Antony Garelick

Which doctors and with what problems contact a specialist service for doctors? A cross sectional investigation

BackgroundIn the United Kingdom, specialist treatment and intervention services for doctors are underdeveloped. The MedNet programme, created in 1997 and funded by the London Deanery, aims to fill this gap by providing a self-referral, face-to-face, psychotherapeutic assessment service for doctors in London and South-East England. MedNet was designed to be a low-threshold service, targeting doctors without formal psychiatric problems. The aim of this study was to delineate the characteristics of doctors utilising the service, to describe their psychological morbidity, and to determine if early intervention is achieved.MethodsA cross-sectional study including all consecutive self-referred doctors (n = 121, 50% male) presenting in 2002–2004 was conducted. Measures included standardised and bespoke questionnaires both self-report and clinician completed. The multi-dimensional evaluation included: demographics, CORE (CORE-OM, CORE-Workplace and CORE-A) an instrument designed to evaluate the psychological difficulties of patients referred to outpatient services, Brief Symptom Inventory to quantify caseness and formal psychiatric illness, and Maslach Burnout Inventory.ResultsThe most prevalent presenting problems included depression, anxiety, interpersonal, self-esteem and work-related issues. However, only 9% of the cohort were identified as severely distressed psychiatrically using this measure. In approximately 50% of the sample, problems first presented in the preceding year. About 25% were on sick leave at the time of consultation, while 50% took little or no leave in the prior 12 months. A total of 42% were considered to be at some risk of suicide, with more than 25% considered to have a moderate to severe risk. There were no significant gender differences in type of morbidity, severity or days off sick.ConclusionDoctors displayed high levels of distress as reflected in the significant proportion of those who were at some risk of suicide; however, low rates of severe psychiatric illness were detected. These findings suggest that MedNet clients represent both ends of the spectrum of severity, enabling early clinical engagement for a significant proportion of cases that is of importance both in terms of personal health and protecting patient care, and providing a timely intervention for those who are at risk, a group for whom rapid intervention services are in need and an area that requires further investigation in the UK.

Psychotherapy assessment: Theory and practice

SUMMARY The history and developments in psychotherapy assessment are reviewed. Suggestions for an extended assessment of several sessions derived from the clinical experience of a District Psychotherapy service are put forward with clinical illustrations. The advantages in terms of flexibility, and the ability to embrace the range of factors involved as well as the influence this has in generating a sense of containment in the patients, are discussed. The implications of this approach on technique, and its differentiation from ongoing psychotherapy, are highlighted. It is suggested that assessment should be seen as an entity in its own right, with its own clinical technique.

Reflections on purchasing psychotherapy services: The importance of unconscious factors

Summary The ambivalence towards psychotherapy services, underlying oedipal anxieties and the sense of exclusion from the therapeutic dyad, is explored. Their significance and the role of unconscious factors and their interplay with organisational dynamics are discussed, drawing on personal experience. Their importance in the purchasing of psychotherapy services is considered and the development of helpful strategies is described.

Paranoia or adaptation? The implications of a kings fund review on a psychotherapy department

SUMMARY This paper examines the impact of a Kings Fund Review on an established psychotherapy clinic during a period of major change in NHS mental-health services resulting from government initiatives. Some of the political, social and personal pressures on psychotherapists and their effects on the structure and process of the Clinic are considered. The benefits of the Review in helping Clinic staff to identify and distinguish between those initiatives to ‘fight’ and those where ‘adaptation’ is appropriate are illustrated. Through an understanding of the unconscious processes involved, strategy and tactics employed to maintain the identity, core values and therapeutic integrity of the Clinic are discussed.

A sea change for sick doctors - how do doctors fare after presenting to a specialist psychotherapy service?

Abstract Background: Little is known about doctors who present to services following an episode of psychological distress. MedNet is a psycho-dynamically informed confidential self-referral service for doctors. Aims: To examine the health and work trajectory of MedNet clients between 2002 and 2007 followed up in 2010. Method: We report and compare service-monitoring data for 124 doctors on engagement with health services, whether in work or not, sick leave utilised, and reported distress measured by CORE-OM at intake and at one follow-up time point. Results: 95.6% of doctors continue to work and progress in their careers. 58.3% remained engaged with services. Sick leave had reduced significantly at follow-up. Distress was significantly reduced, but no differences were found with respect to social functioning and well-being. An interesting shift was observed in doctors’ use of medication from treating somatic complaints towards treating mood symptoms. Conclusions: Doctors show improvements and continue to progress in their careers after a psychotherapeutically orientated intervention. A shift in doctors’ perception of their difficulties is indicated from more somatic to psychological concerns. Many doctor–patients continue with ongoing professional support.

Finding a space to think and a way to talk

Mental mechanisms and issues of psychoanalytic technique in the treatment of psychotic states are explored and illustrated with clinical vignettes. The value of establishing a psychosis workshop to facilitate understanding and an appropriate language to communicate with the patient drawing on the work of Dr Richard Lucas and the author is described.