THE HOSPITALISATION PROCESS AND INITIAL EXPERIENCES

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INTRODUCTION AND BACKGROUND

Mental health problems are on the increase worldwide; more and more people are in need of help. A recent report on the mental health in the USA in 2015 stated that 42.5 million (18.19 per cent) of adults in America suffer from mental illness, 19.7 million (8.46 per cent) suffer from a substance use problem and 8.8 million (3.77 per cent) report serious thoughts of suicide. Only 41 per cent of individuals with mental illness reported receiving treatment (Mental Health America 2015).

TRAINING OF REGISTRARS

It takes four years of post-graduate training to become a psychiatrist in South Africa. After completion of their undergraduate studies, physicians first have to work for two years under supervision, followed by a year of community service, before they can apply for a post as a registrar at one of the eight universities in South Africa that have medical schools. Many candidates first work as general medical practitioners before deciding on further training. Most registrars are thus in their late twenties or early thirties when they start their specialisation.

PROBLEM STATEMENT AND RESEARCH QUESTION

After many years of working in psychiatry, my impression is that most psychiatrists focus on biological aspects of psychiatry. This impression is strengthened by my experiences in an academic training hospital where I have worked for the last five years. For various reasons most registrars seem to „manage‟ their patients. By „manage‟ I mean that treatment is not embedded in a therapeutic relationship. The patient is rather „a someone‟ for whom pharmacological treatment is prescribed based on his or her symptoms. A reductionistic approach is followed.

Objectives

The steps taken to reach the aims were:
a. An empirical study of the world of the hospitalised psychiatric patient, of their  experiences, as delineated in the research design. This will be compared to findings of an in-depth literature research on experiences of psychiatric patients, their needs and wishes, as well as on person centred care.
b. An empirical study of the therapeutic relationships that develop between patients and members of the MDT, of the quality and type of this relationship from the patients‟ perspective. An in-depth literature research will also be done on therapeutic relationships, to be able to better understand the situation in our hospital.
c. An empirical study to understand what factors influences the interaction between registrar and patient; part of this will be an effort to understand how the hospital as system influences this therapeutic relationship between registrar and patient.

DECLARATION
DEDICATION
ACKNOWLEDGEMENTS
SECTION 1 THE STUDY AND ITS METHODOLOGY
1 CONTEXTUALISING THE STUDY
1.1 Introduction and background
1.2 Training of registrars
1.3 Problem statement and research question
1.4 Aims and objectives
1.4.1 Aims
1.4.2 Objectives
1.5 Personal interest
1.6 My different roles in the hospital
1.7 Anticipated contributions
1.7.1 Theoretical contributions
1.7.2 Methodological contributions
1.7.3 Practical contributions
1.8 Existing knowledge
1.9 Thesis structure
2 RESEARCH APPROACH AND ITS IMPLEMENTATION
2.1 Introduction
2.2 Qualitative research as research approach
2.3 My research philosophy
2.4 The place of literature in qualitative research and the relation between theory and research
2.5 The process of coding and different ways of data analysis in the development of theory
2.6 Research ethics
2.7 Qualitative research design
2.8 Research methodology
2.8.1 Study setting
2.8.2 Study population and sampling
2.8.3 Sample size and data saturation
2.8.4 Collection and recording of data
2.8.5 Data management
2.8.6 Data analysis and synthesis as a cyclical process
2.8.7 Representing the data: writing up
2.9 Strategies to ensure quality
2.10 Summary of Chapter 2
SECTION 2 THE FINDINGS
3 INTRODUCTION TO THE FINDINGS
3.1 Admission to Weskoppies Hospital
3.2 The participants
3.2.1 Brief clinical summary of research participants
3.2.2 Profile of the research participants
3.2.3 Summary of the interviews and patients
3.2.4 Summary of the distribution of patients in terms of race and gender
3.3 Making sense of the data: the development of models of containment and therapeutic relationships
3.3.1 First model: Important relationships in a psychiatric hospital
3.3.2 Second model of important relationships in a psychiatric hospital
3.3.3 Third model: A setting emerges
3.3.4 Fourth model: The concept of containment is introduced
3.3.5 Fifth model: A different way of seeing the setting
3.3.6 Sixth model: The hospital as community
3.3.7 Seventh model: The final model of therapeutic relationships
3.4 Summary of Chapter 3
4 THE HOSPITALISATION PROCESS AND INITIAL EXPERIENCES
4.1 Central Admissions
4.2 Hospital environment
4.3 Admission to different teams
4.4 Open wards
4.5 Closed wards
4.5.1 Introduction
4.5.2 Daily routine in the closed wards and being locked into the dormitories
4.5.3 Feeling helpless
4.5.4 Forced treatment
4.5.5 The transfer to an open ward
4.6 Sexual needs linked to loneliness
4.7 Ethical violations
4.8 Other comments
4.9 Summary of Chapter 4
5 HOLDING AND CONTAINMENT – OR THE LACK THEREOF: THE PRIMARY FACTORS
5.1 Nursing staff
5.1.1 Positive experiences with nursing staff
5.1.1.2 Attitudes and attributes
5.1.1.3 The importance of nursing staff
5.1.1.4 But things can go wrong
5.1.1.5 Burnout? The positive experience with trainee staff
5.1.2 Negative experiences with nursing staff
5.1.2.1 Experiences with nursing staff in closed wards
5.1.2.2 Everything that you say is written down (observations)
5.1.2.3 Conflict in the ward between staff and patients
5.1.2.4 A reactionary attitude with lack of containment
5.2 Registrars
5.2.1 Positive experiences with registrars
5.2.1.1 Registrars are important
5.2.1.2 Belief in the doctor
5.2.1.3 Attributes of doctors who become important to their patients
5.2.2 Differences between registrars
5.2.3 Some further comments on the role of the doctor
5.2.4 Negative experiences with registrars
5.2.4.1 Consultations once a week
5.2.4.2 And then mostly short symptom orientated consultations
5.2.4.3 Other factors that impair the development of a therapeutic relationship
5.3 The rest of the multi-disciplinary team (MDT)
5.3.1 General comments about the team
5.3.2 Psychologists
5.3.3 Occupational therapists
5.3.4 Social workers
5.3.5 The pastoral counsellor
5.3.6 Other members
5.4 Other people involved
5.4.1 Fellow patients
5.4.2 Other staff: Cleaners
5.4.3 Medical students
5.5 Studying of hospital files
5.6 Summary of Chapter 5
6 HOLDING AND CONTAINMENT – OR THE LACK THEREOF: THE SECONDARY FACTORS
6.1 Religion, spirituality, culture and language
6.1.1 Religion and spirituality
6.1.2 Culture and language
6.2 Family and friends
6.3 Summary of Chapter 6
7 THE THERAPEUTIC RELATIONSHIP: A POSSIBILITY AWAITING REALISATION
7.1 Is a therapeutic relationship important to patients and why?
7.2 Factors that influence the development of a therapeutic relationship
7.2.1 Aspects around time, frequency of being seen and boundaries
7.2.1.1 Seen soon after admission and informed about program
7.2.1.2 Frequency of being seen
7.2.1.3 Addressing unrealistic expectations
7.2.1.4 Having time
7.2.1.5 Boundaries
7.2.2 Short rotations
7.2.3 Attitude
7.2.3.1 Being interested in the patient
7.2.3.2 Listening
7.2.3.3 Creating an atmosphere of acceptance, trust and safety
7.2.3.4 Collaboration
7.2.3.5 Giving positive feedback
7.2.3.6 Being available and easy to reach
7.2.3.7 Keeping promises
7.2.3.8 Understanding the fears of the patient
7.2.3.9 Overcoming resistances
7.2.4 The therapeutic relationship and the team
7.2.5 Psycho-education
7.2.6 Seeing the registrar with students present
7.2.7 Other important factors
7.3 Does a therapeutic relationship need a long time to develop?
7.4 What is possible in challenging circumstances?
7.5 Summary of Chapter 7
SECTION 3 TOWARDS A MODEL OF THERAPEUTIC RELATIONSHIPS IN A PSYCHIATRIC HOSPITAL
8 LITERATURE REVIEW
A summary of the literature review
8.1 Mental health care: The ideal
8.1.1 What is a hospital supposed to be?
8.1.2 What is mental health?
8.2 Mental health care: The reality
8.2.1 Difficult feelings and what to do with them
8.2.2 Difficult experiences around time
8.2.3 Difficult experiences in closed wards: forced medication, seclusion and other measures of containment
8.2.4 Difficult experiences around non-adherence or non-compliance
8.2.5 Problems in the practice of nursing
8.2.6 Complaints by patients
8.3 Models of mental health care
8.3.1 The present dominant model or paradigm in medicine
8.3.2 A systems approach
8.3.3 The wish and need for person-centred care
8.3.4 Research on patients‟ experiences and their opinions about what constitutes good care
8.4 Central aspects of relationships
8.4.1 Existence as “being-in-a-relationship”
8.4.2 Mirror neurons
8.4.3 Attachment
8.4.4 Empathy
8.4.5 Language
8.4.6 Verbal and non-verbal behaviour
8.4.7 Holding, containment, or keeping someone in mind: a psychoanalytic perspective
8.4.8 From holding to being remembered and the continuity of life
8.5 The therapeutic alliance
8.5.1 Definitions and descriptions
8.5.2 Why does it matter?
8.5.3 Trust
8.5.4 The particular place of therapy or consultations
8.5.5 Social class
8.5.6 Different models of interacting with patients
8.5.7 The intercultural and interracial therapeutic relationship
8.5.8 First consultation and frequency of being seen: comments from a psychoanalytic point of view
8.6 Training of psychiatric registrars
8.6.1 Some general comments on training
8.6.2 Mentoring needs
8.6.3 Balint groups
8.6.4 What attention should the registrar‟s personal characteristics and mental health receive?
8.6.5 What needs attention? A few central aspects
8.6.5.1 Being present, listening, explaining
8.6.5.2 Reflecting on the treatment facility
8.6.5.3 Including psychoanalytic concepts, skill and attitudes in teaching
8.6.5.4 The need for on-going professional development
8.7 Linking the literature review with the rest of the study
9 AN ANALYSIS OF THE CARE AND TREATMENT OFFERED AT WESKOPPIES PSYCHIATRIC HOSPITAL, LEADING TO THE DEVELOPMENT OF A MODEL AND SUBSTANTIVE THEORY OF THERAPEUTIC RELATIONSHIPS
9.1 Introduction
9.2 Encounters in the hospital
9.2.1 Superficial encounters
9.2.2 Negative encounters
9.2.3 Meaningful encounters
9.2.3.1 Seemingly superficial encounters that can be meaningful
9.2.3.2 Encounters with religion, spirituality, culture and language
9.2.3.3 Meaningful deep encounters
9.2.4 Reflections on encounters
9.3 Containment
9.4 The multi-disciplinary team
9.5 The seventh model: A model and substantive theory of therapeutic relationships
9.5.1 The frame, including the treatment paradigm
9.5.2 The inner circle
9.5.2.1 The patient and the MDT
9.5.2.2 Management: the fourth semicircle
9.5.2.3 Illustrations of the containing function, or lack thereof, of the „inner circle‟
9.5.3 Outside the inner circle but still inside the wall
9.5.4 Outside the wall
9.5.4.1 The community, family and friends
9.5.4.2 Religion, spirituality, culture and language
9.5.4.3 The socio-economic and political situation
9.5.5 The red bar – the therapeutic relationship
9.5.6 Wrapping up the seventh model and substantive theory of therapeutic relationships
9.6 Obstacles in the realisation of a therapeutic relationship
9.6.1 Superficial encounters
9.6.2 Negative encounters
9.6.3 Splitting of the bio-psycho-socio-spiritual approach
9.7 How common is a therapeutic relationship?
9.8 Some concluding remarks on the model and substantive theory of therapeutic relationshps
9.9 Summary of Chapter 9
10 AN ANALYSIS OF THE TRUSTWORTHINESS OR „GOODNESS‟ OF THE STUDY
10.1 Concerns about case study and insider research
10.2 The trustworthiness or „goodness‟ of the study
10.2.1 Reflexivity
10.2.2 Audit trail
10.2.3 Triangulation or crystallisation
10.2.4 Peer reviewing
10.2.5 Thick descriptions
10.2.6 Member validation
10.3 Summary of Chapter 10
SECTION 4 CONCLUDING NOTES
11 SUMMARY, IMPLICATIONS AND RECOMMENDATIONS
11.1 Introduction
11.2 A summary of the study and the findings
11.3 Ethical problems flowing from the study
11.4 Key contributions and implications
11.4.1 Theoretical contributions
11.4.1.1 A model and substantive theory of therapeutic relationships
11.4.1.2 Containment as key concept
11.4.1.3 Shortcomings in the training of registrars
11.4.1.4 Three strategies for ensuring quality and trustworthiness in qualitative studies
11.4.2 Methodological contributions
11.4.2.1 Qualitative research
11.4.2.2 Combining a case study approach with methods of analysis stemming from
grounded theory
11.4.3 Practical contribution or value of the study
11.4.4 Summary of contributions
11.5 Recommendations
11.5.1 Recommendations to provincial management
11.5.2 Recommendations to hospital management
11.5.3 Recommendations to the Department of Psychiatry, UP, and the College of Psychiatrists of the CMSA, South Africa
11.5.5 Concrete suggestions specific to the situation in WKH
11.5.5.1 General recommendations about the interaction between registrars and patients
11.5.5.2 Registrar allocations to the teams and allocations of wards
11.5.5.3 The academic programme
11.5.5.4 The out-patient clinics
11.5.5.5 Ward programme
11.5.6 The role of the consultants
11.6 A final assessment of the situation in WKH
11.7 Limitations and future research
12 PERSONAL REFLECTIONS
REFERENCES

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THE THERAPEUTIC RELATIONSHIP AS REFLECTED IN THE EXPERIENCES OF HOSPITALISED PSYCHIATRIC PATIENTS: AN EXPLORATIVE- DESCRIPTIVE STUDY