l l a d n a , e s u o h s \200\231 r e h t a f y m y r t a i h c y s P f o s r e t h g u a d e h t On this view, knowledge of mental states is doubtful, but often this is not so, eg a baby b eing put to the breast after separation from her mother, or an audience giving a standing o vation, or screaming fans waving at an idol, and we know without doubt that these mental st ates comprise unalloyed satisfaction, pleasure, and adulation. So often it \200\231s non-ve rbal behavior that allows valid judgment about mental states: don \200\231t rely on words a lone \200\224 those capricious (but indispensable) tokens of disguise and deception. How ma ny diff erent selves are rolled up into your patient? \201\201 Here is an example: a perso n who happens to be black, who happens to be Muslim, who happens to be male, who happens to be questioning his sexual orientation while trying to be a good son and a good brother. He is trying on new identities and new relationships with Allah. How do these identities invo lving race, culture, religion, gender, and sexuality feed into his mental state now?27 In t he mental state examination, give space to \201 nd out about these roles, to get a feelin g for which causes most turmoil, ambivalence, and introspection, the 3 \200\230vital signs \200\231 of psychic life \200\224TAI.1 Aim to understand how good the patient is at articu lating these roles. Try to understand from which platform the patient feels most comfortabl e in tackling his problems \200\224and pay respect to each role separately, in order to gai n trust.28 Try to \201 nd out how plastic or rigid each identity is \200\224the more plas tic, the easier it is for the ego to function harmoniously (ie \200\230good identity integ ration \200\231).29 Lear: \200\234Who is it that can tell me who I am? \200\235 Fool: \200\234Lear \200\231s shadow \200\235. Just as Shakespeare creates metaphysical places, su ch as Lear \200\231s30 and Viola \200\231s Illyria, where answers to questions of identity can take shape, so psychia- trists create spaces in the silences of mental state examinatio ns where our multiple personas can visit each other. Our masks shift and a few rays illu- m ine our \200\230shadow selves \200\231, as we come to know the diff erence between who we are and who we think we are. Acknowledging that we have a shadow is hard, but vital.31 Ment al state examinations start this process leading to questions such as \200\234Who knows mo st about who you are? Who else? How do their views diff er? What truths about you do they a cknowledge or hide? \200\235 l l a m a I \200\234 : a l o i V . h t a e d o g e = n o i t a r g e t n i y t i t n e d i t c e f r e P . s e v l e s y h t w o n k \200 f l e s y h t w o n K 1 Tai Chi in Confucian philosophy is the mother of yin and yang, the Supreme Ultimate Fist which trans- cends and harmonizes those \200\230internal necessities in our our being \200 \231 which forever drive us on. Herman Melville Moby Dick Ch 36 How to avoid doctor-dependency A patient may become over-dependent on his or her doctor in many spheres of medicine. This is a particular danger in psychiatry because of the intimate and intense rather one-sided or asymmetrical relationship which may be built up between th e patient and psychiatrist \200\224who will often know more about a patient \200\231s hopes and fears than any close friend. This encourages the patient to transfer to the therapist thoughts and attitudes that are often directed to parent- \201 gures. This process (known as transference) powerfully stimulates doctor-dependency, sometimes with serious consequenc es. Other risk fac- tors for doctor-dependency: Chronic illness/prescribing; inability to a chieve the sick role \200\224eg if you have chronic back pain, your suff ering is hidden fr om others (no scars, no bleeding, etc), and you may feel delegitimized in your sick role be cause you cannot be diagnosed or helped. But equally, because of this, you hold power over your doctor. It is diffi cult for her to challenge your ideas without damaging the therapeu tic relationship. So the doctor is forced to col- lude with your de \201 nition of ill-hea lth. This may harm you and society.32 Signs of non-therapeutic dependency Repeated phoning for advice, inabil- ity to initiate any plan without help from a therapist, and disallowing of your attempts to terminate treatment (eg by threatening relapse). Assessing whether dep endency is a problem Clearly, in the examples above, the patient \200\231s dependency on hi s doctor is non-therapeutic. At other times, for example, early in treatment, doctor-depend ency may help. In these circumstances the danger is that the doctor will be \202 attered by his patient \200\231s dependency on him. Most therapists either want to be loved by thei r patients or want to dominate them (or both), and it is important to know, in each session with each patient, just where you lie within the space marked out by these axes. Ask yours elf: \200\234Why do I look forward to seeing this patient? \200\235 \200\234Why do I drea d seeing Mr X? \200\235 \200\234Why do I mind if this patient likes me? \200\235 \200\207 When you feel good after seeing a patient always ask yourself why (it is so often because h e is becoming dependent on you). Avoiding dependency Planning and agreeing speci \201 c, l imited goals with pa- tients is one way of limiting dependency. If the patient agrees from the outset that it is not your job to provide him with a new job, wife, or family, he is mo re likely to have realistic expectations about therapy. 326 y r t a h c y s P i Planning discharge from the start of therapy helps limit doctor-dependency. Discharge is ea sy from the outpatient departments, but for the GP the concept of discharge is diluted by t he fact of his contractual obligations. The patient is quite within his rights to turn up t he day after being \200\230discharged \200\231 and de- mand that therapy be started all ov er again. The GP must have more subtle methods at his disposal to encourage the patient to discharge himself. For ex- ample, he can learn to appear completely ineff ective, so that t he dependency cycle (patient presents problem \200\203doctor presents solution \200\203pati ent sabotages solution \200\203doctor presents new solution) is never started. Another meth od is to bore your patient by endlessly going over the same ground, so that the pa- tient s eizes control and walks out as if to say \200\234I \200\231ve had enough of this! \200\235 . The foregoing makes patients out to be perpetual seekers after succor and emotional support \200\224and so they may be. But a great mystery of clinical medi- cine is that, spontaneou sly and miraculously, many apparently irremediably dependent patients can change, and start leading mature and independent lives. So don \200\231t be downcast when you are looking af ter such people: there is much to be said for simply off ering a sympathetic ear, staying w ith your pa- tient through thick and thin, and waiting for time to go by and for the wind t o change. Of course, the wind may change back again, but, if it does, you will not be back at square one, for you will be able to inject the proceedings with the most powerful psycho therapeutic agent of all, namely hope. 327 How to improve quality of care We have chosen Psychiatry for this universal topic because i f the concept of quality can be made sense of here, despite Psychiatry \200\231s notorious lack of objec- tivity, then its applicability across the \201 eld medicine can be upheld. Quality is 33 but an important topic not just because it has political currency,Lord Darzi 2008 because it has important personal relevance too, for your next patient. Ancient princ iples for improving quality (derived from Hippocratic thought, OHCM p1) Perpetually reaffi rm and renew your commitment to put the patient \201 rst and do whatever it takes to make your patient better. Traditional approach- es to quality in psychiatry stem from this: \200\234We need better inpatient care, with better availability of psychotherapy and more h ighly motivated, energetic men- tal health professionals who aren \200\231t burnt out by ov erwhelming caseloads. \200\23534 New principles In areas such as surgery, performance-manag ement and quality center around: \200 Effi cacy \200 Safety \200 Equity (equal access to bene \201 ts) \200 Choice \200 Holistic patient experience/compassion. How do thes e precepts shape up in the world of psychiatry? Let \200\231s take a look, one at a time. E ffi cacy: If agreed guidelines exist, we can compare care received with care advised, eg in schizophrenia, in one study 50% had poor psychosocial care (note the need for patient int erviews to unearth the extent of such problems). 35 But beware: how do you quantify success for people whose illness precludes them from seeing themselves as being ill? Patients may have their delusions and hallucinations treated so that none are left: but this does not eq uate with 100% quality of care if the problem is not the delusions and the hallucinations b ut rather urban alienation (p391), poverty, or unemployment. The hallucina- tions may be a way of coping with the latter. See p316. Safety: Monitoring metabolic eff ects of new antip sychotics is a safety quality marker,36 as is antipsychotic choice. See npsa.nhs.uk/patient safety. National Patients \200\231 Choice: Off ering a choice as to which hospital to be co mpulsorily incarcerated in seems like tokenism. Also, sectorization (each team having its o wn geo- graphical area) precludes choice. But because choice does not work in some areas it does not mean it has no role in others. It is legitimate to regard choice of psychotherapy , drugs, or both as a marker of quality of care in depression. Equity: When this is looked for, ethnic minorities, children, and older people are often disadvantaged.39,40 (Obvious, perhaps, but ameliorable.) Holistic patient experience/patient satisfaction. This is discus sed on p510. \200\207Some clinicians reject the new methodology: \200\234What we have to do is get away from measurements and statistics and calculations and pieces of paper publis hed by politicians and get back to what we know intuitively is the cor- rect way to help pe ople. \200\23534 But what if our intuitions are wrong or contradic- tory? Is it possible to combine the best of the old and the new? Maybe \200 Synthesis (old+new) Find out who want s what \200\203If the patient \200\231s views are known, comply with them \200\203make a co mmitment in your heart to put your patient \201 rst \200\203do what it takes to make your patient better \200\203attack all dis- eases with vigor \200\203promote health where possi ble \200\203palliate where cure is impossible \200\203update care in the light of evidence \200\203set yourself targets by all means, provided one target is not to let targets skew t he care you give \200\203take steps to \201 nd out if you have actually done what you int ended (audit, p506). Motivating professionals Only pay them if your quality goals are met? A fav- ourite NHS tactic, but undermining of the notion of professionalism and prone to val uing the measurable over more important goals. If we had to select just one winning idea fr om this page to take forward to our next patient we would go with Hippocrates: make a commi tment in your heart to put your patient \201 rst. This is very hard: just try it. (Did yo u notice how compassion got squeezed out of this page? How did that happen? Why does this a lways happen?) NHS review y r t a i h c y s P 37,38 Safety Agency How to talk with young people about sex Sexual issues are easier when an overt part of cons ultations (contraception, fertility, and sexual diseases). More commonly they are a covert part of other emotional or behavioral problems. We may \201 nd sexual dialog embarrass- i ng and avoid it \200\224with unpredictable or fatal consequences, eg for those made suicida l by abuse41 or by confusing emotions relating to sexuality. 328 Language is important. It may be medical (eg \200\230coitus \200\231); slang (eg \200\230 fucking \200\231); or socially acceptable (eg \200\230having sex \200\231). It is not advi sable to use slang as peo- ple think you are trying to be fashionable. Most will expect soc ially acceptable language; slang may shock and may put up barriers. But occasional mirrorin g of the patient \200\231s words can gain rapport. Ask if your words are acceptable. \200 Ambiguity is a frequent pitfall \200\224even for the most consummately articu- late of all interlocutors:42 \200\234Ah! \200\235 said Mr. Woodhouse, shaking his head and \201 xin g his eyes on her with tender concern. \200\224The ejaculation in Emma \200\231s ear expres sed, \200\234Ah! there is no end of the sad consequences of your going \200 \200\235 Jane Austen Emma Ch 12 Make sure that you both know what the other is talking about! If a new p hrase crops up (slang changes all the time), ask for an explanation right away (a little ge ntle helping on your part usually overcomes any embar- rassment). y r t a h c y s P Don \200\231t assume sexual knowledge. Not all young people know everything. Just as when w e were younger, sex can be confusing and mysterious. There are still many myths, and it is just as hard as it ever was for young people to ad- mit that they don \200\231t know someth ing. Sex education in schools is uneven, and may be useless or non-existent (teachers may b e too embarrassed to do it).43 \200 Don \200\231t assume a sexual orientation. It may be best to let these issues surface gradually rather than asking directly early on. Imply that it is safe to reveal feelings that are confused or non-standard. Your patient may be boxed in by societal, religious, or family views of what sexuality should be, so that suicide ca n seem the only way out.44 Through your dialog you may be able to show that there are other options, and that \200\234there is no straight way through this world for any of us \200 \235.45 If orientation is causing distress, point out that there is more to a personhood th an sexuality \200\224roles they may be good at may include being a friend, colleague, broth er, daughter, or son \200\224as well as lover, now or in the future. \200\234You don \200 \231t need to have sex just to settle the issue of sexuality; feelings can be explored with out sex acts, which can be left until you feel ready \200\235. In helping gay people decide when to \200\230come out \200\231 eg to parents, explain that reactions can be unpredicta ble.46 \200\234How well do you know your parents? \200\235 \200\234How have they dealed w ith religious or sexual is- sues with your brothers and sisters? \200\235; \200\234Are you economically dependent on your parents? \200\235; \200\234Do you have a social support ou tside the home? \200\235.47 \200 Don \200\231t appear embarrassed. It is easier for peopl e to open up if they think that you aren \200\231t going to blush, tell them off , or, wors t of all, laugh. Don \200\231t act shocked and don \200\231t judge; give the wrong impressi on and they will stop being honest with you \200\224see p319 for further discussion of this vital point. \200 Act as if you have plenty of time to listen \200\224all the time in th e world. The more you practice sexual dialog, the easier it gets. If you avoid it, it will remain a problem to you. Also, your patients may learn techniques of sexual dialog, helpful in their lives as a whole, augmenting self-esteem, enabling sexual negotiation (useful in negotiating safer sexual practices with part- ners).48 Also, you may lay the foundation for honest sexual dialog between this teenager and his or her off spring, 10 \200\22340 years from now. Asking about sexual abuse Have you been in any relationships that made you feel u ncomfortable? Has anyone touched you in a way that made you feel embarrassed? I am wonderin g if anyone has hurt you in a sexual way. Con \201 dentiality Young people need to know th at you will only ever breach this if they (or someone else) is in mortal danger.49,50 i 329 How to perform a risk-assessment This is a common problem: the courts, the GP, or the relat ives want to know \200\234Will he be violent again if he takes the medication? \200\235. A great deal \200\224a man or woman \200\231s freedom, no less, may depend on our answers. T he philosophical problems with giving a straight answer to these questions are given in the BOX below. Regression analysis shows that 4 factors are paramount: 1 Previous violence 2 S ubstance abuse 3 Lack of empathy and 4 Stress.51 When in doubt, use a formal risk assessmen t tool (see BOX). Some of the advantages of these tools derive simply from having a well-st ructured approach, others from com- bining speci \201 c kinds of risk factors (static and dynamic).52 \201\201 500, 995, 484, 682, 338, 672, 639 Imagine \200 there are only 24 people in the wo rld, and each has only 2 types of moves: forward one step at a time, and, sometimes, alas, one step backwards. Surely we should be able to predict what will happen: it \200\231s as s imple as a game of drafts (chequers). We win or lose at drafts by using rules of thumb (heu ristics). In 2007, for the \201 rst time, there was suffi cient computing power to replac e these rules of thumb by perfect knowledge. In drafts, there are >500 billion billion play -positions (500,995,484,682,338,672,639), and now each has been analyzed to decide what the next best move is. Well-programmed computers are right every time.54 When we ask psychiatr ists to do a risk as- sessment we want them to be right every time too. It is vital that th ey are. We blame them if they are wrong. Is this rational? Only if there are no more than 2 4 people in the world, and they only interact with each other in only one way \200\224never moving sideways or forming attachments. 3 5 y r t a i h c y s P . p o t n o t i b e l t t i l e h t e e s y l n o u o y , s g r e b e c i Psychiatrists do best using rules of thumb combined with validated risk assessment tools (i mperfect knowledge), such as the violence risk ap- praisal guide.55 Forensic risk-assessmen t models all stress risk factors, but often disregard the other side of the equation: prote ctive factors. Mediat- ing and moderating eff ects must also be considered.56 We need to in volve patients in the process of risk assessment and risk management. This may increase val idity,57 but it also adds unpredictability: the men and women on the board are now all king s and queens in our client-centered world.53 e k i l e r a e l p o e P How to use the full range of psychiatric services Current UK community psychiatric services can be categorized as follows: \200 Intensivist teams: Crisis and Home Treatment, eg wit h 24-h phone helpline. \200 Support and recovery teams \200\224Community mental health te ams (CMHT); ass- sertive outreach; rehabilitation. Drug and Alcohol teams: part of a wide range of substance abuse services. \200 Inreach me ntal health services \200\224residential care, acute hospital liaison, pri- mary care liais on teams (PCL) \200\224integrated CPNs/Psychiatrists with GP prac- tices/Hospitals with goo d links into secondary community services. IAPT services (improved access to psychological therapies) \200\224off er a wide range of community-based therapies eg CBT (p373), group therapy, etc. Typically all these services are multidisciplinary (to a varying degree) with Nurses, OTs, Physios, Psychologist, Psychiatrists and Social workers. Many of these community services are supported by 3rd-sector (voluntary) organizations eg M IND, Alzheimer \200\231s society, and other local organizations and charities that provide drop-in centers, group or individual therapy, homecare, advocacy, educational information e tc. PWD (patients with dementia) use more or less specialist Residential or Nurs- ing homes; So cial services input is very important as is close working with local councils, and health a uthorities. Integrated care has theoretical advan- tages \200\224eg for a schizophrenic pat ient who is a substance abuser.58,59 How to help patients not to be manipulative Fireships on the lagoon We have all been manipu lated by our patients, and it is wrong to encourage in ourselves such stiff ness of charact er and in \202 exibil- ity of mind that all attempts by our patients to manipulate us inev itably fail. Nevertheless, a patient \200\231s manipulative behavior is often counter-produ ctive, and reinforces maladaptive behavior. A small minority of patients are very manipulat ive, and take a disproportionate toll on your resources, and those of their family, friends , and colleagues. We are all familiar with these patients whom Ford Madox Ford describes as being like \201 reships on a crowded lagoon, causing con \202 agration in their wake.60 After destroying their family and their home we watch these people cruise down the ward or into our surgeries with some trepidation. Can we stop them losing control, and causing mel tdown of our own and our staff \200\231s equanimity? The \201 rst thing to appreciate is that, un- like an unmanned ship, these people can be communicated with, and you can help t hem without resorting to hosing them down with cold water. Setting limits One way of avoidi ng becoming caught up in this web of mala- daptive behavior is to set limits, as soon as th is behavior starts. In a small minority of patients, the therapist may recognize that their needs for time, attention, sedation, and protection are, for all practical purposes, insat iable. Whatever a therapist gives, such patients come back for more and more, and yet in sp ite of all this \200\230input \200\231 they don \200\231t get any better. The next step is to real- ize that if inappropriate demands are not met, the patient will not become sicker (there may be vociferous complaints!). This realization paves the way for setting limits t o behavior, specifying just what is and is not allowed. 330 y r t a h c y s P i Take for example the patient who demands sedation, threatening to \200\234lose control \200\235 if it is not given immediately, stating that he cannot bear living an- other day w ithout sedation, and that the therapist will be responsible for any damage which ensues. If it is decided that drugs do not have a part to play in treatment, and that the long-term a im is for the patient to learn to be respon- sible for himself, then it can be simply state d to the patient that medication will not be given, and that he is free to engage in destru ctive acts, and that if he does so this is his responsibility. The therapist explains that in demanding instant sedation he usurps her professional role, which is to decide these matters according to her own ex- pert judgment, and that such usur pation will not be tolerated. If there is seri- ous risk of real harm, admission to hospita l may be indicated, where further limits may be set. If necessary, he is told that if he in sists on \200\230going crazy \200\231 he will be put in a seclusion room, to protect other s. Fig 1. Drastic measures: sometimes you have to cut your- self free \200 discuss with a coll eague \201 rst, and explain to the patient that continuing contact is not in their best i nterests as you are unable to make any headway. \200\234Your case needs a fresh pair of ey es \200 \200\235 This may be safer than the kind of confrontations that Henrik Ibsen dange r- ously engineers: \200\234When I look back on your long career, it \200\231s as if I saw a battle \201 eld strewn at every turn with shattered lives. \200\235The Wild Duck 1884 331 We live, as we dream \200\224alone. How to help patients be less lonely Conrad; Heart of Da rkness \200\207Health entails harmonious membership of at least one social group. People w ho are unconnected get dementia (and die) sooner.61 As the saying goes, it is healthier to eat a chocolate cake with a friend than to eat broccoli alone. \200\207Being unwanted is t he worst disease that any human can experience. Mother \200\207Loneliness does not come fr om having no people about one, but from being Teresa unable to communicate the things that seem important to one.62 \200\207Loneliness with depression is a predictor of suicide (eg in older women).63 A typi cal candidate for ameliorable loneliness is someone who is depressed after the loss of care giving role \200\224if a partner/spouse has died (p498)64 \200\224or if children have \202 own the parental nest. Loneliness is likely to be worse if the person is shy, has limi ted social skills, and poor self-esteem. Some people, of course, like to avoid their fellow s. For them, intrusion into their private world may cause despair; but, for most, these int rusions are welcome, and necessary for health. Loneliness seriously aff ects 1 in 10 older people, and contributes to alcoholism, depression, and suicide. Suspect that loneliness is important when you \201 nd your hand being gripped for comfort after you thought that a s ocial encounter was over \200\224also whenever there is a verbal outpouring and a \200\230 defeated demeanor. \200\231 y r t a i h c y s P Do not assume that loneliness means social isolation. Someone who has brief visits 3 times a day, from, say, a nurse, a care assistant, and a \200\230meals on wheels lady \200\231 i s not socially isolated, but may be very lonely. But if he or she gets on well with just on e of these visitors, this can be enough to banish loneli- ness. So this is the \201 rst l esson: be nice to people, and take trouble to \201 nd out their hopes and fears. But more is possible: in general, it is depressing waiting for the doorbell to ring, so tailor your suggestions in the light of your patient \200\231s mobility. This needs initiative on your patient \200\231s part, but do not think you must treat your patient \200\231s depression before you tackle a lonely lifestyle: tackling this may be the route out of depression. Are as to think about include: \200 What facilities already exist? Is there a local pub, day center, or lunch club available? \200\234God, I wouldn \200\231t be seen dead in one of th ose places! \200\235 we so often hear. But take time to point out that it does not matter i nitially whether they get anything out of a social interaction. After all, they may meet so meone of like mind, so enabling these arti \201 cial crutches to be thrown away. Is the person religious? There may be activities and outings to plan and talk about, and reminisce over, even if not actually enjoyed at the time. Housing: if the person is planning a move, will they be near family, and other people who speak their own language (metaphorically and literally)? Alternative therapies, eg massage and aromatherapy, can relieve loneliness. \200 Adult ed ucation is a good (expensive) way to make friends; as new skills are acquired, con \201 de nce improves, and socializing becomes more pleasurable. \200 Involvement with community a ction groups may be a source of friends (and a source of frustration and disappointment \200\224but do not expect your inter- ventions to be without side eff ects: the thing is to plan for them). Details of local community activities can be found in the UK at the local Council for Volun tary Services. Other organizations advertise at libraries. While at the library, ask about joining a book club. \200 Befriending schemes can be very helpful to those who are housebound. \200 Technology forums such as the Internet may pro vide relief from boredom and loneliness \200\224and for some this will off er the best chan ce of meeting with a kindred spirit, unlimited by the constraints of time and space. Befriending others, and off ering phone support is an option, whether or not one is housebound. Ask local authorities to help to get suitable phones. How to recognize and treat your own mental illnesses Doctors have a higher than average inc idence of suicide and alcoholism, and we must all be prepared to face (and try to prevent) these and other health risks of our professional and private lives. Our skill at looking af ter ourselves has never been as good as our skill at looking after others, but when the hea l- er himself is wounded, is it clear that his ability to help others will be cor- respondi ngly reduced? Our own illnesses are invaluable in allowing us to un- derstand our patients, what makes people go to the doctor (or avoid going to the doctor), and the barriers we may erect to resist his advice. But the idea of an ailing physician remains a paradox to the a verage mind, so that we may ask: \200\207Can true spiritual mastery over a power ever be w on by someone who is counted among her slaves?65 If the time comes when our mental state se ri- ously reduces our ability to work, we must be able to recognize this and take appropria te action. The following may indicate that this point is approaching: \200 Drinking alcoh ol before ward rounds or surgeries. \200 The minimizing of every contact with patients, s o that the doctor does the 332 bare minimum which will suffi ce. Inability to concentrate on the matter in hand. Your thoughts are entirely taken up with the workload ahead. y r t a h c y s P Irritability (de \201 ned as disagreeing with >1 nurse/24h). \200 Inability to take time off without feeling guilty. \200 Feelings of excessive shame or anger when reviewing pas t d b cles. To i avoid mistakes it would be necessary for us all to give up medicine. Emotional exhaustion \200\224eg knowing that you should be feeling pleased or cross with yo urself or others, but on consulting your heart you draw a blank. \200 Prospective studies suggest that introversion, masochism, and isolation are important risk factors for doctors \200\231 impairment. The \201 rst step in countering these unfavorable states of mind is to recognize that one is present. The next step is to con \201 de in someone you trust. Give your mind time to rejuvenate itself. If these steps fail, various psychotherapeutic approaches may be relevant, eg cognitive beh av- ioural therapy (p373), or you might try prescribing the symptom. For example, if you ar e plagued by recurring thoughts about how poorly you treated a patient, set time aside to d eliberately ruminate on the aff air, avoiding distractions. This is the \201 rst step in gaining control. You initiate the thought, rather than the thought initiating itself. The n ext step is to interpose some neutral topic, once the \200\230bad \200\231 series of thoug hts is under way. After re- peated practice, the mind automatically \202 ows into the neu tral channel once the bad thoughts begin, and the cycle of shame and rumination is broken. \200\207In addition \200 learn from the experience! Fig 1. Hands-off ! Don \200\231t get too drawn into treating your own mental illness withou t con- sulting a colleague. If no progress is made, the time has come to consult an expert, such as your general practi tion- er. Our own con \201 dential self-help group for addiction and other problems is the British Doctors \200\231 and Dentists \200\231 Group and may be contacted via the Medi- ca l Council on Alcohol (tel. 020 7487 4445uk). If you are the expert that another doctor has approached, do not be deceived by this honor into thinking that you must treat your new pat ient in any special way. Special treatment leads to special mistakes, and it is far better for doctor \200\223patients to tread well-worn paths of referral, investigation, and treatm ent than to try illusory short cuts. \201\201 333 Burnout (running beyond empty) De \201 nition Falling performance and personal accomplishm ents, emotional exhaustion, nega- tive aff ect, poor leadership, and depersonaliza- tion br ought on by months or years of overex- posure to emotionally demanding situations at work, on the battle \201 eld, or at home. Measurement The Five minute speech sample and the Masl ach burnout inventory.68 Risk factors For doctors: Lack of hobbies, lack of physical activi ty, and lack of enough time for vacations and religious activities are all important.69 Pre ssure of work, con \202 ict with colleagues,70 less personal relationships with patients, overly formal hierarchies, and subopti- mal income are put forward to explain the fact that some doctors (eg urologists) in the public sector are more at risk of burnout compared wit h private-service urologists.71 Factors as- sociated with emotional exhaustion: \200\230ha ving to deaden one \200\231s conscience \200\231, lack of time to provide needed care, work being so demanding that it in \202 uences one \200\231s home life, and not being able to live up to others \200\231 expectations.72 Risk factors for psychiatric nurses: Unrecip- ro cated giving, violent client population73 leading to vicarious traumatiza- tion,74 frequenc y of on-calls.75 High expressed emotion (evidenced by critical comments negative relatio nships) predicts depersonalization elements of burnout.68 For medical students: Impulsivity , depression & money worries are predictive.76 For military personnel: Past history of phys ical trauma is predictive. Management (Diffi cult) Some may respond to plans such as these: \200 Diagnose and treat any depression (p336 \200\2237). \200 Allow time for the perso n to recognize that there is a problem. \200 More hobbies, and more nice holidays. \200 Advice from wise colleagues in the specialty (regular follow-up). Mentor- ing consists in forming a supportive relationship with an independent col- league for the sole purpose of s upport. Fig 2. Have you felt this way? Signs of burnout: \200 Stress and depression \200 Fatigue \200 Non-restorative sleep6 7 \200 Emotional exhaustion \200 Motivation \200\201; apathy \200\200 \200 Libido \200\201 \200 Insomnia \200 Guilt or denial \200 Paranoia/isolated \200 Demoralizat ion \200 Amnesia \200 Indecision \200 Temper tantrums \200 Low personal accom- y r t a i h c y s P 6 6 . l u o s d e t c r a f n i plishment Depersonalization \200 Vicarious traumatization \200 Irritability/impatience r u o y r o f y d e m e r y l n o e h t s i e u g o l a i d \200\207 r e t a l t u o Return meaning and purpose to life via dialog, self-transcendence and a sense of connectedn ess with others (meaning-centered psychotherapy).77 \200 Learn new professional skills \200\224or consider early retirement. \200 Set achievable goals in work and leisure (eg p rotected time with family). Prevention Strategies such as career counseling are said to be eff ective but really do no more than point a lollipop at a furnace.78 n=171 Reducing stres s is one (unproven) way of avoiding burnout. Psychiatrists have found their own \200\230st ress busting \200\231 groups helpful \200\224these entail problem-solving with air- ing of stresses \200\224ideally accompanied by talking to colleagues for support and catharsis. Ha ving outside interests helps, as does getting support from family and friends, time managem ent, and exercise.79 On a more universal plane, \200\207we are all responsible for each ot her \200\231s burnout. By being attentive to our own and others \200\231 feelings of troubl ed conscience we all have a role in preventing the burnout of our colleagues. We need oppor tunities to re \202 ect on our troubled consciences. Appraisals (p508) and less formal rou tes to this awareness are becoming more accepted by professionals.72 n r u b d n a n i e v i g l l i w u o y r o w o n p u k a e p S \200\207 Patients in disgrace: the fat-folder syndrome The sorrow that has no vent in tears may make other organs weep.80 Francis J Braceland One role of the psychiatrist/GP is to act as the terminus for patients who have been shunted from hospital department to department. The aim is to reframe symptom-off ering into problems that need solving. Start by accepting that t he patient is troubled and looking for helpful responses from you that are yet to be de \201 ned. After establishing rapport, agree a contract with the patient, that we will give regular consultations for listening to how the patient feels and will try to off er help, i f she acknowledges that past investigations haven \200\231t helped, that psychological fact ors play a part (somatization, p640), and that she agrees not to consult other doctors unti l a \201 xed number of sessions have elapsed.81 Also, cognitive therapy (p374) examining the way that conscious thoughts and beliefs perpetuate disability, can lead to symptom redu ction.82 334 Autosuggestion/dissociation (formerly \200\230hysteria \200\231) Our stream of consciousne ss doesn \200\231t progress from cradle to grave as a sin- gle line: there are separations (disso- ciations) and con \202 uences, for example, when we daydream, or drive to Porlock with no recollection of the scenery along the way, only of our inner land- scape. Dissociat ion may be adaptive, eg by annihilating pain in near-death events ( \201 g 1). Another exa mple: a man who was homosexually raped had no conscious memory of this, but felt irre- sist ible urges to write insulting letters about the perpetrator. Types of dissociation Amnesia is the commonest type: see BOX. Depersonali- zation: Feeling of being detached from one \200\231s body or ideas, as if one were an outsider, observing the self; \200\234I \200 \231m in a dream \200\235 or \200\234I \200\231m an automaton \200\235 (unre- lated to dru gs/alcohol) eg from stress. Dissociative identity disorder: The pa- tient has multiple pers onalities which interact in complex ways. It is present in 3% of acute psychiatric inpatien ts. Fugue: Inability to recall one \200\231s past loss of identity or formation of a new identity, associated with unexpected, purposeful travel (lasts hours to months, and for wh ich there is no me). Follow-up ( 6yrs) shows that 5% of those referred to a CNS hospital w ho had hysteria/dissociation diagnosed turned out to have organic illness. Treatment Explor ing life stresses may help. Be ready to recognize psychologi- cal components of physical il lness, and get expert psychiatric help, while leav- ing the door open for new diagnoses. y r t a h c y s P i Fig 1. This lady has the knack of dissociating her body and replacing it with the airy noth - ingness of a summer sky. Roland Penrose, the artist, intuited this adaptive response to e xtreme events in her past: he did not know when he painted this that at aged 7 that Lee Mil ler, whose portrait this is, was raped, and had suff ered traumatic douches to deal with th e ensuing gonorrhea. Nor could he have known that in 1945 she would be the \201 rst photo grapher to document the over \202 owing ovens of Nazi concentration camps, no doubt using her dissociative skills to keep her camera steady. How did she end up as the leading fashio n photographer of her day? The nested funnels at the foot of the picture suggest an answer: the mind has an in \201 nite capacity to distill one experience through another, and to c hannel experi- ences in new, creative ways. Night & day, Roland Penrose, reproduced by permission of The Penrose Collection. 335 Is this amnesia dissociative? 1 \200 Has a physical cause been carefully discounted? (Dru gs, epilepsy, etc.) \200 Is the patient young? Beware making the \201 rst diagnosis if >40yrs old. \200 Have the symptoms been provoked by stress? Ask the family. \200 Do rel ated symptoms \200\230make sense \200\231 (eg apho- nia in a news-reader)?