Peter Shoenberg and Jessica Yakeley: Learning About Emotions In Illness: Integrating Psychotherapeutic Teaching Into Medical Education

Learning about Emotions in Illness: Integrating Psychotherapeutic Teaching into Medical Education Edited by Peter Shoenberg & Jessica Yakeley Routledge, 2014, £90.00, hb, 156 pp, ISBN: 9780415644907 

Reading Learning about Emotions in Illness , I found myself reflecting on my emotional response to


LEARNING EMOTIONAL SKILLS AND PATIENT CENTERED MEDICINE
Every generation of medicine faces unique challenges and crises. For this generation, the Institute of Medicine, America's most influential medical policy organization, has identified a "quality chasm" (IOM, 2001) between the ideal and actual practice of medicine. Among 6 key issues, the IOM highlights that aspects of the doctor-patient relationship that may be crucial for healing are often eclipsed by pressures for efficiency, and a growing reliance on technology.
Medical educators are faced with a challenge. They must find ways to teach not only the technologies of basic medicine, but also evidence-based approaches to professionalism, the doctor-patient relationship, and patient centered medicine (Balint, Ball, and Hare, 1969;Balint, 1969) that underlie effective care. This proves to be a difficult task, given a "hidden curriculum" (Hafferty and Franks, 1994) that undermines basic lessons in medical professionalism. Educational research suggests, for example, that current training models produce decrements in empathic skills (Hojat et al., 2009) and that neglect of feelings (in patient and doctor) is often modeled as a way of dealing with the emotional challenges of medical training (Shapiro, 2011).
This little book, Learning About Emotions in Illness: Integrating Psychotherapeutic Teaching into Medical Education, by Peter Schoenberg and Jessica Yakeley, is an important contribution that offers a solution to the dilemmas just described. The authors explore two simultaneously time-tested and radical methodologies, based in psychoanalytic listening skills, for teaching about emotions in illness and the doctorpatient relationship.
In a series of chapters that can serve as a how-to guide, Schoenberg, Yakeley, and others explore over 50 years of wisdom accumulated in a pioneering psychotherapy training track at the University College of London, in which medical students learn to conduct psychodynamic psychotherapy. They detail how such a program, providing careful patient selection, skilled supervision, and a supportive group processes develops not only psychotherapy skills, but also promotes empathy, effective communication skills, and healthy boundaries. Medical educators will appreciate the earnest review by supervisors and faculty, of the benefits, practicalities, and complications in developing and maintaining such a program. The chapter of reflections by former students in the psychotherapy track conveys, vividly, how psychotherapy experiences can be transformative to the student, as well as the patient, and how being held allows students to learn better to hold their patients, in the Winnicottian sense.
Acknowledging that the psychotherapy track is resource-intensive and not optimal for all students, the authors then describe alternative efforts to foster emotional intelligence and patient-centeredness by incorporating Balint Groups (Balint, 1957) into medical training. In the Balint methodology, students are encouraged to bring affectively powerful clinical contacts to small student groups in order to explore psychological factors in illness and medical care. Trained group consultants facilitate a discussion that elucidates not only the patients' psychology of illness, but also countertransferential and defensive aspects of physician responses to the suffering of patients. As with the chapters on the student psychotherapy track, the authors share their learning not only about the benefits of such groups, but also expectable challenges. Narratives by former students of the Balint groups underline the powerful developmental impact of this method on physician communication skills, empathic attunement, and professional identity.
The authors devote the final chapter to the evidence base for these teaching methodologies. Most basically, they find such programs clinically effective, with 87% of patients making good or very good progress under treatment by student psychotherapists. Further, they find that not only are psychotherapy tracks welltolerated by most students, but even that "most of the students considered discussion of their patients in supervision to have been the most rewarding experience of medical school" (p.125) (italics mine). The research reviewed offers some guidance about which students are more likely to benefit from opportunities to provide therapy and suggests that participation in both the psychotherapy track and the Balint Group track enhances communication skills and recognition of the impact of the doctor-patient relationship. Content analysis of Balint group discussions also usefully highlights the most emotionally challenging aspects of medical training and professional identity formation. Anyone interested in developmental processes involved in becoming a physician, will find this research illuminating.
This book should be of interest to medical educators who are looking for evidencebased ways to develop (rather than undermine) empathy and patient-centeredness in medical students, while, simultaneously providing support to students around some of the most emotionally challenging aspects of medicine.
Psychiatric educators will find this book of great interest as well, not only because it emphasizes the important contribution that psychiatry makes towards developing basic doctoring skills, but also because it addresses other crises particular to psychiatry. It is likely not a coincidence that, at the same time that biomedical psychiatry was in ascendancy, recruitment into psychiatry seemed to fall (Mintz, 2013), given that the most idealistic medical students are often discouraged by their experiences on biomedically focused, short-stay inpatient units. Psychotherapy teaching, the authors demonstrate, is a phenomenally potent recruitment tool, increasing recruitment into psychiatry tenfold for students previously interested in psychiatry as well as those who professed no prior interest. This should catch the attention not only of educators interested in recruiting emotionally skilled students into psychiatry, but also those invested in public health and a more optimal distribution of health resources (IOM, 2001), given that 96% of US counties experience shortages of available psychiatrists (Thomas, Ellis, Konrad, Holzer, and Morrissey, 2009).
Psychoanalysis has also suffered in the biomedically reductionistic environment of psychiatry in recent years, as the retreat (or expulsion) of psychoanalysts from academic medicine can leave medical students with misconceptions about the range of possibilities of psychiatric practice, while exposing them to attitudes about psychoanalysis that are, at best, skeptical. One can hope that the experience and evidence summarized in this book will not escape attention, bringing greater balance to medical education and restoring a place for psychoanalytic wisdom in academic medicine. Psychoanalytic theories have always tried to imagine the baby. We wonder, while listening to adults, what were they like as children, or as infants? Who was their mother and how did she care for them? Our ideas about the baby, its mother and the kind of loving care that we imagine will best support development have shifted over the decades, reflecting the multiple psychoanalytic cultures that now co-exist.

David
For many years, an imagined infant, seen through the lens of adult experience, outweighed the evidence of behavioral observation in psychoanalytic theories. This was the case for cognitive psychology as well. In Before Speech (1979), Bullowa remembers that as late as her "medical training" the infant was believed to be born unable to speak or see; scientists were slow to notice that the baby communicates long before it can talk. In her words, "Of course most mothers know otherwise but scientists and other 'experts' haven't always taken them seriously" (p. 1). I do believe mothers experience something of the innate capacity for communication observable at birth, although they also understand the infant's self emerges over the first weeks and months. Perhaps science and psychoanalytic theory were imbedded in fantasies of early relational experience, notably ignoring the infant's perception and contribution, a way of becoming known.
Cognitive science shifted, and psychoanalysis followed when the study of how communication begins was not limited to language development, and instead included the wonderful range of non-verbal communication that is described by the authors. The subtleties and complexities of non-verbal communication are central to their work and the impact of infant research on psychoanalytic theory and practice.
An excellent review of the breadth of current understanding of infant capacities is included in Part I. We now know so much about how infants make sense of the world and how they participate and communicate in the relationships that sustain them. Findings from infant cognitive, social, and perceptual developmental research have changed the game of psychoanalytic theory building and Beebe and Lachmann translate these changes by documenting the construction of self and relationship in pre-verbal infancy.