In our days, and under the great social and economic pressures which have been brought about by the global economic crisis, consultation and collaboration with patients becomes at times more strained and complex. Alongside the clinical challenges which already exist in the area of mental healthcare, many new social problems and practical operational issues are now added in all public health structures. In this article, one gets a glance at some of the problems that have arisen recently in the operation of psychiatric services in Greece via the narrative of the personal experiences of a resident in Psychiatry. Furthermore, the role of training in psychotherapy is explored as a way to cope with the multiple and hard social challenges that continuously arise in the everyday practice.
Key words : psychiatric training, patient’s experience, economic crisis in Greece, training in psychotherapy
Meeting of the two worlds
Psychiatric trainees are usually in the first line of contact for people with mental health problems who come to the psychiatric services. The initial contact with these people and their families, the open hearing of their personal problems and symptoms, the systematic recording in the form of psychiatric history and the exploration of a proper therapeutic plan are the first clinical steps in the meeting of the two sides. The challenge lies in reconciling the request of the person who comes for help and the response that the therapist is asked to give. In this meeting, as doctors we have indeed a very long education and training in scientific knowledge and clinical descriptions that helps, but at the same time a rather limited education and experiential familiarity in terms of basic psychological principles and principles of communication with the patient.
However, in the meeting with the patient we soon come across a particular challenge: the language and perceptions of patients often contrast with the language, concepts or frameworks adopted by the "specialists" in mental health care.
Usually, patients speak with the emphasis on the mental suffering and distress, while psychiatrists diagnose and treat “diseases”. The patient’s experience of sickness is translated by the "specialists" into abnormality of structure and function, while the social or family contexts, stressors, personality and coping strategies of the individual or family are often dismissed as incidental.
In this way, understanding the patient's experience is left out while the emphasis is given on the phenomenological description of psychopathology. Thus a valuable opportunity to build a more stable and stronger therapeutic relationship and alliance is lost. Things become even more complex in the cases where symptoms occur in the absence of disease (such as medically unexplained symptoms), e.g. the somatoform and conversion disorders. These cannot be answered and fully understood by using a firm biomedical model.
At this particular point, our psychotherapeutic sensitization as psychiatrists contributes to a better approach to the patient's experience. Placing the narratives of patients in the foreground and making efforts to translate illness experience and to create a common language and communication point are the preconditions for forming a stable therapeutic relationship. So, training in psychotherapy completes —rather than compete with— the scientific training of psychiatrists. On the one hand it gives them useful skills for understanding the dynamics surrounding mental illness, and on the other it helps them seek ways for a better understanding and cooperation with the patient. This may be due to the fact that people do not exist separately from relationships- nor the symptoms, as argued once by Bateson’s research team. Symptoms are often directed at "someone," a "recipient" either in the external reality or in the intrapsychic reality of the individual.
Economic crisis -changes of reality in the clinics and emergency department
In our days, and under the great social and economic pressures which were brought about by the global economic crisis, the consultation and collaboration with the patients becomes even more complex and complicated for a number of reasons. Alongside the clinical challenges which already exist in the area of mental healthcare, many new social problems as well as practical operational issues are now added day after day in all public health structures. This leads to instability of the therapeutic frameworks as well. A few illustrative examples of the recent upsets in the workplace are the sudden changes in the national health insurance of patients and the rules for drug prescriptions, without adequate notice and without advising the doctors, the big cuts in the wages and overtime pay of all workers, and the closing down of some important mental health structures because of budget cuts.
Rules and frameworks are in constant flux, and the immediate future is not only unknown and unpredictable but also dependent on a reality intertwined with the fear of deprivation. In this reality, all parties - clients, therapists and trainees- are in limbo, subject to constantly changing rules and often without the necessary time to adapt. Every day we are on the alert for the next new announcement or decision which will be sent as an impersonal fax.
As regards the working conditions at the Psychiatric Hospital of Attica, where I recently completed my specialty training, the crisis has left and continues to leave an indelible mark. The Psychiatric Hospital of Attica and all the community structures attached to it are called upon to serve a very big part of the psychiatric population, including the most vulnerable social groups that suffer the most, such as people with chronic mental illness and significant socio-economic difficulties as well as a large population of people with addiction problems. Furthermore, the psychiatric hospital carries much of the burden of a historic challenge for Psychiatry in Greece: that of psychiatric reform, which involves the move from the "asylum" towards the community, a challenge that currently puts pressure on both patients and employees. As young professionals, we have been trained to work in the direction of a smooth "passage" of chronic patients into the community; however, what we experience and live with in our everyday duties is the fear and pressure of an eventual "unloading" of chronic patients in the community, with all the negative impact on their health and the social consequences this entails.
In the emergency department, we see an ever-increasing number of people with mental health issues who are homeless or whose families can no longer care for them as they struggle for their own survival. In addition, in outpatient clinics the number of patients with no health insurance has increased while some of them report having to discontinue their medication due to financial difficulties. At the same time there is an increase of patients with substance and alcohol problems, even among the elderly. In the same social context, first- and second-generation immigrants arrive in clinics with various psychological and psychiatric issues relating to racial discrimination and bullying in the workplace or school. Also, people who are unemployed or who have recently been made redundant and come to the hospital with acute stress reaction or severe adjustment disorders. All these are unsure as to what exactly they would consider as help from the specialists: indeed, the medicalization of social problems does not provide solutions but only intensifies the confusion for both therapists and clients.
At the same time, all of us who work in the field of mental health are now expected to absorb and manage all the tension, anger and insecurity created by this raging tide of upheaval. We often come across the pervasive lack of trust of patients in the system, and hence in the doctors as representatives of the system. The already weak network of social services is now become even more stressed under the weight of the new demands, and thus the responsibility for the multiple requests for support is passed onto the intern and the worker in the first line of contact with the general population. Because of all this, at the end of the day we sometimes find ourselves feeling powerless, frustrated and inadequate, with a visible risk of professional burnout syndrome. An additional difficulty for junior psychiatrists is that despite their own spectre of unemployment and job insecurity, in their therapeutic role they are asked to instill hope and a sense of future prospects in patients.
Furthermore, psychiatric trainees wonder daily as to the whereabouts of the second half of their identity, namely their role not only as workers but also as trainees. As clinical requirements and workloads increase, so does the difficulty of defending their training time when the ever-new needs in the hospital and outpatient clinics are not met by others. Inevitably the crisis impacts the potential and opportunities for education, since the marked and unfortunately ongoing decline in wages leaves few opportunities for the attendance of seminars, conferences and psychotherapy training programmes for those interested in furthering training. At this time one can appreciate, perhaps more than ever, the great educational value of psychotherapy programmes in public contexts. The psychotherapeutic knowledge and familiarity with the basic principles of psychotherapy appears to be even more crucial for mental health workers in the current circumstances.
Crisis and tuition of psychiatric trainees
- “survival strategies for therapists”
Reinforcing the ‘arsenal’ of “survival strategies for therapists” cannot but include the cultivation of curiosity, desire, imagination, creativity and improvisation -concepts that have always had an important role in the field of psychotherapeutic education. In my mind I spontaneously recall words-signs I have come across during my training in psychotherapy as an intern - words like those of holding and containment, consonance and self-reference, narrative, roles and relations in the group and many others, not just concepts but also, and mainly, experiences that I have gained along the way of my training in psychotherapy in public educational programmes and seminars.
In the current social situation, as described above, and while working as an intern at the hospital, one of the ways out I discovered in order to carry on despite these demanding and discouraging conditions was training in psychotherapy:an initially unknown path that gradually revealed many possibilities and surprises. By the end of my specialty training I had discovered many more training opportunities than I originally expected: a series of psychotherapeutic training seminars in the Psychiatric Hospital of Attica and in the external structures of the trust, as well as in the university programme of Eginition Hospital. So at the end of the specialty, the educational path included the completion of a training programme in family psychotherapy, a series of seminars in psychodynamic psychotherapy, as well as a seminar in the Lacanian approach to psychosis. At the same time, there were opportunities to participate in many clinical groups and psychotherapy groups in the rehabilitation units, as well as to undertake cases under supervision. A rich educational journey that proved valuable for a better clinical approach to patients, even those with “particular” personality traits alongside the “particular” characteristics of their family group or family history.
Especially in these times, in my personal experience, training and supervision psychotherapy groups, no matter which school or approach they belong to, operate not only as places of education but also as places of holding and containment, thus strengthening the bonds in the work group. I know that other countries have special support groups for junior psychiatrists and other physicians, the balint groups, which facilitate the investigation and management of "difficult" cases and thus provide additional support for trainees. It would be useful to establish these groups in our country as well, both for psychiatrists and for doctors of other medical specialties who are most at risk of a burnout syndrome. This is more common in working places such as emergency departments, intensive care units, and special units for oncology patients or patients with AIDS. Young professionals (and not only young, necessarily) are in need of support systems and groups in the work structures. Such a need emerges even more clearly in the present conditions of economic crisis, which create the following paradoxical picture: on the one hand a steep increase of needs in the psychiatric and general population, and on the other an ongoing decline in the status of mental health professionals as workers and a destabilization of their working environment in the public health system.
Instead of epilogue
After the recent ‘storm’ and the continuing ’rain’, there are times at work when the ship seems adrift. Confusion, insecurity and uncertainty about the future are, in my opinion, feelings shared by young psychiatrists and older and more experienced specialists alike. Indeed, discussions often fall into the trap of arguing about who suffers most: the young, who are against the spectre of unemployment and lack of prospects, or the older ones, who are faced with wage cuts and the threat of losing what has been built so far? For whom is it harder? For the one that has to start from scratch or the one who watches the demolition?
Psychotherapy comes at this point to enhance the possibility of an internal dialogue between the multiple internal voices, as in polyphonic songs where multiple voices accompany or oppose each other in an interactive way. Perhaps one answer to this question is that it is difficult for both but in different ways, depending on one’s approach to what is actually a common problem. However, we live in a historical context that puts us all (therapists and clients, trainers and trainees) in the same ship in a search of a common chart: a chart which is necessary to understand the route, the potential obstacles, but at the same time the main common objectives and perspectives in order to survive as a group of professionals and as a society.
More than ever before, as residents and young specialists we need the psychotherapeutic knowledge and awareness to "pick up the honey of the soul"-to borrow the title of an interesting workshop held at the Psychiatric Hospital of Attica. Personally, I feel lucky that during my specialty training in the various public mental health services I had the opportunity to taste the “honey” of psychotherapy and get trained in it.
In times of poverty and crisis, feeding on “honey” seems a luxury, but at the same time the desire for honey and the sharing of both the work of collecting it and the energy it provides is necessary in order to respond to the special requirements of the people who trust us and to the great difficulties and challenges of the times.
 This workshop was organised by the Specialised Social & Reemployment Rehabilitation Center(EKKEE) of“18 ANO” Rehabilitation Unit and the Family Therapy Unit, Psychiatric Hospital of Athens. Subject:“Picking up the honey of the soul”: Unexpected events, a systemic approach”.Invited speakers: Jacques Pluymaekers, Psychologist, Family Therapist, President of EFTA-CIM and Sotiris Manolopoulos, Psychiatrist-Child Psychiatrist, Psychoanalyst.
Bakhtin, M. (1973). Problems of Dostoevsky's poetics (2nd edn.; R. W. Rotsel, Trans.). Ann Arbor, MI: Ardis. (Original work published 1929 as Problemy tvorchestva Dostoevskogo).
Bateson, G. (1972). Steps to an Ecology of Mind. New York: Ballintine.
Good, B. (1994). Medicine, rationality and experience. An anthropological perspective. Cambridge University Press
Jacob, K.S. (2012). “Patient experience and psychiatric discourse”.The Psychiatrist, 2012,Vol 36, No 11, p. 414 -417.36, p. 414-417.
Kleinmann, A. (1988). The illness narratives: suffering, healing, and the human condition.Basic Books.
Kleinmann, A. (1995). Writing at the margin. Discourse Between Anthropology and Medicine. University of California Press.
Watzlawick, P., Beavin & Jackson, D. (1967). Pragmatics of Human Communication, ?ew York: W.W. Norton & Co.