, Aldgate East, London and in offices throughout the United Kingdom.  

The number of members of the RMPA in 1952 when the idea of a College was first mooted was 1,242.  In 1972 there were 4,700 members and Associates. The numbers have continued to grow throughout the whole life of the College. There were 8,177 members and Associates in 1992, and 15,860 at the beginning of 2012.

A sporadic memorandum headed Notes and News was developed into a monthly called News and Notes. The later became a refereed journal the Psychiatric Bulletin, now The Psychiatrist, and further journals and books were added when the College developed its own professional publishing department in the 1980’s. This Department now produces four scientific journals and about twelve books annually. 

Another major development was the establishment of the Research Unit in 1989. The proposal to have such a Unit was not popular with University Departments of Psychiatry, but sufficient funds were collected from the membership to establish it at 17 Belgrave Square where further space was available after significant rebuilding. The Unit focussed on those areas that could not easily be carried out by either the Department of Health or individual University Departments. This Research Unit has now evolved into the College’s Centre for Quality Improvement and the National Collaborating Centre for Mental Health and both parts are housed in a separate building in Aldgate East, London.

There have been changes in public attitudes towards mental illness and psychiatry over the last forty years, with greater knowledge by the public and more acceptance of the advantages of treatment, both psychological and pharmacological for the mentally ill.  Some high-profile individuals are more willing to admit to having certain mental illnesses, but people still remain wary about making it known that they have a relative with a serious psychosis.  Tuberculosis and cancer were once rarely mentioned though they are now more freely disclosed by those with these conditions. This is not yet the case with the majority of the more serious mental illnesses. 

The College has organised five public education campaigns. The first launched jointly with the Royal College of Practitioners in 1992 was called “Defeat Depression” and led to an increase in the early detection of depression by general practitioners in the UK, with more prescribing of antidepressant drugs and more awareness of the role of Cognitive Behavioural Therapy in the treatment of depression. The second anti-stigma campaign was launched in 1998 and was “Changing Minds” and this had some modest success. The campaign led to a similar initiative by the Department of Health and some major mental health charities and this is ongoing.

The College has been more proactive in both policy matters and politics. The input to Government from the College in the run up to the new Mental Health Act (1983) was far greater than the Association’s input to the 1959 Act; at a time the Government of the day relied heavily on the Royal College of Physicians rather than the RMPA. The College also became concerned with the world-wide misuse of psychiatry by governments (particularly the Soviet Union, but also South Africa, Romania and China) to incarcerate dissidents in mental hospitals rather than gulags.

The RMPA had seen itself as an organisation representing psychiatry in the whole of the British Empire and had been anxious to develop colonial branches, though attempts to set up overseas divisions generally foundered. Council decided in 2000 that the College should become more active in strengthening its international activities and it created International Divisions based on the WHO geographical divisions.  It organised elections for Chairs and other Officers and had annual meetings with these representatives. 

A new journal, International Psychiatry, was started in 2003.  The College’s Honorary Fellows set up a fund to enable psychiatrists working in low and middle income countries to attend the College’s International Congresses. The College had 2,700 overseas members in 2012. The RMPA  had an Irish Division covering the whole of Ireland and had equal numbers of officers from both the South and the North. The Irish Division continued in this format until it divided into two separate divisions – the Irish Division and the Northern Irish Division. In 2009 the Irish Division metamorphosed into the College of Psychiatry in Ireland which publishes the “Irish Journal of Psychological Medicine”. Irish trainees continue to take and pass the MRCPsych examination.

The world-wide move to continue closing large mental hospitals continued through the whole of the College’s first thirty years. The money saved from the sites of hospitals sold could have gone to strengthening community care and other psychiatric facilities, rather than to other parts of the NHS that politicians and the press considered to be more deserving.  The closure of traditional asylums led to different concerns about the care and treatment of the mentally ill, particularly from carers who often found themselves unsupported. 

The College started to develop an official relationship with patients and carers in the present century. The Service Users Recovery Forum and the Carers Forum were established. Patients and carers now participate in all College activities and are represented on all major committees. A powerful alliance between psychiatrists, patients and carers has now been formed which can be influential when negotiating with the Government.

The College‘s Communications and Policy Department has produced a wide range of prize-winning information leaflets and factsheets on all major psychiatric conditions and treatments. These are produced online in many languages. The College has put a lot of time and effort into developing its website and it receives the highest Google ranking amongst the medical royal colleges with over 360,000 visits per month. The College has also embraced social media such as YouTube and Twitter.

There are many challenges ahead. There is still too much stigma attached to psychiatric patients and this has an effect upon the recruitment into psychiatry. There are  insufficient UK medical graduates choosing to specialise in psychiatry.  Research had shown various reasons for this (“patients are incurable”, “not a scientific discipline” “no evidence-based research” and “the profession are stigmatised by other senior doctors”). The College aims to increase the number of young doctors choosing a career in psychiatry by 50% (an increase of 200 annually) by organising summer schools, taster sessions, setting up social networks, supporting psychiatric societies in medical schools and giving valuable awards to help fund research electives. The College is also seeking a new headquarters to house all its activities, including the Centre for Quality Improvement and the National Collaborating Centre for Mental Health.

The conversion from an Association to College was momentous  bringing about many changes. Forty years have seen improvements in the development of proper education for psychiatrists. The College has developed a closer relationship between the profession, carers and patients.  It is now the voice of psychiatry in mental health policy, teaching, clinical work and the care of patients who have some of the most difficult and intractable illness known to doctors. A “medical superintendents club” has metamorphosed into a highly respected and active Medical Royal College.

September 2012