The double life of a psychiatrist: role changes between hospital and office

There is a tension in the life of a psychiatrist who combines inpatient work with the practice of outpatient psychotherapy. The tension is not a new one, but it was once more easily ignored and did not actively interfere with a young psychiatrist gaining comfort with his or her skills as a psychotherapist. A decade ago, the socially dominant (if erroneous) image of a psychiatrist was someone who practiced psychotherapy. It was seen as the core of what a psychiatrist did. If a psychiatrist was interested in psychotherapy, he might wonder how other activities affected this core identity, but the goal of defining a professional identity around the practice of psychotherapy was relatively straight-forward. The situation is very different today. The change is due largely to two related factors: the major advances in biological psychiatry and the dramatic increase in nonpsychiatrist psychotherapists. Most psychiatric residents today either see their primary identity as based clearly on biological treatment, or else they are left feeling a bit confused. Being a psychotherapist no longer seems central to being a psychiatrist. The practice of psychotherapy therefore no longer provides a clear sense of professional identity. Yet many psychiatric residents are interested in psychotherapy and will be doing it throughout their careers. The question of how to do so comfortably while pursuing other psychiatric activities has a renewed urgency. A first step is to clarify the nature of the tension.     

A note on judgment and insight in psychiatric disability

Reports which include unsupported statements about insight and judgment may delay, and render more difficult, the ultimate decision as to entitlement of patients to benefits under various programs. Such statements should be associated with clinical data which adequately support the statement. Insight usually has very little bearing on the clinical evidence of loss of function resulting from psychiatric illness. Its use may be justified in those few instances where it has a direct bearing on prognosis. Judgment as a concept in the evaluation of psychiatric illness should be specifically restricted to that area of judgment which is associated with the patient's usual and customary level of adjustment in a work situation. This evaluation of judgment as a general concept is based upon many variable and complex factors which do not readily lend themselves to routine adjudication of judgment in the ordinary psychiatric evaluation. The psychiatrist might be more effective in his reporting if he were to avoid generalizing about insight and judgment where insufficient data prevents the forming of a definite opinion.formerly Chief Consultant in Neurology and Psychiatry, Social Security Administration, Baltimore, Maryland.     

Pourquoi et comment aborder la spiritualité et la religiosité des patients souffrant de troubles mentaux sévères : une étude de terrain

ObjectivesThere is evidence that psychiatrists are rarely aware of how religion may intervene in their patient's life. That is particularly obvious concerning patients with psychosis. Yet, even for patients featuring delusions with religious content, religious activities and spiritual coping may have a favourable influence. Indeed, patients with psychosis can use religion to cope with life difficulties related to their psychotic condition, in a social perspective but also in order to gain meaning in their lives. Also, religion may be part of explanatory models about their disorder with, in some cases, a significant influence on treatment adhesion.Patients and methodsThis paper describes a prospective randomized study about a spiritual assessment performed by the psychiatrists of patients with schizophrenia. The outpatient clinics in which the sample was collected are affiliated with the department of psychiatry at the university hospitals of Geneva. Eighty-four outpatients with psychosis were randomized into two groups: an experimental group receiving both traditional treatment and spiritual assessment with their psychiatrist and a control group of patients receiving only their usual treatment. Psychiatrists were supervised by a clinician (PH) and a psychologist of religions (PYB) for each patient in the spiritual assessment group. Data were collected from both groups before and after 3 months of clinical follow-up.ResultsSpiritual assessment was well-tolerated by all patients. Moreover, their wish to discuss religious matters with their psychiatrist persisted following the spiritual assessment. Even though clinicians acknowledged the usefulness of the supervision for some patients, especially when religion was of importance for clinical care, they reported being moderately interested in applying spiritual assessments in clinical settings. Compared to the control group, there were no differences observed in the 3 months’ outcome in terms of primary outcome measures for satisfaction with care, yet the attendance at the appointments was significantly increased in the group with spiritual assessment. The same result was found when restricting analyses to patients for whom an intervention was suggested or patients who invested more in religion. Areas of potential intervention were frequent both in a psychiatric and psychotherapeutical perspective.ConclusionsSpiritual assessment appears to be useful for patients with psychosis. This is in accordance with the recommendations of the World Psychiatric Association which promotes considering the whole person in clinical care. Spiritual assessment is quite simple to perform, providing that clinicians do not prescribe or promote religion, and that no critical comments are made concerning religious issues. Clinicians do not need to know in depth the religious domains of each of their patients, as it appears that each patient accommodates his/her religious background his/her own way.     

Praying with a patient constitutes a breach of professional boundaries in psychiatric practice

The extent to which religion and spirituality are integrated into routine psychiatric practice has been a source of increasing controversy over recent years. While taking a patient's spiritual needs into account when planning their care may be less contentious, disclosure to the patient by the psychiatrist of their own religious beliefs or consulting clergy in the context of treatment are seen by some as potentially harmful and in breach of General Medical Council guidance. Here, Professor Rob Poole and Professor Christopher Cook debate whether praying with a patient constitutes a breach of professional boundaries in psychiatric practice.     

Psychiatric Eclecticism: a cognitive view

Pluralism is necessary in psychiatry to compensate for the errors and biases characteristic of the equipment we use to appraise clinical "reality"--our own perceptual-cognitive apparatus. Our attention to clinical situations is skewed: we notice "data" consistent with past assumptions and formulations, and consequently, those views are reinforced by our perceptions. The eclectic posture involves approaching each clinical situation from multiple theoretical perspectives and settling on a perspective that most closely agrees with the patient's needs and wishes without sacrificing the best information available to the psychiatrist. Such eclecticism defines the psychiatrist's role as that of a broad-based scholar who can apply what he knows to the clinical situation. The author discusses the implications for clinical practice and psychiatric education.     

Assessing competency to make a will.

The finding by a court that the author of a will (the testator) lacked mental capacity or was subject to undue influence at the time the will was executed can invalidate the will. A psychiatrist may be asked to assess the competency of a testator when he or she is planning to create or modify a will or after the death of a testator when the will is challenged. To provide guidelines for such evaluations, the authors reviewed the relevant psychiatric, forensic, and legal literature and drew on their own professional experience as well. They outline a systematic approach to the contemporaneous and retrospective evaluation of the elements that affect decisions about mental capacity and undue influence and offer suggestions for the organization and presentation of expert testimony. Awareness of the relevant legal principles and a systematic clinical approach to the assessment can maximize the quality of the psychiatric consultation and expert testimony.     

Teaching liaison psychiatry and clinical practice of psychosomatic medicine in the general hospital.

One of the recent trends in the general hospital is the increase of psychiatric units and the number of psychiatrists working therein. Thus the psychiatrist has had greater opportunities to participate as a member of a clinical team in the care of patients of other units. Accordingly, daily cooperation with other specialties casts him into new roles which transcend those of the traditional psychiatric consultant. The role of liasion psychiatrist involves the complex relations of doctor--nurse--patient--family, interdepartmental relations, communications and so on. By improving these relationships he tries to bring about a more holistic approach in the general hospital.     

Humanitarian aid to persons with mental disorders]

The role of psychiatrists in the Czechoslovak committee for human rights and humanitarian collaboration has its practical justification. Every year some three thousand applications of different character are addressed to the committee. Ten per cent are formed by mentally altered applicants. Lawyers are unable to evaluate these applications correctly. The task of the psychiatrist is to assess, as far as possible, the clinical diagnosis of the applicant. This is very difficult as the psychiatrist uses as a basis only a written document where he evaluates the contents and the formal aspect. A psychopathological analysis leads frequently to clear diagnostic conclusions. Statistical evaluation reveals that about one third of the applications are submitted by psychopathic personalities, one third is formed by applications of subjects suffering probably from mental disorders or diseases and the last third are paranoid patients. The ethical problem is how to react to the different types of applications. From the legal aspect the committee is not entitled to abuse the confidence of the applicant and even in case of serious mental disease to ask the community psychiatrist for intervention. At present the problem is solved by suggesting to the applicant to attend of his own free will the appropriate psychiatrist. Very frequently it is apparent from the reply that the applicant does not consider this suggestion suitable because he is not aware of his mental disease. In case of paranoid development the position is simplified by the fact that any treatment is without effect.     

Pain in the neck, face, and head. Role of the consultation-liaison psychiatrist

The special nature of pain in the face, head, and neck is not emphasized in the psychiatric literature on chronic pain. Although chronic pain of all types and locations share many features the psychological and symbolic significance of the head in the development of self-esteem, body image, and interpersonal relationships often confers special characteristics of pain on this area. As psychiatric consultation is not likely to be requested for patients with head, face, and neck pain in the absence of blatant "psychiatric" problems, it behooves the psychiatrist to exercise his liaison functions to enhance patient care in the inpatient setting and to help physicians recognize the utility of early psychiatric assessment on an outpatient basis with patients not yet requiring hospitalization. A collegial relationship with internists, dentists, neurologists, and surgeons facilitates the psychiatrist's role as a "team participant," often more effective in providing brief diagnostic, therapeutic, and management recommendations for patients who are usually not psychologically-minded and reluctant to pursue ongoing psychiatric treatment. However, the consultation-liaison psychiatrist can play an important role in expanding his colleagues' awareness of the multiple meanings of pain and the accompanying illness behavior, provide pedagogic help in the interviewing or history-taking process, offer suggestions about psychopharmacologic and other drug treatment, and serve as a resource for appropriate referral to sources of a variety of chronic pain treatments, including biofeedback, acupuncture, and family consultation. To fulfill both his consultative and liaison functions, it is incumbent upon the psychiatrist to be knowledgeable as well about nonpsychiatric aspects of pain of the head, face, and neck. We must acknowledge also how much we yet do not know: for example, why the psyche "chooses" a locus of pain in the body; how an external (or internal) stimulus is converted via cognitive, neuroendocrine, enzymatic, and other pathways to a somatic representation; the biochemistry of pain reduction by naturally occurring and synthetic drugs; and what characteristics distinguish the continuously creative individual who sustains persistent pain with barely an utterance from another who may "cave in" to seemingly trivial distress that results in total invalidism.     

Interruption of recurrent ventricular fibrillation by psychiatric intervention

A 32-year-old man with a recent myocardial infarction had recurrent episodes of cardiac arrest that resisted medical management until he was interviewed by a psychiatrist. During the interview he shared his terror and associated to an episode during adolescence when he stole a car and was shot in the chest. After the interview he slept for the first time in three days, and subsequently had no further incidence of cardiac arrest. The case illustrates the potentially life-saving role of psychiatric intervention in reducing sympathetic tone in patients with cardiac instability.     

Cooperation between mental health professionals and doctors in a Balint-oriented supervision group

A Balint-oriented supervision group for physicians is described concentrating on the study of the patient-doctor relationship, the recognition and diagnosis of psychiatric problems, and the planning of psychiatric treatment. The group includes five general practitioners, a gynecologist, a dermatologist, a psychiatrist and a psychologist, who have met once a month for an hour over a period of 12 years. Interaction between the physicians and the mental health professionals is illustrated by two clinical examples. The group helps the physician recognize, tolerate and use his countertransference feelings, and facilitates the examination and treatment of patients suffering from psychiatric problems. In Balint-oriented group work, the focus can be moved from physical symptoms to include observation of the patient's emotional life and significant object relations, to the factors that are crucial for his psychological balance. This kind of holistic observation in the examination and treatment of psychiatric problems is as important as appropriate laboratory investigations in the diagnosis and care of physical diseases.     

Patient suicide : Model for medical student teaching and mourning

The molding of the physician's role and identity takes place during crucial clinical years in medical training. This professional identity is influenced by experiences and models. The suicide of a medical student's patient provides a natural experiment for observing and working with important aspects of the developmental process of physicians in integrating the affective component of clinical work and learning. The facilitation of grief and mourning in a medical student and his five colleagues assigned to the same outpatient psychiatric rotation are important aspects of the clinical, educational, and professional developmental issues raised by the patient's death.     

The psychiatrist-administrator: Odd man out?

The development of community psychiatry as a recognized subspecialty of psychiatry and the concomitant growth of community mental health programs have once again brought into focus the role of the psychiatrist-administrator in the practice of public psychiatry. This paper explores the principal conflicts that the psychiatrist-administrator faces in his multiple roles as a physician, psychiatrist, administrator, community services planner, and clinician. Unless he can work toward a resolution of the conflicts and problems that arise, he is in danger of becoming the "odd man out"--the psychiatrist-adminstrator who does not have complete acceptance from any of the groups to which he belongs and within which he is trying to define his combined and complex role.     

Substance misuse and substance-related disorders in forensic psychiatry.

There is a broad range of substance-related problems that arise for the forensic psychiatrist. For many, what is most challenging about addressing these issues are the complex behavioral, biological, clinical, and social phenomena involved. Substance- related illnesses are on the cutting edge of brain research. Substance-related behavior that brings individuals to the attention of forensic psychiatrists involves a wide spectrum of substance use patterns, but even substance misuse may have profound and relevant effects, forensically. The social forces that mold our laws and attitudes toward addictive drug use are at work in almost every forensic context. Substance-related issues provide a rich medium for the application of forensic psychiatric principles and practice. As in all of forensic psychiatric work, the psychiatrist should be familiar with each forensic context in which addiction issues arise. They should become familiar with the relevant definitions, criteria, and legal requirements that apply in each specific area of their practice, rather than assume that clinical definitions and clinical reasoning will carry them. Comfort and effectiveness with addiction issues requires willingness to continually educate oneself about this rapidly changing field, and familiarity with one's own attitudes and beliefs regarding addictive illness.     

Australian Psychiatrists' Support for Psychiatric Advance Directives: Responses to a Hypothetical Vignette

This study examines whether Australian psychiatrists would support requests in a psychiatric advance directive (PAD) and the reasons underlying their decisions in response to a hypothetical vignette. An online survey was completed by 143 psychiatrists. Fewer than 3 out of 10 psychiatrists supported the patient to create a PAD which requested cessation of pharmacotherapy (27%) or remaining out of hospital and not being subject to an involuntary treatment order (24%) should their depression condition deteriorate. A thematic analysis showed that patient autonomy was the strongest theme among those who supported the patient to create a PAD, whereas the clinical profile of and risk to the patient and the professional or ethical imperative of the psychiatrist were strongest among those who were unsure about supporting the patient or who did not support the patient. These findings provide a challenge about how to fulfil obligations under the United Nations Convention on the Rights of Persons with Disabilities (2006).     

Once more into the breach: Doubts about liaison psychiatry

The author, a consultation/liaison psychiatrist, reviews five important questions about liaison work which are pressing, but remain unanswered. With some trepidation, he seeks to temper the enthusiasm of his colleagues who, by prematurely promising more than can ever be delivered in the name of “holistic” and “biopsychosocial” medicine, may lead our discipline astray.     

Books Received

In his later seminars, Lacan puts forward the suggestion that the laws of “Language” and the “Name of the Father” may be the neurotic solution to questions of existence and identity. In contrast, he suggests, the solution of the psychotic (or the artist) may be more idiosyncratic. Using the case of a young man who began to lose his mind in the process of trying to overthrow the Law of his father and install his own sense of values, I will consider two concepts: (1) ways in which what might appear to be a psychotic diathesis is instead a turbulent struggle to establish and maintain an autonomous identity; and (2) the role of the psychoanalyst in establishing an environment in which that important work might be accomplished.     

Le psychiatre expert judiciaire et les auteurs d’homicides

The forensic psychiatric expertise of homicide perpetrators is a standard practice in criminal justice matters. Its validity relies heavily on the knowledge, professional experience and methodology of forensic psychiatrist experts. In the present interview, Daniel Zagury, an important figure of forensic psychiatric expertise in France, shares his clinical practice. In addition, he describes his experience with homicide perpetrators, particularly with serial killers and Islamic terrorist attackers on French soil. Finally, he addresses the recurring and crucial controversy of criminal responsibility, or the lack of it, in perpetrators.     

Memories and reflexions of a psychiatrist of former times]

After 64 years as a psychiatrist, the author relates his experiences in psychiatric centers and in official practice as an expert. In this way, he comments on the evolution of psychiatry spanning three quarters of a century. In particular, he recalls the various methods of treatment used successively, their success and failure and the resulting accidents. He also describes the development of help given and the increasing tendency to reduce obstacles to the freedom of movements of those suffering from mental illness. Mention is also made of the changing working conditions found in psychiatric hospitals and the conception to which has the practicien himself of his role. With regard to the official practice as an expert, different objectives and approaches to the problem have been observed in the past and others are to be hoped in the future.