Psychotherapist, psychiatrist, and patient : a triadic relationship

An increasing number of psychiatrists consult to nonmedical psychotherapists and treat their patients with medication. This dual treatment arrangement is known as "split treatment." Split treatment arrangements generate a triangular relationship among the three parties-patient, psychotherapist, and psychiatrist. Both the transferential aspects of the triangular relationship among the two therapists and a patient and the overt interpersonal conflicts that may arise-such as ideological and interdisciplinary conflicts-are discussed. Enhanced awareness of both sets of factors may facilitate the cooperation between psychiatrists and psychotherapists.     

精神科医生对迟发性运动障碍的认知及临床实践状况调查

目的 探讨精神科医生对迟发性运动障碍（TD）的认知及临床实践状况。方法 应用自行设计的TD知识及态度问卷对106名临沂市精神科医生进行调查。 结果 精神科医生对TD临床表现项目掌握情况最好（86.79%）,发病机制项目掌握情况最差（56.60%）。市级精神科医生对TD基础知识的掌握情况好于县区级精神科医生（P<0.01）。98.11%的精神科医生认为有必要进行TD诊断和治疗的培训,81.13%的医生接受过TD诊断和治疗的培训,其中,仅62.79%的医生接受过正规课程培训,34.92%的医生对TD的诊断和治疗没有信心。91.51%的医生认为在应用抗精神病药物前,应与患者及家属讨论TD发生的危险性,但仅76.42%的医生在临床实践中常规执行。98.11%的医生认为在应用抗精神病药物期间,应监测异常不自主运动,但仅74.52%的医生常规监测,53.77%的医生作监测结果记录。65.10%的医生认为TD是造成医疗纠纷及诉讼的原因之一,76.41%的医生认为没有患者的同意,抗精神病药物不得长期超适应证使用。结论 应加强对精神科医生TD知识的培训,在临床工作中,应严格执行知情告知并常规监测TD的发生。     

Toward a multidimensional model for psychotherapy supervision based on developmental stages

The need for a systematic approach to psychotherapy training in psychiatric education is greater than ever. Most models of psychotherapy supervision focus on supervisee development and ignore developmental issues concerning the other participants in the supervisory triangle. The author reviews theories of psychotherapy supervision and identifies factors that contribute to the dynamic interrelationships among psychiatrists who are supervising psychotherapy, the psychiatry resident supervisees, and their patients as each party progresses through stages of development. A dynamic formulation of psychotherapy supervision based on developmental stages can result in a better understanding of the instructional process, its greater effectiveness, and associated changes in program structure. Further development of a comprehensive dynamic model depends on additional research.     

Evaluation of a statewide public health nursing training in Utah

Public health nurses continue to struggle to provide culturally relevant services that focus on the multiple needs of an ethnically diverse population while at the same time providing services to the population at large. This article describes the formative research, implementation, and results of a statewide effort to broaden UtahAEs public health nurses perception about their role and responsibility in addressing and serving the emerging needs of underserved and atrisk populations in Utah. A total of 51% of Utah state and local health department public health nurses participated in the training. There was a statistically significant increase in the mean level of perceived understanding of topic material from pretest to posttest, and 80% of participants reported applying what they learned in the training to their practice. Our experience demonstrates that even with limited resources, it is possible to deliver high quality training to a large proportion of public health nurses practicing in urban, rural, and frontier populations; observe significant results in their comprehension of training material and, most importantly; see application of what they learned in the training to their health care practice.     

全国生物安全三级实验室建设与管理现况调查及分析

目的掌握我国生物安全三级(BSL-3)实验室建设与管理现况,为卫生行政部门制定政策提供依据。方法设计《全国生物安全三级实验室建设与管理工作概况调研表》,统一发放并由专人填写。对反馈信息进行整理和分析。结果 72家调查对象中,除3家单位无建设BSL-3实验室计划外其余反馈调研表的40家单位处于BSL-3实验室建设及运行的不同阶段,其中实验室正式运行的仅占20%。已建成实验室平均建设费用为646.4万元,已运行实验室平均运行费用为38.475万元/年、维护费用为22.57万元/年。开展实验活动主要集中在近几年能引起多发高发传染性疾病的5种高致病性病原微生物。建设及运行过程中主要存在的困难为无法通过环评和运行经费不足。结论我国BSL-3实验室建设与管理已走上规范化、法制化道路,但由于各单位建设条件不同、对标准规范理解程度不同等原因,仍存在一定的问题和困难。建议国家及地方管理部门、建设单位加强沟通协调以逐步解决存在的问题,提升我国BSL-3实验室建设、管理的整体水平。     

Impairment and disability rating in low back pain

LBP is one of the two most common forms of disability in Western society (mental illness is the other), and remains a thorny problem in the arena of disability evaluation. Disability evaluation after LBP differs whether the pain is work-related or not. If work-related, guidelines for disability evaluation differ by jurisdiction and type of employment (e.g., private vs. federal employee). When outside of the workplace, thresholds for disability differ between entitlement programs (Social Security Disability) and private insurance programs (long-term disability insurance). In the patient without obvious findings, the disability evaluating physician needs to be caring and compassionate and yet maintain an objective stance with the understanding that there may be significant psychosocial overlay in patients with nonobjective pain complaints. Although some would argue that objective independent medical evaluation is an oxymoron, psychiatrists have excellent training and perspective with which to do so. The patient suffering from catastrophic brain injury or spinal cord injury offers a useful contrast--on the most severe end of the disability spectrum--to the patient with persisting low back complaints but normal physical examination. As a society, we have to wisely manage the funds that comprise our social "safety net" in order to provide for persons with severe disability who cannot provide for themselves. It would then follow that patients with minor impairments/disabilities should receive minor (i.e., noninflated) ratings. Psychiatrists need to enable rather than disable their patients.     

一般病人护理病历书写过程中的问题与对策

在《北京朝阳医院护理文书书写标准》实施过程中 ,护理部分别对运行中护理病历和终末护理病案共 198份进行检查 ,对护理病历中出现的护理记录内容不具体、重点不突出、记录不及时准确、不客观等问题进行了分析 ,并认为提高护理人员对护理病历书写重要性的认识 ,是保证护理病历质量的前提 ;加强护理病历书写技能、护士观察能力和疾病症状学知识的培训 ,是提高护理病历质量的重要环节 ;而加大护理病历质量的监控力度 ,制作护理病历模板 ,实施弹性排班 ,是提高护理病历质量的手段。     

浙江省公共卫生骨干培训效果评价及相关因素分析

目的评估参加培训学员的理论和技能培训效果,为进一步改进培训方法、完善培训内容和提高培训质量提供参考依据以及相应的对策和建议。方法采用自填问卷的方法,调查2011年4月参加浙江省第一期复合型公共卫生骨干培训的学员的理论和技能培训效果。结果共发放问卷99份,有效问卷92份,有效率92．93％。参加培训的学员对理论培训和技能培训的总体满意度分别达到94．50％和90．48％,logistic回归分析发现理论培训中的培训教材质量和课程时间安排对总体效果的影响具有统计学意义（P均〈0．05）,技能培训中的培训教材质量对总体效果的影响具有统计学意义（P〈0．05）。82．61％的学员认为《社区预防医学》基本理论有提高,79．34％的学员认为《公共卫生案例分析》技能有提高。本科及以上学历的学员对大部分课程的掌握程度优于大专学历的学员。结论复合型公共卫生骨干理论培训和技能培训总体效果较好,但对于培训教材质量、课程时间安排等对总体培训质量产生影响的因素应在今后的培训中进一步完善和加强。     

Opening doors: factors influencing the establishment of a working relationship between paraprofessional home visitors and at-risk families.

The purpose of this phenomenological study was to identify and describe factors that influence the establishment of a working relationship between paraprofessionals and at-risk families. In-depth, semi-structured interviews were conducted with a purposive sample of 6 family visitors and 6 public health nurses hired to visit at-risk families in their homes. Analysis revealed that nurses have an important role to play in marketing home visiting programs and facilitating family visitor access to the home. Factors related to the family visitor, the client, and the client's household influenced relationship development. Family visitor-client engagement occurred through "finding common ground" and "building trust." Increased understanding of these factors will help both nurses and family visitors to access those families who are hard to reach and resist support and the provision of services. The findings have implications for nurses who are responsible for hiring, training, and supervising family visitors.     

The UK psychiatrists' experience of rationalising antipsychotics in adults with intellectual disabilities: A qualitative data analysis of free-text questionnaire responses

Background

Overprescribing of off-licence psychotropic medications, particularly antipsychotics, for challenging behaviours in people with intellectual disabilities without a psychiatric disorder is a significant public health concern. In the United Kingdom, the National Health Service England launched an initiative in 2016, ‘STopping Over-Medication of People with learning disabilities, autism or both (STOMP)’, to address this concern. STOMP is supposed to encourage psychiatrists in the United Kingdom and elsewhere to rationalise psychotropic medication use in people with intellectual disabilities. The current study aims to gather UK psychiatrists' views and experience of implementing the STOMP initiative.

Methods

An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disabilities (estimated 225). Two open-ended questions allowed participants to write comments in response to these questions in the free text boxes. One question asked about the challenges psychiatrists faced locally to implement STOMP, and the other asked for examples of successes and positive experiences from the process. The free text data were analysed using a qualitative method with the help of the NVivo 12 plus software.

Results

Eighty-eight (estimated 39%) psychiatrists returned the completed questionnaire. The qualitative analysis of free-text data has shown variation within services in the experience and views of the psychiatrists. In areas with good support for STOMP implementation provided through adequate resources, psychiatrists reported satisfaction in the process with successful antipsychotic rationalisation, better local multi-disciplinary and multi-agency working, and increased awareness of STOMP issues among the stakeholders such as people with intellectual disabilities and their caregivers and multidisciplinary teams, and improved quality of life caused by reduced medication-related adverse events in people with intellectual disabilities. However, where resource utilisation is not optimum, psychiatrists seemed dissatisfied with the process with little success in medication rationalisation.

Conclusions

Whereas some psychiatrists are successful and enthusiastic about rationalising antipsychotics, others still face barriers and challenges. Much work is needed to achieve a uniformly positive outcome throughout the United Kingdom.     

Power wheelchair driving challenges in the community: a users’ perspective

Purpose: There is limited information on the difficulties individuals experience in manoeuvring their power wheelchairs during daily activities. The aim of this study was to describe the nature and context of power wheelchair driving challenges from the perspective of the user. Methods: A qualitative design using semi-structured interviews with power wheelchair users. Qualitative content analysis was used to identify themes. Results: Twelve experienced power wheelchair users were interviewed. Findings revealed that power wheelchair driving difficulties were related to the accomplishment of activities of daily living, and the influence of environmental context. Four key themes emerged: (1) difficulties accessing and using public buildings-facilities, (2) outdoor mobility, (3) problems in performing specific wheelchair mobility tasks/manoeuvres and (4) barriers and circumstances that are temporary, unforeseen or specific to a particular context. Conclusion: This qualitative study furthers our understanding of the driving difficulties powered wheelchair (PW) users experience during daily activities. This knowledge will assist clinicians and researchers in two areas: in choosing assessment measures that are ecologically valid for power wheelchair users; and, in identifying and refining the content of training programs specific to the use of power wheelchairs.

• Implications for Rehabilitation

• A better understanding of the everyday challenges individuals experience in driving their power wheelchair will assist clinicians and researchers in:

• Choosing assessment measures and identifying training programs for this population.

• Refining the content of power wheelchair training programs.

     

Socialization of Hospice Volunteers: Members of the Family

The purpose of this study is to examine the turning points volunteers found important in their hospice training and volunteer experiences. Seventeen individuals who had recently completed hospice training were asked about the turning points in their training and volunteering that were important in their becoming and remaining a hospice volunteer. The study finds that volunteers have a wide variety of intrapersonal, interpersonal, and group reasons for becoming and remaining a hospice volunteer. The findings suggest that hospice staff need to create a wide variety of events which volunteers can identify with to help people want to become and remain volunteers. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworth.com]     

Training case managers to deliver focused psychological strategies

ABSTRACT:  Anxiety and mood disorders are prevalent in the Australian community and can be functionally disabling. Access to treatment for these disorders can be difficult, particularly in rural areas where there is limited availability of specialist mental health practitioners such as psychiatrists and clinical psychologists. One way to address this problem is to improve the skills of local mental health practitioners in recognizing and providing treatment for these disorders. This paper describes a program that aimed to enhance access to psychological treatment for depression and anxiety by improving the skills of rural mental health case managers through training and education and support by psychiatrists and clinical psychologists. Thirty-two case managers participated in the program which delivered 10 training modules using a cognitive behavioural therapy framework. Case managers consisted primarily of psychiatric nurses, with others having social work or psychology backgrounds. Participants were assessed pre- and post-training using quantitative and qualitative measures. The effect of the training was noted in several areas including attitudinal changes, improved knowledge of psychological therapies, and changes to stated practice. However, there was concern expressed by participants about their competence and confidence to translate skills learned into practice. While the results of such a program are promising, they highlight some of the complexities of delivering such programs in rural settings.     

Doctors’ characteristics and the use of long consultations at out-of-hours services 2008–2017: a registry-based follow-up study in Norway

Abstract

Objective: The aim was to analyse whether there was a change in percentage of long consultations over a 10-year period, and whether individual doctors changed their use of time as they got more experience and specialisation during the same period.

Design and setting: This is a registry based study encompassing all consultations in primary care out-of-hours service in Norway in 2008 and 2017.

Subjects: For both years all doctors were included in cross sectional analyses. In addition, doctors who participated both years were included in a separate follow-up analysis.

Main outcome measures: Long consultations (>20?min) were identified by a time fee in the claims’ database.

Results: There were 4610 doctors in 2008 and 5620 in 2017, 904 participated both years. In 2008 a time fee was claimed in 38% of consultations, in 2017 in 47%. Older doctors made less use of the time fee, as did doctors who had many consultations, regular general practitioners, and general practice specialists. The general practitioners who participated both years increased their use of the time fee from 33% to 38% of consultations. Those who specialised in general practice during the 10-year period increased their use of the time fee from 34% to 37%.

Conclusions: Experienced doctors have fewer long consultations than inexperienced doctors. Over years there is a strong trend towards increasing the use of time fee during out-of-hours consultations. This trend is only partly offset by increasing the experience of the doctors.

• KEY POINTS

• Although consultation length may be associated with patient satisfaction there is also a cost-efficiency aspect to be taken into account

• ?Percentage long consultations out-of-hours increased from 38% in 2008 to 47% in 2017

• ?Experienced doctors had fewer long consultations

• ?Experience only partly offset the trend towards more long consultations

     

Violence in mental health care: the experiences of mental health nurses and psychiatrists

Violence against mental health service personnel is a serious workplace problem and one that appears to be increasing. This study aimed to ascertain the extent and nature of violence against mental health nurses and psychiatrists, and to identify what support, if any, they received following exposure to violence. Mental health staff working within five West Midlands Trusts in the United Kingdom were surveyed using a postal questionnaire to investigate the extent and nature of violence they encountered in their daily work. There was an overall response rate of 47%, which included a response rate for psychiatrists of 60% (n=74) and for mental health nurses of 45% (n=301). Though both groups experienced violence at work, nurses were found: to have been exposed to violence significantly more during their career; to have been a victim of violence within the previous 12 months of the survey; and to have suffered a violent incident involving physical contact. Whilst a higher proportion of nurses than psychiatrists received some support following a violent incident, a large proportion of both groups did not receive any, although most felt in need of it. The implications of this study for training and management are discussed.     

Medical psychotherapy: an evolving concept

The term "medical psychotherapy" is gaining ascendancy in its use to describe the approach to therapeutic intervention used by psychiatrists who conceptualize their function as being at the more medical end of the spectrum of psychiatric practice styles. The following definition represents an attempt to crystallize a model that is in an active stage of evolution. I hope to stimulate continued debate and refinement of the concept.     

Pedestrian navigation and public transit training interventions for youth with disabilities: a systematic review

Abstract

Purpose: Being able to travel independently, whether as a pedestrian or by taking public transportation, is a critical element to maintaining quality of life and participation in the community. The objective of this systematic review is to understand the best practices and effective components of pedestrian and public transit training interventions for youth with disabilities.

Method: Systematic searches of seven international databases identified 29 studies meeting our inclusion criteria. We analyzed these studies based on participant characteristics, methods, results, and quality of evidence.

Results: Among the 29 studies, 857 participants (aged 5–39, mean 18.3 years) were represented across 10 countries. Although the intervention outcomes varied across the studies, 24 of them reported an improvement in at least one of the following: pedestrian and general navigation skills, pedestrian safety, landmark recognition, route knowledge, and public transportation skills.

Conclusions: Our findings highlight that pedestrian and public transit interventions have the potential to improve the participation and quality of life of children and youth with disabilities. More rigorous, theoretically informed interventions, using standardized measures are needed to enhance pedestrian and transit training skills among youth with disabilities.

• Implications for rehabilitation

• Travel training interventions have the potential to effectively support youth with disabilities in learning pedestrian and public transportation navigation skills.

• Clinicians and educators should encourage youth with disabilities to participate in travel training programs enhance their independence skills and participation in the community.

• Clinicians, educators, and program managers can help to build relevant content for travel training programs and connect youth to programs.

     

The relationship among leadership preferences, head nurse leader style, and job satisfaction of staff nurses.

A better understanding of the effects of the relationships between staff nurses and their leaders is needed if retention of vital resources is to occur in this age of increasing need and decreasing resources in the health care industry. This study investigated the interactions among leadership preferences of staff nurses, the perceived leader behavior of their nurse managers, and their job satisfaction. Although a "match" or "mismatch" relationship was not found, one surprising finding was the high positive relationship between structuring behavior of head nurses and job satisfaction of staff nurses. Implications and recommendations for training nurse managers are offered.     

创伤后应激障碍患者脑功能变化磁共振研究进展

创伤后应激障碍(post-traumatic stress disorder,PTSD)是指人在遭遇或对抗重大压力后,其心理状态发生变化产生的一种失调后遗症.PTSD早期被军事精神病学家和精神分析学家探索,是一个引起广泛社会关注的公共卫生问题.近年来全球发生一系列突发公共卫生事件,如2013年流行的SARS以及2019...     

The psychiatric management of end-of-life pain and associated psychiatric comorbidity

Involvement by psychiatrists in the care of patients who are terminally ill has been limited historically; however, psychiatrists increasingly are participating in the care of these people who are facing the most challenging times of their lives. Pain management is considered to be an area of subspecialization for psychiatrists beyond their traditional role of being psychopharmacologists and psychotherapists. Biologically focused psychiatrists are able to address neuropsychiatric disorders, including pain and depression in the medically ill, and actively improve the quality of life for dying patients and their family members. This article provides a review of the recent literature that has addressed the involvement of psychiatrists in end-of-life care. Beginning with an example of the scientific aspects of cancer-related treatment from a patient’s perspective, and into the major treatment considerations, this article addresses pain, its recognition, and management challenges when the end of life approaches. The prompt recognition of frequently overlooked and underestimated concomitant depressions, delirium, dementia, and other mental disorders is important for mental health specialists. The importance of psychiatric care for patients who are terminally ill and the role of psychiatrists in the phase of care also are discussed.