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Psychiatry, subjectivity and emotion - deepening the medical model
No full textMorale among psychiatrists continues to be seriously challenged in the face of recruitment difficulties, unfilled posts, diagnostic controversies, service reconfigurations and public criticism of psychiatric care, in addition to other difficulties. In this article, we argue that the positivist paradigm that continues to dominate British psychiatry has led to an undervaluing of subjectivity and of the role of emotions within psychiatric training and practice. Reintegrating the subjective perspective and promoting emotional awareness and reflection may go some way towards restoring faith in the psychiatric specialty
Learning about emotions in illness: Integrating psychotherapeutic teaching into medical education. Explorations in mental health
No full textGood communication between the doctor and patient is essential for the patient to establish a trusting relationship with their doctor and to make the best use of the appropriate treatment. Traditional methods for teaching communication skills have focused on simulated clinical situations in which students learn how to improve their communication, with actors playing the part of the patients, rather than from live experiences with patients. Psychodynamic psychotherapy, with its emphasis on learning to reflect on experiences, offers the student the possibility of learning from a real experience with a patient. Such opportunities allow students to learn directly about patients’ emotions, as well as to appreciate their own emotional responses to illness and to communicate better with their patients.
In this book, Peter Shoenberg, Jessica Yakeley, and their contributors who include students and teachers, discuss two different teaching approaches developed at University College London to help medical students understand the role of emotions in illness, communicate more effectively, and gain a deeper understanding of the doctor patient relationship. The benefits of Ball, Wolff and Tredgold’s Student Psychotherapy Scheme are considered alongside Shoenberg and Suckling’s short term student Balint discussion group scheme to provide clear guidance about how psychotherapeutic understanding can be used to inform medical education, with positive results.
At a time when medicine is becoming increasingly technological and there is a growing demand by the public for more psychologically minded doctors, this book will be a key resource for physicians, general practitioners, psychologists, psychiatrists and psychotherapists who are involved in medical teaching and for medical students
Self-referrals to a doctors’ mental health service over 10 years
No full textBackground:
The adverse impact on doctors’ health of constant organizational change in healthcare is well established.
Aims:
To investigate the change in self-referral rates to a doctors’ mental health service, and associated morbidity over a decade.
Methods:
All doctors attending a doctors’ mental health service between 1 January 2002 and 31 December 2011 were asked to complete the Clinical Outcomes in Routine Evaluation questionnaire and Maslach burnout inventory as part of routine assessment before treatment. Univariate analysis of variance was used to test for statistically significant differences between severity scores in different years.
Results: Between 1 January 2002 and 31 December 2011, 1062 doctors attended the service; 852 (80%) completed both questionnaires and 64 (6%) completed one of them. The overall response rate was 86% (916/1062). Referrals increased >4-fold, from 44 in 2002 to 185 in 2011. Sixty-one per cent scored above the threshold for psychological distress and 59% for burnout. There were no significant changes in morbidity over time.
Conclusions:
Increasing numbers of doctors sought help from the doctors’ mental health support service. More than half scored above the thresholds for burnout and psychological distress and these proportions were consistent over 10 years. Doctors may be more willing to seek help than a decade ago. Further research is needed to confirm the underlying reasons for this. More resource is needed to meet the increase in demand
The application of a domains‐based analysis to family processes: Implications for assessment and therapy
No full textSocial domains are classes of interpersonal processes each with distinct procedural rules underpinning mutual understanding, emotion regulation and action. We describe the features of three domains of family life—safety, attachment and discipline/expectation—and contrast them with exploratory processes in terms of the emotions expressed, the role of certainty versus uncertainty, and the degree of hierarchy in an interaction. We argue that everything that people say and do in family life carries information about the type of interaction they are engaged in—that is, the domain. However, sometimes what they say or how they behave does not make the domain clear, or participants in the social interactions are not in the same domain (there is a domain mismatch). This may result in misunderstandings, irresolvable arguments or distress. We describe how it is possible to identify domains and judge whether they are clear and unclear, and matched and mismatched, in observed family interactions and in accounts of family processes. This then provides a focus for treatment and helps to define criteria for evaluating outcomes
Struggling with cultural prejudice while observing babies: Socio-centric and egocentric positions
No full text
Exposure to acute child psychiatry presentations for core psychiatrists
No full textDeclaration of interest -
R.C. sits on the College’s Emergency Care Taskforce, which is currently considering the value of out-of-hours training.
We are writing to draw attention to the lack of clarity provided by the Royal College of Psychiatrists regarding the role of the core trainee psychiatrist in assessing child and adolescent psychiatry patients out of hours. We believe it is important this issue is addressed as it confers broad implications for training, recruitment and service delivery. Crises of paediatric mental health tend to present out of hours. Ireland’s 4th annual child and adolescent mental health service report details ‘striking patterns in the number of [self-harm] presentations seen’: 51% of presentations were in the 8-hour period of 7pm to 3am.1 This finding appears typical for paediatric psychiatry liaison services around the UK.
It is well known that in some trusts core trainees are excluded from child and adolescent mental health services (CAMHS)-led out-of-hours care pathways. This situation seems particularly unsatisfactory given that placements in developmental psychiatry are no longer obligatory. By failing to adequately furnish our future adult psychiatrists with skills in child and adolescent mental health, we are reinforcing a culture whereby young people are potentially falling through the care gap between CAMHS and adult mental health services.2,3 Indeed, this very issue is highlighted in a joint paper from the inter-faculty group of the child and adolescent psychiatry and the general and community psychiatry faculties which presents recommendations for the provision of psychiatric services to adolescents and young adults.4 Furthermore, by restricting the level of exposure to child psychiatry, we are doing little to encourage core trainees to perceive the specialty as a future career option.
As well as having an impact on the quality of training, the issue has far-reaching implications for patient care. The current lack of clarity fosters an atmosphere of uncertainty as situations arise where no one knows who holds responsibility to clerk a young person on arrival, thereby leading to potential delays in the patient being seen. Emergency department delays are a source of great concern to acute care trusts and create negative attitudes to psychiatric services in general. If we cannot manage to work in a safe and effective way, we are further contributing to the hostility not only towards our specialty but also to our patients, who are at their most vulnerable.
It is therefore our view that there should be an explicit expectation for core trainees to have exposure to the full range of acute psychiatric presentations, including child and adolescent patients, out of hours. It is of course essential that this experience would be supported by robust and accessible supervision structures in the form of a second on-call specialty trainee or consultant child psychiatrist. Although we recognise that the College is unable to tell trusts how to deliver their out-of-hours services, it would be helpful if the core psychiatry curriculum contained more robust guidance as to the role of the core trainee in assessing child and adolescent psychiatry cases out of hours. Such a move would help to create clarity as well as holding local education providers to account
'I'm beyond caring’, a response to the Francis Report: The failure of social systems in health care to adequately support nurses and nursing in the clinical care of their patients
No full textLord Francis was commissioned to look at why the serious problems (between January 2005 and March 2009) at Mid Staffs Foundation Trust were not identified sooner and the appropriate action taken. Lord Francis was also asked to outline what lessons could be learned to enhance patient care. The report was delivered on 5 February 2013 and contained 290 recommendations. The key message was that the National Health Service needed to put the patient first and everything else should flow from that principle. Poor standards of care should not be tolerated and staff would be expected to speak out when they felt patient care was being compromised. Lord Francis also recommended that there should be one regulatory body and that the role of the Care Quality Commission was to be reviewed
The impact of co-morbid personality disorder on use of psychiatric services and involuntary hospitalization in people with severe mental illness
No full textPurpose:
To examine the impact of co-morbid personality disorder (PD), on inpatient and community-based service use and risk of involuntary hospitalization, amongst patients with severe mental illness (SMI).
Methods:
We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) with and without co-morbid PD, and PD cases, aged ≥18 years, in a large secondary mental healthcare case register. Using multivariable logistic regression, we examined the association between co-morbid PD and high level of inpatient and community-based service use (defined as the top decile of service use), and involuntary hospitalization, respectively, adjusting for socio-demographics, clinical symptoms and social functioning.
Results:
Severe mental illness patients with co-morbid PD (SMI-PD) (n = 961) had more severe symptoms and social functioning problems compared to SMI patients without PD (n = 10,963) and patients who had PD but no concurrent SMI (n = 2,309). A greater proportion of SMI-PD patients were high inpatient service users (22.4 vs. 10.1 %). This association was attenuated but remained significant, after adjustment (fully adjusted odds ratio, OR 2.31, 95 % CI 1.88–2.84). The association between SMI-PD and high community-based service use was confounded by symptoms and social functioning. Compared to patients with SMI, SMI-PD patients were significantly more likely to experience involuntary hospitalization (fully adjusted OR 1.56, 95 % CI 1.31–1.85).
Conclusions:
In SMI patients, co-morbidity with PD is robustly associated with both high use of inpatient psychiatric services and an increased likelihood of involuntary hospitalization. Patients with SMI and co-morbid PD are likely to require tailored interventions that target both the underlying personality pathology as well as the Axis I disorder
The Family Drug and Alcohol Court Service in London: A new way of doing care proceedings
No full textIn this article, three professionals from the Tavistock & Portman NHS Foundation Trust, who have been instrumental in developing the Family Drug and Alcohol Court (FDAC) clinical model, introduce the background to this project. The FDAC model is highly dependent on a collaborative approach from local authorities, Government, the Courts, the NHS and the charitable sector, and we hope to give a flavour of that here. In addition to describing what it is that makes FDAC significantly different from other models of working, we also want to give a description of what it is like to be a social worker within the multi-disciplinary team