The Experience Of The Psychiatric Interview Following Self-Harm

Nevison, C., 2000. The Experience Of The Psychiatric Interview Following Self-Harm. Reformulation, ACAT News Spring, p.x.

As a third year clinical psychology trainee doing a CAT related final year with Allison Shanks (Ridley) in Edinburgh I have chosen to do a thesis with a CAT flavour. After a comprehensive mail sweep in December 1999 you will either have completed the questionnaire I sent and have varying degrees of awareness about my proposed project, or have more paper buried in one of your desk trays. I would like to take this opportunity to thank all of you who found time to complete the questionnaire and return it, but for the purposes of this introductory article I will assume that the reader is unaware of this work.

The focus of the study are individuals who deliberately self-harm (DSH) and who are admitted to hospital (St John’s Hospital, West Lothian). This group poses a large clinical challenge and their management varies greatly across the country. Studies suggest multiple self-harm is frequent and suicide levels of up to 10% have been found in this group (Nordentof et al 1996). Many of these patients do not have a mental illness but do suffer from personality disorder (reported rates range between 13% and 65%) (Urwin and Gibbons 1979, Casey 1989).

My study is concerned with testing hypotheses regarding the interaction between the patient and psychiatrist in the psychiatric assessment interview following an overdose. It is based upon the work of Tim Sheard et al (in press) - which you may be familiar with from presentations at CAT Conferences.

It is hypothesised that - as with any individual - the way the individual construes the interpersonal world will be reflected in the transference and counter-transference in the psychiatric interview. Sheard et al believe that the three particular themes which are common in the transference and counter-transference in this situation are hostility, avoidance, and rescue and that these are on a continuum.

Because of the pressure to reciprocate, the psychiatrist may easily be drawn into an enactment of reciprocal roles. Thus, one can see how the interaction may reinforce the client's view of the world. Likewise it may reinforce the psychiatrist’s view of this client group.

In the project I will interview patients after they have been seen by the psychiatrist for psychiatric assessment. (They will have been seen beforehand when I will have informed them about the research and sought their consent for participation). They will be asked to complete a number of questionnaires including the Personality Diagnostic Questionnaire 4 (Hyler 1994), Personality Structure Questionnaire (Broadbent, Clark and Ryle in press), Client Response File (derived from Sheard et al) and the Empathy Scale (Burns 1994). The psychiatrist will complete a brief version of the Assessor Response File (Sheard et al). The Client and Assessor Response File are concerned with measuring the nature and intensity of the transference and counter-transference responses. The questionnaire I asked ACAT members to complete was to help in adapting Sheard et al’s measure so that it could be used in this context.

It is predicted that higher levels of personality disturbance and lower levels of integration (as measured by Broadbent et al’s measure) will be associated with poorer therapeutic alliance and more intense transference and counter-transference responses. If supported, this will highlight how this interview may inadvertently be perpetuating difficulties, and the usefulness of trying to avoid this, whether through the use of an intervention such as that of Sheard et al, or through teaching (perhaps using a CAT model). The latter would be aimed at increasing awareness and understanding of this client group's difficulties.

The study will also look at the general attitudes of staff who deal with this client group. There is some evidence that staff can have negative attitudes towards this client group (Sidley and Renton 1996). This may be related to previous experience or cultural attitudes.

Individuals attending their first assessment interview in psychology or psychiatry will form the comparison group. It is expected this group will have lower levels of personality disturbance and provoke less intense transference and counter-transference responses.

The project began data collection in January 2000 and will continue until April 2000. I hope to have approximately 60 patients with DSH and approximately 40 subjects in the comparison group. I will be back to say more later in the year.

Charlotte Nevison

References

Broadbank, M., Clark, S. and Ryle, A. (In press). The Personality Structure Questionnaire. c/o ACAT Office, Academic Department of Psychiatry, St Thomas’ Hospital, London.

Burns (1994). Therapeutic Empathy in Cognitive Behavioural Therapy: Does it really make a difference? In Salkovskis, P. (1996) Frontiers of Cognitive Therapy: The State of the Art and Beyond, 138-140. Guildford Press.

Casey, P.R. (1989). Personality disorder and suicide intent. Acta Psychiatrica Scandinavica, 79, (3), 290-5.

Hyler S.E. (1994). The Personality Diagnostic Questionnaire 4 and Instructions for Use. Unpublished manuscript.

Nordentoft, M. Breum, L. Munck, L.K. Nordestgaard, A.G. Hunding, A. Bjaeldager, P.A.L. (1993). High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts. British Medical Journal, 306, 6893: 1637-41.

Sheard, T., Evans, J., Hicks, J., King, A., Nereli, B., Rees, H., Sandford, J., Slinn, R. and Ryle, A. (in press). A CAT Derived One To Three Session Intervention For Repeated Deliberate Self-harmers: Part One The Model And Its Rationale.

Sidley, G. and Renton, J. (1996). General nurses attitudes to patients who self-harm. Nursing Standard, 10, 32-36.

Urwin, P. and Gibbons, J.L. (1979). Psychiatric diagnosis in self poisoning patients. Psychological Medicine, 9, 501-8.

Charlotte Nevison

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