Social Skills: Adolf Meyer’s Revision of Clinical Skill for the New Psychiatry of the Twentieth Century

Adolf Meyer (1866–1950) exercised considerable influence over the development of Anglo-American psychiatry during the first half of the twentieth century. The concepts and techniques he implemented at his prominent Phipps Psychiatric Clinic at Johns Hopkins remain important to psychiatric practice and neuro-scientific research today. In the 1890s, Meyer revised scientific medicine’s traditional notion of clinical skill to serve what he called the ‘New Psychiatry’, a clinical discipline that embodied social and scientific ideals shared with other ‘new’ progressive reform movements in the United States. This revision conformed to his concept of psychobiology – his biological theory of mind and mental disorders – and accorded with his definition of scientific medicine as a unity of clinical–pathological methods and therapeutics. Combining insights from evolutionary biology, neuron theory and American pragmatist philosophy, Meyer concluded that subjective experience and social behaviour were functions of human biology. In addition to the time-honoured techniques devised to exploit the material data of the diseased body – observing and recording in the clinic, dissecting in the morgue and conducting histological experiments in the laboratory – he insisted that psychiatrists must also be skilled at wielding social interaction and interpersonal relationships as investigative and therapeutic tools in order to conceptualise, collect, analyse and apply the ephemeral data of ‘social adaptation’. An examination of his clinical practices and teaching at Johns Hopkins between 1913 and 1917 shows how particular historical and intellectual contexts shaped Meyer’s conceptualisation of social behaviour as a biological function and, subsequently, his new vision of clinical skill for twentieth-century psychiatry.     

不同人群对精神病的态度

目的：了解社会不同人群对精神病的态度。方法：采用定性研究方法建立精神病态度问卷,然后使用该问卷在北京地区对精神分裂症病人及其病人家属、社区居民和精神科医护人员进行调查,结果：病人认为宝现人不会给他人带来危险,对精神病人的社会人才 治疗希望持最积极态度;家属与病人的看法趋向一致。但对精神病人的可治疗性和社会贡献不乐观;与病人、家属比较、社区居民对精神病则持最悲观和最消极态度;精神科医护人中峄精神病人的社会价值,行为的危险性以及是否要限制精神病人的社会活动等问题的看法,与病人,家属比更显悲观,但较社区居民的看法更开明,在精神病因上精神科医护人员的看法与其他三组人群不同,更倾向精神病是生物因素导致,而非人和家庭问题引起。论：尽快实施有效的干预措施,改变人对精神病的人不良态度,消除歧视,提高病人,家属的自信心和适应能力,将会对精神病的治疗与健康,改善精神病人的生活质量有着重大意义。     

A comparison of the emphasis given to nine therapies in residency training and later practice of psychiatrists

This study compared the emphasis given to various therapies in six psychiatry residencies and by psychiatrists in their later practice. Eighty-seven psychiatrists and 29 residents were surveyed in 1987. The two groups reported that almost the same amounts of time of their respective training programs had been devoted to the nine therapies surveyed. Patterns of practice were observed, including the finding that those who were highly trained in a therapy practiced it more than did those who had less training. Both those who were highly trained and those who were not extended their practices to the use of therapies in which their training was not extensive. Problems in the study design and variables affecting this type of research are identified as guidance for future investigations.     

Psychiatric education in an era of rapidly occurring scientific advances.

Scientific advances in the fields of molecular biology, neurobiology, pharmacology, epidemiology, genetics, neuroimaging, and cognitive neuroscience are influencing psychiatric diagnosis and treatment, and this influence will grow substantially in the future. The current shortage of psychiatrists will increase over the next several decades, resulting in the need to train primary care physicians in basic psychiatric care and the use of non-physician mental health professionals to administer time-intensive, formal psychotherapies. The juxtaposition of these two trends-an increasing scientific influence on the clinical practice of psychiatry and fewer psychiatrists to deliver that treatment-is cause for changes in the approach to psychiatric education. In addressing these issues, the authors suggest that (1) psychiatry should be more integrated into undergraduate medical education in both basic science and clinical curricula, (2) residents in primary care disciplines should have more direct exposure to psychiatric training, (3) joint instructional experiences involving psychiatry and primary care residents should be encouraged, (4) psychiatry residency programs should maintain flexibility in order to incorporate rapid advances in diagnostic procedures and treatments into residency training, (5) research experience should be integrated into psychiatry residency programs, and (6) departments of psychiatry must develop the leadership and expertise necessary to implement the incorporation of rapidly advancing scientific discoveries into the psychiatric curriculum.     

Consultation-liaison psychiatry 1990

Consultation-liaison (C-L) psychiatry is a subspecialty concerned with clinical service, teaching, and research by psychiatrists in nonpsychiatric health care settings. These activities are focused on the physically ill and on the somatizing patients. The main objective of C-L psychiatry is to maintain a bridge between psychiatry and medicine for the sake of providing biopsychosocial health care. C-L psychiatry's functions include clinical work, teaching, and research at the interface of psychiatry and medicine. This field has grown substantially in the past two decades as is brought out in this article.     

Labelling and illness in primary care: comparing factors influencing general practitioners' and psychiatrists' decisions regarding patient referral to mental illness services.

GPs and psychiatrists from South Wales were asked to make decisions based on the information included in each of 16 vignettes describing depressed and anxious subjects. This information contained randomly assigned sex, psychiatric label, good and bad psychosocial context and age as well as eight different severity ratings of depression and anxiety symptoms. Our results showed that both GPs and psychiatrists were influenced in their decision making by the severity of the illness, but that GPs alone were also strongly influenced by the presence of male sex and by the presence of a psychiatric label. Good or bad psychosocial context had no influence on the GPs' referral decision, and previous experience in psychiatry or other vocational training had no detectable effect, but this may be because of the sample size.     

Psychiatrists' attitudes,knowledge, and experience regarding genetics: a preliminary study

PurposeThis study is the first survey of a random national sample of US psychiatrists to assess attitudes, knowledge, and clinical experience regarding genetics. We hypothesized that clinicians with more recent genetics training would demonstrate more positive attitudes and greater genetics knowledge and experience than those with less recent training.MethodsA probability sample of US psychiatrists (n = 93) was invited to participate in a mail survey regarding genetic medicine.ResultsForty-five psychiatrists completed the survey (response rate = 48%). All believed that genetics strongly or moderately influenced a person's mental health. Respondents expressed positive attitudes toward incorporating genetics into psychiatric practice, but most did not have recent genetics training or experience in referring patients to genetic counselors or ordering genetic tests. Psychiatrists who had genetics training within the previous 5 years had more experience in providing genetic services.ConclusionsThis survey identified areas of strength (positive attitudes about providing genetic services, belief in the heritability of mental illness) and future targets for educational intervention (general genetics, information about testing and counseling resources). The association between recent training and a greater level of clinical genetics experience suggests that educational efforts may be successful in preparing psychiatrists to provide genetic services in the future.     

Hospital unit stressors that affect nurses: Primary task vs social factors

Liaison psychiatrists often define needs of hospital units in terms of their primary task, such as coronary care. However, it is possible that social systems variables also affect these needs. This study tests the assumption that primary task determines nurses stress and attitudes by comparing the work attitudes and clinical distress of nurses on two general medical units (GMUs) and two medical intensive care units (ICUs). The nurses in the ICUs differed from those in the GMUs in some work attitudes, but not in level of clinical distress. One ICU had much lower levels of clinical distress than any of the other units. The findings suggest that while primary task is an important element in determining some attitudes of nurses, social systems variables also contribute substantially to the stress level of unit nurses.     

Recognition of childhood depression: personal reminiscences

Prior to 1970, childhood depression was not considered a valid clinical entity by American psychiatrists. One of the early clues was provided in the 1950s by the author's observation of depressive symptoms in children and young adolescents with undescended testicles. This finding was extended to children with several chronic diseases, many of whom exhibited depressive symptoms as well. Eventually, depressive symptomatology was found in children without any physical disorders. This was followed by the introduction of a diagnostic instrument, called the Children's Affective Rating Scale (CARS), later converted into a more formal system called the Child Assessment Schedule (CAS). A provisional classification of childhood depression was published in 1972. Our examination of children with depressive disorders has revealed several modes of family interaction, of which the most important were: separation from important love objects; depreciation and rejection; and affective disorders in parents. Several children with bipolar disorder stimulated our interest in this disorder and led to a pilot study of children of bipolar, lithium-responding parents. Some of these children with bipolar illness had a clear-cut response to lithium and were strong augmenters of the average evoked potentials (EPs). Next, our group investigated the urinary excretion of norepinephrine and its metabolites in chronically depressed children who differed from a normal control group. The foregoing studies, along with major contributions by other child psychiatrists, eventually led to the acceptance of childhood depression as a clinical entity in US psychiatry. The acceptance of juvenile bipolar disorder had to await further research by a new generation of child and adult psychiatrists.     

What is the role of the psychiatrist in primary care?

Psychiatrist services are currently in a state of flux because of a change in philosophy towards care in the community. There is much disquiet among psychiatrists about the lack of resources needed to effect this change. However, the most appropriate focus of community care already exists in the form of the general practitioner's surgery, but at present it is rarely used to its full potential because liaison between general practitioners and psychiatrists is poor. Ways of improving the liaison between psychiatric and primary care teams are outlined that if implemented would enable community psychiatry to flourish.     

Clinical Psychologists in Departments of Psychiatry: Current Issues and a Look to the Future

The aim of this article is to discuss issues facing psychologists who work in departments of psychiatry. The authors both have experience in such settings and address relationships between psychologists and psychiatrists, the differences in training backgrounds and approaches to understanding and treating mental health disorders, and issues related to productivity. In many departments, clinical psychologists do not have equal standing with psychiatrists when it comes to compensation, competition for resources, and administrative representation. Nevertheless, when calls for increasingly multimodal research and treatment approaches are considered along with the requirement that psychiatry residency training programs require instruction in empirically supported psychological treatments, one recognizes that psychologists will continue to fill important roles in departments of psychiatry for the foreseeable future.     

Should we train psychiatrists as primary care providers?

The author discusses the proposition that psychiatrists would be appropriate primary physicians for specific types of patients. The author reviews the arguments for and against psychiatrists as primary care providers, proposes questions that must be addressed in training for such a role, and describes current models of primary care education and practice for psychiatrists. The author believes that primary care may be an appropriate career track within psychiatry and suggests that the development of family medicine may provide useful guidance in incorporating primary care functions into psychiatry.     

Shared decision-making in ongoing outpatient psychiatric treatment

Objective

Research on patient involvement in decision-making in psychiatry has focused on first encounters. This study investigated what decisions are made, level of patient involvement and factors influencing patient involvement in ongoing outpatient visits.

Methods

72 visits conducted by 20 psychiatrists were video recorded. Patients had a diagnosis of depression or schizophrenia.

Results

On average, there was one medication related and one other decision per visit. Some psychiatrists involved patients more in decisions, as did female psychiatrists. Involvement was lower when patients had more negative symptoms.

Conclusion

Involvement in decision-making appears to be influenced by the individual psychiatrist and specific symptoms but not visit length.

Practice implications

It is noteworthy that patient involvement is not influenced by length of the visit given that this would be a barrier in busy clinical practice. The next step would be to identify the communication patterns of psychiatrists who involve patients more in decision-making.     

COVID-19: risk accumulation among biologically and socially vulnerable older populations

Emerging data show that the health and economic impacts of COVID-19 are being disproportionately borne by individuals who are not only biologically, but also socially vulnerable. Based on preliminary data from Sweden and other reports, in this paper we propose a conceptual framework whereby different factors related to biological and social vulnerability may explain the specific COVID-19 burden among older people. There is already some evidence showing large social disparities in the prevention, treatment, prognosis and/or long-term consequences of COVID-19. The remaining question is to what extent these affect older adults specifically. We provide the rationale to address this question with scientific methods and proper study designs, where the interplay between individuals’ biomedical status and their social environment is the focus. Only through interdisciplinary research integrating biological, clinical and social data will we be able to provide new insights into the SARS-CoV-2 pandemic and inform actions aimed at reducing older adults’ vulnerability to COVID-19 or other similar pandemics in the future.     

Psychiatrists' attitudes to maintenance medication for patients with schizophrenia

BACKGROUND: Maintenance antipsychotic medication is the mainstay of relapse prevention in patients with schizophrenia. Long acting depot antipsychotics were developed to promote treatment adherence and yet their utilization is variable, perhaps due to negative attitudes of both patients and psychiatrists. Recently, a shift away from depots has occurred, in favour of the newer atypical oral antipsychotics. METHOD: This study investigated the current attitudes and knowledge concerning depots, with a newly designed questionnaire, in a cross-sectional postal survey of qualified psychiatrists working in south-east England. RESULTS: A substantial minority of psychiatrists believe that depots are old fashioned (40%), stigmatizing (48%) and are associated with more side-effects than typical oral antipsychotics (38%). Many believe that depots are as efficacious as oral medication (91%) but are less acceptable to patients (69%) and relatives (66%). A large majority consider depots enhance patient compliance (81%) and prevent relapse (94%). Psychiatrists would be persuaded to prescribe depots if they were associated with fewer side-effects, in patients where compliance is an issue, and if atypical depot antipsychotics were available, presumably because they would have a lower incidence of side-effects. Additionally, psychiatrists' knowledge about depots was positively associated with attitudes. More favourable patient-centred attitudes were reported by psychiatrists with higher depot use. CONCLUSION: Practising psychiatrists have several strongly endorsed attitudes towards depot medication that are associated with knowledge and prescribing habits. By updating psychiatrists' knowledge about depots, in turn their attitudes may become more positive and prescribing practices may subsequently change.     

The separation of mothers and babies in the treatment of postpartum psychotic disorders in Britain 1900–1960

Summary Background: In the first half of the twentieth century, women with postpartum psychotic disorders were routinely separated from their babies, whether they were cared for at home or in asylums. Treatment of mothers with their infants started in the 1950s but the reasons for this change in policy have not been explored. Methods: Examination of secondary and primary historical sources, including a systematic manual search of articles in the Journal of Mental Science (1900–1960) using key-words, use of other journals and successive editions of British textbooks and a search of the Wellcome Institute history of medicine catalogue. Results: The sources used document the influence of the rise of psychoanalysis, the absence of women carers in positions of power in the asylums, changes in psychiatry as a specialty and changes in family structures on the treatment of women with postpartum psychotic disorders. Conclusions: Changes in practice were associated with improvement in psychiatric treatment, changes in the nature of asylums as a result of government policy, changes in family structures with a lack of surrogate care, the development of social psychiatry and the increase in women psychiatrists. Practices in psychiatry are influenced by current paradigms and social and political influences in addition to evidence based knowledge.     

Lifetime influence of one year with Gerry Smith

I spent just one year working with Gerry Smith; it was during the research elective portion of my last year of psychiatry residency. That single year's experience has had a lasting influence on my career choices, not just in terms of content of work, but also in the approach to the professional life as a whole. Whereas the work I do today may bear little direct resemblance to what I did in the Bourne Laboratory more than 25 years ago, Gerry had a major influence on the what and the how of my professional career. Gerry was more than a mentor; he was a friend, philosopher, and guide. He promoted a value system that included a passion for learning and collegiality. He always stressed that empirical data trumped expert opinions, and that it was necessary to challenge long-held scientific dogmas from time to time. Through personal example, he showed the importance of giving back to one's trainees what one had received from the mentors. He also showed how even animal research could be an enjoyable social activity. Last but not least, Gerry's way of treating the laboratory staff, including faculty and trainees, as a family, was one of a kind. Most mentors are useful for teaching content of research; Gerry is one of those few who serve as role models-not only as scientists but also as professionals.     

General practitioners and psychiatrists: comparison of attitudes to depression using the depression attitude questionnaire.

BACKGROUND. Variation in the management of depression may be linked to doctors' attitudes to depression. AIM. A study was undertaken comparing the attitudes to depression between general practitioners and psychiatrists. METHOD. A sample of 74 general practitioners and 65 psychiatrists in Wales was surveyed by postal questionnaire. Attitudes were assessed by the depression attitude questionnaire and patient management was assessed by a questionnaire on prescribing practice. RESULTS. General practitioners differed significantly from psychiatrists in attitudes, particularly in areas covering professional ease in dealing with patients with depression and identification of depression. Those general practitioners who reported use of low antidepressant doses were significantly more likely than general practitioners prescribing standard doses to believe in psychotherapeutic treatments. Users of short-term continuation therapy expressed a lack of therapeutic optimism and comfort in dealing with depressed patients. CONCLUSION. General practitioners and psychiatrists differ significantly in their attitudes to depression. The attitudes which vary among general practitioners reflect practice. The depression attitude questionnaire may prove useful in indicating how educational initiatives to improve primary care detection and management should be directed.     

The psychiatric rotation: Traditional inpatient or consultation clerkship?

Thirty-nine medical students on a junior clinical clerkship in consultation psychiatry were compared with 21 students on a more traditional inpatient clerkship for changes in formal psychiatric knowledge, interest in psychiatry, self-rated psychiatry skills, and attitudes about psychiatry. Both groups showed comparable increases in objective knowledge and increased comfort with psychiatric patients. Minor but no fundamental differences between the two groups were ascertained by objective testing. The findings support the observation that students on a consultation clerkship can learn clinical psychiatry as well as those on traditional inpatient clerkships.