'Sense of Safety' Presentation 1

"the way a question is posed constrains its possible answers.' Sadler 2005

"Depression is an overinclusive term with a lack of conceptual clarity between symptom, syndrome, episode and illness." Casey, Dowrick et al (2001)

"You violate a patient's dignity if you treat them with a theory that is inadequate .... have the humility to remain confused."

Kluft (2015)

"I don't think I should be classified as mentally unwell because I had an abusive childhood. I am traumatised and should be classified as that...one can easily get misdiagnosed and never get the right help." Jen 2009

Psychiatrists label you and medicate you and mine gave up and called me nonresponsive.”

Anon Oct 2010

Complex trauma alters:

• Affect regulation (included self soothing, addictions, self harming behaviours)

• Attention and consciousness (amnesias, dissociative episodes, depersonalisation)

• Self Perception (chronic guilt, shame, self stigma, worthlessness)

• Relationship with others (difficulties with trust and intimacy)

• Connection with their body (inc somatisation, body memories or dismissive and ignoring)

• Systems of meaning (hopelessness, despair, feeling punished, deep hope)

• Perception of the Perpetrator (may exacerbate ambivalent, avoidance or disorganised attachment)

Love is relief from scanning the outer world for threat and our inner worlds for shame Goleman p 316 (2006)

"What happens with states of mind when a sense of terror or grief in response to loss is not met with reasonably attuned comforting?" Peter Fonaghy

“What is the goal of civilisation? The ability to feel safe in someone else’s arms.” Stephen Porges

Recovery:

Movement from despair to hope, passive to active sense of self, others in control to being in personal control, disconnectedness to connectedness... (King et al 2007)

Finding meaning in life, identity and taking responsibilty for recovery (Andresen et al 2003)

Sense of safe connection, hope for change, empowering the person to take active responsibility for his or her growth within their context (Jacobson and Greenley 2001)

"integrating what is newly discovered through the innovative methods of clinical work" Fonaghy (2003)

Proposing a novel approach to distress

Empirical evidence

Clinical consensus

Patient preference

Courtois and Ford (2014)

Not;

deterministic diagnosis (Diekelman 2002)

'scientific' pan-determinism (Foucault)

fixed lifelong diagnoses

one label for many presentations

pharmacotherapeutic focus

'sick-role'

ignoring patient goals

Not:

diagnostician as 'ascendant observer' (Verhaeghe 2004)

mind/body dualism

tertiary focus on the disorder

managing a 'scientific specimen' (Mirowsky)

objectifying and categorising (Epstein)

passive patient with no responsibility (Frank 2004)

biopositivism...new biological psychiatry

symptom focused

"dysfunctional machines" Dowrick 2004 p 12

Not:

atheoretical

symptoms with no meaning

artificial syndromal classification

disconnnected 'co-morbidity'

'fake mastery' (Pellegrino)

'myth of medical certainty' (Reeve)

'expectation of certainty' (Reeve p 4)

'spurious precision' (Wood 2009, p 180)

'masked meaning' Foucault

naming the malady provides some semblance of control

Research as sensemaking: paradigms are "specific story telling traditions" Denzin and Lincoln 1999 p 6

“‘disciplinary tribalism’ Meyrick 2006

"methodological fundamentalism" p 1319 Carter 2007

’take a broad and inclusive, rather than a narrow and dismissive approach” p 352 Greenhalgh 2004

"long standing tensions within the qualitative research community over the most appropriate means by which to evaluate rigor." p 1316 Carter 2007

Measures of TD quality:

• responsive goals
• broad preparation
• evolving methodology
• significant outcome
• effective collaboration
• communal reflection…” p 1056-7 (Wickson 2006)

…”emergent metaphors of understanding” p 10 Sommerville 2000

transcendent language – “a metalanguage in which the terms of all the participant disciplines are, or can be expressed.” P 27 Sommerville 2000

(sematic: serving as a sign or warning of danger)

“people unconsciously assess their social environments for signals of safety and danger, relaxing their defences when it seems safe to do so.” Rappoport (1997) p 250.

an ordinary human skill

lay language

holistic

helps prioritise care

makes defences make sense

sensory

physiological (neurobiol, immunol,)

intrapsychic

intersubjective

belonging

connection

coherence

stable sense of self

identity

similar to 'sos':

'sense of personal security'

'psychological safety'

'adaptation to trauma'

framing their distress in a non pathologising communally understood way

"safe to relinquish the pathological adaptation" p 251 Rappaport (1997)

" If the therapist orients himself or herself according to the issue of safety, the therapeutic task can become relatively simple" p 261 Rappaport

unattended need in my community

misdiagnosis of many trauma survivors

confusing multiple diagnosis

primary care constrained by dumbed down tertiary frameworks

voice of the patient ignored

symptom collation and classification

specific medication treating a broad range of illnesses...

'sense of safety'

Attempts to get safe:

Escape: Avoidance, Freeze

Flight, Addictions, Withdrawal, Suicide, Fantasy, dismissive/avoidant attachment

Approach: Seek mastery, Fight, DSH, anxious attachment, reenactment

opposite of 'sos':

defensiveness

helplessness

hopelessness

demoralisation

loss of assumptive world

(1997)

"the ability to establish a clear organisation framework within which doctors and patients can operate is likely to bring with it a sense of security and purpose, often conspicuously lacking in patients who feel low in mood, hopeless and without motivation, and whose self esteem might lead them to worry about bothering the doctor with their trivial concerns (Gask, rogers et al 2003). Providing the sense of security and purpose may be intrinsically therapeutic." p 92 Dowrick 2004

Areas of research:

Stress

Neurobiol

Grief and Loss

Trauma

Attachment

Attention

Perception

Affect

Immunology

?teachable

"safety takes precedence over story" Courtois

Early results of sense of Safety research

Stress

homeostasis

social and emotional wellbeing

Maslow

Safe haven

Secure base

objective and subjective

Table 1 (adapted from Dixon-Woods et al 2006)

Appraisal prompts for informing judgements about quality of papers:

• Are the aims and objectives of the research clearly stated?

• Is the research design clearly specified and appropriate for the aims and objectives of the research?

• Do the researchers provide a clear account of the process by which their findings we reproduced?

• Do the researchers display enough data to support their interpretations and conclusions?

• Is the method of analysis appropriate and adequately explicated?

An approach to assessment of

human distress in primary care.

ignoring lived experience, social context, subjective sense of their own life, understanding purpose or hope, other ways of knowing, aetiology....instead categories and labels - "myth of medical certainty" (Reeve) - who is this treating??

For later SOS:

a process that includes:

checking, risk taking, exploration, assessment and

reassurance, comforting, soothing

?latent growth competence

“Cncepts that have an intuitive relevancy and a roll-off-the-tongue quintessence may resonate widely; Good concepts help elucidate recurrent practical concerns where people grasp for meaning.” p 6

reflection and recognition...Kircher 2003 p43

If safety is important, why don't we measure it?

Perhaps looking for safety is more practical than what we currently do?

Critical interpretive synthesis

"natural sematic metalanguage Wierzbicka 1999

"The literature on somatisation suggests pateitns with MUS are less aware of their emotions and use maladaptive coping strategies when coping with everyday problems." p112 (Caretti Porcelli 2011)

"questioning taken-for-granted assumptions" (Dixon-Woods et al 2006)

“CIS evolved as a method to synthesise a large and diverse body of literature of different study designs around a particular topic…” p 59 (Flemming and McInnes 2012)

focus is on development of concepts and theory rather than on exhaustive summary of all data.(Flemming and McInnes 2012)

Critical interpretive synthesis: the research literature is looked at as ‘an object of scrutiny’ …p64 Flemming 2012

aim to generate theory (Dixon- Woods 2006)

"

the primary output of a CIS is a synthesising argument (Flemming and McInnes 2012)

Participatory Action Research

"the purpose of the searching phase as identifying potentially relevant papers to provide a sampling frame...... prioritise papers that appeared to be relevant, rather than particular study types or papers that met particular methodological standards. We might therefore be said to be prioritising "signal" (likely relevance) over "noise" (the inverse of methodological quality)" (Dixon-Woods et al 2006)

My writing 2008: "current mental health care does not empower the sufferers or their community to cope robustly with their real life situation. It seems to work as a symptom collation, rather than prevention and early intervention. I want to see people through growth focused glasses."

"Conventional systematic review methods are thus better suited to the production of aggregative rather than interpretive syntheses. Their defining characteristics are a focus on summarising data, and an assumption that the concepts (or variables) under which those data are to be summarised are largely secure and well specified." (Dixon-Woods et al 2006)

vague descriptions with 'wide variety of interpretation" p 65 Dowrick 2004

Including “many different forms of evidence” p4(Dixon-Woods, Cavers et al. 2006)(not just affregating and summarizing comparable data

The primary output of a CIS is a synthesising argument in which evidence from the included studies are integrated into a coherence framework, and this evidence has been transformed into a new conceptual form called a synthetic construct (Flemming and McInnes 2012)

"Conventional systematic review methodology has demonstrated considerable benefits in synthesising certain forms of evidence where the aim is to test theories (in the form of hypotheses), perhaps especially about "what works". However, this approach is limited when the aim, confronted with a complex body of evidence, is to generate theory."

“generating solutions to practical problems.”

P 178 (Meyer 2000)

Depression can be diagnosed "irrespective of close temporal relationship between an identifiable stressor and symptoms....[so self limiting adjustment disorder is ] systematicaly removed from clinical consideration" p 65 Dowrick 2004

“collaborative spirals of planning, acting, observing, reflecting and replanning.” P 178(Meyer 2000)

“participatory, democratic process concerned with developing practical knowing…mutual sensemaking…emerges over time.” P 2 (Reason and Bradbury 2001)

new approaches seemed to make a difference

there are new sensorimotor and trauma specific interventions that make a difference - therefore it is negligent not to offer them... the fields of scientific enquiry swirling around mental health have been adding new information to the international literature that has been changing patient outcomes in their discipline.

''oversimplified'

(rossouw 2014)

Anyone who opposes "descriptive biological psychiatry" is a "beleaguered defender of holism, empathy and the complex understanding of the individual."

rate of antidepressant use double between 2000 and 2011 (Stephenson, Karanges et al 2013)

Effective

treatments

ignored

Nat Institute of Mental Health no longer funds research using the DSM....NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

Quilter and facilitator of mulitdisciplinary team

In writing a critique of professions: "knowledge is improved by making it more complex and deep and more comprehensive and multiple." p 234 Abbott 2001

p 7 Sadler (2005) Values and Psychiatric Diagnosis

Transdisciplinary research

patient dissatisfaction (Tyrer, 2009)

unclear outcome measures

symptom nuking approaches

ignoring the self

unmet need (Shorthouse 2016)

medicalisation of human sorrow

categorising so the sick are not like us

disregarding inner worlds and meanings

assumptions about the unity of the self leading to simplistic understandings and inability to see what is being hidden and unsaid

loss of use of human wisdom to help

loss of other tasks of the encounter (Sadler (ethical., pragmatic...)

loss of collaborative empowerment in mutual relationship

loss of something human that used to be taught in apprenticeship

"to integrate the natural, social and health sciences in a humanities context, and in so doing transcend their traditional boundaries."

transdiciplinary research is a scientifc essential to counteract the effects of specialisation (Hamberger 2004)

Refugee questioner

Research not

integrated

into care

Bamboozled GP

possibility for lone researchers to adopt TD approaches …individual to fuse knowledge from a number of different disciplines and engage with stakeholders in the process of generating knowledge. “ p1052 Wickson 2006

Unheard

patient stories

'drug dealer'

"It has been extremely unfashionable to attribute psychopathology to real life experience." Bowlby (1984)

Given the enormous worldwide health budget expended on mental health care the commensurate misery for patients and their families, coherent integration of these advances in understanding mental distress and its treatment becomes urgent

.”a mismatch between increasingly multi-disciplinary models of health and health policy and a continued reliance on models of bio-medically defined evidence, focusing on experimental models and the need to tie down attribution.” p 800 Meyrick 2006

"a new paradigm of knowledge is emerging simply beacuse the old boxes don't fit the new questions." Boyer (1990) p 37

Bricolage

“exists for questions that don’t lend themselves to easy answers.” p6(Rogers 2012)

Areas of research not integrated into mental health assessment:

neurobiology (Cozolino 2006)

trauma (Courtois 2009)

grief (Murray 2001)

memory (Schwabe 2010)

attachment relationships (Allen 2001, Maunder 2001)

sense of self (Mikulincer 1995)

recovery (King 2007)

Dissociation (Boon 2011)

resilience and growth (Calhoun 2006, Bonnano)

"the concept of depression contains important theoretical and functional problems that render both its validity and utility open to question...It overlaps in dignostic terms with a range of common pain conditions, and with medically unexplained symptoms, and almost disappears from view in the face of the patient's social difficulties." p 11 Dowrick (2004)

“critical, multi-perspectival, mulit-theoretical, and multi-methodological approach to inquiry.” p1 (Rogers 2012)

“dedicated to questioning and learning from the excluded” p48 (Kincheloe 2004)

"enumeration of symptoms that produces negative value judgements promotes conformity and has no meaning for treatment."

Therapeutic frameworks ignored:

mentalisation (Fonaghy 2004)

somatosensory (Ogden 2006)

neuropsychotherapy (Rossouw 2011)

coherence therapy (Ecker 2008)

Meaning making (Neimeyer 2006)

R brain (McGilchrist 2009)

creative therapies (Reynolds 2000)

interpersonal neurobiology (Seigel 2001)

Internal family systems (Schwartz)

psychotherapy

trauma specific care

“uncover the underlying framework that govern phenomena…” p2 (Rogers 2012)

Verhaeghe, P., Ed. (2004). On Being Normal and Other Disorders: A Manual for Clinical Psychodiagnostics. New York, Other Press,.

cocreation can be with more expert or more audience focussed.” p 46 Dietrich 2016

For later

need to critique experience too (Gabriel 2004)

”solutions with consumers rather than creating solutions for them.” p 45…

still having belef in the possibility of some "unity of knowledge" p 38 Sommerville 2000

Monologic research: "entities are often removed from the context that shaped them, the processes of which they are a part, the relationships and connections that structure their being in the world." p 74 Kincheloe (2004)Quesioning interdisciplinarity

"landmark papers" Greenhalgh (2004)

”The greater demand for qualitative research from the health, health service research ethics and public health fields presents a particular challenge as this new audience comes from a predominantly positivist bio-medical standpoint.” p 801 Meyrick 2006

“berry picking”

“berry picking” Ludvigsen 2015

pluralism Barker,Pistrang - 2012

“recognize how we actively construct our knowledge.” p4 (Rogers 2012)

“bricolage focuses on surface features, on things as they appear, and seeks similarities and other relationships among these” Sage Qual Handbook

Research plan:

• Particpatory Action Research
• Critical interpretive synthesis
• Expert opinion: advisory panel
• Stakeholder co-creation:

conference workshops

social marketing codesign

"disparate interests are worthy of respect" Kluft 2015

(adapted from Treating Complex Traumatic Stress Disorders (2009) Courtois, Ford)

How did I get here?

GPs are uniquey placed...

Proposing a novel approach

What methodology to approach this paradigm shift?

Early signals of 'sense of safety'

Sense of safety

“Where the research field is highly complex and methods emergent rather than predefined, internal and external peer review is even more critical than usual, and such peer review must be formative (intended to feed into the process) rather than summative (that is, intended to judge its outputs.” p 374

An approach to assessment of human distress in primary care

“Much of the chaos caused by biomedicine follows from the ever expanding aspiration to control disorder. Thus the diagnostic success of medical technologies generated lower tolerance for uncertainty and greater medical surveillance of people with unexplained symptoms.”Timmermans 2013

the language that separates mind and body is "obsolete" Sommerville and Rapport 2000 p 38

“medicine has been technologically reinvented in the past half century, yet it remains in some ways what i has always been, an intensely personal effort to deal with the pain and incapacity of particular men and women” p 3 Timmermans 2013…

Verhaeghe, P., Ed. (2004). On Being Normal and Other Disorders: A Manual for Clinical Psychodiagnostics

. New York, Other Press,.

"if we accept that reality is a coherent whole comprising several layers, then we can agree that we must constantly be aware of all layers as we look at anyone in particular." p[6] McGregor 2004

healing

Journey

Growth

movement

journey we are all on...

ATTENTION

"generous stories" p196 Lewis 2014

assessment of an ongoing process, not symptom description

define the direction the patient is going

co-creation

Looking for signal, not noise

A metaneed

worth looking for and aiming for

pragmatic joint goals

collaborative growth

"Medical and technical conceptions of health and illness have become a language which is used in very powerful ways to perpetuate the depersonalising and dehumanising practices of care."

Whole person

'Collusive phenomenon': "the doctor does not have to elicit and then manage emotional distress and the patient does not have to face up to their own distress and perhaps their own partial responsibility for their current predicament. Both take refuge in safer roles: the doctor as fighter of supposed organic disease and the patient as victim." (p 109 Dowrick 2004 quoting Goldberg and Huxey 1992)

learning

RECOVERY

Personhood

agency

conscious

COHERENCE

owning responsibility

hope

active sense of self

empowering

intentional

adaptability

Todres, L., et al. (2007). "Lifeworld-led healthcare: revisiting a humanising philosophy that integrates emerging trends." Medicine, Health Care and Philosophy 10(1): 53-63.

humane

creative

perspective

"persons actively leading their own lives" p12 Dowrick (2004)

posttraumatic growth

small steps

dignity

Holism

Coping not cure (Lewis p 167

depathologises

Embodied

Sensory

Perceptive

Attentive

Voiced

intrapsychic

'creatively conscious goal' (Reeve)

what obstacles are there to growth?

A unified connected SELF

Current constraints

outcome named

sense of mastery

competence

hidden and presentable parts

what is stuck?

Enablement (Howie)

Gestalt

Currently no reference to relationships in standard assessment

transformation

patients subjective experiences (Brendel 2007)

Subject not an object

a way to "extricate [my]self from a consultation which is filled with diagnostic complexity and confusion..." Dowrick p 111 2004....tool for fending off professional anxiety." (Macdonald Morrison 2009 in Dowrick p114)

diagnosis as 'defence against confusion and uncertainty' p 109 Dowrick 2004 quoting Dowrick (1999), Griffiths 2005)

Relational

mind AND body

intentionally looking for 'experience of illness' (Diekelman 2002 p 4)

Seen and heard

MUS and somatising included

inner voices embraced

"intentional collaborative deliberation" Elwyn

strengths

CONNECTION

prosody R brain

all parts included

co-regulation

communal

dissociated parts welcome

Role reduced to identification (Boardman 2009), prescription and referral (Palmer 2010)

mentalising

Tuning in

attending

noticing

"Primary care mental health assessment should not limit its assessment to symptomatic pathology or disordered behavioural responses."

workplace lieterature about growing..

co-existence

Accused of under and over diagnosis

Accused of medicalising human sorrow (Blazer 2005)

attachment

self efficacy

Empower wellness to be withing their reach

tertiary diagnosis i'mposed 'on primary care (Callaghan and Berrios 2005) p109 in Dowrick 2004

what will help them grow up to be people of character who know they are loved? my notes Oct 2015

insisting on an understanding of each person as integrated mind and body with sense of self, intrapsychic processes, memories, triggers, spiritual and meaning making aspects

Everyday language

intersubjective space

Not:

reductionist

decontextualised

"depersonalised mechanistic reductionism" Little (1995)

Disease model (Reeve, 2010)

mutual

shared understanding

how and what

Enormity of the task of encountering distress

dyadic therapeutic relationship

mirror neurons

"Resilience is made up of ordinary rather than extraordinary processes, derived from family love and close friendships or from positive experiences in the worlds of education and work." Masten 2001 (quoted in Dowrick) found article 'ordinary magic'...by Saskar

Barry, C. A., et al. (2001). "Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor–patient communication in general practice." Social Science & Medicine 53(4): 487-505.

intentionally managing power

Performing psychiatric triage in the community

Time and financial limitations

Reductionist classificatory 'atheoretical'

'objective' approaches to people

'Myth of medical certainty....'

Quality of relational connectedness as an essential part of assessment of human distress. Attachment has clear research into how people experience connection and its impact on development, neurophysiology, mental state and health...there is also a body of literature on its impact on health behaviours (Maunder)

Transdisciplinary

(p8 Reeve)

Contextual

where is the edge of our scientific /medical jurisdiction?

"Language is a vital part of the commitment to being with the individual in their context."

patient as expert of their experience

"In the 'swampy lowlands' of general practice patients present with undifferentiated problems that they believe to be health related, where disease models are often inadequate to explain illness experience, and where illness is often complex, dynamic and uncertain."

p 1 Reeve (2010)

Korner, A., et al. (2010). "Formulation, conversation and therapeutic engagement." Australasian Psychiatry 18(3): 214-220.

Trauma

Loss and grief

Strengths and resources

Past and present

'what happened to you?'

not

'what is wrong with you'

history

aware of real life context

Complexity

EBM and SBM (scientific bureaucratic medicine) are increasing the voice of the disease and decreasing the voice of both clincian and patient (Reeve 2010)

impact of trauma on development, affect regulation...

memories

Modifiable conditions (Diekelman 2002 p 4) (Tinetti and Fried 2004)

vested interests

"patients subjective experiences" p 312 Brendel 2007

?Lived experience?

Clinical pragmatism

Pragmatic

Pluralistic

Particpatory

Provisional

Sense Making

Bruner “learning as individual meaning making”.

meaning making

PERCEPTION

assumptive world

beauty

order

Brendel 2007

"meaning and mystery are restored to human experience" p 10 Reason 1994

patient defined

spirit

moral injury

Bricolage

"An approach to health and medicine that is not reductionist is an implicit part of the comprehensive care provided by GPs. We are not doctors for particular diseases, or particular organs, or particular stages in the life cycle - we are doctors for people." .

in the midst of uncertainty, loss, suffering, joy and complexity

purpose

The generalist must know and understand the interplay and influence between each life story and social context, and physical and emotional health, linking biomedical and other aspects of being human."

Freeman, J. (2005). "Towards a definition of holism." The British Journal of General Practice 55(511): 154

Robust assessment requires:

Most humans will process their life experience, including illness experiences in a way that affects health...assumes that symptoms have meaning...meaning-making is an integral aspect of adapting and coping with life, including grief and loss...may be appropriate to think about developmental and stuck meanings...neimeyer...assumptive world...shame

Gunn, J. M., et al. (2008). "The promise and pitfalls of generalism in achieving the Alma-Ata vision of health for all." Medical Journal of Australia 189(2): 110.

GP setting

undifferentiated distress presents daily

sustainable framework

new knowledge can be integrated

aware of the social and neighbourhood context

daily personal negotiation of the boundaries between medical and social conceptualisations of distress...

Metanarratives of a novel approach

strategic point of intervention (WHO)

unique GP goals for assessment (Lynch 2012)

Critical interpretive syntheses

GP skills

Generalism is a form of living knowledge... a transdisciplinary expertise

Crosses the mind/body divide in each consulation

complexity is our friend

Relational encounters

Vested interest in the patient getting well and in prevention of harm to the next generation. Advocates on behalf of our community

Already place a high value on safety......

resisting the medical gaze

prevention and early intervention

eg. electrolyte imbalances, medication interactions, acute management of medical emergencies, pain and addiction management, fitness to drive, suicide and DSH assessment, domestic violence awareness, caring for the infant-mother bond in maternal depression and breastfeeding.........

Whole person and family care in the face of uncertainty, complexity and unfixable problems

aware of a broad scope of ways of seeing the person

not foreclosing on diagnosis too early

translate medical jargon

tolerating uncertainty

Care about puppies in people's lives...:)

continuity of care

But: Gps can't handle complexity, costs would go up, patients won't take responsibility, impossible to integrate? (Lewis 2007)