Création d’une consultation psychiatrique ouverte aux préparationnaires du 5e et du 6e arrondissement de Paris : retour d’activité sur l’année 2017–2018

Part of the French post-secondary education system is the Classes Préparatoires aux Grandes Écoles (High School Preparatory Classes) which consists of two intensive years (or three years sometimes) to pass the entrance examination of the Grandes Écoles. Grandes Écoles are highly selective, elite, and prestigious institutions [10]. The difficulties for these students are a higher stress (succeed the entrance examination), lack of time (all their time is dedicated to studies). The access to public psychiatric health system depends on where you live. Due to their schedule, they spend most of their time in the high school and they can’t consult in the psychological centre whom they depend [9]. In these conditions, in December 2017, public psychiatric care of the 5th and 6th districts of Paris created a psychiatric consultation in one high school opened to the students in Classes Preparatoires which signed a convention with the psychiatric ward.ObjectivesThis study aims to debrief the activity and the student profiles in the first year of this consultation.Patients and methodsThe patients are composed of students registered in Classes Préparatoires from the 5th and 6th district of Paris and who came to the psychiatric consultation, aged from 16 to 19 years old and referred by school nurses, school doctors, psychiatric ward or student himself. Retrospective study based on the activity of the consultation and medical files of psychiatrics consultations between December 2017 and July 2018.ResultsFifteen students consulted with a mean of 5.2 ± 2.9 consultations per students, eleven of them were oriented by school nurses. Eleven students benefited from a regular follow-up or an “in case of need” consultation. Five students had already received a psychotropic drug before the consultation; at the end of the year, ten of them received medication. The most prescribed category of medication are antidepressants and anxiolytics with seven patients apiece. The most represented disorders are a major depressive disorder (41%), adaptative disorder (29%), anxiety disorder (12%). Four students stopped their studies in the high school during the academic year. Two students needed to be hospitalized in the psychiatric ward of the district, they continued their education in their high school after hospitalization.ConclusionThe consultation for the Classes Préparatoires aux Grandes Écoles allowed an access to a psychiatric offer next to the place those students spend most of their time, without going to an emergency structure and with a shorter waiting time compared to the psychological centre in public health system. This consultation enables the evaluation, the follow-up and the orientation of the students, including the hospitalization when it is needed but also to sustain some students in their studies. In views of requesting a psychotherapy and the usual waiting time in the psychotherapeutic centre for students which already exist, there is important need to provide increased resources for these students.     

Evaluation of social problem solving after traumatic brain injury

A trial of a procedure for the assessment of social problem-solving skills (the Social Problem-Solving Test; SPST), designed to assess 18 component skills distributed across five domains of functioning, is reported. A group of 48 persons with traumatic brain injury (TBI) observed seven videotaped scenarios involving a complex social interaction between two people. They were first questioned about their interpretation of the event, and how the actors should respond, and then asked to complete a role-play in which they were required to implement a strategy to reach a specified goal. Their performance on each of the components was compared with the results from 20 aged-matched family controls. The TBI participants were most impaired in their ability to perform in a socially skilled manner in the role-play and evaluate this performance, and their orientation towards resolving the problem was characterised by greater anxiety and evaluation of difficulty. The results support the usefulness of procedures designed to identify the specific deficits in social problem solving of persons in post-acute rehabilitation.     

Evaluation of social problem solving after traumatic brain injury

A trial of a procedure for the assessment of social problem-solving skills (the Social Problem-Solving Test; SPST), designed to assess 18 component skills distributed across five domains of functioning, is reported. A group of 48 persons with traumatic brain injury (TBI) observed seven videotaped scenarios involving a complex social interaction between two people. They were first questioned about their interpretation of the event, and how the actors should respond, and then asked to complete a role-play in which they were required to implement a strategy to reach a specified goal. Their performance on each of the components was compared with the results from 20 aged-matched family controls. The TBI participants were most impaired in their ability to perform in a socially skilled manner in the role-play and evaluate this performance, and their orientation towards resolving the problem was characterised by greater anxiety and evaluation of difficulty. The results support the usefulness of procedures designed to identify the specific deficits in social problem solving of persons in post-acute rehabilitation.     

More Practice, Less Preach? The Role of Supervision Processes and Therapist Characteristics in EBP Implementation

Identifying predictors of evidence-based practice (EBP) use, such as supervision processes and therapist characteristics, may support dissemination. Therapists (N = 57) received training and supervision in EBPs to treat community-based youth (N = 136). Supervision involving modeling and role-play predicted higher overall practice use than supervision involving discussion, and modeling predicted practice use in the next therapy session. No therapist characteristics predicted practice use, but therapist sex and age moderated the supervision and practice use relation. Supervision involving discussion predicted practice use for male therapists only, and modeling and role-play in supervision predicted practice use for older, not younger, therapists.     

A collaborative-interactive model for mental health consultation: Teacher inservice education by psychiatric clinicians

Primary prevention of emotional disorders is often cited as a goal in community mental health consultation. The daily contact with children and parents by the classroom teacher can yield effective prevention, if the teacher is appropriately prepared to act as a resource, and by clinicians given an awareness of emotional difficulties in children and their parents. Though consultation is often described as facilitative of change, typically discussions of such programs emphasize technique rather than content. Presented here is acollaborative model based upon a didactic input of humanistic psychology, upon which educator and clinician draw as they become allies in pursuit of answers to questions raised in current examples from the teacher's classroom experience. Excerpts and results of the model's effectiveness are given.     

Mental health consultation

This paper presents a systematic model describing current consultation. It originates from the needs of consultees to adapt to new roles and to meet grassroots pressure. It builds upon the earlier consultation models of Caplan and Berlin and their intention that consultation have far-reaching consequences. It has strong roots in the public health tradition of primary prevention. Processes consistent with the model focus on relationship, self-disclosure, and role modeling to effect change in other systems. Examples of pay-off for consultees and their systems are presented.     

A college credit model of in-school consultation: A functional behavioral training program

Classes and workshops for teachers in mental health principles and techniques are abundant but rarely have they been taken directly to the teachers' school or classroom. The program discussed is a pilot study combining the didactic structure and credit of a college seminar with the immediate relevance, support, and training of a traditional in-school consultation. Teachers were trained in the implementation of functional-behavioral intervention skills. Evaluative data collected from attitudinal questionnaires received from the teachers and records obtained from teacher implemented interventions support the effectiveness of this model in training teachers as therapeutic change agents in their classrooms.     

Role-Play Assessment of Therapist Adherence and Skill in Implementation of Trauma-Focused Cognitive-Behavioral Therapy

Numerous efforts are underway to train clinicians in evidence-based practices. Unfortunately, the field has few practical measures of therapist adherence and skill with which to judge the success of these training and implementation efforts. One possible assessment method is using behavioral rehearsal, or role-play, as an analogue for therapist in-session behavior. The current study describes aspects of reliability, validity and utility of a behavioral role-play assessment developed to evaluate therapist adherence and skill in implementing Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). TF-CBT role-play assessments were conducted with a sample of 43 therapists as part of a larger training study. The TF-CBT role-play assessments were independently coded for TF-CBT adherence and skill by a certified TF-CBT trainer and three clinical psychology doctoral students. Findings indicated good interrater reliability for the individual items (ICC: M?=?.71, SD?=?.15). Regarding utility, 67.19% (n?=?43/64) of contacted therapists completed the role-play assessment, which took an average of 30 min (M?=?31.42, SD?=?5.65) to complete and 60 min (M?=?62.84, SD?=?11.31) to code. Therapists with a master’s degree were more likely to complete the role-play assessment than those with other degrees but no other differences in demographic variables, practice characteristics, or TF-CBT knowledge or training were found between participants and nonparticipants. Role-play assessments may offer an alternative to observational coding for assessing therapist adherence and skill, particularly in contexts where session recordings are not feasible.

     

Virtual Reality Job Interview Training in Adults with Autism Spectrum Disorder

The feasibility and efficacy of virtual reality job interview training (VR-JIT) was assessed in a single-blinded randomized controlled trial. Adults with autism spectrum disorder were randomized to VR-JIT (n = 16) or treatment-as-usual (TAU) (n = 10) groups. VR-JIT consisted of simulated job interviews with a virtual character and didactic training. Participants attended 90 % of laboratory-based training sessions, found VR-JIT easy to use and enjoyable, and they felt prepared for future interviews. VR-JIT participants had greater improvement during live standardized job interview role-play performances than TAU participants (p = 0.046). A similar pattern was observed for self-reported self-confidence at a trend level (p = 0.060). VR-JIT simulation performance scores increased over time (R ² = 0.83). Results indicate preliminary support for the feasibility and efficacy of VR-JIT, which can be administered using computer software or via the internet.     

Need for Child Mental Health Consultation and Paediatricians' Perception of these Services: A Survey in the West Midlands

Background:  High rates of psychopathology have been noted in children presenting to GP surgeries and paediatricians. However, paediatricians do not always recognise this and when they do the Child and Adolescent Mental Health Service (CAMHS) is often unable to meet their consultation needs.
Method:  This postal survey looked at paediatricians' perception of the need for child psychiatry consultation in the West Midlands.
Results:  The survey confirmed that paediatricians see a significant proportion of children with mental health problems and the findings showed that their need for child psychiatry consultation was not being adequately met. Lack of access to CAMHS was a significant issue.
Conclusions:  This has implications not only for further development of consultation services within CAMHS but also for improving training in child psychiatry for paediatricians in a more formalised way.     

The Introduction of Role-play to a Group of Women with Learning Disabilities: Graded Stages in Developing Role-play Skills and Some Practical Hints for Facilitating Role-play

This paper describes the experiences of introducing role-play in the context of a women's group aimed at developing assertiveness around appropriate and inappropriate touch. The aim of the group was to provide the women with skills they would be able to generalise to everyday situations. We aim to highlight an approach for overcoming the difficulties we have experienced in previous group work and give a practical guide for people attempting similar projects.     

Caregivers' expectations of services at Baragwanath Hospital, Soweto and their understanding of the child's disability

Sixty-one caregivers were interviewed before and after their first visit with the child in their care to specialist neurodevelopmental outpatient clinics at Baragwanath Hospital, Soweto. The interview focused on their understanding of the child's disability and their expectations of the service offered at the clinics. Before consultation the majority of caregivers had a fair understanding of the child's functional problems and the short-term complications, but after the consultation levels of understanding decreased significantly. Caregivers left the consultation with a significantly improved understanding of the aetiology of the problem. Understanding of long-term complications did not differ significantly before and after the consultation. These findings may reflect the consultative process, as professionals may be more comfortable discussing aetiology than long-term complications. Caregivers in a state of shock may be unable to absorb all the information given, and translation during consultation may also be a confounding factor. Even though more than half the caregivers had no idea what services the clinics offered prior to the consultation, the majority (81%) indicated they were satisfied with the service after the consultation.     

Teaching mental health skills to general practitioners and medical officers.

David Goldberg opened by describing the research that had led up to the present WPA teaching package. Early research had demonstrated that many psychological illnesses were not detected in primary care settings (Goldberg & Huxley 1980; ibid 1992), and these findings have been replicated in 14 centres round the world, with broadly similar results (Ustun & Sartorius 1995). We have found that in the UK the problem is not defects in factual knowledge, but not having clinical skills to assist in the management of mental disorders in general medical settings. The clinical skills needed in primary care are seldom taught in medical schools, and cannot be learned by listening to a lecture: it is necessary to practice them after they have been demonstrated. To do this it is convenient to break complex clinical skills down into their components: these are called "micro-skills", and we will deal later with the way in which these are taught. The most powerful method for improving mental health skills in this setting is to provide doctors with feedback--either video or audio--of their interview with real patients. The emphasis of such teaching must be on the interview techniques used by the doctor, rather than the clinical problems displayed by the particular patient being interviewed (Gask et al 1991). The problem with this is that video-feedback teaching of the necessary type is not always available, so we have developed videotapes that we can send out to distant locations, and which focus the attention of both local tutor and postgraduates on what should be learned. Because it is essential that most of the teaching is done by the live teacher rather than the videotape, there are always several "discussion points" so that postgraduates can ask questions, or describe their own way of dealing with particular situations. The videotapes are supplied together with teaching notes for the tutor, power points slides which can be adapted to suit local conditions, "role plays" to allow postgraduates to practice each skill they wish to learn, and other support materials. There is also a paper written by ourselves in association with Norman Sartorius, who has encouraged us to prepare the teaching package under the auspices of the WPA. Linda Gask described the process of teaching specific 'microskills', by working through how the skills necessary for the management of people who present in primary and general medical settings have been described and taught in the UK (see box 1). A model of the strategies and skills to be [figure: see text] taught was first developed utilizing the experience professionals and teachers from both primary care and mental health. A videotape was produced in which the skills to be acquired were demonstrated by real primary care doctors in role-played interviews with the addition of subtitles to label particular skills. The videotape is then utilised in a group teaching session to model the specific component skills of the model or 'microskills' to the participants in order to demonstrate exactly how the strategies of the model are applied in a real consultation. Watching the videotape will not however change behaviour. To do this, it is necessary to role-play brief scenarios so that the professional is able to practice the actual words he or she would use. This role-play work may be carried out in pairs, with one doctor playing the professional and the other playing the patient, or in threes, with the addition of an observer who ensures that the participants keep to the task. At the end of the role-play all participants provide feedback. These methods are described in much more detail in Gask (1999). Finally, there is also the possibility of videotaping one of these role-played interviews and teaching on this tape with the group as a whole. The specific skills and methods required to do this are described in much more detail along with the research evidence for these methods in Gask (1998). Our approach to facilitating the group in the exercise of videofeedback teaching is summarised in box 2.     

Rollenspiel im Psychodrama

Role-play is one basis of psychodrama and yet a vague concept. The author thus differentiates between role-play as a didactic method and as one of several central techniques of psychodrama. The article describes, using eight case examples, theory, practice and neurobiological considerations with regards to the different complex effects of role-play in the context of psychodrama. The differences between role-play as a didactic method and psychodrama are elaborated.     

Medical care after myocardial infarction.

One hundred patients suffering a myocardial infarction were interviewed in hospital and at 2 and 12 months after the infarct. Patients and families had only a limited recollection and understanding of medical advice and compliance was frequently poor. Compliance did not correlate with any of our psychological or social measures and continued consultation and treatment was not clearly related to the apparent medical or social problems. Despite considerable consultation during the year, doctors underestimated psychosocial morbidity. We conclude there are strong medical and cost-benefit arguments for introducing and evaluating simple routine rehabilitation programmes designed to provide the right treatment for the right patients.Medical opinion on recovery from myocardial infarction is strongly in favour of an optimistic and active convalescence yet we have found substantial psychological and social effects of first infarction, largely unrelated to cardiac state, affecting the family as much as the patient [1–3]. These findings are only of clinical value if they lead to improvement in diagnosis and treatment. Ideally, medical care should be effective in providing information, advice and treatment so as to minimise distress and medical and social disability. Such care should also be efficient, using limited skills and resources to give every patient just as much help as he requires. This paper reports three aspects of effectiveness and efficiency: (1) advice and compliance; (2) consultation: extent and determinants; (3) detection of psychosocial complications.     

Medical students’ learning processes the first time they role-play in psychiatry: A grounded theory study

BackgroundRecent changes in psychiatric care and teaching that limit patient contact for medical students can be overcome in part by simulation-based education. Understanding the learning processes of medical students involved in psychiatric simulation-based programmes could usefully inform efforts to improve this teaching. This study explored the learning processes of medical students the first time they role-play in psychiatry.MethodsWe used constructivist grounded theory to analyse semi-structured interviews of 13 purposively sampled medical students and the six psychiatrists who trained them. To improve the triangulation process, the results of this analysis were compared with those of the analyses of the role-play video and the debriefing audio-tapes.ResultsFive organising themes emerged: improving the students’ immediate perception of patients with mental disorders; cultivating clinical reasoning; managing affect; enhancing skills and attitudes and fostering involvement in learning psychiatry.ConclusionResults suggest that psychiatric role-playing can improve students’ progressive understanding of psychiatry through the development of intuition and by allaying affects. Emotional elaboration and student involvement appear to be key features.     

Which is more important for outcome: the physician's or the patient's understanding of a health problem? A 2-year follow-up study in primary care

ObjectiveWe sought to examine (1) whether the patients' and the family physicians' (FPs') beliefs about the nature of a health problem predict health outcomes and (2) whether the FPs were aware of their patients' beliefs.MethodsA 2-year follow-up study of 38 FPs and 1131 patients presenting with well-defined physical disease (n=922) or medically unexplained symptoms (MUS) (n=209) according to the FPs was conducted. Before the consultation, patients categorized their health problem as being either physical or both physical and psychological. After the consultation, the FPs judged their patients' understanding of the health problem. Outcome measures were (1) patient satisfaction (seven-item Patient Satisfaction Consultation Questionnaire), (2) self-perceived mental and physical health (component summaries of the Medical Outcome Study's Short Form: SF-36) and (3) health care use extracted from patient registers.Main resultsPatients with MUS according to the FPs and patients who believed that the nature of their health problem was both physical and psychological had higher health care use and worse self-rated health than patients in cases where both the FP and the patient had a physical understanding. Patients presenting MUS were more dissatisfied with the consultation than patients with well-defined physical disease.Overall, the FPs' perceptions of their patients' understanding were accurate in 82% of the consultations, but when the patients had a both physical and psychological understanding of their health problem, the FPs were right in only 26% of the consultations.ConclusionsBoth FPs' diagnoses and patients' beliefs predict important health outcomes such as patient satisfaction, use of health care and self-rated health.     

Self-referral to primary care: symptoms and social factors

Previous analyses of data obtained from a comparative study of Health Centre consulters and controls have indicated that the influence of social and demographic factors upon consulting behaviour is slight compared with that of symptom severity. However, the samples were very heterogeneous and some variables may be influential for certain sub-groups but not for others. Subjects were classified according to whether they thought their symptoms were caused by internal physical, external physical or psychological factors. For all groups the likelihood of consultation was highest for those who said they had no idea what caused their ill-health and for those who thought it had an internal physical cause. A significant interaction between marital status and attributed cause showed that the reduced likelihood of consultation amongst women living in a stable relationship with husband or cohabitee, did not apply to those who attributed their symptoms to an external physical cause. Changes in patients' concepts of causation following the consultation with their doctor supported the idea that the GP often succeeds in reassuring patients who cannot understand their symptoms or who, without reason, fear they may be suffering from serious physical illness.