Psychiatry, subjectivity and emotion - deepening the medical model

Caring for affective subjects produced in intimate healthcare examinations

This article is about the feelings - affect - induced by the digital rectal exam of the prostate and the gynaecological bimanual pelvic exam, and the care doctors are or are not instructed to give. The exams are both invasive, intimate exams located at a part of the body often charged with norms and emotions related to gender and sexuality. By using the concept affective subject, we analyse how these examinations are taught to medical students, bringing attention to how bodies and affect are cared for as patients are observed and touched. Our findings show both the role care practices play in generating and handling affect in the students' learning and the importance of the affect that the exam is (or is not) imagined to produce in the patient. Ours is a material-discursive analysis that includes the material affordances of the patient and doctor bodies in the affective work spaces observed.

Attitudes towards People with Mental Illness and Low Interest in Psychiatry among Medical Students in Central and Eastern Europe

This study aimed to examine attitudes towards people with mental illness and psychiatry and interest in career choice in psychiatry among medical students from three medical schools in Czechia and Slovakia. A total of 495 medical students participated in a cross-sectional study. Participants completed (1) the Medical students' version of mental illness: clinicians' attitudes (MICA-2) scale, (2) the Reported and intended behaviour scale (RIBS), (3) the Attractiveness of working on a psychiatry-related position scale (P-ATTRACT), and (4) the Status of psychiatry scale (P-STATUS). Descriptive statistics, group comparisons and regression models were calculated. From 23 to 30% of students considered a specialization in psychiatry. However, only about 1% of them had a strong interest in psychiatry as a future career, moreover, students of higher years of study found psychiatry less attractive compared to those who are in the beginning of the study. The consideration of specialization in psychiatry was found to be statistically significantly associated with less stigmatizing attitudes and lower social distance towards people with mental illness. There were statistically significant differences in stigmatizing attitudes among medical schools, with a medical school emphasizing the education in psychiatry the most showing more positive attitudes. It is necessary to increase the interest in psychiatry and minimize stigma among medical students. Psychiatry curriculum in Central and Eastern European region should include more psychiatry-related courses, training in community and out-patient facilities, peer-lectors, and offer counselling after exposure to emotionally challenging clinical situations.

Medical Students' Career Choice and Attitudes Toward Psychiatry: Case of the Czech Republic

OBJECTIVE

A survey among medical students of all medical schools in the Czech Republic was conducted to investigate attitudes and views of psychiatry and career choice of psychiatry.

METHODS

A Czech version of the Attitudes to Psychiatry Scale (APS) and a questionnaire surveying demographic characteristics and choices of future specialty were distributed to all medical students of eight medical schools in the Czech Republic via the schools' internal communication systems in the form of an anonymous online questionnaire.

RESULTS

Out of a total of 10,147 medical students in the Czech Republic (academic year 2019/2020), 2418 students participated in the survey (response rate 23.8%). Psychiatry as a non-exclusive career choice was considered by 31.3% respondents; child and adolescent psychiatry was considered by 15.4% respondents. Psychiatry as the only choice was considered by 1.6%, and child and adolescent psychiatry was not considered at all. The interest in both specialties was declining since the first year of study. The status of psychiatry among other medical specialties was perceived as low; students were rather discouraged from entering psychiatry by their families. They did not feel encouraged by their teachers to pursue career in psychiatry despite the fact that they were interested in psychiatry. They also felt uncomfortable with patients with mental illness.

CONCLUSIONS

Despite high enthusiasm for psychiatry in the first year of medical school, only a small proportion of medical students consider to choose psychiatry, and especially child and adolescent psychiatry, as a career at the end of medical school.

Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review

Despite the importance of psychotherapists' subjective experiencse working with patients with mental issues, little is known about the relationship between therapists' emotional reactions and patients' personality problems. The present study is a systematic review of quantitative research on the association between patients' personality pathology and psychotherapists' emotional, cognitive and behavioural reactions in individual psychotherapy setting. A systematic database search (from January 1980 to August 2019) supplemented by manual searches of references and citations identified seven relevant studies. Significant and consistent relationships were found between therapist reactions and specific personality traits or disorders. In general, odd and eccentric patients tend to evoke feelings of distance and disconnection; emotionally dysregulated patients tend to evoke anxiety and incompetence, and anxious and withdrawn patients tend to evoke sympathy and concern. However, the relatively small sample of studies and methodological inconsistencies across studies limit firm conclusions and suggest the need for more systematic research. Findings from this review indicate that patients who share the same personality disorder or symptoms tend to evoke specific and similar cognitive, emotional and behavioural reactions in their therapists. This suggests that therapists overall reactions toward patients may be source of valuable diagnostic information.

Evaluating the effectiveness of video cases to improve patient-centeredness in psychiatry: a quasi-experimental study

OBJECTIVES

To evaluate the effectiveness of including interactive video-based patient cases in preparatory lectures on medical students' patient-centredness and attitudes towards psychiatry.

METHODS

This study was designed as a quasi-experimental intervention study. A preparatory lecture on diagnostic interviewing was given to 204 fourth-year medical students before a 4-week psychiatry clerkship. The students were divided into two groups. One group (n=102) received a preparatory lecture including an interactive video case portraying a doctor performing a diagnostic interview with a simulated patient (intervention group). The other group (n=102) received a conventional preparatory lecture using text-based instructional material (control group). We conducted a paired sample t-test to compare the students' confidence in exhibiting patient-centred communication and their attitudes towards psychiatry before receiving the preparatory lecture and after having completed a minimum of three weeks of clerkship training.

RESULTS

A total of 102 students, 51 in each group, completed a questionnaire at both measurement points. In the intervention group, we found a statistically significantly difference for the students' patient-centredness before (M=69.4, SD=10.0) and after (M=73.8, SD=8.6) the intervention t(97)=2.38, p= 0.02, but no changes in attitudes t(98) =1.07, p=0.28. In the control group, we found no changes in patient-centredness or attitudes.

CONCLUSIONS

Video cases in preparatory lectures appear to be better than text-based material at improving students' patient-centredness in psychiatry. However, neither video cases nor text-based material seem to influence the students' attitudes.

Ethical dilemmas in psychiatry: When teams disagree

Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. We discuss how conflicting emotions and perspectives within teams acquire ethical significance and how negotiation and reflection are essential for good-quality ethical reasoning to take place.

Learning Objectives

• Understand the different effects and importance of reasoning and emotions in moral decision-making

• Use a clinical scenario involving a difficult and controversial procedure to explore the impact of social persuasion in moral decision-making

• Consider the effects of heuristics against rational thinking

Epistemic injustice in psychiatry

It has been argued that those who suffer from medical conditions are more vulnerable to epistemic injustice (a harm done to a person in their capacity as an epistemic subject) than healthy people. This editorial claims that people with mental disorders are even more vulnerable to epistemic injustice than those with somatic illnesses. Two kinds of contributory factors are outlined, global and specific. Some suggestions are made to counteract the effects of these factors, for instance, we suggest that physicians should participate in groups where the subjective experience of patients is explored, and learn to become more aware of their own unconscious prejudices towards psychiatric patients.

Limitations of the biopsychosocial model in psychiatry

A commitment to an integrative, non-reductionist clinical and theoretical perspective in medicine that honors the importance of all relevant domains of knowledge, not just "the biological," is clearly evident in Engel's original writings on the biopsychosocial model. And though this model's influence on modern psychiatry (in clinical as well as educational settings) has been significant, a growing body of recent literature is critical of it - charging it with lacking philosophical coherence, insensitivity to patients' subjective experience, being unfaithful to the general systems theory that Engel claimed it be rooted in, and engendering an undisciplined eclecticism that provides no safeguards against either the dominance or the under-representation of any one of the three domains of bio, psycho, or social.