Robert Higgo

Spirituality and the threat to therapeutic boundaries in psychiatric practice

There is a determined campaign to make exploration of patients’ spiritual experience an intrinsic and necessary part of routine psychiatric care. This has support from the Royal College of Psychiatrists, though there has been no consultation with psychiatrists. Whilst many of the proposals are uncontroversial, some involve serious breaches of normal professional boundaries of behaviour as set out in General Medical Council guidance. The contentious proposals are that a spiritual history should be taken from all patients, even where they resist; that it is sometimes acceptable to pray with patients; and that clinicians should support “healthy” religious beliefs and challenge “unhealthy” ones. The proposals are based on a model of universal spirituality which, we argue, is culture bound and lacks neutrality. This paper explores these issues and the consequences that might flow from altering professional boundaries in psychiatry. We conclude that the changes are unnecessary and should be resisted.

Psychiatric Interviewing and Assessment: Contents

Acknowledgements Introduction Part I. What Am I Trying to Find Out Here?: 1. Diagnosis 2. History 3. Mental state and psychopathology 4. Cognitive state assessment and organic disease Part II. The Main Principles of One to One Interviewing: 5. Office based psychiatric assessment 6. Understanding and managing relationships with patients Part III. The Difficult Interview: 7. Difficulties relating to psychosis 8. Unpopular patients Part IV: Self awareness 9. Values and beliefs 10. Culture 11. Who should I be? Part V. Out of the Clinic: 12. Interviewing with other team members 13. Interviewing families and other informants 14. In the community Part VI. Drawing it all Together: 15. Personality 16. Risk and safety 17. Note keeping, letters and reports Afterword: Getting alongside patients.

Psychiatric Interviewing and Assessment: Index

Acknowledgements Introduction Part I. What Am I Trying to Find Out Here?: 1. Diagnosis 2. History 3. Mental state and psychopathology 4. Cognitive state assessment and organic disease Part II. The Main Principles of One to One Interviewing: 5. Office based psychiatric assessment 6. Understanding and managing relationships with patients Part III. The Difficult Interview: 7. Difficulties relating to psychosis 8. Unpopular patients Part IV: Self awareness 9. Values and beliefs 10. Culture 11. Who should I be? Part V. Out of the Clinic: 12. Interviewing with other team members 13. Interviewing families and other informants 14. In the community Part VI. Drawing it all Together: 15. Personality 16. Risk and safety 17. Note keeping, letters and reports Afterword: Getting alongside patients.

Severe mental illness and social factors

This chapter examines the evidence about the relationship between poverty and severe mental illness, by which we mean psychotic disorders. In Chapters 2 and 3 the nature of poverty in the UK in the twenty-first century is discussed in detail. It is important to recognise from the outset that the concept of poverty is complex. Individual income is difficult to measure, and may not be as relevant as relative income, perceived disadvantage or social exclusion. It is easy to inadvertently conflate these concepts, and this is apparent in parts of the literature. In this chapter, some work is cited that uses the concepts of social disadvantage and deprivation rather than poverty per se. The movement between discussion of different types of social adversity should not be taken to imply that the differences between them are irrelevant. On the face of it, it appears self-evident that being poor is bad for people’s health. A strong association between poverty and ill health is well established for nearly all types of disease and in all parts of the world (Black et al., 1993). The association between material deprivation and mental illness is just as strong as it is for physical illness. However, it is by no means universally accepted that this relationship is causal; that exposure to poverty leads to mental ill health. Much of the discussion in the psychiatric literature has taken social factors to have a modulating effect on more profoundly causative bio-genetic factors. It is only recently that the possibility of a strictly causal role for social factors has been seriously addressed within the mainstream psychiatric research literature. There is a body of opinion that has long preferred the view that a reverse causation applies, that mental illness causes poverty. The suggestion is that mental illness undermines people’s ability to work and to maintain their social position. Interest in non-biological factors has sharply increased in recent years with regard to schizophrenia in particular. The association between this disorder and social factors is very strong and consistent. A particular type of social factor, namely growing up in inner-city deprivation, seems to be especially powerful in conferring a heightened risk of schizophreniform disorders. For this reason we shall concentrate here on the evidence regarding schizophrenia.