August 2009  << Back  

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Clinical Skills in Psychiatric Treatment

Richard  Balon, MD

Wayne State University, Detroit, MI, USA

Psychiatry, like many other disciplines and areas through their history, has gone through periods of excitement and of disillusion. It seems that we are going through a period of disillusion or maybe lack of excitement at present. During times such as these, we tend to reflect on past achievements or the lack of them. Drs. Poole and Higgo, authors of this volume on clinical skills in psychiatric treatment, remind us of some of the disillusions of the recent past, eg, no major new technologies have emerged over the last 3 decades. Many new drugs emerged, but they mostly just have a different side-effect profile from the old ones. Drs. Poole and Higgo also note that although there has been “steady progress in improving psychotherapies, these techniques are essentially modifications of older techniques” (p 8).

By Rob Poole and Robert Higgo; Cambridge University Press; New York, NY; 2008; ISBN: 978-0-521-70570-7; $70 (paperback), 228 pp.

Nevertheless, the authors do not endorse therapeutic nihilism. There has been lack of technical progress, but they (and we) have witnessed a dramatic improvement in the quality of mental health services. In their opinion our treatment techniques, both pharmacological and psychological, are not magic bullets; they may be a necessary part of treatment, but not sufficient to help people overcome mental illness (p 9). They believe that, “the way that treatment is delivered, and the relationship between professional and patient, is absolutely critical” (p 9). Drs. Poole and Higgo also believe that there are some key values and principles that underpin good clinical practice (p 9). These values, principles, and issues related to various clinical skills are the themes of this volume. They feel that these clinical skills should help psychiatrists put together the available interventions, develop better strategies to help patients recover from mental illness despite the lack of therapeutic breakthroughs, and improve their work within the multidisciplinary team.

The book consists of an Introduction and 4 parts: Part I “Underlying principles,” Part II “The context and location of treatment,” Part III “Problems in treatment,” and Part IV “Coping,” and concludes with an Afterword and References. A brief introduction summarizes the chapters of each part. In addition, each chapter concludes with a very good feature—main points of that particular chapter.

The 4 chapters of Part I deal with “underlying principles of rational, strategic treatment” (p 5). Chapter 1, “Starting points,” reminds us, among others, that clinical skills are not just our interpersonal skills but also intellectual clinical skills and managerial clinical skills. Chapter 2, “A triangle of forces,” focuses on the 3 factors that can legitimately influence our decision making process—the scientific evidence, the practitioner’s clinical experience, and the practical situation—and their interaction and balancing. The practical situation, in the authors’ words, includes patient’s wishes, other people’s concerns, the patient’s lifestyle and culture, the social environment, and realistic obstructions to the delivery of technically ideal interventions (p 14).

Chapter 3, “Treatment objectives,” attempts first to answer the question “What is psychiatric treatment for?” It further discusses rehabilitation and recovery from mental illness. The authors emphasize that “the essence of recovery is that the person gains, or is restored to, a state of personal autonomy and a sense of well being. It does not mean a denial of the recurrent or chronic nature of some mental illnesses” (p 25). In addition, the authors continue their argument for a limited role of psychiatrists in the treatment of mental illness, suggesting that “Psychiatric treatment should only be undertaken if the patient is unlikely to experience a timely recovery without it” (p 29).

The fourth chapter, “Strategic treatment” focuses on a strategic rather than reactive approach to treatment and issues such as forming a shared understanding of the nature of the problem; clarity of the objectives and limitations of treatment; prioritizing problems, sharing the overall plan, and proceeding in a stepwise fashion; anticipating and evaluating setbacks, and deciding when to change the plan; maintaining realistic therapeutic optimism, and recognizing when enough has been achieved. These are all important issues in strategizing the treatment plan. The chapter contains a useful table of “Ten incrementally ominous signs that treatment is failing” (p 38).

The 6 chapters in the second part address various issues concerning “Teams” (chapter 5), “Teamwork” (chapter 6), inpatient treatment in the era of community psychiatry” (chapter 7), use of legal compulsion (chapter 8 “Compulsion and locked doors”), outpatient clinics, day hospitals and other settings (chapter 9 “Not at home, not in the hospital”), and various “Models of care” (chapter 10) in the context of social policy and public attitudes. In the chapter on teams, I liked the emphasis on the fact that “Secretaries, reception staff, and record clerks have pivotal roles” (p 45) in the function of any facility. I liked less the continuing downplaying of the role of psychiatrists in a statement that “Psychiatrists tend to work best in teams when they accept that they are not in charge, and that their time and expertise is a team resource. It is probably inevitable that psychiatrists carry the greatest authority in clinical matters, but having authority and trying to control everything are very different” (p 49). This statement probably reflects the United Kingdom and United States community mental health system realities. However, speaking to one of my friends in London, UK, who became severely depressed recently, I found out that psychiatrists in the UK “don’t talk to you, they just hand you a prescription.” Whether this reality is best for the patient remains an important question.

The chapter also includes good discussion of effective leadership and effective teams and the difference between generic and specialist team. The chapter closes with interesting comments about second opinion. The authors suggest that asking for a colleague’s opinion may be important and legitimate, but the procedure is essentially defensive and problem-solving is not the objective (p 55). The chapter on teamwork again emphasizes that psychiatrists should basically function as consultants to other professionals rather than working directly with patients! Nevertheless, as noted later in chapter 9, the authors themselves have not abandoned one-to-one office-based psychiatric treatment and continue to see a small number of patients.

The chapter on inpatient treatment contains some interesting ideas, including the observation that modern psychiatric units rarely are well designed (p 72). The chapter on outpatient clinics and day hospitals includes a funny table listing the “Eleven immutable features of the traditional British outpatient clinic” (eg, “patients are never seen at the right appointment time,” or “patients are never discharged, they are only ever lost to follow-up”) (pp 90-91). The discussion of the strange rise and fall of day hospitals also is interesting. The chapter on models of care includes an interesting debate on whether holistic care is necessarily a good thing. The authors think that it is impossible for mainstream psychiatry to embrace complementary therapies but suggest that it is reasonable to adopt a position of skeptical tolerance (p 107).

The 6 chapters in Part III are “concerned with the commonly occurring practical problems of treatment,” (p 109) such as “engagement” (chapter 11), “compliance and concordance” (chapter 12), “treatment resistance” (chapter 13), “complicated problems” (chapter 14), “managing risks” (chapter 15) and “staying well” (chapter 16). The chapter on engagement provides some tips on establishing your credibility with the patient. In the chapter on compliance and concordance the reader finds an explanation of concordance, “concordance means that the clinician and patient agree on a treatment plan and adhere to it” (p 121). Another interesting discussion in this chapter includes issues such as “why don’t patients do as they are told?,” “why do patients adhere to treatment plans?,” and a good discussion of side effects, including important questions such as whether the problem is really due to the drug and how much does it bother the patient. The chapter on treatment resistance includes a discussion/suggestion of developing a personal prescribing algorithm. I also liked the emphasis on the fact that “psychotropic drugs treat symptoms, not diseases” (p 143). The chapters on complicated problems and managing risks include a wealth of good clinical advice. The last chapter of this section, “staying well,” focuses on recovery from mental illness.

The 2 chapters of the last part, “Coping,” deal with the fact that “some problems have no solution, and one just has to find ways of coping with them” (p 189). Chapter 17, “Coping with dilemmas,” discusses issues such as personal idiosyncrasies, unethical policies, difficult families, quick fixes, unacceptable choices, and treating colleagues. Finally, chapter 18, “Coping with change,” focuses on new issues, such as routes to burn-out, healing oneself, new treatments, emergent disorders, and professional use of euphemisms and neologisms.

This is an interesting, thoughtful, and thought-provoking volume. One does not have to agree with all of the authors’ opinions and suggestions to appreciate the wealth of their clinical knowledge and wisdom of some of their recommendations. The authors suggest that very little in their book is unique to British practice (p 1). One may disagree at least in some parts (the suggestion of pure consultant role for psychiatrists). A large part of this book is applicable only to the severely mentally ill and to practice in community mental health psychiatry. Nevertheless, this book contains a lot of interesting and important material for the development of good clinical skills and organizational abilities. I would recommend it to all clinically oriented psychiatrists and to psychiatric residents, in both cases especially to those working in the community mental health setting.