Michael Ascher, MD

Regardless of the systems in place at medical schools, psychiatrists and psychiatry residents play an important role in molding the attitudes of medical students toward mental illness. Studies have consistently demonstrated that 

attitudes on the part of medical students

 toward these patients are more negative than toward patients with other medical conditions.

 Even more concerning, it appears that these negative feelings may worsen over time. Further, 

 of patients with substance use disorders are especially prone to 

It has been shown that patients who encounter doctors who are 

 toward mental disorders are less inclined to seek help in the future and more likely to become psychologically distressed by the encounter.

 Addressing these concerns while students are still in medical school can potentially improve the future care of numerous patients. Here are some steps psychiatrists, faculty, and psychiatry residents can take to help medical students along the way, no matter what specialty they choose:

 While the data is somewhat inconsistent, psychiatrists and psychiatry trainees have been found to possess more 

 attitudes toward serious mental illness-especially 

 and borderline personality disorder-than non-psychiatric illness.

 Medical students often model their thinking and behaviors after their more seasoned colleagues, so it is important that clinicians examine how they communicate both verbally and nonverbally with their students (and patients).

about their experiences working with patients with psychiatric disorders

This should be done in a nonjudgmental and inviting way. Students are often overwhelmed by their psychiatry rotations and have difficulty expressing their thoughts and feelings. Routinely encouraging medical students to identify the personal emotions that various patients elicit can open a dialog.

3. Begin a discussion about countertransference 

and how to effectively use those feelings in the therapeutic space. Teach students to use their sensibilities and countertransference to more deeply understand and garner empathy for all patients. This can then lead to better therapeutic outcomes. 

 have demonstrated that open discussions, journaling, and mandatory end-of-rotation reflection papers can improve students’ outlook and experiences.

4. Exercise didactic thinking and offer educational reflection exercises.

 Even brief interventions have been shown successfully to improve attitudes, and a 

 can have a huge impact on patient outcomes.

 to tolerate uncertainty and to set realistic and attainable goals with their patients.

6. Encourage students to train in Motivational Interviewing

 (MI), which embodies an atmosphere of acceptance and compassion.

 This can help them view challenging patients in a new way and minimize frustration. Specifically, MI can provide clinicians with a 

 with patients that tends to increase the expression of empathy and support patient self-efficacy.

Dr Baez is a third-year psychiatry resident at Montefiore Medical Center in the Bronx, New York. Dr Avery is an Addiction Psychiatry Fellow at New York University School of Medicine in New York City. Dr Ascher is an Addiction Psychiatry Fellow at the University of Pennsylvania School of Medicine in Philadelphia.

Medical student attitudes about mental illness: does medical-school education reduce stigma?

Overcoming stigma: involving families in medical student and psychiatric residency education

Medical students’ attitudes toward mental disorders before and after a psychiatric rotation

 Lindberg M, Vergara C, Wild-Wesley, Gruman C. Physicians-in-training attitudes toward caring for and working with patients with alcohol and drug abuse diagnoses. 

A study of stigmatized attitudes towards people with mental health problems among health professionals

 Kreek MJ. Extreme marginalization: addiction and other mental health disorders, stigma, and imprisonment. 

Stigma and mental health professionals: a review of the evidence on an intricate relationship

 Livingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. 

 Nordt C, Rossler W, Lauber C. Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophr Bulletin. 2006;32:709-714.


“Attitude is a little thing that makes a big difference”: reflection techniques for addiction psychiatry training

 Galletly C, Burton C. Improving medical student attitudes towards people with schizophrenia. 

Addressing stigma to strengthen psychiatric education

 Martino S, Haeseler F, Belitsky R, et al. Teaching brief motivational interviewing to Year three medical students. 

Articles

Regardless of the systems in place at medical schools, psychiatrists and psychiatry residents play an important role in molding medical students' attitudes toward mental illness.

Thinking About Mental Illness: 6 Steps for Medical School Faculty

Psychotherapy research has demonstrated that a strong therapeutic alliance is associated with clinical success on a variety of issues and treatment approaches.

 This alliance exists when a clinician and patient develop a collaborative bond and come to an agreement on treatment goals and tasks.

 The ability to work purposefully together will only develop after a clinician and patient have established a relationship of trust and positive regard. Inevitably, situations arise during the course of therapy that can test the process of successful mental health treatment. While these purported ruptures can feel particularly overwhelming for both clinician and patient, the process of working through challenges can lead to therapeutic breakthroughs and, ultimately, a strengthened alliance.

Risk assessment is one such situation with the potential for rupture. As mental health professionals, we must regularly assess whether a patient is in imminent danger of hurting himself or others, and whether the patient is unable to care for self, necessitating hospitalization. In suicide risk assessment, it is essential to assess both protective and risk factors in order to get a full picture of the potential danger.

 While the appropriate course of action is clear in some instances, there are also cases that fall into a gray area. When treating patients whose circumstances are not simple and clear-cut, the clinician must carefully weigh the risks, benefits, and alternatives to hospitalization, as well as create a space for dialogue about these factors with the patient.

In the age of managed care, the path to hospitalization is not a simple one. It can be a delicate matter to anticipate what the experience of involuntary hospitalization will be like for the patient, to decide how much information to disclose to the patient, and to obtain proper informed consent from him. The process of evaluation and admission in the emergency department (ED) can be a traumatizing experience. Patients must often sit in crowded waiting rooms with others who are also in the midst of mental health crises. The environment can be chaotic, with patients yelling, crying, or acting in aggressive or provocative ways. Psychiatric patients are often required to surrender their personal belongings, and they may feel like they are being temporarily imprisoned. In addition, ancillary and supportive staff may be fatigued and appear hurried and disconnected. Comprehensive evaluation by the proper mental health staff can be an arduous process that may feel intrusive and impersonal.

When the clinician believes a patient’s life is in danger, the patient’s clinical condition and suicide risk assessment must supersede concerns for the secondary effects of hospitalization. In many situations, it is important for the clinician to discuss openly with the patient the potential implications of an emergency hospital admission. Engaging in an honest dialogue before the decision to hospitalize a patient can preserve the foundation of trust. The therapeutic alliance can be strengthened when the clinician invites the patient to discuss the processes, goals, potential setbacks, and concerns related to an emergency hospitalization. The clinician should assess what the patient knows about hospitalization and what they would like to learn. After providing the patient with the necessary information, the clinician should elicit the patient’s interpretation of the information in order to gauge levels of understanding and address any confusion.

The patient’s individual attachment styles, psychopathology, and life experiences should be considered before having a conversation about hospitalization. Assessing these factors allows the professional to anticipate possible patient responses to hospitalization. The process of hospitalization, if “prescribed” by the clinician, has the potential to cause irreparable harm to the relationship if not properly discussed and explored, both before and after the ED crisis visit. Alternatively, when correctly addressed, hospitalization can function as a curative intervention that communicates deep caring and concern for the patient’s well-being.

Following an emergency crisis visit, the clinician and patient should explore what hospitalization means to the patient, and the clinician should give the patient space to discuss her thoughts, feelings, and emotions. The patient should also be encouraged to discuss any positive and negative feelings towards the therapist that may have emerged in connection with hospitalization. Exploring these topics when the patient is not in a state of intense distress can serve to build a trusting relationship and increase the patient’s feelings of agency and autonomy.

Dr Briggie is a Staff Psychologist at the Center for Motivation and Change in New York, NY. Ms Kreiter is a Research Assistant at the Family Center for Bipolar at Beth Israel Medical Center in New York, NY. Dr Ascher is a Postdoctoral Fellow in Addiction Psychiatry at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition. 

Hoboken, NJ: John Wiley & Sons, Inc.; 2013.


Psychotherapy Relationships That Work, 2nd Edition.

 New York: Oxford University Press; 2011.


 Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. 

Negotiating the Therapeutic Alliance: A Relational Treatment Guide.

 Simon RI. Assessing protective factors against suicide: questioning assumptions. 

A therapeutic alliance can serve to build a trusting relationship between clinician and patient and increase the patient’s feelings of agency and autonomy.

Therapeutic Alliance in the Aftermath of an Emergency Crisis Visit

Poor adherence to psychotropic medication regimens is one of the major roadblocks to improved clinical outcomes. In today’s time-pressed practice of psychiatry, with its emphasis on the brief medication management visit, clinicians and patients often feel rushed and disconnected, which results in a poor therapeutic alliance. When the therapeutic alliance is positive, medication adherence is better and 

Integrating mindfulness into our practices may help foster the therapeutic alliance and ultimately medication adherence.

Engaging in mindfulness activities either individually or with patients who come to us for brief medication visits can have a profound influence on the therapeutic process. Mindfulness can help us and our patients settle down and be more present during the session. This can provide the catalyst for more meaningful engagement and better therapeutic outcome. While there is no universally agreed on definition of mindfulness, it is helpful to understand the concept as embracing humanness and accepting one’s body, thoughts, feelings, and emotions without judgment.

The use of mindfulness exercises has become increasingly prominent in both cognitive-behavioral and psychodynamic practice. In the primary care setting, mindfulness scores following mindfulness training were found to correlate with improvements in empathy and decreased physician burnout.

 Our mindfulness practice may directly benefit patients as well. In a recent study, researchers looked at the impact on therapeutic outcome after a clinician took part in a brief, 5-minute mindfulness-centered exercise.

 Results indicate that the patients “perceived the sessions as being more effective when their therapists engaged in the exercise prior to the start of the session.”

Introducing patients to mindfulness may provide them with greater awareness, attention, openness, and insight. Emerging evidence has associated the practice of mindfulness meditation with functional changes in default mode network activity and 

 in brain regions involved in learning and memory, emotion regulation and self-referential processing, and perspective taking.

Opening a medication management visit with a 2-minute mindfulness exercise may improve the efficiency and therapeutic value of even brief medication management visits and may be an impetus for patients to explore deeper meditative practices that can have a profoundly beneficial effect on overall health and wellness. We encourage clinicians to consider the utility of mindfulness in the clinical setting. The practice can have far-reaching effects for clinician and patient both inside the therapy space and beyond.

This article was first posted online on 5/3/2013 and has since been updated.

Teaching Mindfulness: A Practical Guide for Clinicians and Educators

. New York: Springer; 2011. This is a wonderful resource for clinicians who are interested in learning more about mindfulness.

Therapeutic alliance perceptions and medication adherence in patients with bipolar disorder.

 Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. 

Dunn R, Callahan JL, Swift JK, Ivanovic M. Effects of pre-session centering for therapists on session presence and effectiveness. 

 Brewer JA, Worhunsky PD, Gray JR, et al. 

Meditation experience is associated with differences in default mode network activity and connectivity

How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective

Engaging in mindfulness activities either individually or with patients who come to us for brief medication visits can have a profound influence on the therapeutic process.

Mindfulness and the Medication Management Visit

Families are an underutilized resource in psychiatric practice. Given the current practice of brief hospitalizations, families are expected to provide more illness monitoring and in-home care. When family members are included and welcomed as members of the treatment team, patient care improves and the psychiatrist’s job is easier. Reaching out to the families of patients can help psychiatrists generate clearer diagnostic formulations, develop more effective treatment, and plan for emergencies.

What should psychiatrists do when patients don’t give permission to contact their families?

Many psychiatrists erroneously believe that the sharing of information with others, without the patient’s explicit consent, is prohibited by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA violations may have serious consequences, so it is important to have a clear understanding of what the 

 The following information is extracted from the website of the 

US Department of Health and Human Services

 and provides guidance for health care providers. Here are some guidelines:

(1) Health care information may be shared with relevant individuals present when the patient has given prior approval, or simply does not object

(2) Asking a friend to be in the interview room provides the implicit right to disclose information in their presence

(3) Clinicians also have the authority within the Privacy Act to share information based on their professional judgment, believing that there would be no objection to its discussion. For example, a clinician may share information about medication with those providing transportation from the hospital

(4) If the patient is not present but has requested an individual to gather information for him or her, or is incapacitated by an emergency, a physician may once again use best judgment in sharing information. This may include a proxy picking up of medications from the pharmacy or receiving other protected information

(5) Physicians should be aware of state laws within their region of practice that may affect the use of the Privacy Act within scenarios of emergency or safety concern

Using these guidelines, family members (or friends) who accompany the patient can be invited into the interview and the benefits of their inclusion explained. Most evidence-based family interventions are psychoeducational, where illness symptoms and treatments are explained and feelings and beliefs about the illness are explored. When patients understand the goal of 

Family involvement is often misunderstood as being a hindrance to individuation, when in fact family-oriented interventions can improve patient functioning, agency, and autonomy. This is often the case when young adults are forced, because of illness, to return home to live with their parents. The use of shared decision-making may help the patients frame their long-term goals in line with the goals of the family.

Psychiatrists can help the patient prepare for the family meeting. With a clear agenda, the patient will be less anxious and be more accepting of family members working with them. Psychiatrists can proceed, using one of the most underutilized evidence-based interventions in psychiatry-

US Department of Health and Human Services. Does the HIPAA Privacy Rule permit a doctor to discuss a patient’s health status, treatment, or payment arrangements with the patient’s family and friends? 

http://www.hhs.gov/hipaafaq/notice/488.html

 Swindell JS, McGuire AL, Halpern SD. Beneficent persuasion: pechniques and ethical guidelines to improve patients’ decisions. 

Family involvement is often misunderstood as being a hindrance to individuation, when in fact family-oriented interventions can improve patient functioning, agency, and autonomy.

Michael Ascher, MD

Articles

Thinking About Mental Illness: 6 Steps for Medical School Faculty

Therapeutic Alliance in the Aftermath of an Emergency Crisis Visit

Mindfulness and the Medication Management Visit

Confidentiality and the Family: 5 Guidelines for Better Outcomes