The capacity to attain subjectivity and emotion: the value of continuity of care

In a refreshing and thought-provoking editorial, Yakeley et al ¹ remind us about the concept of subjectivity. ‘Affective subjectivity’ is defined as ‘the awareness of and reflection on our emotional responses and their influence on our work, and the development of a capacity for self-reflection and emotional attunement with our patients’. ¹ The authors list a number of factors that have led to a reduction in the capacity of psychiatrists to develop and use affective subjectivity. One of these is the loss of continuity of care.

Over the past 10 years we have seen a gradual erosion of the capacity to offer continuity of care to our patients. Psychiatric teams are now fragmented, specialist and largely separate. This enhances splitting within and between teams and makes it difficult for patients to be held in mind for very long.

When I trained as a house officer and junior psychiatrist in the early 1990s, continuity of care was awarded so much importance across the medical specialties that we worked extremely long hours to offer this. An in-depth knowledge of your patient was expected and great emphasis was placed on personally following up their progress and seeing it through. While the long hours were far from ideal, the pendulum has swung so far back that continuity of care is now largely gone. All too often the concept of holistic care is being replaced by diagnoses and treatment plans, rather than formulations based on the biopsychosocial model, ² which include affective subjectivity. If a patient is only seen once or twice it is often impossible to expand on developmental and attachment aspects in the history or think about their meaning for the patient, psychiatrist and mental health team.

Without the capacity for doctors to follow patients through, it is very hard to allow subjective feelings to emerge or to use them in the understanding of psychological trauma. I run a Balint-style case discussion group for core trainees in psychiatry. Over the course of the year the barriers to allowing subjective feelings, so well described by Yakeley et al, gradually reduce. For most trainees a deeper understanding of counter-transference and how this can help us create an empathic approach to our patients begins to develop. It is frustrating, however, that the majority of the cases brought are not seen again by the trainee. This denies the patient the opportunity to develop a trusting relationship or to experience any kind of attachment (the concept of psychiatric staff as attachment figures is described by Gwen Adshead ³ ). It also denies the trainees the opportunity to use the understanding gained from the case discussion group to help their patient.

If we are to apply subjectivity and emotion in our work, I think continuity of care needs to be revived. This in turn would enable psychiatrists, once again, to enjoy getting to know patients across a period of time using both subjective and objective skills and thus enhance job satisfaction.