World Psychiatric Association perspectives on person-centered psychiatry and medicine.

Introduction

The status of psychiatry around the world, as perceived during the first decade of this millennium reflects the great opportunities and challenges for understanding the human mind. We have learned much about neurotransmission, learning, memory, and brain development, and these basic insights have made possible the design of several classes of psychoactive drugs and psychosocial techniques for treatment [1].

Nevertheless, mental disorders remain the greatest source of burden and disability to people around the world [2]. The classification of mental disorders is still based on behavioural descriptions that do not correspond to basic mechanisms and are not as prescriptive of treatment methods as it was once hoped they would be. There is little data to guide the combination of multiple treatments for particular patients. People with mental disorders feel stigma and discrimination, which reduces their access to methods that promote recovery. The status of practicing psychiatrists is being diminished by managed care systems that reduce patients to diagnostic codes and reduce psychiatrists to technicians who just prescribe drugs. And understanding of the clinical condition and contextualization of care are still largely underdeveloped.

The challenges facing psychiatry are similar to those facing general medicine in the treatment of all common and complex disorders like diabetes and cardiovascular conditions. The recovery movement starting in the rehabilitation field has pointed out the need to consider both the positive and negative aspects of health and a substantial change in perspective, particularly for long-term care. There is urgency to involve all stakeholders in diagnosis and treatment processes and to emphasize hope, empathy, and respect for the needs of the whole person, as described by Alanen and colleagues [3].

Background

Ancient Greek philosophers and physicians, like Socrates, Plato and Hippocrates, advocate holism in Medicine [4]. Socrates taught that “if the whole is not well it is impossible for the part to be well” and that “everything comes from the psyche, bad things and good things for the body and the whole person” [5]. It is striking that these perspectives are re-emerging with renewed vigour in today's world through assertions that there is no health without mental health and by focusing local and international health efforts on the totality of the person [6-8].

And here the person is to be thought of in a contextualized manner, in the words of the philosopher Ortega y Gasset, I am I and my circumstance. In addition, evidence is growing for the value of integrating mental health into general health and public health practice [9]. These concerns are emerging in response to many deficiencies in health care recognized in both developed and developing countries, including neglect of the needs of real people and the fragmentation and inadequacies of health and social services [1, 10–13]. A major perspective to deal with these limitations emphasizes a comprehensive and holistic concept encompassing ill and positive health as well as a biological, psychological, social, cultural and spiritual framework [14-18]. The mental health care field in many countries is being stimulated by a recent movement emphasizing recovery and resilience [19, 20] which promotes the fulfilment and empowerment of patients as active participants in their own health care. Also, increasing interest is appearing towards clinicians applying themselves as whole human beings, and not as impersonal providers of care [21, 22]. All these perspectives reflect growing aspirations towards meeting scientifically, humanistically and ethically our responsibilities as psychiatrists and health professionals [23-25].

WPA institutional program on psychiatry for the person

The institutional program on psychiatry for the person: from Clinical Care to Public Health (IPPP), approved by the 2005 General Assembly, involves a WPA initiative affirming the whole person of the patient within his context as the center and goal of clinical care and health promotion, at both individual and community levels. This involves the articulation of science and humanism to optimize attention to the ill and positive health aspects of the person. As care is basically a partnership experience, the program involves the integration of all relevant health and social services. Furthermore, the program also involves advancing appropriate public health policies.

Garrabe and Hoff (in press) have noted that the principles behind psychiatry for the person could be already detected at the very beginnings of the WPA. As an introduction to the whole Institutional Program, two editorials were published in World Psychiatry, one broadly focusing on articulating medicine's science and humanism [26] and another on the dialogic basis of our profession [27].

Conceptual component

This component deals with analyses and delineations of the conceptual bases of psychiatry for the person. It has produced an editorial and a paper in international journals presenting the objectives of this component [28, 29].

Additionally, a monograph on the conceptual bases of psychiatry for the person is being prepared with the following table of contents: Introduction, 1. Historical perspectives, 2. Philosophy of science perspectives, 3. Ethics perspectives, 4. Biological perspectives, 5. Psychological perspectives, 6. Social perspectives, 7. Cultural perspectives, 8. Spiritual perspectives, 9. Users perspectives, and 10. Literature and art perspectives.

Clinical diagnosis component

There are two work objectives in this component. The first one involves collaborating with WHO towards the development of ICD-11. There was a preliminary background phase in this process during the first half of this decade involving principally the WPA Classification Section and the WHO Classification Office and leading to two monographs [30, 31]. A full development of the ICD-11 Mental Disorders Chapter has started in early 2007 under the direction of the WHO Mental Health Department.

The second and main work objective of the IPPP clinical diagnosis component is the development of a person-centered integrative diagnosis (PID). At its heart is a concept of diagnosis defined as the description of the positive and negative aspects of health, interactively, within the person's life context. PID would include the best possible classification of mental and general health disorders (expectedly the ICD-11 classification of diseases and its national and regional adaptations) as well as the description of other health-related problems, and positive aspects of health (adaptive functioning, protective factors, quality of life, etc.), attending to the totality of the person (including his/her dignity, values, and aspirations). The approach would employ categorical, dimensional, and narrative approaches as needed, to be applied interactively by clinicians, patients, and families. A starting point for the development of PID would be the schema combining standardized multiaxial and personalized idiographic formulations at the core of the WPA International Guidelines for Diagnostic Assessment (IGDA) [32-34].

As an introduction to this IPPP component's work, a broad ranging volume on psychiatric diagnosis: challenges and prospects [35] has been prepared. A paper on “Towards innovative international classification and diagnostic systems: ICD-11 and person-centered integrative diagnosis” has been published by JE Mezzich and I. Salloum as an invited editorial in Acta Psychiatrica Scandinavica [36]. Other papers pertinent to this developmental work include an editorial on Clinical Complexity and Person-centered Integrative Diagnosis [37] and On Person-centered Integrative Diagnosis [38].

Clinical care component

The thrust of the work of this component has been educational efforts towards achieving person-centered care. The two main developments being planned are an approach to person-centered clinical care and a curriculum to carry out training of the above-mentioned approach.

The teaching of medicine and that of psychiatry in particular, has experienced many changes lately. There was a time when the core curriculum in psychiatry, written by the WPA together with the World Federation for Medical Education, became a landmark because it did not only define the competencies in psychiatry that every physician should be taught, but mainly because it called our attention on prevention of illness and promotion of health.

Once these two concepts have been widely accepted, and after a period of revolutionary scientific and technological advances which include outstanding molecular and genetic research, and the articulation of bio-psycho-social, cultural and spiritual approaches with interdisciplinary collaboration in partnership with patients, families and advocacy groups, the time has come for another major change in our approach to psychiatry: considering the whole person of the patient in context as the center of our work.

Public health component

Public health in modern times has a broad scope as the organized global and local effort to promote and protect the health of populations and reduce health inequalities. This ranges from the control of communicable diseases to the leadership of intersectoral efforts in health [39]. Evidence is growing for the value of integrating mental health in general health and public health practice [9, 40]. Despite this, public health programs in many countries around the world have yet to recognise and include mental health and mental illness as areas of relevant action.

Psychiatry for the person is a basis for advocacy that emphasises the value and dignity of the person as essential starting points for public health action. This includes development of policies and services, and the research and evaluation supporting these. Failure to recognise the humanity and dignity of citizens living with mental illness as well as the value of mental health to the individual and community have resulted in abuse and neglect of the former and lost opportunities to improve mental health through population-based and person-based initiatives. The neglect of individual needs and the fragmentation and inadequacies of health and social services are matched by patchy policy development [10, 12, 13, 41]. Public health actions to promote mental health prevent illness and provide effective and humane services benefit from and contribute to the development of psychiatry for the person.

IPPP events

1. London Conference on Person-centered Integrative Diagnosis and Psychiatry for the Person: It was organized on October 26–28, 2007 by both the WPA IPPP and the Health Department of the UK. It represented a powerful opportunity for synergism between person-centered care and Britain's Shared Vision Project.

2. Paris Conference on Psychiatry for the Person: This was organized on February 6–8, 2008 by the WPA IPPP, the French Member Societies of WPA, and the five WPA European Zonal Representatives. The city and the professional community that served 58 years ago as the cradle of WPA, sponsored a special type of conference, clearly focused and intensely interactive, without commercial accompaniments.

3. Philippe Pinel Prize on Psychiatry for the Person: Articulating Medicine's Science and Humanism: In 2007, the WPA Executive Committee established this Prize to honor Philippe Pinel, a pioneer in the quantitative systematization of clinical psychiatry and an inspiring humanist who broke the chains of mental patients. The winner in 2008 is Prof. Yrjo Alanen of Turku, Finland, world-acclaimed for his innovative work on Need Adaptive Assessment and Treatment integrating scientifically valid therapeutic techniques with attention to the experience and views of patients with psychotic disorders.

Collaborative extension of the person-centered approach to general medicine

Over the past few years, the leadership of the WPA started to cultivate close relations with the leaders of major international medical and health organizations. In the course of these interactions, a topic that attracted considerable common interest has been the person-centered approach to medicine.

This led to the preparation of a Geneva Conference on Person-centered Medicine on May 29 and 30, 2008. It took place under the auspices and on the premises of the University Hospitals of Geneva, organized by the WPA IPPP, in collaboration with the World Medical Association (WMA), the World Organization of Family Doctors (WONCA), the World Federation of Neurology (WFN), the World Federation for Medical Education (WFME), the Council for International Organizations of Medical Sciences (CIOMS), the World Federation for Mental Health (WFMH), the International Council of Nurses (ICN), the International Alliance of Patients' Organizations (IAPO), and the Paul Tournier Society.

The conference was aimed at presenting and discussing the experience on person-centered principles and procedures gained under the IPPP as well as the conceptual bases of person-centered medicine, engaging interactively major international bodies, and identifying promising organizational steps for the further development of person-centered medical and health care.

Colophon

The efforts for person-centered care that started in the World Psychiatric Association and other institutions and groups are now productively unfolding through collaboration with major international medical and health organizations.