- Some practical tips for getting
published at student/trainee level
- Sparking an interest in
psychiatry
- The on-call experience
- Are medical skills
lost?
- Aspects of
psychiatry
- A psychoanalytic
view
- Treating people who don't want to
be treated
- Dark side
of the moon: a course in mental health and the arts, Bob
Adams (links to the article in the Psychiatric
Bulletin - a username and password will be requested)
1) Some practical tips for getting published at
student/trainee level
This may sound rather trivial, but it is
certainly true – one of the most important things that it takes to
get published is luck! Talk to people who do research in areas you
are interested in and express your interest in being on a paper.
You might be surprised how many teams would welcome input from a
student or trainee. Of course, the second most important
thing, failing the first one, is perseverance.
Choose a topic that you
are enthusiastic about, as completing a project is very hard work
and you don’t want to spend all that time on something of medium
interest to you.
To produce publishable
data is often not the most difficult part. It is not impossible to
design and carry out a research project and write up its findings
completely on your own, but it usually helps if you do it with
someone who has done it before. As with many things in life, choose
well who you join! You want someone who has everything for a
successful paper apart from what you can provide. Working with
someone very famous is not an absolute prerequisite for getting
published yourself, and sometimes it is better to choose a person
who is perhaps not so prominent but has more time to supervise you.
Often the best option is to join a team that includes students who,
as a rule, get their work published while working there.
Once you have generated
the data, make sure you don’t let it lie around for long, because
you will start forgetting the details of the project and it will
become disproportionately more difficult to write it up, or someone
else will have published on the same thing rendering your work less
publishable. Also, other things will start to compete for your
attention and time, and you can forget about it.
Agree at the beginning
who is going to be on the paper, who is going to be the main
author, and who is responsible for what during the writing up.
Don’t try to get the manuscript perfect immediately, start
circulating the first draft for comments early on. Don’t feel too
let down if your co-authors suggest culling huge chunks of the
result of your hard work.
Carefully read through
the “instructions to authors” section of the journal you have
selected for the submission of your manuscript to avoid
disappointment. Reading a few issues of the journal will give you
an idea how well your paper would fit with the content of that
journal. A common mistake is to assume that the reviewers would be
familiar with all the concepts, methods, and circumstances in your
research – they will likely not be. Make sure your paper is
understandable for someone with a less specific knowledge base.
Also, check through the spelling and grammar of your paper – few
things irritate reviewers more than poor English, which can easily
detract from the real scientific value of your work. Last but not
least, try and make your style interesting so that reading your
paper will be fun.
Don’t take the reviewers’
comments too personally – their suggestions can greatly improve the
quality of your manuscript! Always respond to every single point
they make in an organized way. Also, don’t get disheartened if your
submission gets rejected; most journals only publish a small
minority of all the manuscripts submitted to them for peer review.
Resubmit your improved manuscript to another journal.
Once you have published a
paper, the next one will feel easier because many of the skills you
learnt through getting the first one published will come in handy
the second time round.
Dr Robert Dudas, SpR
Back to top
2) Sparking an interest in psychiatry
At medical school, one of
the days I remember the best was walking onto a psychiatry ward for
the first time. The environment was completely different to the
strip-lit and uniformed wards of the general hospital, and the
atmosphere seemed charged (my first instinct was to blame static
electricity resulting from cheap trousers). After finding a willing
patient, I presented my examination findings to a consultant, who
then proceeded to unnerve me by demonstrating the ability to
accurately anticipate/cold-read the patient’s background. Although
I have since realised that this ability is based on experience (as
in many medical specialties, sheer volume of clinical work leads to
pattern recognition), when the placement concluded with a visit to
a high security hospital, I left intrigued.
Following graduation I
found myself immersed in the cut-and-thrust of accident and
emergency medicine and was content for a good while. Slowly though,
I began to notice that patients’ lives and stories would largely
pass by, undigested like conveyor belt sushi. Eventually I decided
to leave and apply for core psychiatric training (CPT).
Having recently completed
CPT, I find myself wondering why the difficulties with recruitment
and retention in psychiatry are so severe? For sure, the specialty
has more to offer medical students than learning how to arrange
chairs for an interview. Most psychiatrists profess and maintain an
interest in people and thus shrug-off a classic retort favoured by
medical school interview panels: “why don’t you become a social
worker then?” Psychiatry is as complex and challenging as
human nature and has an unrivalled capacity to create novel and
sometimes inspiring situations, ranging from sad to funny and
despairing to hopeful. As your training progresses, you are
privileged to note that the human condition applies to us all and
you learn how to listen and communicate effectively, contain your
own and other’s anxiety and develop the ability to think on your
feet. Even if you don’t choose psychiatry as a career, the skills
and experiences gained will have lasting value, wherever you end
up.
Dr David Brunskill
Specialty Registrar in forensic psychiatry
Back to top
3) The on-call experience
Being on-call for a
medical specialty and providing round the clock care is a unique
and challenging experience. As a trainee, it is probably the arena
where most professional development occurs, often out of necessity.
In psychiatry you work independently from the very beginning of
training and you gradually learn how to contain your own anxiety,
when to seek support and how and when to take decisions for which
you are clinically responsible.
A wide variety of
psychiatric referrals are made, many originating from the emergency
department. As a psychiatrist, you can feel like a guest and the
welcome can be variable. However, you are an ambassador for mental
health services by default and, by demonstrating a professional
attitude and showing a willingness to discuss clinical matters with
referring staff, there is a chance to address the underlying stigma
still associated with psychiatry (and those people who self harm in
particular).
Prolonged exposure
confers a sense of what is understandable behaviour in response to
life situations, and what is less so. More than any other
specialty, you look down the telescope of life and, if you do
enough assessments, you will access all layers of British society
and realise that good mental health is important to us all. In
return for the privilege of exploring the intimate details of
peoples’ lives, you will field diverse and challenging questions
from patients and their families alike. In the absence of a
textbook to refer to, you need to develop an ability to think on
your feet. As well as being asked directly what is wrong with them
and the world at large, you may be asked to intervene personally in
peoples’ lives, be issued ultimatums about being admitted into
hospital and be invited to ease an individual’s responsibility for
their actions. Many such questions do not have a straightforward
answer and, if this sounds daunting, it is worth remembering that
we tend to underestimate the simple act of listening.
Being on-call in
psychiatry is a rich experience. Mental distress and disorder can
be seen to have their roots in peoples’ real and imperfect lives
and you are reminded that we are complex, social animals. As
Engleby surmised when considering his own mental health problems,
“my own diagnosis of the problem is simple. It’s that I share 50%
of my genome with a banana and 98% with a chimpanzee. Bananas don’t
do psychological consistency, and the tiny part of us that’s
different - the special homosapiens bit - is faulty. Sorry
about that” (Faulks, 2008).
Dr David Brunskill
Specialty Registrar in forensic psychiatry
Back to top
4) Are medical skills lost?
Doctors considering core
psychiatric training (CPT) may be anxious that hard-won medical
skills will disappear. Whilst it may be true that, as your training
progresses, the opportunities and responsibility for practical
procedures and physical examination decrease, psychiatrists will
always be medical doctors, specialising in mental health. Medical
training instils a systematic way of approaching health problems.
This persists in psychiatry with the necessary addition of lateral
thinking and a biopsychosocial approach. Medical skills are neither
redundant nor lost in translation, but adapted and added to along
the way and it is more accurate to consider that what you lose with
the one hand, you gain with the other.
A good way of
illustrating the medical skills required in psychiatry is to
consider the senses all clinicians rely on. The
examination of the mental state calls upon you to move beyond
inspection to a more sustained observation of appearance
and behaviour. This observation includes recording visual
information such as cleanliness, dress, dentition, agitation,
distractibility, movements and mannerisms, eye contact and body
language. The discipline of recording this information develops a
skill with real clinical currency (think about someone you live
with – can you remember what they were wearing this morning?)
When listening
to the patient’s own words, take the time to record verbatim
examples. The narrative should not be discarded, as it is likely to
contain personal meaning however well hidden. Everyone has their
own communication style and psychiatrists often need to be flexible
in order to get people talking. Once you have started this process,
open questions help the individual to identify what is important to
them and closed questions can be used to define, clarify and check
your understanding. Smells reflect the life being led and
thus self-neglect, fear or the telltale presence of spent alcohol
pooling in the pores can be indicators.
All medical specialties
accord attention and value to a clinical hunch, and the equivalent
in psychiatry is probably gut feeling. However, the
decision-making process is complex, and clinical intuition (based
on the foundations of a good history and examination) should be
supplemented with collateral information, appropriate
investigations and objective clinical tools. Touch may
literally consist of a handshake but, as a doctor, being touched
emotionally (and thus left with an aftertaste) is commoner
than is admitted. Medical students asked “how did it make you
feel?” may experience initial discomfort, but the cliché has valid
and honest roots. Cultivating self-awareness and recognising the
validity of your own reactions to others contributes to successful
clinical practice. Although these skills apply to other medical
specialities, psychiatry uniquely recognises them and incorporates
training and experience in psychotherapy and a weekly hour of
consultant supervision as part of CPT. The importance of human
interactions is at the very heart of training.
Dr David Brunskill
Specialty Registrar in forensic psychiatry
Back to top
5) Aspects of psychiatry
Psychiatry: A unique type of
medicine
In a very basic way, doctors
working in mental health use much the same skills as those working
in other areas. Medical school always felt like a challenge in
which you cram your head with as much information as you can and
hope to hold onto enough of it for long enough to get through your
exams. When I started working, I realised that for 5 years they had
been teaching me a system or a strategy for managing sick people in
a (largely) foolproof way. When you leave medical school you have a
highly systematic method for quickly assessing the patient, rapidly
identifying which one of the thousands of things you have learnt
about is going wrong in front of you, focusing on the dangers
associated with that particular problem and quickly devising an
efficient plan to deal with what you’re seeing.
It may not always be as obvious,
but a structured approach and absolute precision are as important
in mental health as in any other specialty. The difference lies in
the knowledge base that we work from. Neurobiology and the
pathophysiology of mental illness is an important part of this
knowledge base. The same principles apply here as in any other area
of medicine. There are, however, a number of differences. The first
is that our understanding of the pathophysiology of mental illness
is more limited than in many other areas of medicine. The second
difference is that neurobiology is only one of a number of
different ways that we have come to conceptualise mental illness.
We also recognise that the mental wellbeing or otherwise of the
individual is linked to their life experiences. Their development
and experiences through childhood and beyond can be a significant
factor in the development of mental illness. More current
circumstances and life events can also contribute to the
development of mental illness. The theories and knowledge base that
underpin this aspect of our understanding are as complex and
important as the neurobiology of mental illness. The treatment of
these kinds of problems is also much less straightforward than
writing a prescription.
Treating the whole patient
The biological, psychological and
social aspects of each individual case need to be carefully
considered and attended to in thinking about management. This is a
considerable challenge and the reality is that you could happily
devote your whole career to fully understanding just one aspect of
the model. It is no simple task to develop a full and workable
model to guide your practice. Our capacity to utilise these models
to understand the people that we work with is technically
important. It is also often the case that the sense of being
understood is one of the most powerful interventions that we can
offer to the people with whom we work. In psychiatry, our
relationship with our patients is often as important as any
technical intervention that we can provide. Mental illnesses are
often considered to be less “serious” than physical illnesses. The
reality is that the morbidity associated with mental illness tops
most charts comparing the specialties. Mortality is not
insignificant and never inconsequential. Death by suicide is always
tragic and has massive implications for friends and
family.
Psychiatry is complex, challenging and
absorbing
Working in psychiatry you still use
the core skills that you develop as a medical student and a doctor.
It is complex, challenging and absorbing. The big draw of
psychiatry is that you have the freedom to make what you want of
it. You can choose to specialise in any of numerous subspecialties.
Within your specialty, you can choose to work in a way that bests
suits your personality and how you think about psychiatry. It is
this variety, flexibility and freedom that make it such an
interesting area to work. I have always enjoyed my work and found
it extremely satisfying. It’s also true that time spent with the
patients is often much more fun than work really ought to
be.
Dr James Pick
Back to top
6) A psychoanalytic view: On being reminded
When I was a medical student
looking through psychiatric text books and reading about various
mental and personality disorders, I had the somewhat disturbing
realisation that some aspects of these descriptions reminded me of
myself.
Despite the difficulty that we might have recognising that some of
our patients’ difficulties remind us of aspects of ourselves, I
think that, at the heart of the human relationship that can become
therapeutic, is the use we make of ourselves emotionally to
understand our patients. This is the basis of empathy. The idea
behind the title 'On being reminded’ is that, in psychoanalytic
psychotherapy, the concept of transference can be understood as the
patient being reminded in their experience of the therapist of
someone from their past or some aspect of a relationship from their
past. The therapist too can be reminded in their experience of the
patient of someone from their past or of an aspect of a
relationship from their past and this is one part of what is known
in psychoanalytic psychotherapy as the countertransference.
Both patient and therapist are
mainly unaware of these reminders as they are unconscious, but it
is in the emotional impact of these mutual echos of the past in the
present that the work of trying to understand the patient takes
place in psychoanalytic psychotherapy. This is the theraputic work
of using the resonance of the past in the present relationship with
the therapist to process now what happened (or did not happen)
then.
Another way of thinking about the
idea of being reminded is that many people who come into
psychotherapy in NHS settings have endured severe emotional
deprivation and traumatic experiences in childhood, that is, they
have had an experience in growing up of not having been adequately
minded or held in mind in their development. For some patients,
privation may be a more appropriate word to describe their
experience than deprivation, to denote a primary lack of care
rather than care which has been inconsistent or which has first
been present and then became absent. What some, though not all, of
these patients seek is a relationship in which they can be held in
mind with the unconscious aim of being re-minded in a sense of
being held emotionally and psychologically in mind in a way that
they may never have encountered in their previous development.
This, in my view, is at the heart of what makes a therapeutic
relationship therapeutic. That is the process of a unique
relationship between the professional and the patient in which a
shared human experience, a shared emotional encounter, can take
place in which both parties are engaged in a process of emotional
and psychological work.
In psychoanalytic psychotherapy
this concept of working over one’s emotional difficulties from the
past is understood as working through. This working through
needs to take place in the patient in terms of working over and
working through their conflicts from the past with the therapist
but it also involves the therapist working over and through some of
their own conflicts that will be evoked in the emotional
relationship with the patient. This can be understood to be a
process of transference working through and counter-transference
working through for patient and therapist together.
In my twenty odd years in
psychiatry and psychotherapy, I have come to see that beyond the
specialist therapeutic setting, this process of an ordinary human
encounter in which the professional is prepared to be receptive to
the patients’ emotional communications, is at the heart of good
psychiatric practice generally.
As a Consultant Psychiatrist in
Psychotherapy one of my roles, alongside my therapeutic work, is to
consult with colleagues in psychiatry and other mental health
disciplines. I therefore encounter many situations where
people achieve what I am describing in terms of a genuinely
receptive emotional encounter with their patients, but also
struggle to maintain this level of emotional contact and enter an
impasse with some of their patients. I am interested in what
leads to people getting stuck emotionally and this links with the
whole concept of a disturbing process of being reminded. It is
when the patient presses the professional’s emotional and
psychological buttons that they get under that professional’s skin
and if that can’t be thought about and understood it can lead to
some very stuck situations clinically.
Dr James Johnston
Consultant psychiatrist in psychotherapy, Leeds
Back to top
7) Treating people who don’t
want to be treated
One of the unique challenges of
working as a psychiatrist is that you will frequently encounter
patients who do not want any contact with psychiatry and do not
recognise their difficulties as being due to any kind of health
problem. This dilemma challenges the clinical and ethical
skills of all psychiatrists. You will have to consider a number of
issues. Firstly, and most importantly, patients have a right
to autonomous decision making with regard to their health. The
following rights are enshrined in the European Convention on Human
Rights:-
1. The obligation to respect Human Rights
5. The right to liberty and security
8. The right to respect for private life
9. The right to freedom of thought, conscience and
religion
10. The right to freedom of expression
14. The right to prevention of discrimination
They are also protected by the Mental Capacity Act 2005 and the
Mental Health Act 1983 (amended 2007).
As a psychiatrist, you will be
expected to weigh these rights against the risks that a patient may
pose to himself or other people. In order to make a risk
assessment, you will be required to use your own clinical skills
and judgement, but also communicate with individuals and agencies
involved in the patient’s care in addition to informants, such as
family members and informal carers.
The Mental Health Act allows for
the lawful detention and treatment of patients suffering from a
mental disorder, and for them to be treated and detained in
hospital and assessed and treated against their wishes. One of
the most difficult decisions psychiatrists have to make is whether
to recommend detention to hospital for treatment of mental
disorder, knowing that this may have serious repercussions for the
individual, not least the long term relationship with the
psychiatrist and his team.
Patients with mental health
problems present a special problem. As a result of their
illness they may cause harm to themselves or other people. Their
condition may be a cause for concern for their family, carers and
society in general. The patient, however, lacks the ability to
understand they are unwell and seek help
appropriately. Appropriate help may take the form of
in-patient or out-patient treatment and pharmacological or
psychological treatment. The powers of the Mental Health Act
aim to ensure that such people may be admitted to hospital against
their will. The Mental Health Act contains very detailed
safeguards regarding the circumstances in which patients may be
detained, the conditions on treatment, and rights for patients who
are detained.
When a patient is detained to
hospital, the psychiatrist will have the challenge of establishing
a relationship with the patient who does not believe that they have
a health problem of any kind, does not wish to remain in hospital,
and may reject the treatment offered to them. Establishing
relationships in circumstances such as these are some of the
greatest challenges to your personal and communication skills you
are likely to encounter in any branch of medicine. You are likely
to experience difficult interviews and will need to draw on the
skills of the team around you for help for the patient and support
of your own management plans. Patients with mental health
problems severe enough to warrant detention may be in hospital for
quite some time and the rewards in treating these patients may
be slow in coming and subtle. However, the reward of restoring
a patient to a degree of independence and autonomy from the
distress and chaos encountered during a period of mental ill
health, is one of the most satisfying therapeutic rewards you are
likely to experience in medicine.
Dr Tim Branton
Consultant psychiatrist, The Mount
Back to top
Back to student area home page
Page last updated on 4 August 2009 by
E Baker-Glenn