Experiences of Sexual and Reproductive Health Care Access for Women and Nonbinary People With Early Psychosis: Towards an Integrated Perspective of Service Users and Clinicians.

OBJECTIVE: Individuals with psychosis are at elevated risk of adverse sexual and reproductive health (SRH) outcomes, and not receiving adequate SRH care. SRH is important for youth, yet little is known about SRH care access and experiences among those with early psychosis. This study explored SRH care experiences among women and nonbinary individuals with early psychosis. METHOD: We conducted semistructured qualitative interviews with 19 service users (cisgender and transgender women, nonbinary individuals) receiving care in 2 early psychosis programs in Ontario, Canada. We also conducted semistructured interviews and focus groups with 36 clinicians providing SRH or mental health care to this population. Participants were asked about SRH care access/provision experiences and the interplay with psychosis. Using a social interactionist orientation, a thematic analysis described and explained service user and clinician perspectives regarding SRH care. RESULTS: Amongst both service users and clinician groups, common themes developed: (a) diversity of settings: SRH services are accessed in a large range of spaces across the health care system, (b) barriers in nonpsychiatric SRH care settings: psychosis impacts the ability to engage with existing SRH services, (c) invisibility of SRH in psychiatric settings: SRH is rarely addressed in psychiatric care, (d) variability of informal SRH-related conversations and supports, and cutting across all of the above themes, (e) intersecting social and cultural factors impacted SRH services access. CONCLUSIONS: SRH is important for health and wellbeing; improvements are urgently needed across the healthcare system and within early psychosis programs to meet this population's multifaceted SRH needs.

Power to the people? A co-produced critical review of service user involvement in mental health professions education.

Meaningful service user involvement in health professions education requires integrating knowledge held by "lay" people affected by health challenges into professional theories and practices. Involving service users redefines whose knowledge "counts" and implies a shift in power. Such a shift is especially significant in the mental health field, where power imbalances between health professionals and service users are magnified. However, reviews of the literature on service user involvement in mental health professional education do little to explore how power manifests in this work. Meanwhile critical and Mad studies scholars have highlighted that without real shifts in power, inclusion practices can lead to harmful consequences. We conducted a critical review to explore how power is addressed in the literature that describes service user involvement in mental health professions education. Our team used a co-produced approach and critical theories to identify how power implicitly and explicitly operates in this work to unearth the inequities and power structures that service user involvement may inadvertently perpetuate. We demonstrate that power permeates service user involvement in mental health professional education but is rarely made visible. We also argue that by missing the opportunity to locate power, the literature contributes to a series of epistemic injustices that reveal the contours of legitimate knowledge in mental health professions education and its neoliberal underpinnings. Ultimately, we call for a critical turn that foregrounds power relations to unlock the social justice-oriented transformative potential of service user involvement in mental health professions education and health professions education more broadly.

"The genie is out of the bottle": a qualitative study on the impact of COVID-19 on continuing professional development.

BACKGROUND: The onset of the COVID-19 pandemic catalysed a monumental shift in the field of continuing professional development (CPD). Prior to this, the majority of CPD group-learning activities were offered in-person. However, the pandemic forced the field to quickly pivot towards more novel methods of learning and teaching in view of social distancing regulations. The purpose of this study was to obtain the perspectives of CPD leaders on the impact of the pandemic to elucidate trends, innovations, and potential future directions in the field. METHODS: Semi-structured interviews were conducted between April-September 2022 with 23 CPD leaders from Canada and the USA. Interviews were audio-recorded, transcribed, and de-identified. A thematic analysis approach was used to analyse the data and generate themes. RESULTS: Participants characterised COVID-19 as compelling widespread change in the field of CPD. From the interviews, researchers generated six themes pertaining to the impact of the pandemic on CPD: (1) necessity is the mother of innovation, (2) the paradox of flexibility and accessibility, (3) we're not going to unring the bell, (4) reimagining design and delivery, (5) creating an evaluative culture, and (6) a lifeline in times of turmoil. CONCLUSION: This qualitative study discusses the impact of the pandemic on the field of CPD and leaders' vision for the future. Despite innumerable challenges, the pandemic created opportunities to reform design and delivery. Our findings indicate a necessity to maintain an innovative culture to best support learners, to improve the healthcare system, and to prepare for future emergencies.

The development and evaluation of a virtual, asynchronous, trauma-focused treatment program for adult survivors of childhood interpersonal trauma.

BACKGROUND: The long-term mental and physical health implications of childhood interpersonal trauma on adult survivors is immense, however, there is a lack of available trauma-focused treatment services that are widely accessible. This study, utilizing a user-centered design process, sought feedback on the initial design and development of a novel, self-paced psychoeducation and skills-based treatment intervention for this population. AIMS: To explore the views and perspectives of adult survivors of childhood interpersonal trauma on the first two modules of an asynchronous trauma-focused treatment program. METHODS: Fourteen participants from our outpatient hospital service who completed the modules consented to provide feedback on their user experience. A thematic analysis of the three focus groups was conducted. RESULTS: Four major themes emerged from the focus groups: (1) technology utilization, (2) module content, (3) asynchronous delivery, and (4) opportunity for interactivity. Participants noted the convenience of the platform and the use of multimedia content to increase engagement and did not find the modules to be emotionally overwhelming. CONCLUSIONS: Our research findings suggest that an asynchronous virtual intervention for childhood interpersonal trauma survivors may be a safe and acceptable way to provide a stabilization-focused intervention on a wider scale.

Meaningful engagement through critical reflexivity: Engaging people with lived experience in continuing mental health professional development.

Engaging people with lived experience of mental health system encounters in the design and actualization of continuing professional development initiatives for mental health professionals can have transformative systemic impacts. Yet, despite evidence that involving people with lived experience benefits mental health professional education, far less focus has been placed on how to engage people with lived experience in continuing professional development initiatives. Tensions persist regarding the role of lived experience perspectives in continuing professional development, as well as how to establish people with lived experience as partners, educators and leaders in a thoughtful way. We propose that meaningful and equitable partnerships with people with lived experience can be realized by engaging in critical reflexivity and by systematically challenging assumptions. This paper explores three topics: (1) the current state of engagement with people with lived experience in continuing professional development initiatives; (2) barriers to meaningful engagement and (3) recommendations for using critical reflexivity to support the involvement and leadership of people with lived experience in continuing professional development for mental health professionals. PATIENT OR PUBLIC INVOLVEMENT: This viewpoint manuscript was co-designed and co-written by people with diverse lived and learned experiences. Each author's professional roles involve meaningfully and equitably partnering with and centring the perspectives of those with lived experience of mental health system encounters. In addition, approximately half of the authorship team identifies as having lived experience of accessing the psychiatric system and/or supporting family members who are navigating challenges related to mental health. These lived and learned experiences informed the conception and writing of this article.

Swept under the carpet: a qualitative study of patient perspectives on Long COVID, treatments, services, and mental health.

BACKGROUND: A constellation of often disabling long-term physical symptoms enduring after an acute SARS-COV-2 infection is commonly referred to as Long COVID. Since Long COVID is a new clinical entity, research is required to clarify treatment needs and experiences of individuals affected. This qualitative descriptive study aimed to provide insight into Long COVID treatment and service experiences and preferences of individuals experiencing Long COVID and the intersections with mental health. METHODS: The study was conducted out of a tertiary care mental health hospital, with online recruitment from the community across Canada. A total of 47 individuals (average age = 44.9) participated in one of 11 focus groups between June and December 2022. Five focus groups were conducted with participants who had pre-existing mental health concerns prior to contracting SARS-CoV-2, and six were with people with Long COVID but without pre-existing mental health concerns. A semi-structured interview guide asked about service experiences and service preferences, including mental health and well-being services. Discussions were recorded, transcribed, and analyzed using codebook thematic analysis. RESULTS: When accessing services for Long COVID, patients experienced: (1) systemic barriers to accessing care, and (2) challenges navigating the unknowns of Long COVID, leading to (3) negative impacts on patient emotional well-being and recovery. Participants called for improvements in Long COVID care, with a focus on: (1) developing Long COVID-specific knowledge and services, (2) enhancing support for financial well-being, daily living, and building a Long COVID community, and (3) improving awareness and the public representation of Long COVID. CONCLUSIONS: Substantial treatment barriers generate considerable burden for individuals living with Long COVID. There is a pressing need to improve treatment, social supports, and the social representation of Long COVID to create integrated, accessible, responsive, and ongoing support systems.

Evaluating recovery colleges: a co-created scoping review.

BACKGROUND: Recovery Colleges (RCs) are education-based centres providing information, networking, and skills development for managing mental health, well-being, and daily living. A central principle is co-creation involving people with lived experience of mental health/illness and/or addictions (MHA). Identified gaps are RCs evaluations and information about whether such evaluations are co-created. AIMS: We describe a co-created scoping review of how RCs are evaluated in the published and grey literature. Also assessed were: the frameworks, designs, and analyses used; the themes/outcomes reported; the trustworthiness of the evidence; and whether the evaluations are co-created. METHODS: We followed Arksey and O'Malley's methodology with one important modification: "Consultation" was re-conceptualised as "co-creator engagement" and was the first, foundational step rather than the last, optional one. RESULTS: Seventy-nine percent of the 43 included evaluations were peer-reviewed, 21% grey literature. These evaluations represented 33 RCs located in the UK (58%), Australia (15%), Canada (9%), Ireland (9%), the USA (6%), and Italy (3%). CONCLUSION: Our findings depict a developing field that is exploring a mix of evaluative approaches. However, few evaluations appeared to be co-created. Although most studies referenced co-design/co-production, few described how much or how meaningfully people with lived experience were involved in the evaluation.

Embedding lived experience into mental health academic research organizations: Critical reflections.

BACKGROUND: As part of a growing emphasis on engaging people with lived experience of mental health conditions in mental health research, there are increasing calls to consider and embed lived experience throughout academic research institutes. This extends beyond the engagement of lay patients and also considers the potential roles of academic researchers with lived experience. When the lived experience of academic researchers is applied to academic work, there is the potential to improve the relevance of the research, while destigmatizing mental illness within academia. However, there are different and often contrasting perspectives on the way a lived experience academic researcher initiative should be implemented. OBJECTIVES: This article describes some of the key issues to be considered when planning an initiative that leverages and values the lived experience of academic researchers, including the advantages and disadvantages of each potential approach. DISCUSSION & RECOMMENDATIONS: Institutions are encouraged to reflect on the ways that they might support and value lived experience among academic researchers. In developing any such initiative, institutions are encouraged to be transparent about their objectives and values, undertake a careful planning process, involve researchers with lived experience from the outset and consistently challenge the stigma experienced by academic researchers with lived experience. PATIENT OR PUBLIC CONTRIBUTION: Multiple authors are academic researchers with lived experience of mental health conditions.

Interprofessional continuing professional development programs can foster lifelong learning in healthcare professionals: experiences from the Project ECHO model.

BACKGROUND: The success of continuing professional development (CPD) programs that foster skills in lifelong learning (LLL) has been well established. However, healthcare professionals often report barriers such as access to CPD and cost which limit uptake. Further research is required to assess how accessible CPD programs, such as those delivered virtually, impact orientation to LLL. Project Extension for Community Healthcare Outcomes (Project ECHO®) is a CPD model that has a growing body of evidence demonstrating improvements in knowledge and skills. Central to this model is the use of a virtual platform, varied teaching approaches, the promotion of multi-directional learning and provider support through a community of practice. This study aimed to explore whether participation in a provincial mental health ECHO program had an effect on interprofessional healthcare providers' orientation to LLL. METHODS: Using a pre-post design, orientation to LLL was measured using the Jefferson Scale of Lifelong Learning. Eligible participants were healthcare professionals enrolled in a cycle of ECHO Ontario Mental Health from 2017 to 2020. Participants were classified as 'high' or 'low' users using median session attendance as a cut-point. RESULTS: The results demonstrate an increase in orientation to LLL following program participation (Pre: 44.64 ± 5.57 vs. Post: 45.94 ± 5.70, t (66) = - 3.023, p < .01, Cohen's d = 0.37), with high ECHO users demonstrating greater orientation to LLL post-ECHO. CONCLUSION: Findings are discussed in the context of self-determination theory and suggest there may be components of CPD programs that more readily support increased motivation for LLL for interprofessional healthcare professionals.

Challenges of End-Stage Renal Disease Patients in Ethiopia.

Affecting all aspects of patients' lives, end-stage renal disease (ESRD) presents significant challenges. Individuals with ESRD face biological, psychological, economic, and social issues. ESRD patients in Ethiopia bear multifaceted burdens of multiple medical conditions, including comorbid hypertension, diabetes, cardiac problems, anemia, gastrointestinal issues, and bone and mineral disorders. The aim of this study was to address the gap in research on patients in Ethiopia with ESRD and examine biopsychosocial and economic challenges. A qualitative hermeneutic phenomenology design was employed. In-depth interviews were held with 10 women and 10 men. Major themes include the physical corollary of ESRD (e.g., fatigue), and psychological (e.g., fear of loss of capacity and/or occupation) and socioeconomic challenges (e.g., difficulty obtaining social and economic support). Along with complications of ESRD and side effects of dialysis, patients face trauma and social and economic repercussions. Social workers are well positioned to help manage associated biopsychosocial and economic challenges. The findings indicate the need for policies that promote multidisciplinary teams in working with patients who are diagnosed with ESRD.

"It was great to break down the walls between patient and provider": liminality in a co-produced advisory course for psychiatry residents.

Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants' complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning.

Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey.

OBJECTIVES AND BACKGROUND: The aim of this study was to characterize equity and inclusion in acute care surgery (ACS) with a survey to examine the demographics of ACS surgeons, the exclusionary or biased behaviors they witnessed and experienced, and where those behaviors happen. A major initiative of the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma was to characterize equity and inclusion in ACS. To do so, a survey was created with the above objectives. METHODS: A cross-sectional, mixed-methods anonymous online survey was sent to all EAST members. Closed-ended questions are reported as percentages with a cutoff of α = 0.05 for significance. Quantitative results were analyzed focusing on mistreatment and bias. RESULTS: Most respondents identified as white, non-Hispanic and male. In the past 12 months, 57.5% of females witnessed or experienced sexual harassment, whereas 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Sexual harassment, racial/ethnic prejudice, or discrimination based on sexual orientation/sex identity was more frequent in the workplace than at academic conferences or in ACS. Females were more likely than males to report unfair treatment due to age, appearance or sex in the workplace and ACS (P ≤ 0.002). Surgeons of color were more likely than white, non-Hispanics to report unfair treatment in the workplace and ACS due to race/ethnicity (P < 0.001). CONCLUSIONS: This is the first survey of ACS surgeons on equity and inclusion. Perceptions of bias are prevalent. Minorities reported more inequity than their white male counterparts. Behavior in the workplace was worse than at academic conferences or ACS. Ensuring equity and inclusion may help ACS attract and retain the best and brightest without fear of unfair treatment.

INNOVATE Research: Impact of a workshop to develop researcher capacity to engage youth in research.

BACKGROUND: Engaging youth in research provides substantial benefits to research about youth-related needs, concerns and interventions. However, researchers require training and capacity development to work in this manner. METHODS: A capacity-building intervention, INNOVATE Research, was co-designed with youth and adult researchers and delivered to researchers in three major academic research institutions across Canada. Fifty-seven attendees participated in this research project evaluating youth engagement practices, attitudes, perceived barriers, and perceived capacity development needs before attending the intervention and six months later. RESULTS: The intervention attracted researchers across various career levels, roles and disciplines. Participants were highly satisfied with the workshop activities. Follow-up assessments revealed significant increases in self-efficacy six months after the workshop (P = .035). Among possible barriers to youth engagement, four barriers significantly declined at follow-up. The barriers that decreased were largely related to practical knowledge about how to engage youth in research. Significantly more participants had integrated youth engagement into their teaching activities six months after the workshop compared to those who were doing so before the workshop (P = .007). A large proportion (71.9%) of participants expressed the need for a strengthened network of youth-engaged researchers; other future capacity-building approaches were also endorsed. CONCLUSIONS: The INNOVATE Research project provided improvements in youth engagement attitudes and practices among researchers, while lifting barriers. Future capacity-building work should continue to enhance the capacity of researchers to engage youth in research. Researchers notably pointed to the need to establish a network of youth-engaged researchers to provide ongoing, sustainable gains in youth engagement.

Enhancing researcher capacity to engage youth in research: Researchers' engagement experiences, barriers and capacity development priorities.

BACKGROUND: There is increasing emphasis on engaging youth in research about youth, their needs, experiences and preferences, notably in health services research. By engaging youth as full partners, research becomes more feasible and relevant, and the validity and richness of findings are enhanced. Consequently, researchers need guidance in engaging youth effectively. This study examines the experiences, needs and knowledge gaps of researchers. METHODS: Eighty-four researchers interested in youth engagement training were recruited via snowball sampling. They completed a survey regarding their youth engagement experiences, attitudes, perceived barriers and capacity development needs. Data were analysed descriptively, and comparisons were made based on current engagement experience. RESULTS: Participants across career stages and disciplines expressed an interest in increased capacity development for youth engagement. They had positive attitudes about the importance and value of youth engagement, but found it to be complex. Participants reported requiring practical guidance to develop their youth engagement practices and interest in a network of youth-engaged researchers and on-going training. Those currently engaging youth were more likely to report the need for greater appreciation of youth engagement by funders and institutions. CONCLUSIONS: Engaging youth in research has substantial benefits. However, skills in collaborating with youth to design, conduct and implement research have to be learned. Researchers need concrete training and networking opportunities to develop and maximize these skills. They also need mechanisms that formally acknowledge the value of engagement. Researchers and those promoting youth engagement in research are encouraged to consider these findings in their promotion and training endeavours.

Mechanisms of change and participant outcomes in a Recovery Education Centre for individuals transitioning from homelessness: a qualitative evaluation.

BACKGROUND: Recovery Education Centres (RECs) are increasingly implemented to support the process of recovery for individuals experiencing mental health challenges. However, the evidence on key REC mechanisms and outcomes, particularly for diverse subpopulations or service delivery contexts is scant. This study identified mechanisms and outcomes of an REC focused on adults with mental health challenges transitioning from homelessness. METHODS: Qualitative methods were used to explore in-depth the experiences of homeless and unstably housed participants experiencing mental health challenges in Toronto, Canada. Twenty service users participated in semi-structured interviews between July 2017 and June 2018, six to 14 months following REC enrollment. A realist informed interview guide explored participants' perspectives on key REC mechanisms and outcomes. Interviews were audio-recorded, transcribed verbatim and analyzed using inductive thematic analysis. Investigator triangulation and member checking processes enhanced analytical rigour. RESULTS: Participants perceived that program participation supported the process of recovery through several mechanisms: a judgment-free environment; supportive relationships, mutuality and role modelling; deconstruction of self-stigma; and reclaiming of one's power. Participants described several outcomes at the personal, interpersonal and social levels, including improvements in health and well-being; self-esteem, confidence and identity; sense of empowerment, control and personal responsibility; as well as improvements in interpersonal skills, pro-social behaviours and ability to self-advocate; and increased goal development and future orientation. CONCLUSIONS: Findings suggest RECs can support the process of recovery among people transitioning from homelessness and can successfully support subpopulations experiencing mental health challenges and social disadvantage.

Goals of care or goals of life? A qualitative study of clinicians' and patients' experiences of hospital discharge using Patient-Oriented Discharge Summaries (PODS).

BACKGROUND: Recognizing the need for improved communication with patients at the point of hospital discharge, a group of clinicians, patients, and designers in Toronto, Canada collaborated to develop a standardized tool known as the Patient-Oriented Discharge Summary (PODS). Although quantitative results suggest PODS helps mitigate gaps in knowledge, a qualitative inquiry from the clinician and patient perspective of psychiatric hospital discharge using PODS has not been widely explored. Our aim was to explore clinicians' and patients' experiences with PODS. METHODS: We used a qualitative thematic analysis to explore clinicians' (n = 10) and patients' (n = 6) experiences with PODS. We used convenience sampling to identify and invite potential participants at the Center for Addiction and Mental Health in Toronto, Canada to participate in semi-structured interviews between February 2019 and September 2019. Data were analyzed using a thematic analysis approach to develop descriptive themes. RESULTS: Emerging themes from the data between clinicians and patients were both different and complementary. Clinicians described PODS using the concept of "goals of care." They relayed their experiences with PODS as a discrete event and emphasized its role in meeting their "goals of care" for discharge planning. Patients provided more of a "goals of life" perspective on recovery. They characterized PODS as only one facet of their recovery journey and not necessarily as a discrete or memorable event. Patients focused on their outcomes post-discharge and situated their experiences with PODS through its relation to their overall recovery. CONCLUSIONS: PODS was experienced differently by clinicians and patients. Clinicians experienced PODS as helpful in orienting them to the fulfillment of goals of care. Patients did not experience PODS as a particularly memorable intervention. Due to the information advantage that clinicians have about PODS, it is not surprising that clinicians and patients experienced the PODS differently. This study expanded our understanding of hospital discharge from clinicians and patients perspectives, and suggests that there are additional areas that need improvement.

"You are in Some Sort of Occupational Adolescence": An Exploratory Study to Understand Knowledge, Skills, and Experiences of CanMEDS Leader Role in Psychiatry.

OBJECTIVE: The study explored knowledge, attitude, and practices of Canadian Medical Education Directions for Specialists (CanMEDS) "'Leader" role in faculty psychiatrists in a university setting. METHODS: This is a qualitative study using a thematic analysis approach. Participants were identified by purposive, convenience, and snowball sampling. Telephone interviews were conducted to explore participants' perceptions of leadership. Qualitative analysis was carried out using a constant comparative analysis approach to identify themes across the interview data. Data was transcribed and coded into themes and categories to form an analysis of physicians' knowledge, attitude, and practices of the CanMEDS "Leader" role. RESULTS: Twenty-eight faculty psychiatrists participated in the study. The following themes and subthemes emerged from analysis: (a) characteristics of leadership and lack of clarity regarding CanMEDS "Leader" role (subthemes: differences between manager and leader, lack of specificity and practicality, relevance to practice) and (b) the meaning of leadership (subthemes: "positional leadership" and "everyday leadership," physician as team leader, developing leadership skills, getting beyond "occupational adolescence"). CONCLUSION: Participants perceived CanMEDS "Leader" role description as a high-level vision, which needs practice-oriented guidance. Participants conceptualized the dual nature of physician leadership at an individual level and at an organizational level. Leadership training is important both in residency as well as lifelong learning.

Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment.

OBJECTIVE: Co-production involves service providers and service users collaborating to design and deliver services together and is gaining attention as a means to improve provision of care. Aiming to extend this model to an educational context, the authors assembled a diverse group to develop co-produced education for psychiatry residents and medical students at the University of Toronto over several years. The authors describe the dynamics involved in co-producing psychiatric education as experienced in their work. METHODS: A collaborative autobiographical case study approach provides a snapshot of the collective experiences of working to write a manuscript about paying service users for their contributions to co-produced education. Data were collected from two in-person meetings, personal communications, emails, and online comments to capture the fullest possible range of perspectives from the group about payment. RESULTS: The juxtaposition of the vision for an inclusive process against the budgetary constraints that the authors faced led them to reflect deeply on the many meanings of paying service user educators for their contributions to academic initiatives. These reflections revealed that payment had implications at personal, organizational, and social levels. CONCLUSION: Paying mental health service user educators for their contributions is an ethical imperative for the authors. However, unless payment is accompanied by other forms of demonstrating respect, it aligns with organizational structures and practices, and it is connected to a larger goal of achieving social justice, the role of service users as legitimate knowers and educators and ultimately their impact on learners will be limited.

From hermeneutics to heteroglossia: 'The Patient's View' revisited.

This article explores conceptual and methodological challenges surrounding the recovery of patients' voices in the history of medicine. We examine the debate that followed Roy Porter's seminal article, 'The Patient's View: Doing Medical History from Below' (1985). Porter argued that patients should be given a central role in medical history, aiming to restore to patients a voice and agency that is often lost in 'physician-centered' historical narratives. His work carried significant influence but also sparked an ongoing debate about the possibility of conducting 'patient-centered' history of medicine. The growth of the medical humanities has afforded renewed attention to patient narratives, supporting the need to recognise patients' voices in contemporary healthcare and medical education. However, several barriers complicate and problematise the expansion of a patient-centred epistemology across historical periods. Postmodern critics have expressed scepticism that 'the patient's view' can be recovered from history, with some claiming that 'the patient' is a construct of the 'medical gaze' whose subjectivity cannot be reconstituted outside of sociohistorical discourses of knowledge and power. Psychiatry in the mid-20th century presents a particular challenge for patient-centred history. We discuss the influence of postmodern theorists, especially Michel Foucault, whose work is seen as undermining the possibility of a patient-centred epistemology. We argue against Foucault's erasure of the patient, and instead explore alternate constructivist epistemologies, focusing on the hermeneutics of Hans-Georg Gadamer and dialogism of Mikhail Bakhtin, to help address historiographical challenges in recovering 'the patient's view'. To illustrate the value of Gadamerian and Bakhtinian approaches, we apply them to a case study from the Verdun Protestant Hospital (Québec, Canada) from 1941 to 1956, which sheds light on the introduction of the first antipsychotic, chlorpromazine, into clinical practice. We highlight how Gadamer's hermeneutics and Bakhtin's dialogism together offer insights into patient perspectives during this liminal period in the history of psychiatry.

Understanding Engagement with a Physical Health Service: A Qualitative Study of Patients with Severe Mental Illness.

OBJECTIVE: Individuals with severe mental illness (SMI) are disproportionally affected by medical comorbidities, resulting in poor physical health and premature death. Despite this, care for chronic medical conditions is suboptimal, and there is limited research that explores this phenomenon from the patient's perspective. The aim of this study was to identify barriers and facilitators of engagement with a physical health service experienced by individuals with SMI. METHODS: Adults with SMI were recruited from a large psychiatric hospital and offered referral to a physical health service focused on the prevention and treatment of obesity and diabetes. Interviews were conducted at referral, 3, and 6 months. Data from 56 interviews of 24 participants were analyzed using the framework method to identify factors influencing engagement. RESULTS: Barriers to engagement were identified at individual, medical program, and health system levels. Factors influencing the individual experience included difficulty in care coordination, affective symptomatology, and ability to bond with providers. Factors at the program level included difficulty adjusting to the clinic environment and the inability to achieve treatment goals. Factors at the system level included challenges in attending multiple appointments in a fragmented health system, lack of social support, and financial constraints. CONCLUSIONS: This qualitative study suggests that traditional models of medical care for chronic conditions pose challenges for many individuals with SMI and contribute to health disparities. Adaptation of medical care to populations with SMI and close collaboration between medical and mental health services are necessary to improve medical care and, subsequently, health outcomes.