Psychiatrists' perceptions of conditions and consequences associated with the implementation of open notes: qualitative investigation.

OBJECTIVE: In a growing list of countries, patients are granted access to their clinical notes ("open notes") as part of their online record access. Especially in the field of mental health, open notes remain controversial with some clinicians perceiving open notes as a tool for improving therapeutic outcomes by increasing patient involvement, while others fear that patients might experience psychological distress and perceived stigmatization, particularly when reading clinicians' notes. More research is needed to optimize the benefits and mitigate the risks. METHODS: Using a qualitative research design, we conducted semi-structured interviews with psychiatrists practicing in Germany, to explore what conditions they believe need to be in place to ensure successful implementation of open notes in psychiatric practice as well as expected subsequent changes to their workload and treatment outcomes. Data were analyzed using thematic analysis. RESULTS: We interviewed 18 psychiatrists; interviewees believed four key conditions needed to be in place prior to implementation of open notes including careful consideration of (1) diagnoses and symptom severity, (2) the availability of additional time for writing clinical notes and discussing them with patients, (3) available resources and system compatibility, and (4) legal and data protection aspects. As a result of introducing open notes, interviewees expected changes in documentation, treatment processes, and doctor-physician interaction. While open notes were expected to improve transparency and trust, participants anticipated negative unintended consequences including the risk of deteriorating therapeutic relationships due to note access-related misunderstandings and conflicts. CONCLUSION: Psychiatrists practiced in Germany where open notes have not yet been established as part of the healthcare data infrastructure. Interviewees were supportive of open notes but had some reservations. They found open notes to be generally beneficial but anticipated effects to vary depending on patient characteristics. Clear guidelines for managing access, time constraints, usability, and privacy are crucial. Open notes were perceived to increase transparency and patient involvement but were also believed to raise issues of stigmatization and conflicts.

Therapeutic stance towards persons with psychosis - a Grounded Theory study.

OBJECTIVE: Over the last decades, psychotherapy of psychosis has increasingly gained attention. The quality of the therapeutic alliance has been shown to have an impact on therapy outcome. Yet, little is know about the influence of the therapeutic stance on the alliance. In this study, we explore psychotherapists' stance towards persons with psychosis with the aim of better understanding its characteristic-hindering and helpful-aspects. METHOD: 6 semi-structured interviews with psychotherapists from three different schools (CBT, PD, ST) were analysed with Grounded Theory. Credibility was checked through external and peer-researcher-supported debriefing. RESULTS: 4 core categories were generated and interrelated in a theoretical model. Therapists' stance was initially characterized by insecurity. Diffent ways of dealing with insecurity yielded different stances: a monological and an open one. A helpful stance was conceived as stemming from openness and was characterized by a dialogical structure. A co-presence (or "dosing") of you and I was conceived as its core aspect. CONCLUSION: These findings specify the interpersonal dynamics arising from different stances and their impact on the therapeutic alliance and process. Research is still needed to further understand the characteristics of helpful and hindering therapeutic stances, which should also inform the training of psychotherapists.

Reasons for Acceptance or Rejection of Online Record Access Among Patients Affected by a Severe Mental Illness: Mixed Methods Study.

BACKGROUND: Over the past few years, online record access (ORA) has been established through secure patient portals in various countries, allowing patients to access their health data, including clinical notes ("open notes"). Previous research indicates that ORA in mental health, particularly among patients with severe mental illness (SMI), has been rarely offered. Little is known about the expectations and motivations of patients with SMI when reading what their clinicians share via ORA. OBJECTIVE: The aim of this study is to explore the reasons why patients with SMI consider or reject ORA and whether sociodemographic characteristics may influence patient decisions. METHODS: ORA was offered to randomly selected patients at 3 university outpatient clinics in Brandenburg, Germany, which exclusively treat patients with SMI. Within the framework of a mixed methods evaluation, qualitative interviews were conducted with patients who chose to participate in ORA and those who declined, aiming to explore the underlying reasons for their decisions. The interviews were transcribed and analyzed using thematic analysis. Sociodemographic characteristics of patients were examined using descriptive statistics to identify predictors of acceptance or rejection of ORA. RESULTS: Out of 103 included patients, 58% (n=60) wished to read their clinical notes. The reasons varied, ranging from a desire to engage more actively in their treatment to critically monitoring it and using the accessible data for third-party purposes. Conversely, 42% (n=43) chose not to use ORA, voicing concerns about possibly harming the trustful relationship with their clinicians as well as potential personal distress or uncertainty arising from reading the notes. Practical barriers such as a lack of digital literacy or suspected difficult-to-understand medical language were also named as contributing factors. Correlation analysis revealed that the majority of patients with depressive disorder desired to read the clinical notes (P<.001), while individuals with psychotic disorders showed a higher tendency to decline ORA (P<.05). No significant group differences were observed for other patient groups or characteristics. CONCLUSIONS: The adoption of ORA is influenced by a wide range of motivational factors, while patients also present a similar variety of reasons for declining its use. The results emphasize the urgent need for knowledge and patient education regarding factors that may hinder the decision to use ORA, including its practical usage, its application possibilities, and concerns related to data privacy. Further research is needed to explore approaches for adequately preparing individuals with SMI to transition from their inherent interest to active engagement with ORA. TRIAL REGISTRATION: German Clinical Trial Register DRKS00030188; https://drks.de/search/en/trial/DRKS00030188.

They have taken out my spinal cord: an interpretative phenomenological analysis of self-boundary in psychotic experience within a sociocentric culture.

Introduction: In the tradition of phenomenological psychiatry, schizophrenia is described as a disturbance of the minimal self, i.e. the most basic form of self-awareness. This disturbance of the minimal self at the individual level is assumed to precede the intersubjective disturbances such as boundary weakening. However, the role of intersubjective disturbances in the emergence and recovery of schizophrenic experience still remains an open question. This phenomenological study focuses on how encounters with others shape self-experience during from psychosis by analyzing this process from the perspective of cultural differences, which in current research is especially under-researched. While most phenomenological accounts are based on first person-accounts from Western, individualist cultures where the self is conceived and experienced as separate to others, the present study qualitatively investigates psychotic experiences of patients from Jaffna, Sri Lanka. Method: Semi-structured interviews were conducted with three participants with a diagnosis of schizophrenia or first episode psychosis. The interviews were transcribed and analyzed using interpretative phenomenological analysis (IPA). Eight group experiential themes were identified across interviews. Results: The data suggest that intersubjective processes of boundary weakening such as invasiveness and hyperattunement may shape minimal self-experience and more specifically contribute to a mistrust of the own senses and to hyper-reflexivity. Interestingly, boundary weakening yields pervasive emotions and can be experienced as a threat to the whole social unit. On the one hand, the strengthening of self-other-boundary was achieved through opposition, closedness and withdrawal from others. On the other hand, this study suggests that the re-opening of self-other-boundaries in response to the crisis may help establish connectedness and may lead to recovery.

Paving the way for systemic phenomenological psychiatry - the forgotten heritage of Wolfgang Blankenburg.

Phenomenological psychopathology focuses on the first-person experience of mental disorders. Although it is in principle descriptive, it also entails an explanatory dimension: single psychological symptoms are conceived as genetically arising from a holistic structure of personal experience, i.e., the patient's being-in-the-world - and of its dynamic unfolding over time. Yet both classical and current phenomenological approaches tend to identify the essential disorder or "trouble générateur" (Minkowski) of mental illness within the individual, thereby neglecting the relevance of the social context not only for the emergence of symptoms but also for their treatment. The work of Wolfgang Blankenburg on schizophrenia represents a noteworthy approach to overcome this individualistic tendency. He introduced the concept of "loss of common sense" as the structural core of schizophrenic experience and being-in-the-world and he considered the social and most importantly familial context for the emergence of schizophrenic experience. By accounting not only for personal experience but also for interactional structures of families and social milieus in which experience is embedded, Blankenburg thereby offered ways to combine phenomenological and systemic explanations of mental disorders. Beside his most renowned work on "the loss of common sense," in this paper we also present his family studies of young persons with schizophrenia, which have so far received little if no attention. We thus discuss the different ways in which Blankenburg expanded the phenomenological approach into a more systemic and social direction. We then link Blankenburg's work with current systemic explanatory models of schizophrenia and explore the clinical and scientific implications of this link. Finally, we call for further research on the synergy effects between the two.

Reopening Selves: Phenomenological Considerations on Psychiatric Spaces and the Therapeutic Stance.

Classical and contemporary phenomenological approaches in psychiatry describe schizophrenia as a disorder of common sense and self-affection. Although taking into account intersubjectivity, this conceptualization still puts forward an individualistic view of the disorder, that is, the intersubjective deficit resides within the person. To overcome such individualism, in this article, we first propose that schizophrenic experience might be understood as arising from a dialectic relation between the self's loss of openness to the world and the world's loss of openness to the self. To show the relevance of social factors at the onset of schizophrenic experience, we propose a phenomenological analysis of trigger situations. In the second and main part of this article, we then focus on the implications of these phenomenological insights for the clinical practice: we argue that if schizophrenia is understood as a loss of openness between self and social world, psychiatric institutions should be transformed into spaces that enable a reopening of selves. We first describe enclosing phenomena such as coercive treatment to then, in contrast, present particular forms of open psychiatric spaces such as open door approaches and open dialogue. Besides the institutional-structural level, we also highlight aspects of openness at the intersubjective level of the individual agents, thus particularly emphasizing the role of an open therapeutic stance. We thus speak of (re)opening selves as we believe that the reopening of the patients' self cannot but be related to and fostered by a reopening of the professionals' self and stance. We thus argue that openness in the therapeutic stance is key to initiating the further process of recovery, which we describe as a reattunement of selves both at the bodily and narrative level. Last but not least, we sketch out possibilities for future phenomenological research on the question of psychiatric space and draw some broader societal implications.

Person-Centered Psychiatry as Dialogical Psychiatry: The Significance of the Therapeutic Stance.

In this article, we present holistic and person-centered perspectives in psychiatry, with the aim of better understanding what a focus on personhood might really mean and what clinical implications it might have. We first introduce classical and philosophical concepts of personhood, in order to then outline person-centered approaches in psychiatry, which mainly focus on the person of the patient. We then argue that, for it to really be person-centered, psychiatry must necessarily also focus on the person of professionals. We thus explore the notion of stance, as the expression of the therapist's personhood. By unpacking the effects that a professional's stance can have on patients, we finally turn to a consideration of the interpersonal sphere. More specifically, we propose clinical considerations on a therapeutic stance that strives to support and to help the person of the patient unfold. Such a stance must - we argue - necessarily be a dialogical one. Drawing on these considerations, we thus claim that a truly person-centered approach in psychiatry must necessarily and automatically be interperson-centered and dialogical. In the concluding remarks, we finally discuss broader societal implications and outline future research perspectives.

Psychiatrization of Society: A Conceptual Framework and Call for Transdisciplinary Research.

Purpose: Worldwide, there have been consistently high or even rising incidences of diagnosed mental disorders and increasing mental healthcare service utilization over the last decades, causing a growing burden for healthcare systems and societies. While more individuals than ever are being diagnosed and treated as mentally ill, psychiatric knowledge, and practices affect the lives of a rising number of people, gain importance in society as a whole and shape more and more areas of life. This process can be described as the progressing psychiatrization of society. Methods: This article is a conceptual paper, focusing on theoretical considerations and theory development. As a starting point for further research, we suggest a basic model of psychiatrization, taking into account its main sub-processes as well as its major top-down and bottom-up drivers. Results: Psychiatrization is highly complex, diverse, and global. It involves various protagonists and its effects are potentially harmful to individuals, to societies and to public healthcare. To better understand, prevent or manage its negative aspects, there is a need for transdisciplinary research, that empirically assesses causes, mechanisms, and effects of psychiatrization. Conclusion: Although psychiatrization has highly ambivalent effects, its relevance mainly derives from its risks: While individuals with minor disturbances of well-being might be subjected to overdiagnosis and overtreatment, psychiatrization could also result in undermining mental healthcare provision for the most severely ill by promoting the adaption of services to the needs and desires of the rather mild cases. On a societal level, psychiatrization might boost medical interventions which incite individual coping with social problems, instead of encouraging long-term political solutions.

[Pilot Project: Reinforcement of Outpatient Palliative Care in the State of Brandenburg - An Analysis of Documentation Data of Primary Palliative Care]. / Pilotprojekt zur Stärkung der ambulanten Palliativversorgung im Land Brandenburg ­ Analyse von Dokumentationsdaten der allgemeinen ambulanten Palliativversorgung.

BACKGROUND: Quantitative data on primary palliative care (AAPV) in Germany is scarce. In order to reinforce outpatient palliative care, a pilot project was implemented and evaluated in 2 regions of Brandenburg. The aim of this study was to gain an insight into AAPV based on documentation data from the pilot project: How was AAPV realized in the pilot project? How does the implementation of AAPV differ in the 2 project regions? MATERIALS AND METHODS: The study is based on retrospective analysis of the data on 108 patients documented by 13 physicians in 2 regions of Brandenburg using PalliDoc® software. The results were analysed by descriptive statistical methods. RESULTS: Each participating doctor documented the care process of 7.7 patients on average during the observation period. Overall, about 66% of the patients were diagnosed with a tumour as the main diagnosis. The average duration of care for patients in the pilot project was 171.3 days. On average, doctors documented 9.1 contacts per patient with contacts lasting 20:28 min. The average route to the patient was 9.3 kilometres. CONCLUSIONS: Our results indicate that the execution of AAPV is highly dependent on regional circumstances as well as on the existing offers and services of hospice and palliative care. Compared to data from the evaluation of palliative care teams in other German regions, it appears that the care processes in AAPV last longer and a larger number of patients without underlying oncological disease has been treated under AAPV than in specialized palliative care.

[Psychopharmaceutical Medication in Brandenburgian Nursing Homes - An Exploratory Study]. / Psychopharmakamedikation in brandenburgischen Pflegeheimen ­ eine explorative Studie.

OBJECTIVE: Psychopharmaceuticals are often prescribed in nursing homes for elderly. Together with the general polypharmacy, the risk for adverse drug reactions and interactions is increased. METHODS: Medication data of 398 nursing home residents were analyzed. Guided interviews and focus groups were carried out with nurses, prescribing physicians and relatives. RESULTS: About 70 % of the residents received psychotropic drugs often with sedative properties. High work load, sociodemographic development and shortage of psychiatrists and neurologists had an influence on the prescription rates. CONCLUSION: Nurses and physicians need to be aware of possible adverse drug effects and interactions of psychotropics. The overall amount of psychopharmaceuticals prescribed in nursing homes should be reduced.

["If they were to stop coming, I'd panic" : Palliative care networks from the perspectives of patients and informal care givers]. / "Wenn die mal nicht mehr kommen würden, dann kriege ich eine Krise" : Netzwerke der ambulanten Palliativversorgung aus Sicht von Patienten und Angehörigen.

OBJECTIVE: This study examines the perspectives of patients and family caregivers on outpatient palliative care networks. It contrasts primary palliative care (AAPV) and specialized outpatient care (SAPV) services, particularly in regard to pain management. METHODS: The study is based on 27 semi-structured, problem-focussed interviews with 21 patients and 19 informal caregivers. Recruitment was based on purposive sampling in two regions of Brandenburg, Germany. The data were analysed using qualitative content analysis. RESULTS: In AAPV, the general practitioner (GP) is both the central point of contact as well as the coordinator of the care network. In SAPV, the GP plays a less important role. This can lead to conflicts between GPs and health care professionals of the palliative care team. Compared to AAPV, palliative care teams are attributed greater intervention capacities in acute situations as well as expertise in pain therapy. Thus, the option of parenteral administration of opioids is considered a benefit of specialized care. The use of nursing services varies considerably depending on the individual care network-in some cases care is completely taken over by relatives. Relatives are the closest to the patient within the care network and perform key tasks. CONCLUSION: The personal and professional composition of networks of outpatient palliative care varies individually according to care situation and form. Care networks of AAPV and SAPV differ with regard to the accessibility of health care professionals and pain therapy. Home-based palliative care is often made possible by informal care givers in the first place.

[Existence, Absence and Power of Madness: A Critical Review of Michel Foucault's Writings on the History and Philosophy of Madness]. / Die Existenz, Abwesenheit und Macht des Wahnsinns. Eine kritische Übersicht zu Michel Foucaults Arbeiten zur Geschichte und Philosophie der Psychiatrie.

This article discusses Michel Foucault's main writings on "madness and psychiatry" from his early works up to the 1970s. On the one hand, we reconstruct the overall theoretical and methodological development of his positions over the course of the different periods in his oeuvre. On the other hand, we also take a closer look at Foucault's philosophical considerations regarding the subjects of his investigations. After an initial introduction of our conceptual approach, we draw on the most recent research on Foucault to show to what extent the phenomenological description of the topic at hand and the historical-critical perspective that are reflected in his early writings of 1954 (the Introduction to Binswanger's Dream and Existence and Mental Illness and Personality) laid the ground for his later work. Moving on to Foucault's work during the 1960s, we look at the core features and methodological bases of his 1961 classic Folie et déraison (History of Madness). His propositions regarding the "absence of madness" in modernity are conceptualized as an inherently contradictory attempt to liberate the topic under study from the common assumptions at that time. We then situate his 1973/74 lectures on Psychiatric Power in the context of his shift towards analyzing the dynamics of power and highlight the renewed shift of focus in his statements on the "productivity" of madness as an effect of power. Finally, we sum up our critique by taking into account the history of the reception of Foucault's writings and ask about their potential significance for the contemporary philosophy and history of psychiatry.

[Phenomenological anthropological social psychiatry--paving the way for a theoretical reanimation]. / Phänomenologisch-anthropologische Sozialpsychiatrie--Wegmarken für eine theoretische Wiederbelebung.

This article tries to link the present lack of theoretical discussion within German Social Psychiatry with a loss of phenomenological and anthropological thought. The so-called Phenomenological Psychiatry used to play a very important role in German psychiatry during the 50 ies until the 70 ies and had strong influences on the first reformers of German psychiatry, such as Walter Ritter von Baeyer, Heinz Häfner, Caspar Kulenkampff, Karl Peter Kisker and Erich Wulff. Their reforms were not only founded by a social criticism put forth by theories such as marxism (Basaglia, Wulff) or structuralism (Foucault) but also by a concrete notion of what it is like to suffer from mental illness and what kind of needs are linked to such suffering. This very notion was given by the phenomenological approach. Finally the article tries to give reasons for today's reciprocal loss of connection of the phenomenological and the socio-psychiatric school.