Guide Conversing With Uncertainty: Practicing Psychotherapy in A Hospital Setting

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Guest blog by British psychiatrist Dr Tom Stockmann.
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However, many vacancies remain unfilled. In such circumstances, the consequences can be even more significant. When the NHS was established in , it was supported by around , staff. Due to changes in how data are collected over time, piecing together the long-term trend is difficult, but the available information suggests a growth in hospital doctors has been by far the most dramatic and consistent. In , there were 3, people per hospital medic or dental staff, but this has declined to approximately The trend in the level of GPs per head of population — as far as we can tell — appears less consistent, with falls in the number of staff in relation to the population in the s and more recently, but with increases in the interim.

Meanwhile, the level of nursing appears to have been stagnant for some time. It has been well documented that, over the last few decades, the demand on the health service has risen dramatically. This, in part, can be attributed to a growing and ageing population, as well as advances in medicine and technology that have enabled a wider range of healthcare services to be provided. In addition, there have been specific pressures to increase staff in response to safe staffing guidelines, and to meet the targets as detailed in key policy documents such as the GP Forward View.

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Where the NHS has failed to keep pace with the increased demand for staff by managing the inflows and retention of its workforce, gaps have appeared. A key factor contributing to the shortfalls has been a failure to train sufficient numbers of staff. This has been particularly pronounced for nurses, where there was a large decline in the number starting nursing after the early s. When domestic supply of staff is insufficient, then the health service has a heavy reliance on international recruitment.

Higher levels of recruitment have often been driven by national targets and support and in response to unforeseen additional demand for staff such as following the Francis Inquiry and safe staffing guidelines.

Conversely, lower levels have been in part due to a shift towards creating a sustainable domestic supply acknowledging ethical concerns about recruiting from less developed countries, more restrictive immigration policies and slower expansion in the number of posts in response to financial pressures. This is contrasted by an increase in the number of new non-EEA doctors joining the register in recent years.

Systemic Doctoral Research Theses. Tavistock

As well as recruiting new staff, it is also vital to keep the existing workforce. Generally speaking, the rates at which staff leave the NHS workforce has worsened in recent years, with the issue being particularly stark for nurses. Further discussion on how we have ended up with shortages are included in our paper on the lessons from history on the workforce, where we argue that the workforce has often been neglected or not prioritised in previous NHS policies and plans, and pick out three key lessons for avoiding such mistakes in future.

Comparisons with other countries must be treated with caution due to differences in, for example, geographies, service design, and data. However, it appears the UK as a whole the level at which data is published have relatively few staff in key groups compared to other developed countries. For instance, per head of population, the UK has fewer than half as many nurses as Norway 8 nurses compared to 18 and is among the lowest in terms of levels of doctors. Looking at the four health services in the UK suggests that England is lagging behind for some key staff groups. In particular, while Scotland has historically had more GPs per person — which may be explained, in part, by its rurality, with more GPs required in areas of lower population density — a decade ago England had higher levels than in Wales and Northern Ireland.

Excludes GP registrars, locums and retainers. Given the difference in data sources across the countries, this comparison should be treated with caution. The staff shortages we detail in this short explainer represent a real cause for concern for the NHS.

Whereas financial problems can be solved by increasing funding, it is far more difficult to solve workforce ones: when clinical professionals leave, they are not easily or quickly replaced. As a result, we and other commentators argue that the workforce crisis is just as critical as the financial one , if not more so. The level of demand for health care is expected to continue to increase, and therefore so will the need for staff. There is also a threat posed by the ageing demographic of staff for some groups. For example, in the nursing professions there is a large cohort fast approaching pensionable age.

A third are aged between 45 and 54 and one in seven In midwifery the position is even starker, with a third of midwives already over 50 and eligible to consider retirement at The NHS is reliant on staff from overseas, putting it in a vulnerable position as continued uncertainty over the impact of Brexit remains.

In any case, as with all the levers for supplying and retaining staff, urgent and concerted action is needed if the NHS is to have the number of staff if needs. With that in mind, our report with the other health think tanks reiterated that staffing is the make-or-break issue for the NHS in England — setting out a series of policy actions that, evidence suggests, should be at the heart of plans to address current and predicted shortages.

NHS Digital. The estimate on independent healthcare provider staff is based on limited data which does not capture the entire workforce within this sector but, conversely, includes staff providing non-NHS commissioned services. NHS England. Royal College of Physicians. NHS Employers. Health Education England.


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Nuffield Trust. NHS Improvement. There is a gradual maturation of this dialogue, from the use of objects, to signs, and then to language. From words come our thoughts. The words that form our thoughts are not static symbols. As such, psychosis could be seen as more normal that it presently is, a natural human tendency.

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This risks alienating and invalidating the person and family in distress, who may all be attempting to communicate experiences for which there are not yet any words. In so doing, could we be missing an opportunity to harness their own potential to help themselves? Emotional trauma often resists conversation. A key concept in Open Dialogue is transparency. The clinicians are part of the polyphony. The aim is to avoid objectification and distance between clinicians and others.

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Some readers may have noted the indebtedness of Open Dialogue to the insights of Carl Rogers, the founder of person-centred therapy. Open Dialogue clinicians need to embody the three basic Rogerian features of a therapist: congruence transparency , unconditional positive regard, and empathy. The mystical physician to the king of Thrace said the soul was treated with certain charms, my dear Charmides, and that these charms were beautiful words.

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If the dialogue is to be transformative, the clinicians must remain within the living moment. They do not enter the meeting with an agenda, and the conversational path taken is completely improvised.


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  4. The starting point is the actual language used by the family to explain the problems. Every utterance is acknowledged, with all voices unconditionally accepted. In a polyphony, members can see that their words are accepted by others, allowing them the safety and confidence to reflect on their meaning. It is this process, rather than the eventual content, that is most important.

    The use of one technique or another made way for a more collaborative conversation. This idea has been transferred to Open Dialogue. In Open Dialogue every crisis is assumed to be unique. This is not to say that medication and hospital admission are never used, but efforts are made to expand the dialogue, and to sit with the pain, the risk, and the uncertainty. Everyone in the meeting shares this uncertainty.

    Together, all come to realize that the situation can be endured. The ambiguity is undone through shared language. Dialogue dissolves the need for action. Early on, meetings may be very frequent to create a sense of safety. In Open Dialogue, healing occurs when the speaker is moved. Love is the life force, the soul, the idea. There is no dialogical relation without love, just as there is no love in isolation. Love is dialogic. Great to read this article about the background and recent international developments of Open Dialogue network therapies in the US and England. The Open Dialogue conference will take place on 2 February in London.

    It is great that this type of alternative ways of treating psychosis is becoming available. I came across the following published article that talks about the illusory theoretical underpinnings of psychiatry: McLaren, N. Psychiatry as Bullshit. Ethical Human Psychology and Psychiatry, 18 1 , It explains that current psychiatric trainees and junior psychiatrists blindly accept the methods used in psychiatry because they assume that much smarter people before them have somehow sorted out all the details relating to the theories underlying psychiatry!

    The article concludes that the institution of modern psychiatry is replete with bullshit! Neel Burton,M. Were not going to win with these mental issues until we address the subconscious properly. I was cured of a repression by a psychiatrist, I had OCD, didn't follow through, now I'm schizophrenic.