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Holistic psychiatry without the whole self

  • David Richard Crossley (a1)
Summary

This article considers why whole-person care is often aspired to but remains problematic for psychiatry. One reason is that psychiatry wants to use ideas about the self in restricted senses rather than examine the idea as a whole. In particular, this includes wider issues that interconnect values to identity, which then ambiguously get raised in clinical practice, such as questions about who it is good to be. This issue is the context behind unresolved boundary disputes in mental health around well-being, spirituality, self-esteem and recovery, and reflects broader cultural tensions about the making of modern identity best understood in a historical context. It has impacts on service design, therapeutics and training. Suggestions are made about how the self can be approached in psychiatric practice.

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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
David R. Crossley (david.crossley@wales.nhs.uk)
Footnotes
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See commentary, pp. 101–103, this issue.

Declaration of interest

None.

Footnotes
References
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1 Taylor, C. Sources of the Self: The Making of Modern Identity. Harvard University Press, 1989.
2 Taylor, C. A Secular Age. Belknap Press of Harvard University Press, 2007.
3 Berrios, GE, Markova, IS. The self and psychiatry: a conceptual history. In The Self in Neuroscience and Psychiatry (eds Kircher, T, David, A): 939. Cambridge University Press, 2003.
4 King, M, Leavey, G. Spirituality and religion in psychiatric practice: why all the fuss? Psychiatrist 2010; 34: 190–3.
5 Bora, R, Leaning, S, Moores, A, Roberts, G. Life coaching for mental health recovery: the emerging practice of recovery coaching. Adv Psychiatr Treatment 2010; 16: 459–67.
6 Cook, C, Powell, A, Sims, A (eds). Spirituality and Psychiatry. Royal College of Psychiatrists, 2009.
7 Williams, R. Lost souls. In Lost Icons: Reflections on Cultural Bereavement: 139–88. Continuum International Publishing, 2000.
8 Corresponding Committee on Religion, Spirituality and Psychiatry. Religious/Spiritual Commitments and Psychiatric Practice (resource document). American Psychiatric Association, 2006.
9 Williams, R. Rome Lecture: Secularism, Faith and Freedom. 23 November 2006 (http://www.archbishopofcanterbury.org/articles.php/1175/rome-lecture-secularism-faith-and-freedom).
10 Carrette, J, King, R. Selling Spirituality: The Silent Takeover of Religion. Routledge, 2005.
11 Culliford, L, Eagger, S. Assessing spiritual needs. In Spirituality and Psychiatry (eds Cook, C, Powell, A, Sims, A): 1638. Royal College of Psychiatrists, 2009.
12 Rogers, C. Becoming a Person. Constable, 2004.
13 Matthews, E. Body Subjects and Disordered Minds: Treating the Whole Person in Psychiatry. Oxford University Press, 2007.
14 Zahavi, D. Phenomenology of the self. In The Self in Neuroscience and Psychiatry (eds Kircher, T, David, A): 5675. Cambridge University Press, 2003.
15 Fulford, KWM. Moral Theory and Medical Practice. Cambridge University Press, 1989.
16 Barker, P, Buchanan-Barker, P. The Tidal Model: A Guide for Mental Health Professionals. Routledge, 2005.
17 National Mental Health Development Unit. Mental Well-Being Checklist. NMHDU (http://www.nmhdu.org.uk/silo/files/mental-wellbeing-checklist-a4.pdf).
18 Crossley, D, Lepping, P. Role confusion, values-based practice and the demise of the generalist. Psychiatrist 2009; 33: 79.
19 Flaming, D. Becoming a nurse: ‘It's just who I am’. Med Humanities 2005; 31: 95100.
20 Gilbert, P, Pehl, J, Allan, S. The phenomenology of shame and guilt: an empirical investigation. Br J Med Psychol 1995; 67: 2336.
21 Gilbert, P. What is shame? Some core issues and controversies. In Shame, Interpersonal Behaviour Psychopathology and Culture (eds Gilbert, P, Andrews, B): 330. Open University Press, 1998.
22 Tangney, JP, Wagner, P, Gramzow, R. Proneness to shame, proneness to guilt and psychopathology. J Abnorm Psychol 1992; 10: 469–78.
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BJPsych Bulletin
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Holistic psychiatry without the whole self

  • David Richard Crossley (a1)
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eLetters

The role of holistic, patient-centred research

Caroline S. Cooper, Consultant psychiatrist
28 March 2012

I was struck by the article by Dr Crossley and its consideration of the tensions between "being person-centred yet scientific" (1). We try to provide patient-centred care within the framework of evidence-based medicine, although we try to ascertain that evidence base using structured, standardised processes.

Other thinking behind the patient-centred approach has been developedby Fulford, expanding arguments surrounding the concept of disease (2). Inhis model of the "balanced or full-field model of health care" he examinesthe balance between the objective concept of disease and the subjective concept of illness. In these, he states, there is a tension between the views of the patient (who is subjectively experiencing the feelings and complaints of being ill), and the doctor, (who takes the role of the expert in the area of disease, an objective, scientific concept).

If we want to emphasise the subjective experience of patients in our work, then I would like to suggest we increase our exposure to the subjective experience in research. Categorising original research articlesover 2 decades from the three highest profile general psychiatric journalsrated by both Journal Impact Factor, and by the proportion of psychiatrists reading them (3) (namely the British Journal of Psychiatry, the American Journal of Psychiatry and Archives of General Psychiatry) showed that their focus is on objective research, with biological or epidemiological domains accounting for 70% of the articles published (n=5710). When articles were rated using a narrow operational definition of whether their main aim was to study the subjective experience of the patient (4), only 2% (156 articles) met the criteria. Variables associatedwith subjective experience research (perhaps unsurprisingly) included psychosocial research topics (OR=10.2; 95%CI 7.4-14.2), and qualitative (OR=34.6; 95%CI 5.74-208.7) and cross sectional (OR=4.2; 95%CI3.1-5.9) research methodologies. It is likely that journals from other disciplines (such as the social sciences and psychology) would have more articles pertaining to the subjective experience of patients, as would psychiatric journals with explicit aims to publish articles relating to ethics and patient-centred care; however British psychiatrists are less exposed to these than the journals investigated (3).

There is no reason why a subjective, values-based approach cannot sitalongside the objective, factual approach, and conflicts between values-based practice and evidence-based medicine are unnecessary. To be person-centred we must have a strong understanding of the factual evidence for our interventions, but also understand the patient's unique set of values and experiences. Evidence-based medicine promotes the integration of threekey elements: best research evidence, clinical expertise and patient values (5). In order to do this effectively there should be application ofthe patient-centred ethos in taking into account the illness experience, the person and the context in which the illness presents in order to find common ground between both the physician's and the patient's perspective.

References

1.Crossley DR. Holistic psychiatry without the whole self. Psychiatrist 2012; 36 97-100.

2.Fulford KWM. Concepts of disease and the meaning of patient-centred care. In (Eds) Fulford KWM, Ersser S, Hope T. Essential Practice in Patient-Centered Care. Oxford: Blackwell Science, 1996.

3.Jones T, Hanney S, Buxton M and Burns T. What British psychiatrists read: Questionnaire survey of journal usage among clinicians. British Journal of Psychiatry 2004; 185, 251-257.

4.Calton TC, D'Silva K, Cheetham A, Glazebrook C. Breaking the Covenant: International Schizophrenia Research and the Concept of Patient centredness 1988-2004. In (Eds) Alanen, YO, Silver, AL and Gonzalez de Chavez, M. The History of the International Society for the Psychological Treatment of Schizophrenia and Other Psychoses, Madrid: ISPS publications,p303-320 2006.

5.Sackett DL, Strauss SE, Scott Richardson W, Rosenberg W & Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM (2nd Edition). Churchill Livingstone, Edinburgh, 2000.

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Conflict of interest: None declared

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