Patient-centred psychiatry

I was pleased to hear from Anna Ludvigsen that the Royal College of Psychiatrists has a scoping group to look at how to make training more patient-centred. Believe it or not, medicine hasn't always been patient-centred. Historically, clinical training has emphasised a doctor-centred or disease-centred approach, which involves diagnosing the patient's disease and prescribing a management plan appropriate to the diagnosis. A patient-centred approach is designed to attain an understanding of the patient as well as the disease.

Patient-centred medicine is based on the University of Western Ontario method (Levenstein et al 1986, Stewart et al 2003). It is not technology-centred, doctor-centred, hospital-centred or disease-centred. Instead, it explores patients' main reasons for consultation, their concerns and their need for information. It seeks an integrated understanding of the whole person, including emotional needs and life issues. It finds common ground with patients on what the problem is and mutually agrees about how to manage the problem. Its focus encourages prevention and health promotion. It also emphasises the continuing relationship between the patient and the doctor. It provides a realistic and effective use of time in the consultation. It also has to be sensitive to context as, for example, an acutely ill patient may require more focus on disease. It also has to be sensitive to patient preference as, for example, some patients may require more information than others.

The approach may well have its origins with Michael and Enid Balint, both psychoanalysts, who began work in the 1950s to help general practitioners reach a better understanding of the emotional content of the doctor patient-relationship. and so improve their therapeutic potential (see UK Balint Society). Patient-centredness may be a poorly understood concept. Doctors vary in the degree to which their practice is patient-centred, although on the whole most doctors provide patients with partially patient-centred care.

Critical psychiatry is the application of the patient-centred method in psychiatry. Inherently it is a challenge to biomedical psychiatry. In my publications, I have tried to emphasise how it restates the conceptual position of Adolf Meyer and George Engel (eg. see my article).