[Autonomy: to what extent is the concept relevant in psychiatry?]

BACKGROUND

Autonomy is an important concept in psychiatry, but because it is a somewhat abstract and ambiguous notion, it is not applicable in its entirety in a psychiatric context. This becomes obvious in situations where patients are receiving long term care and treatment.

AIM

To modify the concept of autonomy in such a way that it acquires an extra dimension that renders it applicable to daily psychiatric practice.

METHOD

The literature was reviewed in order to find articles that reveal the tensions that arise between autonomy and dependence in psychiatry and that reflect the human characteristics that are concealed behind the modern concepts of autonomy, freedom and respect for autonomy.

RESULTS

Concepts such as person, identity, acknowledgement, dialogical ethics and life histories are used as an addition to the concepts of autonomy of Kant and Mill. A phenomenological and a context sensitive conception of autonomy is needed within the perspective of dialogical ethics. A dialogical perspective requires from psychiatric professionals a susceptibility for what the patient as a human being really has to say. On the basis of a dialogue where there is space and attention for life histories, backgrounds and the potentials of patients, a new perspective can be developed that is shared by the persons involved.

CONCLUSION

In psychiatry, statements about real autonomy and genuine respect for autonomy are only truly meaningful within the context of doctors, nurses and patients. A hermeneutic approach to patients which involves dialogue creates new opportunities in the field of staff-patient relations.

[Ethical issues in psychiatry under coercion]

Psychiatry is now subject to two apparently contradictory movements. On the one hand, the need to respect the autonomy and rights of patients is reinforced and coercive measures are strictly defined and limited. On the other hand, security concerns in our society leads to prosecution of psychiatric disorders, especially when accompanied by behavioral problems or criminal acts. In these situations of compulsory treatment or care provided in prisons, a number of dilemmas emerge. The place of the healthcare professional in treatments ordered by the Judge and problems related to administrative detention are discussed in more detail.

Where Christ did not go: men, women and Frusculicchi. Gender identity disorder (GID): epistemological and ethical issues relating to the psychiatric diagnosis

Gender Identity Disorder (GID) is classified as a mental illness and included in the DSM-IV and ICD-1O. It will also be included in the DSM-V. The psychiatric diagnosis, in spite of some apparent advantages, has significant psychological and social adverse implications. This paper discusses some of the main epistemological reasons to consider gender variance as a mental disorder. It will also evaluate whether reasons of other kinds (pragmatic, rather than epistemological) may justify the inclusion of gender variance amongst mental illnesses.

Professional boundaries in the era of the Internet

OBJECTIVE

The era of the Internet presents new dilemmas in educating psychiatrists about professional boundaries. The objective of this overview is to clarify those dilemmas and offer recommendations for dealing with them.

METHOD

The characteristics of social networking sites, blogs, and search engines are reviewed with a specific focus on their potential to present problems of professional boundaries for psychiatrists.

RESULTS

The professional boundary questions that have arisen in the expanded world of online communication can be subdivided into three areas: ethical concerns, professionalism issues, and clinical dilemmas. Only the first category involves true boundary problems as normally defined.

CONCLUSIONS

The expansion of the Internet has redefined traditional areas of privacy and anonymity in the clinical setting. Guidelines are proposed to manage the alteration of professional boundaries, as well as issues of professionalism and clinical work, that have arisen from the complexities of cyberspace. The author discusses implications for residency training.

Results of a multisite survey of U.S. psychiatry residents on education in professionalism and ethics

OBJECTIVE

The authors assess the perspectives of psychiatry residents about the goals of receiving education in professionalism and ethics, how topics should be taught, and on what ethical principles the curriculum should be based.

METHOD

A written survey was sent to psychiatry residents (N=249) at seven U.S. residency programs in Spring 2005. The survey was based on an instrument originally developed at the University of New Mexico, consisting of 149 questions in 10 content domains, with 6 questions regarding ethics experiences during training and 5 demographic questions.

RESULTS

A total of 151 psychiatry residents (61%) returned usable responses to our survey. Residents reported receiving a moderate amount of ethics training during medical school (mean: 5.20; scale: 1: None to 9: Very Much) and some ethics training during residency (mean: 4.60). Residents endorsed moderate to moderately-strong agreement with all 11 goals of medical education in professionalism and ethics (means: 5.29 to 7.49; scale: 1: Strongly Disagree to 9: Strongly Agree). Respondents were more likely to endorse the value of clinically- and expert-oriented learning methods over web-based educational approaches.

CONCLUSION

U.S. psychiatry residents endorse a range of goals for education in professionalism and ethics. At the same time, they prefer that these topics be taught in clinically relevant ways and through expert instruction. The value of web-based approaches warrants further investigation.

What medical students say about psychiatry: results of a reflection exercise

OBJECTIVE

The author describes the results of a reflection exercise for psychiatry clerkship students.

METHOD

The author performed a qualitative analysis on 100 "reflection" papers written by medical students in their psychiatry clerkship and identified the most prominent thematic content.

RESULTS

The most common thematic content involved social issues in psychiatry, the reality of mental illness, the role of trauma, difficulties forming alliances with patients, the efficacy of interventions, the power of empathic connection, and students' personal identifications.

CONCLUSION

Reflection exercises can foster students' awareness of their preexisting attitudes toward mental illness and the evolution of their views during training. Educators can use reflection exercises to better appreciate their students' concerns and target curriculum content toward specific issues.

DSM diagnosis and beyond: on the need for a hermeneutically-informed biopsychosocial framework

While often dubbed "the bible of contemporary psychiatry" and widely hailed as providing "a benchmark" for the profession, on closer inspection the DSM is seen to be shot through with philosophical assumptions that restrict its theoretical cogency and limit it clinical efficacy. Hence, in the interests of enhanced patient-care it is important to think critically about the DSM, with a view to maximising its diagnostic strengths while minimising its weaknesses. The critical analysis undertaken in the present paper underscores the importance of not construing the DSM as a self-contained diagnostic tool but of viewing it, rather, as an indispensable component in a more comprehensive, multidimensional diagnostic process. More specifically, the contention is that the DSM's diagnostic limitations evoke a biopsychosocial framework of application as their necessary corrective, notwithstanding the entrenched tendency to construe these approaches as oppositional. Further, it is contended that a hermeneutically informed biopsychosocial template has particular advantages as an integrating framework.

Survey of the importance of professional behaviors among medical students, residents, and attending physicians

OBJECTIVE

The authors compared the importance of items related to professional behavior among medical students rotating through their psychiatry clerkship, psychiatry residents, and attending psychiatrists.

METHOD

The authors sent an electronic survey with 43 items (rated on the scale 1: Not at All Important; to 5: Very Important) to medical students, psychiatry residents, and attending psychiatrists at one academic center.

RESULTS

Medical students rated several items in the categories Personal Characteristics and Interactions With Patients significantly less important than did residents and attending psychiatrists. Both medical students and attending psychiatrists rated the category Social Responsibility significantly less important than did residents.

CONCLUSION

All three groups surveyed rated the majority of items as Important or Very Important, indicating that they value professional behavior. Resident physicians had the highest mean score in every category measured. Overall, medical students rated most items related to professionalism as less important than the two other groups surveyed.

Psychiatric residents' needs for education about informed consent, principles of ethics and professionalism, and caring for vulnerable populations: results of a multisite survey

OBJECTIVE

The authors examined psychiatric residents' perceived needs for education in informed consent, principles of ethics and professionalism, and treating vulnerable populations.

METHOD

A written survey was distributed to psychiatric residents (N=249) at seven U.S. residency programs in 2005. The survey contained 149 questions in 10 content domains, 6 questions regarding personal ethics experiences during training, and 5 demographic questions. Here, the authors report responses to items regarding informed consent, professional principles, and care of vulnerable populations.

RESULTS

A total of 151 psychiatric residents responded to the survey (61% overall response rate). On a scale of 1: Much Less, to 5: Same, to 9: Much More Education Desired, psychiatric residents indicated that 9 topics relating to informed consent, 10 issues surrounding professional principles, and 25 topics relating to care of vulnerable populations should receive more educational attention than currently provided. No topics were rated as needing less education. Higher ratings of the need for additional educational attention were associated with more reported ethical conflicts encountered during training.

CONCLUSION

Psychiatric residents at seven diverse U.S. training programs expressed the need for greater educational attention to issues around informed consent, ethical and professional principles, and treating vulnerable populations. These findings reflect the ongoing need for educators to devote curricular attention to these areas so that trainees can incorporate such knowledge effectively into their daily clinical practice in an always-complex, highly fragmented medical care environment.

Responsibility of the therapist for the patients' actions (Tarasoff Rules): position of the psychiatrists

BACKGROUND AND AIMS

Patient confidentiality and the therapists responsibility to society may present a challenge in the therapeutic relationship between the psychiatrist and the patient. We examined the attitudes of Israeli psychiatrists concerning the duty to warn and protect according to the Tarasoff Rule.

METHODS

Questionnaires to examine psychiatrists opinions concerning the implementation of the Tarasoff Rule in Israel were sent to senior psychiatrists involved in forensic psychiatry for anonymous completion.

RESULTS

108 (64%) questionnaires were returned. 61 (57%) replied that they encountered similar situations.

CONCLUSIONS

Thorough understanding of the Tarasoff Rule, clarification of the patients potential dangerousness, and timely deliberation of the issues will assist the therapist. Investigation of the medical consensus of senior physicians, as performed in our study, is also a point of reference for formulating an opinion.

Authorizing psychiatric research: principles, practices and problems

Psychiatric research is advancing rapidly, with studies revealing new investigative tools and technologies that are aimed at improving the treatment and care of patients with psychiatric disorders. However, the ethical framework in which such research is conducted is not as well developed as we might expect. In this paper we argue that more thought needs to be given to the principles that underpin research in psychiatry and to the problems associated with putting those principles into practice. In particular, we comment on some of the difficulties posed by the twin imperatives of ensuring that we respect the autonomy and interests of the research subject and, at the same time, enable potentially beneficial psychiatric research to flourish. We do not purport to offer a blueprint for the future; we do, however, seek to advance the debate by identifying some of the key questions to which better answers are required.

Canadian residents teaching and learning psychiatry in Ethiopia: a grounded theory analysis focusing on their experiences

OBJECTIVES

The Toronto Addis Ababa Psychiatry Project (TAAPP) is an international collaboration between University of Toronto and Addis Ababa University. University of Toronto psychiatric residents may participate in TAAPP as an elective. The authors explored the Canadian resident experience in a qualitative study of the project.

METHODS

Eleven residents were interviewed using a semistructured questionnaire. Grounded theory was employed to organize participants' experiences and highlight emerging themes. The computer software NVivo7 was used to facilitate data analysis.

RESULTS

Participants described gaining competency as health advocates, collaborators, scholars, and teachers. They endorsed increased sensitivity to cross-cultural issues and greater awareness of global health issues, including practical and ethical ramifications of working at an intersection of cultures. Residents gained international perspective psychiatric practice.

CONCLUSION

The elective provided unique opportunities for acquiring clinical, teaching, collaborative, leadership and advocacy skills. It prompted participants to consider ethical and cross-cultural issues and allowed them to be mentored intensively by Ethiopian and Canadian teachers and peers.

The diseased embodied mind: constructing a conception of mental disease in relation to the person

Without a better understanding of mental disease, patients diagnosed with a mental disease may be mistreated clinically and/or socially, and caregivers and families may be wrongfully blamed for causing the disease and/or for not effectively helping and developing meaningful relationships with the patient as person. In trying to understand mental disease and why its various dimensions raise difficulties for our systems of classification and our medical models of diagnosis and treatment, a framework is required. This framework will connect metaphysical, epistemological, and ethical considerations in ways that are mutually supportive and illuminating. This, in turn, will benefit those who are diseased and those persons who study, classify, diagnose, and treat disease.