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Psychiatry, subjectivity and emotion – deepening the medical model

  • Jessica Yakeley (a1), Rob Hale (a1), James Johnston (a2), Gabriel Kirtchuk (a3) and Peter Shoenberg (a4)...
Summary

Morale among psychiatrists continues to be seriously challenged in the face of recruitment difficulties, unfilled posts, diagnostic controversies, service reconfigurations and public criticism of psychiatric care, in addition to other difficulties. In this article, we argue that the positivist paradigm that continues to dominate British psychiatry has led to an undervaluing of subjectivity and of the role of emotions within psychiatric training and practice. Reintegrating the subjective perspective and promoting emotional awareness and reflection may go some way towards restoring faith in the psychiatric specialty.

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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.
Corresponding author
Jessica Yakeley (jyakeley@tavi-port.nhs.uk)
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Declaration of interest

None.

Footnotes
References
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Psychiatry, subjectivity and emotion – deepening the medical model

  • Jessica Yakeley (a1), Rob Hale (a1), James Johnston (a2), Gabriel Kirtchuk (a3) and Peter Shoenberg (a4)...
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eLetters

Challenges and opportunities in (neuro)psychiatry

Ketan D. Jethwa, Former Academic Clinical Fellow in Psychiatry
06 July 2014

It would appear that British psychiatry is retreating to a neurophobic position (1). The disconnect between psychiatry from its medical foundations is further exacerbated by the lack of medical experience in specialties relevant to psychiatry such as neurology, endocrinology and geriatric medicine. This is related to the constraints placed on training by service provision and the separation of psychiatric and medical services. The Future of Mental Health Services Report (3) headed by Prof Bhugra in collaboration with the Mental Health Foundation called for greater collaboration between psychiatric and general medical services.

Elucidating the nature of mental illness and developing effective treatments requires enthusiastic and talented academics and clinicians. Instead of ideological turf wars, collaboration between disciplines is required to appreciate the nuanced interactions between genetics, biochemistry and the environment.

For example, the classical distinction between affective and psychotic experiences is becoming increasingly blurred. The formation of delusions is associated with a 'jumping to conclusions' cognitive bias (3). This can result in an intolerance of uncertainty and anomalous interpretations of internal or external stimuli. There is renewed focus onthe ways in which affective processes can contribute to the formation of delusions and how these mechanisms can be modified using cognitive-behaviour techniques (4). These insights from cognitive neuropsychology are substantiated by neuroimaging studies. The salience network, an intrinsic large-scale cerebral network, shows strong connectivity between the anterior cingulate gyrus and insular cortex. This network enables switching between different dynamic brain states. Dysfunction in this network has been implicated in the formation of the key symptoms of psychosis: inappropriate salience attached to ambiguous stimuli can predispose to and perpetuate unusual beliefs or delusions (5). There is hope that research such as this will begin to impact on clinical practice by highlighting these brain-mind links.

As a specialty we need to be far more proactive in promoting psychiatry as clinical neuroscience both at undergraduate and postgraduatelevel. We must make sure that the scientific underpinnings of psychiatry are explicit within mental health services and in our interactions with patients and the public in general.

References:

1.Bullmore, E., Fletcher, P. & Jones, P. B. (2009) Why psychiatry can't afford to be neurophobic. Br J Psychiatry, 194 (4): 293-295.

2.Anon (2013) Mental health services must act to avoid sleep walking intothe future. [online] Available from: www.mentalhealth.org.uk(Accessed 27/12/2013).

3.Broome, M. R., Johns, L. C., Valli, I., Woolley, J. B., Tabraham, P., Brett, C., Valmaggia, L., Peters, E., Garety, P. A. & McGuire, P. K. (2007) Delusion formation and reasoning biases in those at clinical high risk for psychosis. Br J Psychiatry Suppl, 51 s38-42.

4.Garety, P. A. & Freeman, D. (2013) The past and future of delusionsresearch: from the inexplicable to the treatable. Br J Psychiatry, 203 (5): 327-333.

5.Palaniyappan, L. &Liddle, P. F. (2012b) Does the salience network play a cardinal role in psychosis? An emerging hypothesis of insular dysfunction. J Psychiatry Neurosci, 37 (1): 17-27.

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Conflict of interest: None declared

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The capacity to develop subjectivity and emotion: the value of continuity of care.

Rhona J Sargeant, Consultant Medical Psychotherapist
23 June 2014

Yakeley et al (1) remind us about the concept of subjectivity. This isa refreshing and thought provoking editorial. 'Affective subjectivity' isdefined as 'the awareness of and reflection on our emotional responses and their influence on our work, and the development of a capacity for self-reflection and emotional attunement with our patients'. The authors list a number of factors which have led to a reduction in the capacity of psychiatrists to develop and use affective subjectivity. One of these is the loss of continuity of care.

Over the last ten years we have seen a gradual erosion of the capacity to offer continuity of care to our patients. Psychiatric teams are now fragmented, specialist and largely separate. This enhances splitting within and between teams and makes it difficult for patients to be held in mind for very long.

When I trained as a house officer and junior psychiatrist in the early 1990s, continuity of care was awarded so much importance across themedical specialities that we worked extremely long hours to offer this. Anin-depth knowledge of your patient was expected and great emphasis was placed on personally following up their progress and seeing it through. While the long hours were far from ideal, the pendulum has swung so far back, that continuity of care has now largely gone. All too often the concept of holistic care is being replaced by diagnoses and treatment plans, rather than formulations based on the bio-psycho-social modal (2) , which include affective subjectivity. If a patient is only seen once or twice it is often impossible to expand on developmental and attachment aspects in the history, or think about their meaning for the patient, psychiatrist and mental health team.

Without the capacity for doctors to follow patients through, it is very hard to allow subjective feelings to emerge, or to use them in the understanding of psychological trauma. I run a Balint-style case discussion group for core trainees in psychiatry. Over the course of the year the barriers to allowing subjective feelings, so well described by Yakeley et al, gradually reduce. For most trainees a deeper understanding of countertransference and how this can help us create an empathic approach to our patients, begins to develop. It is frustrating, however, that the majority of the cases brought are not seen again by the trainee. This denies the patient the opportunity to begin to develop a trusting relationship or to experience any kind of attachment. The concept of psychiatric staff as attachment figures is described by Gwen Adshead (3). It also denies the trainees the opportunity to use the understanding gained from the case discussion group to help their patient.

If we are to use subjectivity and emotion in our work, I think continuity of care needs to be revived. This in turn would enable psychiatrists, once again, to enjoy getting to know patients across a period of time using both subjective and objective skills and thus enhancejob satisfaction.

References:

1. Yakeley J, Hale R, Johnston J, Kirtchuk G, Shoenberg P. Psychiatry, subjectivity and emotion-deepening the medical model. Psychiatric Bulletin 2014; 38:97-101.

2. Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129-492.

3. Adshead G. Psychiatric staff as attachment figures: Understanding management problems in psychiatric services in the light of attachment theory. British Journal of Psychiatry 1998; 172: 64-69.

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Conflict of interest: None declared

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