Teaching Forensic Psychiatry and Psychology in Europe

Abstract

Although the roles and practice of forensic psychiatrists and forensic psychologists vary across Europe, there are commonalities in the knowledge and skills required. This chapter will outline the routes to practising in these professions and the components of training. Key teaching themes including mental health legislation, risk assessment and management, professionalism and ethics and expert witness training will be explored. The role of European initiatives in education and training will also be discussed.

This chapter will go on to describe a range of teaching methods and consider how each may be optimally utilised within the field of forensic mental health. Finally, the role of forensic mental practitioners in reducing mental health stigma and in promoting careers in the field will be considered.

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1 Introduction

Working within the fields of forensic psychiatry and psychology requires an effective combination of knowledge, clinical skills and professionalism which must be developed through academic learning and clinical experience. Whilst a general expertise is developed through core psychiatry and clinical psychology training, those working in forensic services must have detailed knowledge of risk assessment and management, criminal justice services and the role of a medicolegal expert. Furthermore, experience must be gained in a range of clinical environments including secure psychiatric facilities, prisons and outpatient settings.

Most clinicians working as either forensic psychiatrists or psychologists will have a role in the teaching and supervision of trainees and may also be involved in undergraduate teaching.

They may also have a role as teacher in the courts or legal systems [1]. In this chapter, we aim to discuss the teaching of forensic psychiatry and psychology across Europe and to outline the range of teaching methods that may be employed. Specialist training in forensic psychiatry and psychology will be discussed in detail in the next chapter.

Additional challenges that the forensic practitioner must be prepared and equipped for arise from the paradoxical political and public misconceptions that, on one hand, those with mental disorder pose a risk to others and should be infinitely detained, and conversely that due to their offending behaviour they are less deserving or in need of care or resources. This may be amplified in developing countries where there may be a more limited understanding of mental disorder and limited resource. It is our belief that those working in the field of forensic mental health have a role, not only as teachers but to act as ambassadors and to reduce mental health stigma.

2 European Routes to Practising in the Professions of Forensic Psychiatry and Forensic Psychology

The pathways to becoming a practitioner working in the fields of forensic psychiatry and psychology vary across Europe, but there are commonalities in the training and skills required. As specialist training will be discussed in detail in the next chapter, here we aim to provide an overview of the process to undertaking specialist training and outline the key components of this training.

Prior to undertaking specialist training in most European countries, forensic practitioners undertake an undergraduate degree in medicine or psychology.

2.1 Psychiatry

Undergraduate medicine curricula include psychiatry, but there are significant variations in the quantity of teaching and experience of forensic mental health within this both nationally and internationally. Some institutions, for example, the University of Edinburgh, include teaching on mentally disordered offenders and the structure and provision of secure care within its undergraduate curriculum. Some but not all students have the opportunity to undertake clinical placements in forensic settings. Following completion of an undergraduate medical degree, psychiatry can be selected as a career pathway. This will involve clinical training, assessment of competencies and in some countries postgraduate examinations.

In the UK, psychiatric trainees wishing to receive specialist accreditation in forensic psychiatry must undertake 3 years of training in forensic psychiatry following completion of core psychiatric training. This is overseen by the Royal College of Psychiatrists who has developed a curriculum and learning outcomes which must be adhered to and award a European Certificate of Completion of Training (CCT).

Accredited training in forensic psychiatry resulting in a CCT is also available in Ireland, Germany, Switzerland and Sweden. In other European countries, such as Denmark, Belgium, Austria, Finland, Norway, The Netherlands and Spain, university or official medical bodies run a diploma course in forensic psychiatry and psychology [2].

2.2 Psychology

In the UK, after undertaking an undergraduate degree in psychology, those interested in working within the field of forensic psychology must undertake a postgraduate degree. It should be noted that there is a clear divide in those that train to become clinical psychologists and work in forensic mental health services and those who train to become forensic psychologists and work mainly with the police or in custodial settings focussing on criminal profiling and altering offending behaviours. In Germany, there are three universities with master’s programmes exclusively focusing on psychology and law. In the Netherlands, there are three accredited academic master’s programmes in forensic psychology which is delivered by Maastricht University, the University of Amsterdam and Tilburg University.

2.3 Components of Training

As will be discussed in the next chapter, the length and structure of specialist training vary across Europe; however, there are commonalities in the components and content of this training. Firstly, specialist training can be conceptualised as comprising both formal teaching and apprenticeship. Formal teaching includes lectures, courses and problem-based learning and is the main mechanism through which theoretical knowledge is imparted to trainees. These teaching formats will be discussed in more detail later in this chapter.

Alongside formal teaching, trainees in forensic psychiatry and clinical psychology undertake apprenticeships, that is, clinical placements working under the supervision and guidance of experienced practitioners. Here, trainees will develop expertise in the assessment of treatment of mental disorder, risk assessment and medicolegal work. Clinical skills are developed in tandem with professional skills, and trainees receive formal supervision from their mentor. Trainees will also gain experience in the administration of psychological theories to both individuals and groups, which is of importance not only for the development of therapeutic skills but also for the professional skill of maintaining boundaries.

Trainees should receive regular feedback from their supervisor over the course of a clinical placement with a formal review on completion of the placement. Clinical and professional competencies should be assessed against a defined curriculum and supervisor’s reports supplemented by workplace assessments and, in some countries, professional examinations.

3 Education Beyond Specialist Training for Forensic Mental Health Clinicians

Accreditation of completion of specialist training in forensic psychology, clinical psychology or psychiatry does not signify an end to educational requirements. Clinicians require ongoing training to both maintain and enhance existing knowledge and skills. Evolving research and policy necessitate changes in practice, and even the most experienced clinicians will require training in legislative changes and new methods, e.g. a new risk assessment tool.

One of the challenges of training forensic mental health clinicians is that, due to the level of specialisation, there is a relatively small body of practitioners who may be spread over a large geographical region. This can make the delivery of training and teaching irregular and not cost-effective. One strategy to overcome this is to make training multidisciplinary and national rather than regional, as exemplified by the School of Forensic Mental Health in Scotland.

The School of Forensic Mental Health (SoFMH) [3] was established in 2007 coinciding with a time of change within the country with new mental health legislation, new initiatives and the development and opening of new forensic facilities. There were major training requirements following these changes, but training in forensic mental health was uncoordinated and unidisciplinary, and access was subject to a geographical lotters. SoFMH was developed to meet these needs and is a virtual school with an administrative centre but delivering training usually on a multidisciplinary basis across Scotland using a variety of teaching methods. The school organises a range of multidisciplinary training events, clinical forums and special interest groups, coordinating research and teaching across the country.

There is a short programme course, postgraduate qualifications such as a master of science degree in forensic mental health delivered electronically which has four core online modules, namely:

• Mental disorder and the law and treatment and interventions for mentally disordered offenders

• Problem behaviours

• Risk assessment and risk management

• Evaluating evidence to develop research and inform practice

In addition, SoFMH has an active research programme linking to its educational remit.

One teaching resource developed by the SoFMH is the ‘New to Forensics’ teaching programme. ‘New to Forensics’ is a learning tool developed between the National Education for Scotland (NES) and the Forensic Network. It is suitable for clinical and non-clinical staff and is multidisciplinary and multiagency in approach. A mentor, who is an experienced forensic mental health worker from within the multidisciplinary team, supports a student through 15 chapters over a 6-month to 1-year period. It includes patient case scenarios in a variety of settings, from high-secure psychiatric care to community. To date, over 1000 individuals have undertaken the programme.

4 European Educational Initiatives

Although specialist training varies across Europe, there are a number of pan-European organisations which exist to share and learn from each other’s experience including the European Association of Psychology and Law (EAPL), the European Federation of Psychiatric Trainees (EFPT), the European Psychiatric Association and the Ghent Group. These bodies will be described more fully in the chapter ‘International Associations’, so here we will focus on their important role in education and training by organising events, disseminating knowledge and developing guidance.

4.1 The European Association of Psychology and Law (EAPL) [4]

The European Association of Psychology and Law (EAPL) was founded in 1992. Its aims are as follows:

• The promotion and development of research, improvements in legal procedures, teaching and practice in the field of psychology and law (e.g. legal psychology, criminological psychology, forensic psychology) within Europe, and the interchange of information throughout the world aimed towards an international cooperation.

They have a publication Psychology, Crime and Law, which is issued eight times a year, and organise an annual conference. There is an active student association, and their website provides fact sheets on a range of forensic issues which summarise current literature into short (two page) documents. Topics include psychopathy, criminal profiling and risk assessment. They also publish a series of articles focusing on the ‘controversies’ in psychology and law and provide information on forensic psychology courses across Europe.

4.2 European Federation of Psychiatric Trainees

In 2009, the European Board of Psychiatry published ‘European Framework for Competencies in Psychiatry’ [5] which was developed in collaboration with the European Federation of Psychiatric Trainees (EFPT) and involved consultation with patient and carer organisation, national psychiatric association and the European and World Psychiatric Associations. They identify seven key roles of the psychiatrist as:

• 1. Psychiatric expert/clinical decision maker

• 2. Communicator

• 3. Collaborator

• 4. Manager

• 5. Health advocate

• 6. Scholar

• 7. Professional

The aim of these objectives is to be used as a reference for national associations and other bodies to develop or review curricula for postgraduate training. The document also provides guidance on how competencies can be assessed and lists three key principles to guide the assessment process.

• Assessment should be transparent.

• Each competency must be assessed.

• Competency assessment must be triangulated.

The document then goes on to outline a range of methods of assessment divided in three domains – knowledge, competency and performance. Knowledge assessments are written examinations (WE) and oral examinations (OE). Competency assessments are clinical examinations (CE) and assessment of simulated clinical encounter (ASCE). Performance assessments, also known as workplace-based assessments (WPBA), are directly observed practice (DOP), multisource assessment of performance (MSAP) and document-based discussion (DBD).

4.3 European Psychiatric Association (EPA) [6]

Founded in 1981, the European Psychiatric Association has active members in 88 countries with a stated mission to improve psychiatry and mental health care in Europe. It provided a number of different educational opportunities including a summer school, courses and e-learning programmes. For early career psychiatrists, they run a ‘Gaining Experience Programme’ offering short observership placements in psychiatric institutions across Europe and run a specific early career psychiatrists programme at the annual European Congress of Psychiatry.

4.4 The Ghent Group

The Ghent Group is a European network of forensic psychiatrists which aims ‘To support aspects of training, which will facilitate the practice of forensic psychiatry across national boundaries in Europe, to meet and develop ideas, to make recommendations about training and to support the development of professional groups in countries developing new services’ [7].

A regular topic of discussion within the group has been the optimum model for teaching and training for specialisation. Multidisciplinary training, including trainee lawyers, has been proposed to enhance understanding of legal issues relating to mentally disordered offenders. Through discussion, the group also concluded that trainees themselves should be involved in discussions to develop best practice in training and teaching, and consequently a training seminar for both consultants and experienced trainees was developed.

The Ghent Group holds training seminars on an annual basis in Kloster Irsee in Bavaria with 25 delegates attending (trainees in forensic psychiatry and young consultant psychiatrists) from across Europe. The format is a mixture of lectures and case vignettes to follow the offender journey from committing a serious offence to release into the community. Participants work in groups of six to consider each stage of the journey in each of the participant’s country comparing and contrasting national positions. One member of each group then presents their group’s discussion to the whole delegation to allow further discussion and debate. Through this process, the pathway, and role of the forensic psychiatrist and psychologists within it, was clarified for each country furthering the participant’s understanding of the system of other countries as well as their own.

5 Key Teaching Themes

In addition to the skills and knowledge acquired during general psychiatry and psychology, training those working in the field of forensic mental health requires additional expertise in the following fields.

5.1 Mental Health Legislation and the Interface Between Mental Health and the Law

Mental health legislation varies across the European Union, and the competent forensic clinician must have a sound understanding relevant to their role of the laws and legal tests in their jurisdiction. This is important both for clinical practice and for undertaking medicolegal work. In order to gain the required knowledge and experience in this area, trainees require specialist teaching and supervision. Firstly, they must develop an awareness of the relevant legislation, and this is most simply delivered via lectures and then further self-directed learning. Once a theoretical knowledge of relevant legislation has been acquired, the trainee must further their understanding by undertaking appropriate medicolegal work under supervision. Ideally, this should involve consultation prior to the patient being assessed, supervision of assessment (at least initially) and review and discussion of draft report. Only by undertaking such work will the trainee develop an understanding of the legal tests and become familiar with the correct terminology. The supervision of such work also provides the trainer with an opportunity to assess progress and provide feedback.

5.2 Risk Assessment and Management

For those working within forensic psychiatry and psychology, risk assessment is paramount to identify and manage risk of harm both to the patient and to others. There are a variety of tools in which practitioners can undertake training and can utilise to recognise and classify risk including actuarial tools like the Risk Matrix 2000 [8] and Structured Clinical Judgement tools like the HCR-20 V3 [9]. The 2007 Briefing Document ‘Giving up the Culture of Blame. Risk Assessment and risk management in psychiatric practice’ [10] concluded that interventions may decrease risk in one area only to increase in another and that risk cannot be eliminated. They also concluded that a perfect risk management system would have only a modest impact on rates of homicide by the mentally ill and may influence debate from a position where the greatest good may be done to the greatest number of people. For this reason, trainees must have guidance and teaching not only in identifying risk but in conceptualising it and being able to manage personal and professional anxiety associated with informed risk management.

5.3 Professionalism and Ethics

For psychiatrists working within the field of forensic mental health, the four moral principles of biomedical ethics recognised by Beauchamp and Childress [11] must be considered. These are the following:

• 1. Respect for autonomy – respecting the patient’s right to make decisions around their own care

• 2. Beneficence – acting in the patients best interest

• 3. Non-maleficence – doing no harm

• 4. Justice – fairness concerning the distribution of resources and who gets what treatment

For forensic practitioners, the pursuit of these ethical standards is complicated not only by having to consider both the general public and the individual but also in some countries by the dual roles of providing care and treatment whilst providing expert opinion and evaluation to the court, often via third parties. As discussed by Arboleda-Florez [12], this raises the question of whether forensic practitioners should identify with a ‘welfare paradigm’ or a ‘justice paradigm’. As result of the justice paradigm, treatment without consent and breaches of confidentiality may be required and indeed be considered best practice. Whilst most experience in this field will be acquired through practice under supervision during training, formal teaching may be of benefit. The Madrid Declaration on Ethical Standards for Psychiatric Practice 1977, most recently updated in 2011 [13], sets out an internationally applicable ethical code on which to base practice and teaching. This declaration devised by the World Psychiatric Association (WPA) also provides guidance concerning 16 specific situations of which the following advice is of relevance to forensic practitioners.

• No 2. Torture

• ‘Psychiatrists shall not take part in any process of mental or physical torture, even when authorities attempt to force their involvement in such acts.’

• No 3. Death penalty

• ‘Under no circumstances should psychiatrists participate in legally authorized executions nor participate in assessments of competency to be executed.’

• No 15. Dual responsibilities of psychiatrists

• ‘These situations may arise as part of legal proceedings (i.e. fitness to stand trial, criminal responsibility, dangerousness, testamentary capacity) or other competency related needs, such as for insurance purposes when evaluating claims for benefits, or for employment purposes when evaluating fitness to work or suitability for a particular employment or specific task.

• During therapeutic interactions conflicting situations may arise if the physician’s knowledge of the patient’s condition cannot be kept private or when clinical notes or medical records are part of a larger employment dossier, hence not confidential to the clinical personnel in charge of the case (i.e. the military, correctional systems, medical services for employees of large corporations, treatment protocols paid by third parties).

• It is the duty of a psychiatrist confronted with dual obligations and responsibilities at assessment time to disclose to the person being assessed the nature of the triangular relationship and the absence of a therapeutic doctor-patient relationship, besides the obligation to report to a third party even if the findings are negative and potentially damaging to the interests of the person under assessment. Under these circumstances, the person may choose not to proceed with the assessment.

• Additionally, psychiatrists should advocate for separation of records and for limits to exposure of information such that only elements of information that are essential for purposes of the agency can be revealed.’

Working with mentally disordered offenders can evoke strong feelings within the professional team providing their care. This is something for which general training can leave trainees underprepared to manage their own feelings and complex team dynamics when the perpetrator of a particular offence, for example, murder or sexual child abuse, requires treatment. Attending a Balint-style case-based discussion group may be helpful in understanding and managing some of the complex emotions generated and allow consideration of the countertransference evoked [14, 15]. In a traditional Balint group, named after psychoanalyst Michael Balint, participants meet regularly with a leader and discuss a clinical case brought by one of the participants. Discussion focuses on the doctor-patient relationship and is useful for discussing cases where strong feels have been evoked in the clinician. Non-case-based reflective practice groups also have a role in allowing forensic trainees a forum to discuss and consider the challenges and implications of working within restrictive environments and the emotions this generates. Typically these sessions take place on a weekly basis and are facilitated by someone out with the clinical team. Themes include discussion of the complex dynamics of working within institutions and multidisciplinary team.

5.4 Clinical Expert/Witness Training

As previously discussed, one role of forensic clinicians is to provide an expert opinion on an individual’s mental health to courts or other legal bodies. This evidence can be written or verbal. Giving verbal evidence in court can be an anxiety-provoking experience for which trainees should receive guidance, training and support. This will reduce anxiety and improve the impact of evidence delivered. Key components are as follows:

• Training on the content of the written report which forms the basis for any examination

• Knowledge of court proceedings and etiquette

• Advice regarding delivery of evidence

• Practice in undergoing cross-examination

Such teaching can be delivered on an informal basis, such as during a supervision session, or in a more formal environment. Some bodies and agencies provide specialist training in this field, for example, the Swiss Society of Forensic Psychiatry. Attending court to observe experienced psychiatrists given oral evidence can also provide a valuable training experience.

6 Teaching Methods

As stated earlier, much training in forensic psychiatry and psychology is done through an apprenticeship model during clinical placements. There are a number of traditional and modern methods which can be utilised by teachers of forensic mental health, each with its own advantages and limitations as outlined below.

6.1 Lectures

The most traditional of teaching methods is the formal lecture. This format continues to maintain a place in undergraduate and postgraduate teaching curriculums due to its advantages over more contemporary methods as outlined below [16].

Advantages of Lectures

• Allow large volumes of basic information to be effectively delivered

• Cost-effective, allowing information to be disseminated to a large number to students at the same

• Provide an overview and/or framework for further learning or activities

• Generate a curiosity and interest in a topic

• Allow teacher to retain control of material covered to ensure important learning points are covered

Difficulties with Lectures

• Not suitable where large quality of detailed information is to be imparted as this is unlikely to be retained

• Communication flows primarily from teacher to student

• Limited opportunity to check learning or to gain feedback of effectiveness of teaching

• Poor student engagement with students adopting passive roles

These difficulties can be overcome or at least minimised by integrating interactive techniques such as asking questions and reviewing. Lectures may be appropriate in forensic psychiatry and psychology where a basic theoretic information needs to be delivered, for teaching of undergraduates about the provision of forensic mental health services or presenting new research at conferences or seminars.

6.2 Problem-Based Learning

Problem-based learning is a teaching method in which small groups of students explore their existing knowledge, identify areas for further learning, perform independent research and then return for group discussion. Learning centres around a clinical case or problem and meetings occur in the presence of a facilitator. As with lectures, there are advantages and disadvantages to utilising problem-based learning [17].

Advantages

• Development of generalisable skills, e.g. self-directed learning

• Experience of small groups highly relevant to working with teams

• Increased motivation of learning

• Development of extensive, flexible knowledge base

• Improved communication and psychosocial skills

• Can be used flexibly across curriculum

Disadvantages

• Anxiety and uncertainly during initial phase of skills acquisition

• Increased resources required

• Clinicians concern that students lack knowledge

• Costly

• May be more suitable for mature students

• Unfamiliar to teachers and other staff

This method may be useful in forensic mental health not only as a method for current trainees to develop knowledge and the habits of self-directed lifelong learning but through discussion of interesting and complex cases to inspire students and junior trainees to pursue a career in this field [18].

6.3 Utilisation of Technology

Over the last 20 years, education has evolved to include a range of technologies in developed countries. This can range from the use of Microsoft PowerPoint in lectures and tutorials to online e-learning modules. When used effectively, technology can improve engagement and enhance the learning experience, but when used ineffectively can distract from learning and feel misplaced.

• 1. Podcasts

  Podcasts, that is, audio or video file downloaded via the Internet onto a computer or a mobile device, are especially useful in providing specialist information that can be accessed at a convenient time to recipients across the globe. These allow for quick dissemination of recent updates in research and case law and are particularly valuable in geographical regions with a small number of forensic practitioners where specialist local teaching is not feasible.

• 2. Use of videos

  Video cameras offer a cheap and readily available opportunity to record interviews with consenting patient. When used in case presentations, they offer the audience an opportunity to assess the mental state of the patient and increase engagement. Case presentations provide the opportunity to teach others about themes or topics that arose in a particular case and to generate ideas and opinions regarding diagnosis, care and treatment from colleagues. Videos are also useful during the teaching of clinical and research tools, for example, the Hare’s Psychopathy Checklist-Revised (PCL-R) 2003 [19], as an adjunct to case information. This can allow demonstration and practice in the use of the tool and generate discussion to improve inter-rater reliability. Policies must be in place to ensure full consent is acquired prior to a video being made, videos are appropriately stored and videos are destroyed when no longer required.

• 3. E-learning modules

  In many European countries, continued professional development (CPD) is required by employers and to maintain membership of professional bodies. This often requires clinicians to record time spent training and at conferences. Attending such events, especially for those working in small or remote departments, can be costly and time-consuming. Electronic learning modules (e-learning) are a cost-effective way of undertaking core or additional learning at a convenient time. Such modules are best suited to theoretical learning but are also useful for facilitating consideration of ethical and legal issues. In the UK, the Royal College of Psychiatrists has a range of CPD-accredited online modules related to forensics from the assessment and treatment of sexually abnormal behaviour to people with intellectual disability in custodial settings. These forensic modules are found amongst a large collection encompassing different psychiatric specialities, clinical skills, professional skills and ethical issues.

6.4 Role Play

Although anxiety provoking for participants, role play can be an invaluable teaching method for forensic clinicians. In Scotland, forensic psychiatric trainees in the national training scheme attend monthly teaching sessions, with one session devoted to giving evidence at a mental health tribunal or in court. Prior to the session, the trainee supplied an anonymised report to a consultants forensic psychiatrist who reads the report and then takes the role of a lawyer and cross-examines the trainee upon it. The court or tribunal environment is simulated by other trainees taking the role of judge and other members of the court and the trainee having to adhere to court etiquette.

7 The Role and Responsibility of Teachers in Forensic Mental Health to Reduce Mental Health Stigma

Despite improved understanding and awareness of mental health issues, mental health services remain underfunded [20] compared to physical health equivalents, and stigma continues to affect an individual’s likelihood to present for help in a timely fashion. Due to limited public understanding, particularly of psychotic disorders like schizophrenia, a culture of fear prevails and there are misconceptions that those suffering from mental disorder are more likely to be perpetrators of crime than victims. It is the authors’ belief that those clinicians working within the field of forensic mental health have a role of educating not only trainees but the wider public to reduce this stigma.

8 Promotion of a Career in Forensic Mental Health

Reiss and Chamberlain [21] estimated that only half of UK medical schools provide clinical placements, workshops, seminars or specialist study modules in forensic psychiatry, and this is likely to be replicated across Europe. Even psychiatric or psychology trainees may not have had exposure to forensic mental health with Reiss and Famoroti [22] finding that a significant proportion of psychiatric trainees had not visited a prison. Lack of awareness and exposure to the speciality is likely to affect recruitment. Ensuring able candidates attracted to forensic practice has been one of the considerations of the Ghent Group. Practising clinicians can play a role in promoting careers in forensic mental health through attendance at careers fairs and by organising work experience placements or ‘taster weeks’ for interested individuals.

Conclusions

Despite different routes to practice in forensic mental health across Europe and variations in legislation, there are common skills and expertise which are required by all forensic practitioners. Alongside national training, our European context offers the additional opportunity for clinicians to learn how neighbouring countries address universal problems and to further understanding of our own practice.

As outlined in this chapter, there are a number of traditional and evolving teaching methods which can be used to develop knowledge and enhance expertise. Forensic clinicians should consider teaching and training as a core component of their occupation and endeavour to impart their skills and expertise.

As international links develop and evolve, forensic clinicians have the opportunity to share and learn from each other’s experiences. This will influence both practice and policy necessitating additional training and teaching. Through sharing of knowledge and ongoing research, forensic psychologists and psychiatrists across Europe can work together to improve both standards of teaching and of patient care.

Take-Home Messages

• Forensic psychologists and forensic psychiatrists require expert knowledge and skills which must be gained through formal learning and apprenticeship.

• Training is optimised by utilising a range of teaching techniques.

• Forensic mental health is an evolving field, and it is essential that practitioners engage in lifelong learning.

• Pan-European bodies offer the opportunity to improve training and education by facilitating the exchange of ideas and experiences.