Person-centred care in psychiatry mental health

Although there might be many definitions regarding what constitutes person-centred care, most experts and health care organisations have agreed that this focuses on helping people as individuals experiencing physical or mental health problems, rather than treating diseases and forgetting about the person sitting in front of us.

Despite the universal recognition of the importance of adopting a person-centred approach, there have been some limitations in implementing this in practice. For example, in 2018 the Royal College of Psychiatrists (RCPsych) published a report focused on reinforcing a person-centre approached in the training of psychiatrists (Royal College of Psychiatrists, 2018). The main findings of this report noted that despite the recognised benefits for trainers and trainees of having a person-centred approach, the current RCPsych core curriculum still does not adequately include the key elements to guarantee the adoption of a person-centred approach in future psychiatrists. You can read more about this report in the great blog written by Dr Linda Gask for The Mental Elf (Gask, 2018).

Based on this report, doctors Boardman and Dave have published a paper which highlights the importance of adopting a person-centred approach in the practice of medicine and psychiatry, and discusses some implications for psychiatric practice. Here you can read some of the key points reported in this well-written and insightful paper.

This paper highlights the importance of adopting a person centre approach in psychiatry and the current barriers to implementing this approach.

How we got here

Over the last few decades, the practice of medicine has been criticised as having become overly-standardised and impersonal; but at the same time, the role of patients within the professional relationship has moved from a compliant role to a more participatory one. Indeed, even the word ‘patient’ is often challenged as an outdated construct and part of a medical hierarchy; ‘person’, ‘service user’ and ‘individual’ are preferred by many. These factors, along with the increased number of people experiencing mental health problems, the lack of resources, and inequalities accessing mental healthcare services, have made evident the need to move from a care system that is deemed impersonal and focused-on-profit care, to a more personalised person-centred approach.

Why do we need to adopt a person-centred approach in psychiatry?

Despite psychiatry’s current model focussing on the biological, psychological and social aspects of the individual (which can arguably be considered as person centred) there are still aspects of psychiatric practice that could be thought of as barriers to successfully implementing person-centred care.

Throughout history, the practice of psychiatry has frequently been criticised for ‘labelling’ people and ‘categorising’ them into ‘disorders’ that risk dehumanising and marginalising people, without adequately considering people’s experiences, culture, ethnicity, religion or even past trauma. Additionally, as part of their professional duties, psychiatrists are often involved in detaining individuals under the Mental Health Act (‘sectioning’) by assessing and challenging a person’s mental capacity. This represents a fundamental challenge to adopting a person-centred approach.

Independent reports have also confirmed that the power balance in the doctor-patient relationship is still heavily inclined towards professionals, with some work suggesting that only 60% of individuals report feeling completely involved in their own care decisions (Fisher et al, 2016). Another barrier that has been identified is clinicians’ own attitudes and practice, as some studies have found psychiatrists can overrate their performance and their ability to work collaboratively, and their knowledge regarding human rights is often poor (Berwick, 2009; Entwistle, 2013).

What are the principles of person-centred care?

Regardless of its many definitions, the main principles of person-centred care are:

the delivery of a holistic or integrative care that responds to people’s needs and values;
treating people with dignity, respect and compassion;
and empowering and involving people in decision making, to develop a partnership approach.

These principles have the ultimate objective of recognising that “people with severe mental illness are people”, and they should be treated like that, regardless of their age, mental health condition or intellectual disabilities. So, by adopting this principle of “personhood”, people’s experiences of illness, along with their histories, strengths, values and beliefs, are considered not only to establish diagnosis and offer treatments, but also, and most importantly, to help them live the lives they wish for themselves.

To wholly offer person-centred care interventions, it is also necessary to consider and understand people’s culture, social context, community connections, and spirituality, which help build their identity. Furthermore, due to our current globalised and digitalised world, migration and having a social media presence, have not only become common, but have added another layer to people’s identity, which also need to be considered within the person-centred approach.

Person-centred care is: the delivery of a holistic or integrative care that responds to people’s needs and values; treating people with dignity, respect and compassion; and empowering and involving people in decision making, to develop a partnership approach.

Key aspects of a person-centred approach

Recognition of people’s rights

Even when clinical decisions are fundamentally based on the principle of achieving the best outcome for patients, restricting people’s individual freedom, which is something psychiatrists occasionally need to do, poses a balancing act for clinicians to fully align to the principles of person-centre care. While psychiatrists need to consider and respect people’s rights to live how they want, they also need to provide effective care. This requires clinicians to be knowledgeable about human rights and relevant legislation, and to have an attitude that shows respect and consideration of people’s wishes and human rights.

Implications for practice and service organisations

The key principles and values of person-centred care are similar to those of personal recovery; as both focus on facilitating individuals’ personal recovery goals. Currently one’s history, strengths, values and social circumstances are gathered to take decisions about diagnosis, treatment and support. However, to effectively implement a person-centred approach, diagnosis, treatment and support should be developed in collaboration with patients, with the aim of helping people live the life they want. This may well result in a plan quite different to one a psychiatrist would draw up themselves or consider ‘best evidenced’.

Implications for clinicians

Adopting a person-centred approach can also help professionals improve their work satisfaction and reduce their stress levels, as they also want to treat patients with dignity, compassion and respect, facilitating people to live independent and fulfilling lives. However, to achieve this, clinicians need to work in well-coordinated services that recognise that just as for patients, clinicians are first and foremost people too. A person-centred approach recognises that clinicians’ wellbeing is essential as person-centred care cannot be delivered by burned-out and depersonalised clinicians.

Values and evidence

Currently most health institutions have adopted clinical guidelines and protocols based on evidence-based medicine. However, it’s important to remember that clinicians need to adapt this guidance to each person’s particular situation. Additionally, in order to practice person-centred decision making in psychiatry, evidence-based medicine needs to be complemented with the following values that support clinical practice: communication, dignity, empathy, fairness, honesty, humility, respect and trust.

Training

Although the Royal College of Psychiatrists has recognised its curricula for core trainees does not adequately include capabilities and competencies associate with person-centred care, the College has made some important recommendations to ensure future generations of psychiatrists are better trained and assessed to adopt such an approach. These recommendations include:

that the language of the curricula should include themes such as shared-decision making, co-production or collaborative care;
and that the competencies include general aspects of person-centred care, like ethics, community engagement or social inclusion.

The RCPsych has also highlighted the importance of including patients and carers in the planning and delivery of psychiatric training and recommended that trainees’ skills and competencies regarding person-centred care are also assessed.

The main goal of adopting a person-centred approach is to ensure clinicians collaborate with patients to develop care plans and treatments that facilitate individuals to live the lives they want for themselves.

Conclusions

Regardless of where in the world they are, the training curricula and psychiatry practice guidelines should ensure that psychiatrists can offer person-centred care to everyone they treat. Even though training and practice may vary from place to place, and the standardisation of training might not be possible, there is a key element that can be implemented all over the world: cultivating the right values and attitudes needed to adopt a person centred-approach.

Current psychiatric training and practice should include the key values and principles to ensure psychiatrists can offer effective person-centred care.

Strengths and limitations

The main strength of this paper is that it reinforces the importance of implementing a person-centred approach within the psychiatric practice; as it highlights not only the many benefits this approach has on patients’ lives, but also on clinicians’ practice and even stakeholders and service providers.

In this paper, authors also recognise the need of including and assessing competencies related to person-centred care to ensure these are rooted in future generations of psychiatrists.

However, the authors did not provide clear examples about how to overcome current barriers or limitations to implement a person-centre approach; or about how to ensure its effective implementation and evaluation in psychiatrists’ practice.

Implications for practice

Although this paper highlights the need to include person-centred care competencies within the psychiatric training curricula, I think the RCPsych, stakeholders and mental health services need to ensure clinicians not only adopt a person-centred approach, but also that health care professionals fully understand the principles and benefits of adopting this. This will help to avoid feeling this is just something else they need to ‘tick’, in their already saturated everyday activities.

Another important aspect is to recognise that sometimes individuals’ goals differ to those held by clinicians and even health service organisations. Whilst an individual’s goals might be to improve their mental health or fully recover, services might be focused on ‘discharge’, or ‘free beds’ to be able to cope with demands; while a clinician might focus on making sure they have ‘ticked every box’ required within their competencies to ensure their fitness to practice won’t be scrutinised. To adopt a person-centred approach, we need to recognise these differences and have realistic and honest discussions to better deal with these sometimes contradictory objectives.

Finally, while we encourage clinicians to adopt a person-centred approach, they also need to inform service users about the principles and benefits of person-centred care, and work with them to consider all the implications of this approach. As some people might still expect and prefer clinicians to take every single clinical decision without directly involving them, there might be cases when adopting a person-centred approach necessarily includes respecting people’s decision not to be involved. However, as with any other treatment plan, this decision needs to be taken together, and based on the individual’s personal goals.

We need to recognise and address the barriers that currently limit the implementation of a person-centred approach.

Statement of interests

I recently collaborated with one of the authors (Dave) writing an editorial (under submission).

The Mental Elf

The importance of adopting a person-centred approach in psychiatry

How we got here

Why do we need to adopt a person-centred approach in psychiatry?

What are the principles of person-centred care?