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Prescribing for personality disorder: qualitative study of interviews with general and forensic consultant psychiatrists

  • Lawrence Martean (a1) and Chris Evans (a1)
Abstract
Aims and method

To explore experiences of psychiatrists considering medication for patients with personality disorder by analysis of transcribed, semi-structured interviews with consultants.

Results

Themes show important relational processes in which not prescribing is expected to be experienced as uncaring rejection, and psychiatrists felt helpless and inadequate as doctors when unable to relieve symptoms by prescribing. Discontinuity in doctor–patient relationships compounds these problems.

Clinical implications

Problems arise from: (a) the psychopathology creating powerful relational effects in consultation; (b) the lack of effective treatments, both actual and secondary to under-resourcing and neglect of non-pharmaceutical interventions; and (c) the professionally constructed role of psychiatrists prioritising healing and cure through provision of technological interventions for specific diagnoses. There is a need for more treatments and services for patients with personality disorder; more support and training for psychiatrists in the relational complexities of prescribing; and a rethink of the trend for psychiatrists to be seen primarily as prescribers.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Declaration of interest

None.

Footnotes
References
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Prescribing for personality disorder: qualitative study of interviews with general and forensic consultant psychiatrists

  • Lawrence Martean (a1) and Chris Evans (a1)
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eLetters

I prescribe, therefore I am?

Melissa Gill, Senior Registrar
06 July 2014

In their qualitative study (1), we imagine that Martean and Evans captured the views of the majority of psychiatrists in their experiences of prescribing for personality disorder. While we could identify with all of the themes identified as reasons for prescribing, we feel that the article highlighted a number of worrying trends within the profession thatneed to be addressed.

There appears to have been a shift away from a psychotherapeutic approach in psychiatry, toward a distinct reliance on prescribing. The authors identify a theme of utilising prescribing as a method of communicating empathy. We would argue that it is disappointing if psychiatrists can only demonstrate empathy through the use of a prescription pad. It would seem that potential harm, in the form of possible serious side-effects, addiction, polypharmacy and indeed overdosefacilitated by such a prescription, may be more likely than benefit. Primum non nocere, or "first, do no harm" would suggest that, in the absence of convincing evidence for prescribing for personality disorders, the responsibility lies with the doctor to examine alternatives.

The authors themselves identify one potential solution in their recognition that "problems as much or perhaps more than diagnosis may be crucial to explore for patients with personality disorder". Problem-solving therapy has been shown to improve depression, hopelessness and personal problems in patients who self-harm (2) and has demonstrated specificbenefit as a preliminary measure for personality-disordered patients (3). Perhaps this may be a useful initial intervention to avoid feeling helpless in such consultations. Longer-term options such as Dialectical Behavioural Therapy and specialised counselling for trauma experienced in childhood allow deflection away from the prescription.

While we acknowledge that treating patients with personality disorders is often challenging, we believe the profession needs to move away from the notion of "I prescribe, therefore I am". Ultimately, the increased focus on psychotherapy in the updated curricula of both the Royal College of Psychiatrists and the College of Psychiatry of Ireland represents a positive paradigm shift in training toward a return to the psychotherapeutic, rather than solely prescribing, role of the psychiatrist.

References:

1. Martean L, Evans C. Prescribing for personality disorder: qualitative study of interviews with general and forensic consultant psychiatrists. Psychiatr Bull 2014; 38: 116-21.

2. Townsend E, Houston K, Altman DG, Arensman E, Gunnell D, Hazell P et al. The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems. Psychol Med 2001; 31: 979-88.

3. Huband N, McMurran M, Evans C, Duggan C. Social problem-solving plus psychoeducation for adults with personality disorder. Pragmatic randomised controlled trial. Br J Psychiatry 2007; 190: 307-13.

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Conflict of interest: None declared

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Compassion hurts!

Larry Culliford, Retired Psychiatrist
23 June 2014

Feeling stuck, feeling helpless, feeling pressure... The comments from psychiatrists listed under these headings by Martean and Evans (1) took me back to my early days in the profession. Here is a passage from one of my books (2) harking back to that time, revealing how I got valuable help and insight from an unexpected quarter.

"Health and social care professionals face and deal competently with (human suffering) on a daily basis... Arguably, what draws people towards this kind of work is compassion, a natural fellow-feeling for those who are suffering.

The Latin origins of the word 'compassion' mean 'to suffer with'. Compassionate thoughts and feelings are involuntary phenomena... Holding true to... higher instincts and values while establishing one's identity; forging one's way in the world in terms of education and employment; is toobey a sense of vocation - of being called into an occupation that benefits others...

In following a vocation, one also experiences significant rewards: a feeling of benefit, of being blessed, and therefore also gratitude. Putting oneself through training, engaging with the work, joining others as part of a professional body or team in the endeavour, witnessing results; all play a part in giving one's life a profound sense of meaning and purpose and a heart-warming sense of belonging.

This is the situation when things are going well; but the drive to enact compassion needs tempering also with wisdom. We need to know our limitations and not strive excessively beyond them. We need to avoid putting results first, and to acquire the spiritual skills necessary to protect ourselves from exhaustion, from 'compassion fatigue' and 'burnout'. After all... compassion hurts! This is a lesson I too had to learn.

I became emotionally distressed, especially during the early part of my training in psychiatry, over the plight of several patients. I recall particularly one man whose intense depressive condition had failed to respond to years of treatment. He was very miserable, and tearful on a daily basis. I happened to speak of him to a Buddhist monk who asked me, perceptively, where the pain was. It took a while to realize that it was not 'out there' in the locked hospital ward (patient). I was carrying it myself, in my heart.

Then the monk asked WHY I was suffering. I could not exactly say; so he told me. It was because I cared about this man and my other patients. Iimmediately realised two things: that my compassion was involuntary, and that my emotional pain (which I had been thinking of as a problem) was a good thing.

Like many others, I had chosen to be a doctor and a psychiatrist fromdeep-seated motives over which I had no control. This was my vocation, my destiny. I was learning that compassion hurts, but that the pain is unavoidable. The monk advised that I should make such patients my teachers, rather than insist every time on being the one to give somethingto the other. I should allow the principle of reciprocity to work, and learn from those who suffer: learn my limitations, without being overwhelmed by anger, sadness, guilt, shame or any other painful emotion. On the contrary, because of the virtue of my intention to help people, even when it proved unsuccessful, I could feel at least a degree of contentment. These insights changed my working life. My enthusiasm for what I was doing was immediately renewed, and has remained robust."

I am retired now from clinical practice, but the memory of that conversation remains vivid more than 35 years on. I hope this brief account of that felicitous turning point will be of benefit to others too.

References:

1. Martean L, Evans C. Prescribing for personality disorder: qualitative study of interviews with general and forensic consultant psychiatrists. Psychiatr Bull 2014; 38: 116-121.

2. Culliford L. The Psychology of Spirituality:an introduction. Jessica Kingsley Publishers, 2011.

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Conflict of interest: None declared

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