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Psychologyの記事一覧

SeppukuはSuicideではない、murderだ

2017.01.03
昨年の秋、インドやオーストラリア、イタリアにおける自殺者数の推移や、理由、各国の取り組みについて調べた発表のワークショップに参加した。参加者は、メンタル・ヘルスの分野でリサーチャーやプラクティショナーとして経験がある人が多かったので、6年前のような自殺=日本という短絡な発言はでなかった。

日本人は自殺するために生まれたわけではない
http://loveandhatelondon.blog102.fc2.com/blog-entry-1275.html

 発表が終わり、コメンテイターから「日本人としてSeppuku=Suicideということについて」意見はあるかと訊かれた。ある程度予想はしていたし、このような機会があれば言いたいと思っていたことを言った。

 「日本だけでなく、ここに居る人達の中に、実際にHara-kiriで自殺できた人が何人居るかを言える人は居ますか?知らないでしょう、僕だって知らない。僕は個人的には、西欧人が空想する昔の日本での武士階級のSeppukuを自殺とは言わない。あれは、武士の忠誠心(loyalty)を弄ぶ、強制のmurderでしかない。ここに居る皆さんが、Seppukuに関して今まで知ることがなかったであろう歴史があります。それは、武士が切腹を強制されたとき、多くの場合もう一人がその武士のそばに立ち、首を切り落としていた。苦しみを和らげる為とか言う意見もあるが、これをmurderとしない方がおかしい」。

 僕が言ったことを受けて、発表者の教授は、「Seppukuという言葉の表面だけでそれを自殺と断定することの難しさは、メンタル・ヘルスの様々な状況で同様な誤解、誤判断が生じることがあることを知るのは大切なことです」、と綺麗にまとめていた。

 日本でも報道されることのあるHonor killingSeppuku、何が違うのだろうと思う。

スポンサーサイト

イギリス国内の死亡者数の増加

2017.01.02
昨年末、ショウビズ界のビッグ・ネイムの訃報が続いたことがあり、風邪からの回復が人々の予想を超えて長引いているエリザベス女王の健康状態への不安もあって、なんだか確証のない、心もとのない不透明感を感じていた。
 
 元日、オブザーヴァ紙のコラムが興味深い数値を紹介した。

Good health is born of a good society. Little wonder that we’re suffering
https://www.theguardian.com/commentisfree/2017/jan/01/good-health-good-society-we-are-suffering

 統計局の数値。

Deaths registered in England and Wales: 2015
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/2015#number-of-deaths-in-the-uk-rises

 実際のグラフを見ると、死亡者の数は「V」の様な急上昇ではないが、男性、女性ともに、2014年までが緩やかに、確実に死亡者数が減少しているので、注目を集めるには充分な上昇のように思う。

The British are in the midst of a critical health epidemic. In the 12 months to June 2016, the number of deaths jumped by the biggest absolute and relative amount since 1940 – a rise of 52,400. And this appears not solely to be an effect of a growing and ageing population, since the increase is spread across age groups. (Deaths rose by 12% among those aged 90 and over; 10% for 85-89; 7% for 80-84; 5% for 75-70; and 3% for those aged 55-74.) This is unprecedented in peacetime .

The jump, unreported in national media, is not entirely a surprise. Death rates have been rising slightly since 2010, reversing what was a steady fall since the 1970s. This is part of a general decline in health and wellbeing over the same period. The Office for National Statistics’ survey of wellbeing reports that the numbers who are self-reporting satisfaction with their health has consistently declined since 2010. The “happiness index” recorded its lowest ever level in March 2016.


 コラムの後半では、キャメロン政権時代の緊縮財政による福祉政策の大幅な減少が、人々の生活への不安を増大させたことが要因の一つとして挙げられている。

 先月、メンタル・ヘルスへ投資することが人々の不安を解消する助けになるという研究発表、記事が報道された。

Happiness depends on health and friends, not money, says new study
https://www.theguardian.com/society/2016/dec/12/happiness-depends-on-health-and-friends-not-money-says-new-study

Happiness study 'lets austerity off the hook', psychologists claim
https://www.theguardian.com/society/2016/dec/26/happiness-lse-study-austerity-off-the-hook-psychologists-claim

Mental illness and poverty: you can't tackle one without the other
https://www.theguardian.com/science/brain-flapping/2016/dec/13/mental-illness-and-poverty-you-cant-tackle-one-without-the-other

Origins of happiness: Evidence and policy implications
http://voxeu.org/article/origins-happiness

 この議論に直接結びつかないことだが、イギリスの公衆衛生についてずっと考えていることがある。イギリス社会は、この国で暮らす人々へ、どのように衛生教育を、どの程度まで教えれば良いと思っているのだろうか、と。

 日本同様、この冬、イギリスでもノロ・ヴァイルスが猛威を振るっている。予防喚起の報道記事に寄せられる読者からのコメントを読むと、暗澹たる気持ちになる。何でもかんでも皮肉らなければ気が済まないイギリス人の負の気質が全開。先月、イギリス人の友人達とランチをともにしたとき、健康の話題もでて、建設的な意見を言えないイギリス人全般への印象を、「Many British people show their incapacity to be serious when they have to be serious」といったら、場が一気に静まった。

 話がそれた。日本の公衆衛生のレヴェルが高いからといって、死亡者数が激減している、ということはないだろう。しかし、イギリスはNHSの将来を議論するにあたって、「予防」とは何か、どのような意味なのかを、国民にしっかり教育するべき時を迎えているように思う。

ポジティヴ・サイコロジィが見たJAL再生

2013.01.21
先に書いておくと、タイトルは僕の本意からは少し距離があります。でも、日本の企業をヨーロッパ人はどうとらえるか、という一例として紹介。

 以下のポストを送ってくれたのは、ポジティヴ心理学に傾倒するイギリス人の友人。彼は心理学者ではないが、ポジティヴ心理学を牽引するアメリカの心理学者の大ファン。

Beer and Philosophy: Engagement Japanese Style
http://positivepsychologynews.com/news/bridget-grenville-cleave/2013010725067

By Bridget Grenville-Cleave

In the UK business community there is a growing interest in the topic of employee engagement, sparked by a government-commissioned report in 2009, Engaging for Success: Enhancing Performance through Employee Engagement. In November 2012 the report’s authors, David MacLeod and Nita Clarke, established a group called Engage for Success (EfS) which describes itself as a “movement committed to the idea that there is a better way to work, a better way to enable personal growth, organizational growth and ultimately growth for Britain by releasing more of the capability and potential of people at work.”

Anything linked to higher performance, productivity and profit (and making companies more recession proof) is going to interest business leaders. Not surprisingly, how to engage staff in the workplace is making waves in many organizations big and small. It’s also becoming an important topic in positive psychology (for example see the work of Wilmar Schaufeli at the University of Utrecht or the chapters devoted to employee engagement in the Oxford Handbook of Positive Psychology and Work).

But are we over-intellectualizing engagement?

As is the case with many management-related topics, much has been written about employee engagement by various gurus, consultants and HR practitioners which isn’t necessarily evidence-based. A recent discussion in the EfS LinkedIn Group started with the question, “Are we intellectualizing employee engagement too much?” Perhaps, it was suggested, it’s a management capability that some managers ‘get’ because they’re naturals at people-related stuff. And maybe there are other managers who just don’t get it, no matter how compelling the business case?

The question was prompted (not entirely tongue-in-cheek I believe) by a BBC article about the turnaround of Japanese Airlines Company (JAL), which had filed for bankruptcy in 2008 with debts of $25bn, yet by 2012, was back in profit and relisted on the Tokyo Stock Exchange. How had it re-engaged employees and achieved this remarkable turnaround in such a short space of time?

JAL’s remarkable recovery, it seems, is to a great extent attributable to the actions of its Chairman, Kazuo Inamori, who was appointed in late 2009. Leaving aside the fact that, had JAL been a Western company, Inamori would never have got the job on account of his age (80 years old) and lack of aviation experience (prior to joining JAL, he had precisely none), I’m not sure his management techniques would have been endorsed by many Western leaders either. According to several news reports, what Inamori did to re-engage employees and lead JAL back into the black was to insist on compulsory philosophy sessions for all staff, washed down with free beer.

I was so intrigued by this story that I wanted to delve a bit deeper. Having recently stumbled on Honda’s connection with positive psychology, I hoped Kazuo Inamori’s business philosophy might yield some positive psychology gems too.

In a section on his website entitled ‘philosophy keywords’ Inamori outlines his approach to running a business with employee happiness at its heart. Although he doesn’t use positive psychology language, there is a great deal which is based on its principles, for example:

Passion and Meaning

In a section called ‘aim high’, Inamori talks about the need for passion, keeping energy levels high, and having a cause at work to elevate us. Whilst not referring explicitly to flow or strengths, this section captures the essence of performing meaningful work, which we now know is linked to increased well-being.

Optimism and Pessimism

For effective business planning he recommends the following: “Conceive optimistically, plan pessimistically, and execute optimistically“. According to Inamori, it’s essential that we master the ability to switch viewpoints, from optimism to pessimism, and back again to optimism. I really liked this advice; it reminded me of Philip Zimbardo and Ilona Boniwell’s research into time perspectives which suggests that a balanced time perspective (the ability to move between future, past and present orientations) is linked to greater well-being.

Leading a Wonderful Life

In a section on elevating our minds, Inamori suggests the following behaviors:

Having an open mind
Being humble, thankful and cheerful
Acting with a loving, sincere, and harmonious heart

Again, although there’s no overt reference to positive psychology, what springs to mind are the VIA character strengths of open-mindedness, humility, gratitude, optimism and love.

It All Comes Down to Employee Happiness

In an interview earlier this year Inamori told the Wall Street Journal:

When I first came to JAL, I told executives that we have to state the management’s philosophy and share that with everyone at the company. I also told them we don’t need many statements. One thing we need to say is that the management’s goal is to pursue the happiness of all employees, both physically and mentally…That was what it all came down to.

It wasn’t for shareholders, and it wasn’t for executives. It was for all the employees working at the company. We put that at the very beginning of our philosophy statement. ‘This is your company, and its goal is to make all of you happy.’

To share the idea that the company’s goal is to make all employees happy is a prerequisite, before sharing any other ideas. The whole philosophy wouldn’t work without this prerequisite.


Going back to the Engage for Success question about whether we’re over-intellectualizing employee engagement, positive psychology’s answer is definitely ‘no’. Although positive psychology didn’t exist as a science for the larger part of Kazuo Inamori’s career, the roots of much of what he recommends can be found in its research and evidence base.

I’ve no idea how many of the UK’s business leaders will read Inamori’s management philosophy, ask their managers to study it or apply it to their companies, but they probably should. They might opt for handing out free bottles of beer though. Despite some considerable time searching, I’m afraid we still don’t know what brand he supplied.


 
 面白い試みだと思って読み始めたけど、僕にはとてもぬるい内容に思える。日本理解の参考になるとは感じられない。それに、著者自身のリサーチが全く欠落しているので、どうしてこれを書きたかったのかが見えない。心理学関連の論文やエッセイで「research and evidence base」がでてくると、統計で得られたのであろう数字と推測を一般論として「事実」とする姿勢には詭弁を感じる。

 欧米が日本を見ている一例として。

母国語の力:Vaginaと女性器

2012.10.21
いつもブログを訪問する人をドン引きせてしまうかもしれないタイトルですが、僕自身のサイコ・バブルです。

 9月初旬、アメリカ人フェミニスト(らしいです)のNoami Wolfさんの最新の著作、「Vagina」がイギリスでも発売になり、主にガーディアン紙が大騒ぎになりました。

Naomi Wolf: 'Neural wiring explained vaginal v clitoral orgasms. Not culture. Not Freud'
http://www.guardian.co.uk/books/2012/sep/02/naomi-wolf-women-orgasm-neural-wiring

Vagina by Naomi Wolf – digested read
http://www.guardian.co.uk/books/2012/sep/16/vagina-naomi-wolf-digested-read

Naomi Wolf's book Vagina: self-help marketed as feminism
http://www.guardian.co.uk/commentisfree/2012/sep/05/naomi-wolf-book-vagina-feminism

 僕にとってガーディアンが主要新聞なので記事はだいたい読みました。そこからの理解は、この本は、セックスを楽しめなくなったのは精神的な問題ではなく、身体的なことに起因するということを、ウォルフ女史自身の体験を元に書いたものらしいです。
 先に書いた通り、ガーディアン紙の取り上げようは、もう、ヒステリカル。特に女性コラムニストの多くが、ウォルフ女史への嫌悪感をあらわにしていたのはとても興味深かったです。ちなみに、ウォルフ女史は、昨年のオキュパイ・ウォール・ストリート・ムーヴメントでも果敢な行動をとったようです。

 で、この本の直後に、ガーディアン、さらにテレグラフやタイムズも大喜びで取り上げたのは、アメリカ発の映画でした。壮年期後半に差し掛かったセックスレスの夫婦をメリル・ストリープとトミィ・リー・ジョーンズが演じる「Hope Springs」。イギリスではかなりヒットしたようです。

hopesprings_hero-1344276838.jpg

It’s not too late to save our marriage
http://www.telegraph.co.uk/women/sex/9530133/Its-not-too-late-to-save-our-marriage.html

The bedroom blues
http://www.guardian.co.uk/lifeandstyle/2012/sep/08/sex-problems-marriage

 僕にとっては、サッチャー元首相を演じた後に、倦怠期を抜け出したいと願う主婦役をやるストリープは、受ける役をどうやって判断しているのかということが興味のあるところですが、新聞の取り上げ方を読むと、50代を迎えた夫婦のセックスの問題って洋の東西を問わないんだな、と。

 で、ここからが本題。特にウォルフ女史の本のレヴューや批判のコラムを読んでいるとき、Vagina やPenis等の単語がたくさんでてきました。口にしようが、頭の中でこれらの単語を思い浮かべようが、何ら思うことはありませんでした。単に、体の一部にしかすぎないので。
 しかしながら、これらの単語を日本語に訳してみると、ちょっと違った感情がわいてくるのを感じました。で、ネイティヴ・スピーカーにとって、Vagina とかPenisって、もちろん公の場で大声で言う言葉ではないですが、口にするのがはばかれる感覚があるのかを回りの友人たちに尋ねてみました。

 友人と言っても、心理関係、カウンセリングに携わっている人が多いので、皆一様に、「Vagina、Penis は基本、Technical termsだから」。テクニカル・タームズを日本語にすると、技術用語。
 もちろん、宗教関係、育った環境の違いでこれらの言葉を普通に使うことなんて不可能とする人もいるでしょう。でも、言語心理学関連で、体の部位を表す言葉によって、どの言葉が最も心理的に影響が大きく、どの言語が最も無味乾燥なのかと言う統計があればと思いました。
 
 友人たちから言われたことで一つ面白く感じたのは、language dissociation。言葉の無関連性とでも言うのか。同じ事象を表す言語でも、その事象と言葉の関連性を知らなければ、無意味でしかない、ということ。このことを言われたときに思い出したのは、フランスでの経験。パリのサン・ジェルマン地域に、「」というそばをメインにした日本料理のレストランがあります。
 流暢な英語を話すフランス人の友人たちと行ったときのこと。レストランの日本人女性に料理の説明を頼みました。その女性は滑らかな「フランス語」で僕たちの前に並べられた日本料理を説明してくれました。友人たちはわくわくとした表情で説明を聞いていましたが、僕には耳に入ってくるフランス語と目の前にある和食が一致しませんでした。まるで、目の前の料理が、自分が知っている日本食とは別物の様な印象を持ちました。そのときは深く考えなかったのですが、ドイツ語やイタリア語、ロシア語で和食を説明されたら、僕はどう思うのだろうと。

 サイコ・バブルでした。

ラベルとカテゴリィ:ジョン・アーヴィングの新作から思うこと

2012.08.02
2ヶ月以上も前になりますが5月29日に、13作目の「イン・ワン・パーソン」を出版したジョン・アーヴィングの公開インタヴューを観てきました。ロンドンの情報雑誌と老舗書店の共同企画で、インタヴューの模様はすぐに彼らのウェブにアップすると言っていたのですが、なかなかアップされません。これ以上経つと僕の記憶が薄れてしまうので、インタヴュー中に書きなぐったこと、本の主題から僕なりにたまに考えている「ラベリングとカテゴリィ」についてをとっ散らかったままですが、記録として。

http://loveandhatelondon.blog102.fc2.com/blog-entry-1650.html

 アーヴィングのこの作品、なかなか読み終えられないのですが、作中に何度もでてくる文章があります。

My dear boy, please don’t put a label on me - don’t make me a category before you get to know me!

 自分のセクシャリティに悩む主人公が、彼の人生に大きな影響を及ぼす人物に、その人物のセクシャリティを知ってしまったときに「ラベル」を投げつけ、それへの返答です。

 アーヴィングによると、社会、そして人々が「普通」とは見なされないセクシャリティにラベルを貼ることで受け入れることを拒否することについては、「ガープの世界」で書ききったので取り組むことはないだろうと思っていたそうです。しかしながら、21世紀に入っても、社会が「マイノリティ」と称されるセクシャリティへ向ける姿勢に変わりがないことを感じ、再び取り組んだそうです。

 アーヴィングの英語は思いのほか聞き取りやすく、彼がインタヴューの中で話した今回の新作発表に際して寄せられた批判への彼の怒りの部分を聞き漏らすことがなかったので、とても面白かったです。
 この作品の中では、80年代、90年代のHIV/AIDSによって起きたパニックや悲しみを描いた部分があります。リサーチをきちんとしたとはいえ、もしかしたら医療にかかわる部分での批判はあるかもしれないと思っていたそうです。また彼自身の体験として、親友と思っていたゲイの友人が、アーヴィングにエイズにかかったことを知らせず死に至ったことは、個人的にとても衝撃だったそうです。なぜなら、「僕は彼の親友と思っていたけど、もしかしたら、エイズにかかっていることを僕に話さない方が良いというシグナルを無意識のうちに友人に送っていたのだろうか」、とかなり悩んだそうです。

 彼が最もpissed offした批判は、「セクシャル・マイノリティ」と称される人たちから寄せられたそうです。それは、「あなたはゲイではないから、エイズの蔓延については本当のことはかけない」、というもの。僕の想像ですが、アーヴィングが怒ったのは、「ヘテロ・セクシャル」というラベルをアーヴィングに貼付けることによってゲイの人たちは彼らの視点を狭めている、ということではないかと。
 アーヴィングが彼の憤りを語る前に言ったのは、「Label would narrow you」。僕は、この点は、ラベルを貼る側も貼られる側も同じだと感じます。日本だけではないと思いますが、日本の例を。
 
 日本のメディアを読んでいると、過去数年というとても短いレンジにもかかわらず、「草食男子」、「肉食女子」とか「腐女子」などという僕個人には全く意味のなさないラベルが次から次に生み出されています。
 例えば「草食男子」。「草食男子」というラベルを貼ることで自分ではそう思っていない人をすら「カテゴリィ」に無理矢理はめ込む。他方、自ら「草食男子」と名乗る人は、もしかしたらそのようなラベルを自らに貼付けることによって、他者からの理解、コミュニケイションを拒む。「あなたは草食男子じゃないから僕のことを理解できる訳がない」、と。そして、「彼草食男子だからあのような行動をするんだよ」と本人のいないところで、自分の思い込みという乱暴な枠に他人をはめ込む。

 今年の5月に知ったニュースでこんなことを書きました。

パンク歌手の決断と寄せられた言葉:トランスジェンダー
http://loveandhatelondon.blog102.fc2.com/blog-entry-1653.html

 ロッキング・オンの記事でその存在を初めて知ったパンク・バンドのフロント・パーソンのインタヴューがガーディアンに掲載されました。

Laura Jane Grace: 'So I'm a transsexual and this is what's happening'
http://www.guardian.co.uk/music/2012/jul/22/laura-jane-grace-transsexual

 かなり長いですが、ジェンダー、結婚、家族という枠組みに関心がある人にはmust readのインタヴューだと思います。読者からのコメントを読むと、イギリスでもこのようなジェンダーにかかわることへの理解は混乱している印象を持ちます。

 ラベルやカテゴリィを否定する気は全くありません。例えば、「胃がん」であるとか、「狭心症」であるとかのカテゴリィやラベルは、症状や事象を理解するには必要です。他方、そのような必要なラベルやカテゴリィですら、そこに感情が入り込むと、「君は胃がんなんだからそんなことをするのはおかしい」などの言葉がでてくることもあると思います。

 イギリスでセクシャル・マイノリティへのインタヴューや、カウンセリングのケイス・スタディの中でよくでてくる表現があります。

I happen to be a homosexual.

 日本語にすると英語のでニュアンスが伝わらないかもしれないですが、あえて当てはめれば「自分は同性愛者として生まれただけ」。だから、こんなことも言えるかなと。

I happen to be a man.

I happen to be a woman.

I happen to be a Japanese.

I happen to be a British.

I happen to be a heterosexual.

 言葉をもてあそんでいる印象は否めないのは承知しています。しかしながら、ラベルを貼付ける前に、ラベルで自己防衛をする前に、自分の目の前に立っている人の姿を理解することの方が意味のあることではないかな、とつらつら考えます。トランスジェンダーと呼ばれる人たちは、トランスジェンダーと呼ばれるために生まれてきたのではない。そのように生まれてしまった、と。

 ジョン・アーヴィングが言った、「Label would narrow you」の本質が彼の思考のどこにあるのかは判りません。ラベルを貼る側、貼られることを甘んじている側、ラベルを自ら主張することで外から隔絶する人たち、そしてそのラベルをもてはやすだけのメディアは、人々が持つ可能性を見失い、視野を狭めているだけなのではと感じます。

 ま、言うは易しです。最近、立て続けに、「これだからアメリカ人は」ということが重なり、僕が勝手に作り上げた「アメリカ人」というラベルを通してしかアメリカを観ていない自分がいることは、否定できません。

 「イン・ワン・パーソン」、まだまだ途中ですが、読み物としてとても面白いです。ジョン・アーヴィングはストーリィ・テラーとして本当に素晴らしい作家だと思います。夏が終わるまでには読み終わりたいものです。

Mental Health in Primary Care 2

2011.07.15
Mental Health Policy: No health without mental health
Mental health has become a core part of primary care in the UK. However, this central role has only recently been recognised through policy imperatives around the new mental health workforce and opportunities to re-examine how mental health services can be constructed and organised in primary care (Lester and Glasby, P.75, 2010).

In 2011, the UK government made their latest policy of mental health: No health without mental health. The core strategy of this demonstrates a set of “shared objectives to improve mental health outcomes for individuals and the population as a whole”. The six shared objectives are as follows:

More people will have good mental health
More people with mental health problems will recover
More people with mental health problems will have good physical health
More people will have a positive experience of care and support
Fewer people will suffer avoidable harm
Fewer people will experience stigma and discrimination
(DoH, P. 6, 2011a)

According to the government, this new approach means a different approach to direction setting: developing strategies to achieve outcomes. Outcomes strategies focus on how practitioners on the front line can best be supported to deliver what matters to service users within an ethos that maintains dignity and respect (DoH, P. 11, 2011a). In line with the discussion of how the quality of mental health in primary care is improved, what changes the third object, More people with mental health problems will have good physical health, is expected to make is focused on.

As we have already explored, society has improved its awareness of how physical health affects mental health and vice versa. The government has also recognised the relationship as it presents some of the data; having a mental health problem increases the risk of physical ill health and depression increases the risk of mortality by 50% and doubles the risk of coronary heart disease in adults (DoH, P. 23, 2011a). Since about 90% of people with mental health problems are now managed entirely in primary care, ensuring that all people have access to effective primary health care is fundamental to improving the recognition and management of mental health problems (DoH, P. 33, 2011b).

In order to realise the government’s mental health strategy in primary care, improving the skills of primary care staff to enable them to recognise mental health problems earlier and to deliver appropriate treatments in a primary care setting is recommended by the National Institute of Health and Clinical Excellence (NICE) guidelines (DoH, PP.33-34, 2011b). In addition, different types of treatments, such as psychological therapies, in primary care are considered. Psychological therapies have been shown to improve outcomes for people of all ages with long-term physical conditions and mental health problems (DoH, P.61, 2011b). The expansion of psychological therapies has become a government priority, which should make psychological treatment more easily accessible in primary care (RCPSYCH and RCGP, P. 80, 2009). This clear understanding reflects an understanding that investing in mental health has a pay-off through physical health (CEP, P. 7, 2006).

While some GPs show their interest in developing a therapy capacity within their practice, the majority welcome the provision of a psychological treatment outside the practice, to which they can refer their patients (CEP, P. 9, 2006). Partly because of this situation, the government is accelerating a programme for people to have more access to psychological therapies in primary care.
This plan is not new as NHS proposed a plan a decade ago that one thousand new graduate primary care mental health workers would be employed to help GPs manage and treat common mental health problems in all age groups (DoH, 2000, cited in Lester and Glasby, P.70, 2010).

The current programme is called the Improving Access to Psychological Therapies (IAPT) programme and aims to improve delivery of talking treatments to service users with mental health problems (RCPSYCH and RCGP, P. 7, 2009). The policies and details of the programme are;

The IAPT programme began in October 2007 when the government announced annual investment rising to £173m by 2010/11 to fund the roll-out of evidence-based psychological therapy services across England for people experiencing depression and anxiety disorders. The treatments offered are those approved by NICE for treating common mental health problems (NHS, P. 4, 2011b).

Investing around £400 million over the four years to 2014/15 enables every adult that requires it should have access to psychological therapies to treat depression (DoH, P. 2, 2011c).

More people with long-term physical health conditions, medically unexplained symptoms or severe mental illness are routinely offered evidence-based psychological treatments when appropriate, as part of personalised care planning (DoH, P.4, 2011c).

The IAPT programme was created to offer patients a realistic and routine first-line treatment for depression and anxiety disorders, combined where appropriate with medication – which had traditionally often been the only treatment available. The programme was first targeted at people of working age. The economic case on which it was based showed that providing therapy could benefit not only the individual but also the nation, by helping people come off sick pay and benefits and stay in or return to work (DoH, P.5, 2011c).

It is based on a ratio of around 40 therapists serving a population of 250,000 (DoH, P. 13, 2011c).

In the next section, we will explain how IAPT works in primary care setting by introducing its two pilot sites, and then discuss what IAPT can further offer to the society.


How IAPT works in primary care
Psychological, or ‘Talking’, therapy is a broad term covering a range of therapeutic approaches; they involve talking, questioning and listening to understand, manage and treat people’s problems. (NHS, P.19, 2007). A meta-analysis on psychological treatment finds that the psychological treatment of depression is effective in primary care patients. (Cuijpers et al, 2009). Thus, for the government, the Improving Access to Psychological Therapies (IAPT) programme is the main focus on the delivery of psychological therapies as part of a primary care setting.

The IAPT programme is at the heart of the Government’s drive to give greater access to, and choice of, talking therapies to those who would benefit from them and aims to implement NICE Guidance for people with depression. The government calculates that one in six working adults, who are current targets patients group, at any one time are suffering from clinical depression. In the first phase of the programme, two demonstration sites were established in Doncaster and Newham with funding to provide increased availability of cognitive-behaviour therapy-based (CBT) services to those in the community who need them. The services opened in late summer 2006 (CEP, 2008; NHS, P.4 & P.8, 2007).

By September 2007, the number of the patients who attended at least two sessions at both demonstration sites were 1654 at Doncaster and 249 at Newham. Both sites achieved good recovery rates (52%) for people who had depression and/or an anxiety disorder for more than 6 months. Another finding which can be highlighted is to offer patients a self-referral route to psychological therapies in primary care setting. GPs act as a “gate keeper” to specialist treatment services. However, concern that a GP only access system may disadvantage some individuals with mental health problems led the Newham Demonstration site to experiment with self-referral (Clark et al, 2009).
Although the rate of the self-referral at Doncaster was less than 1 %, 21% of the patients at Newham accessed to the treatment were as self-referral (CEP, P. 30, 2008). In addition, providing a self-referral route appears to enable the service to access disabled individuals in the community who are not well served by existing GP only referral systems routes (CEP, P. 2, 2008).

Another notable result is that the two demonstration sites succeeded in helping people off sick pay and benefits so that they could stay in or return to work (DoH, P.5, 2011c). As a worked example, IAPT programme delivers efficiency and possible cash savings to local NHS of an estimated £1,060 on average for each additional person who recovers from depression or anxiety disorder (NHS, P. 2011a).

There are some points about how the IAPT will be developed for the society. Firstly, the current target patients group is working-age people with common mental illness, such as depression and anxiety disorder, but the government is to extend the programme for people with severe mental illness (DoH, P. 16, 2011c). In addition to this group, the government is also to include people with long-term physical health conditions, such as diabetes, cardiovascular disease or chronic obstructive pulmonary disease. The reason is that these people often have comorbid mental health conditions, but they are rarely referred for psychological interventions, despite good evidence that such management of mental health problems can reduce their need for GP appointments (DoH, P. 19, 2011c).

Secondly, the point of who delivers appropriate psychological therapies in primary care should carefully be assessed. In line with the efficiency of CBT, Haby et al (2006) raise an issue. Although they find CBT effective when offered by a psychologist, they are not clear whether psychiatrists, social workers, nurses, general practitioners or other professional groups can achieve the same efficacy. The British government say that the IAPT programme requires a total of 6,000 new IAPT High Intensity and Psychological Wellbeing Practitioners (PWP) workers (NHS, P.18, 2011b) for full coverage across the NHS. The training programme which they propose may better be updated in regular timing in order to keep the quality of the service to the society in primary care setting.



Conclusion
As demonstrated, both government and society have improved their understandings of how mental and physical health affect each other. Their awareness has also motivated primary care staff, for instance GPs, to provide appropriate treatment for mental illness as well as physical health problems. In addition, the government has keenly implemented the specific programmes to ensure the depressed can have more easy access to get psychological treatments in primary care setting. Needless to say, however, GPs are not trained as psychological therapists while the therapists in the programme cannot treat physical health problems. It is a vital point for us to know from whom we can have necessary treatment for either mental or physical health problems in a primary care setting.
(4349 words)


References
The Centre for Economic Performance’s Mental Health Policy Group (2006): The Depression Report
http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_LAYARD2.pdf

The Centre for Economic Performance’s Mental Health Policy Group (2008): Improving Access to Psychological Therapy: Initial Evaluation of the Two Demonstration Sites
http://cep.lse.ac.uk/pubs/download/dp0897.pdf

Clark, D.M., Layard, R., Smithies, R., Richards, D.A., Suckling, R. and Wright, B. (2009): Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, Vol. 47, 910-920

Cuijpers, P., van Straten, A., van Schaik, A. and Andersson, G. (2009): Psychological Treatment of depression in primary care: a meta-analysis. British Journal of General Practice, February, e51-e60

DoH (2000): a plan for investment, a plan for reform cited from Mental Health Policy and Practice by Lester and Glasby (2010)

DoH (2011a): No health without mental health: A cross-government mental health outcomes strategy for people of all ages
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124058.pdf

DoH (2011b): No health without mental health: Delivering better mental health outcomes for people of all ages
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124057.pdf
DoH (2011c): Talking therapies: A four-year plan of action
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123985.pdf

Haby, M.M., Donnelly, M., Corry, J., Vos, T. (2006): Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome. Australian and New ZealandJournal of Psychiatry 40, 9-19

Lester, H. and Glasby, J. Mental Health Policy and Practice second edition (2010) Palgrave Macmillan, Hampshire, UK

NHS (2007): Commissioning a brighter future
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074821.pdf

NHS (2011a): Commissioning Talking Therapies for 2011/12
http://www.iapt.nhs.uk/silo/files/commissioning-talking-therapies-for-201112.pdf

NHS (2011b): Guidance for Commissioning IAPT Training 2011/12 – 2014/15
http://iapt.nmhdu.org.uk/silo/files/guidance-for-commissioning-iapt-training-201112-201415.pdf

The Royal College of General Practitioners (2005): Mental Health and Primary Care
http://www.rcgp.org.uk/PDF/clinspec_printed%20version%20mental%20health.pdf

The Royal College of Psychiatrists and Academy of Medical Royal Colleges (2010): No Health without Mental Health: the supporting evidence
http://www.rcpsych.ac.uk/pdf/No%20Health%20without%20mental%20health%20the%20Evidence.pdf

The Royal College of Psychiatrists and the Royal College of General Practitioners (2009): The management of patients with physical and psychological problems in primary care: a practical guide
http://www.rcpsych.ac.uk/files/pdfversion/cr152.pdf

Pilgrim, D. Key Concept in Mental Health second edition (2010) Sage, London, UK

Running On Empty report (2005)
http://www.psychminded.co.uk/news/news2005/july05/runningonempty.pdf

Schreuders, B., van Marwijk, H., Smit, J., Rijmen, F., Stalman, W. and van Oppen, P. (2007): Primary care patients with mental health problems: outcome of a randomised clinical trial. British Journal of General Practice, November, 886-891


Mental Health in Primary Care 1

2011.07.15
昨年の秋から参加していた精神医療現場についての基礎ワークショップが終了した。必死で仕上げた課題、とてもブリリアントな評価ではないけど、とりあえず良しということになった。つくづく、アカデミックではないことを痛感。

 ということで、内容としてはたいしたことを書いているわけではないけど、イギリスでの精神医療現場についての一面を知りたいという方の参考に少しはなるかなとの期待を込めて。



Relating your discussion to recent and relevant policy, critically discuss the relationship between mental and physical health care and the way in which primary care services can respond to wider issues of mental illness in local populations.



As mental health issues become less stigmatised in our everyday life and society than before, our society shows a clearer understanding of what issues in mental illness we have to tackle to improve the quality of the treatment for those who suffer from mental disorders. Indeed, treatments for people with mental illness, such as depression and anxiety disorder, have been frequently updated by the government. Nonetheless, there are always continuing debates about the most suitable treatment for the depressed in primary care to be provided and how primary care staff should handle mental health problems while they also care for physical health problems.
The aim of this report is, therefore, to discuss how mental health and physical health affect each other while to identify what impact depression, as one of the common mental health in the UK primary care, causes on our society. Then, with an evaluation of a recent mental health policy, we will assess the sort of treatment for the depressed is offered in primary care setting.


Depression
The term ‘depression’ refers to a wide range of mental health problems characterised by low mood, loss of interest and enjoyment in ordinary things and experiences, and a range of associated emotional, cognitive, physical and behavioural symptoms (RCPSYCH and RCGP, P. 40, 2009). At a global level, depression is forecast to be the second most common cause of ‘disability’ by 2020 (Lester and Glasby, P.3, 2010), and depression is the most common mental health problem that doctors diagnose at primary care in the UK (RCPSYCH and RCGP, P.40, 2009). Accelerated by society’s improving attitudes towards mental illness (it is now less stigmatised and we talk about it more openly), the British government’s mental health policy has regularly been updated and developed. It seems that both society’s and people’s understandings of mental illness, such as depression and anxiety disorder, have become clearer and more compassionate than before.

In addition, since the National service framework for mental health: modern standard and service model was issued in 1999 (according to Lester and Glasby [P. 41, 2010] this is the first document in mental health to set a common agenda for local agencies), the quality of effective services for people with mental illness in the UK has been changing and has improved. For instance, better mental health care in primary care setting has been provided and consistent advice and help for people with mental health needs, including primary care services for “individuals with severe mental illness” (Lester and Glasby, P.41, 2010), has been provided and improved.

However, with our new more accurate understanding of mental illness, our society has also become aware of the serious impact caused by mental illness; our understanding of the seriousness of this impact has become clearer and the impact has increased. Although issued in 2006, The Depression Report warns that the total loss of output due to depression is “some £12 billion a year”. In other words, the more people suffer from depression, the less our society flourishes. Mental health effects both our well-being and our economic prosperity.

Furthermore, there are now more discussions focusing in particular on how depression affects physical health. One recent report shows that there is a high prevalence of major depression in people with chronic medical conditions with associated increases in the use of health services, lost productivity and functional disability (RCPSYCH and RCGP, P.42, 2009). Another report concludes: depression itself is a risk factor for physical illness and major depression doubles one’s lifetime risk of developing type 2 diabetes. Depression has also been proven to be a risk factor for the development of heart disease (RCPSYCH and AMRC, PP.9-10, 2010). The UK government is also aware of this point: depression is associated with a 50% increased mortality and doubles the risk of coronary heart disease. Having two or more long-term physical conditions increases the risk of depression seven-fold (DoH, PP. 33-34, 2011b). However, there is an opposing view on the relationship between physical health and mental health: people with chronic medical illness, compared to those without, have an increased risk of depression (RCPSYCH and AMRC, P.9, 2010). In the next sections, we will explore how mental and physical health affect each other and the impact they both exert on in primary care.


Mental health/ Physical health
Approximately one quarter of people with physical illness develop mental health problems as a consequence of the stress of their physical condition (RCPSYCH and AMRC, P. 9, 2010). Since illness is a threat to self, all illnesses have a “psychological impact” (RCPSYCH and RCGP, P.16, 2009) although its outcome can be different among people. If illness is a threat to self-identity, most individuals will be stressed by their symptoms and how they respond can influence the outcome either way. (RCPSYCH and RCGP, P.18, 2009). In other words, a person’s physical health status predicts their mental health and vice versa (Pilgrim, P.50, 2010). In the latest Mental Health policy, No health without mental health, the government clearly demonstrates an awareness that mental health and physical health affect each other: mental health problems such as depression are much more common in people with physical illness. Having both physical and mental health problems delays recovery from both (DoH, P. 23, 2011a).

Here are some figures which display the relationship between mental health and physical health.

Approximately 20% of patients have clinically significant depression at the time of diagnostic cardiac catheterisation.
Depression increases the risk of developing coronary heart disease (CHD) and of adverse outcomes among those who already have CHD (RCPSYCH and AMRC, P.25, 2010).

Depression may be a risk factor for type 2 diabetes; in several prospective studies, depression predates the onset of type 2 diabetes by many years. Depression and depressive symptoms are associated with poorer glycaemic control, diabetes complications and increased risk of death (RCPSYCH and AMRC, P.26, 2010).
Severity of diabetic symptoms is more strongly associated with depressed mood than with glycosylated haemoglobin levels (RCPSYCH and RCGP, P.43, 2009).

These data support the government’s view that both the development of mental health problems and the results are associated with poorer physical health (DoH, P. 9, 2011b).

As discussed above, the awareness of the important relationship between mental and physical health seems to have strengthened in primary care setting. In reality, however, there are still some discrepancies in the clinical setting. According to the joint report issued by two health professionals institutions, most people with chronic illness now receive a regular review of their physical condition by their GP, but psychological status is often neglected despite the fact that all patients with chronic illness should receive a regular review of their physical, psychological, social and spiritual needs (RCPSYCH and RCGP, P.34, 2009).

If we wish to narrow the gap, there are a couple of situations to be considered. For instance, although depression is common in physical illness, particularly in chronic illnesses, mental health services are “separated from physical health services with separate commissioning processes, targets and service boundaries” (RCPSYCH and RCGP, P.7, 2009). In addition, primary care is charged with providing care for common mental health problems and contributing to health promotion, but there is a “lack of clarity about who should lead on the care of those” (RCPSYCH and AMRC, P.17, 2010) with mental health problems.

Another report finds that when a chronic physical disease is found to be present, there is the risk that attention will shift to this disease and the depression may be overlooked (RCPSYCH and AMRC, P.11, 2010). This may be due to prioritisation of physical health problems, perceived lack of expertise among GPs, or reluctance by patients to engage in mental health services. For instance, this causes a situation that the majority of depressed CHD patients do not receive adequate treatment for their depression (RCPSYCH and AMRC, P.26, 2010).

In order to improve the situation that both mental health and physical health are treated as a whole in primary care setting, a criticism which also seems to be a helpful opinion should be considered:

Many mental health care practitioners have little training in how to manage physical care, the rates of physical assessments of those under care are poor and the monitoring of physical health and health education is generally unsatisfactory. This situation results from the fact that healthcare services are often fragmented and un-coordinated, with both clinicians and those under care, unaware of available and appropriate resources (Running On Empty, P.11, 2005).

It is important for health care professionals to understand how mental health can affect overall physical health and vice versa (Running On Empty, P. 19, 2005).


Primary Care
Before we explore the government recent mental health policy, it is useful to understand what role the UK primary care plays in the society. By summarising their description from Mental Health Policy and Practice (Lester and Glasby, 2010), primary care in the UK generally offers rapid access for routine and crisis care in a low-stigma setting. A key strength of the primary care is open access where the patient is seen as part of a complex network of family, friends, work and social life. Because different patients display and talk about their own unique problems, primary care has developed sophisticated ways of working with the uncertainty and complexity of its environment. The front line staff of primary care services are GPs, practice nurses, district nurses, health visitors, practice managers, administrative staff (Lester and Glasby, PP.55-75, 2010).

Recently, primary care has been asked to play another role that provides and increasingly commissions good quality mental health services since most people with mental health issue are seen and treated within this setting (Lester and Glasby, P.13-14, 2010). Primary care in commissioning services has come to meet the needs of local people who are experiencing the common mental health problems of depression and anxiety disorders (NHS, P.1, 2011a).

The need to address patients’ psychological welfare has clearly been recognised in primary care and many people now present to GPs with physical symptoms that often have an underlying psychological component. (RCPSYCH and RCGP, P.6, 2009). As well as their physical needs, primary care has been important for people with mental health problems. There are two reasons; first, over 90% of them will be in contact with their GP or other primary health care worker. Second, only 10% of such patients are referred on to specialist mental health services. Consequently, most people with mental health problems only receive a primary care response (Pilgrim, P.77, 2010).

The need to increase the recognition and treatment of depression in the community through the development of guidelines for depression (Lester and Glasby, P.65, 2010) has been one of the main issues which the UK primary care has been tackling. As a result, at present 2¾ million patients come to GP surgeries each year with depression or anxiety (CEP, P.10, 2006). In the average GP surgery in the UK around one in four people consulting a doctor will be significantly distressed psychologically as defined by validated instrumental measures and systematic clinical assessment (RCPSYCH and RCGP, P.18, 2009). Another report shows that 90 per cent of people with mental health problems are cared for entirely in primary care (RCPSYCH and AMRC, P.17, 2010).

As secondary mental health services focus more and more on severe mental illness, primary care mental health teams and GPs are faced not only with service users with mild or acute psychological issues, but also those with long-standing problems and chronic difficulties. Primary care services are best placed to provide a comprehensive and integrated service for individuals with both physical and mental health problems, providing there is sufficient skill base among the staff and resources to manage these kinds of problems (RCPSYCH and RCGP, P. 76, 2009).

Despite the above, some new issues have recently emerged. First, primary care is the gateway to specialist services but because of limited capacity in the latter, non-specialist staff are often left to manage complex cases (Pilgrim, P.78, 2010). Second, healthcare professionals working in primary care are well placed to understand the relationship between physical health problems and mental health (DoH, P.33, 2011b), but mental health problems are particularly hard to detect when there is an overlap of symptoms (RCPSYCH and AMRC, P.11, 2010) unless the staff are provided training to improve their understanding of the relationship between mental health and physical health. In addition, clinical barriers, such as short appointment times, a lack of knowledge about depression and treatment, or a lack of time to talk to the patient about these issues can also prevent detection of mental illness (RCPSYCH and AMRC, P.11, 2010).
Health professionals express their further concern how mental health problems are not satisfyingly treated in primary care setting;

Some healthcare professionals may not think to enquire about psychological symptoms, or may feel uncomfortable doing so. Even if the symptoms of depression are discussed, practitioners might regard depression and anxiety as understandable reactions to being physically unwell. As such, the patient’s symptoms are normalised and the practitioner might not realise the mental health problem could be treatable (RCPSYCH and AMRC, P.11, 2010).


What GPs do for the depressed in primary care
In the recent British mental health policy context, primary care has been charged with improving services to people with mental health problems in two ways. First, primary care practitioners are now expected to ensure consistent advice and help to people with mental health problems. Second, all patients should have their mental health needs assessed (Pilgrim, P.78, 2010). Therefore, GPs are now seen to play a key role in helping patients to cope with physical illness and “facilitating a natural psychological adjustment” (RCPSYCH and AMRC, P.17, 2010). The majority of people with serious mental illness and with common mental health problems are now registered with a GP while only approximately 10 per cent of people with a mental health are seen by secondary care mental health specialists (Lester and Glasby, P.65, 2010). Mental health issues are the second most common reason for consultations in primary care. GPs in England spend on average approximately 30 per cent of their time on mental health problems (Lester and Glasby, P.65, 2010).

Although they are responsible for most people with mental health problems within primary setting (Pilgrim, P.78, 2010), GPs are criticised for their lack of mental health knowledge and the low achievement in treating depression. For GPs, consultations with patients who have health problems related to anxiety and depression frequently pose a challenge for which there are two main reasons. Firstly, limited time is available: patients with these issues take up more time during a consultation and attend more frequently than other patients, often with vague reasons for their visit. Secondly, the implementation of treatment is often complicated (Schreuders et al, 2007).

This situation echoes a result of a survey. According to Lester and Glasby (P.67, 2010), only one third of GPs have had mental health training in the last five years, while 10 per cent have expressed concerns about their training or skills needs in mental health. Hence, GPs are, in general, less likely to make a diagnosis of depression when people present with physical symptoms (RCPSYCH and RCGP, P. 44, 2009).

In addition, GPs may need to be careful not to over-diagnose depression. In UK general practice, particularly since the advent of once-daily antidepressant medication, there is a growing tendency to use a diagnosis of depression as an apparently handy means of finding one’s way out of consultations that doctors find difficult to resolve (RCPSYCH and RCGP, P. 45, 2009). GPs vary a great deal in their likelihood of making a diagnosis of depression. This is partly related to the way they approach mental health as a clinical problem. In other words, GPs are more likely to make a diagnosis when they feel comfortable about treating depression (RCPSYCH and RCGP, P.43, 2009).

Because poor primary mental health care has the potential to do harm (RCGP, P.5, 2005), it is vital that GPs increase their ability to identify and diagnose cases of depression and anxiety (CEP, P. 9, 2006). GPs are recommended to ask their patients routinely about their mood, particularly those with serious or chronic illness. Many individuals in primary care present with physical symptoms for which it is difficult to establish an underlying cause. Some patients are reluctant to talk about their mental health symptoms and, even within lower-stigma setting of primary care, are worried about the effects of divulging symptoms of mental illness (Lester and Glasby, P.67, 2010). It is important that GPs adopt a balanced perspective and consider physical, psychological and social factors and their interaction (RCPSYCH and RCGP, P. 31, 2009).

The core of a GP’s role is to help patients make sense of often paradoxical symptoms in the context of their whole life story. Listening and helping patients to reflect can often be more relevant than having correct answers. When the system is welcoming and the clinicians have both the skills and time available, general practice is ideally placed to work with patients with mental health problems; (RCGP, P.5, 2005). If GPs improve the quality of their attitudes towards and knowledge about mental health issues, GPs can enable all patients to “help themselves contribute to society, and its understanding of mental health” (RCGP, P.9, 2005) by using mental health in primary care setting.
In the next section, what the latest mental health policy directed by the UK government proposes to improve the quality of the care for the depressed provided in primary care setting will be discussed.


精神医療に関する資料:日本とイギリスの違い

2011.05.22
現在、ため息つきつつイギリスの精神医療に関係する資料を読んでいる。専門資料というより、「啓蒙」資料と表したほうがいいかもしれない。その読む疲れを発散させるために、どれだけの人の役に立つのかなんてことは考えないで、ご紹介。日本からだと、興味があってもその存在すら判らない資料もあるかもしれないし。政策の「質」の違いということではなく、取り組む政策の「内容」に違いがあるという点から、まず、厚生労働省のサイトにある資料を。

精神保健医療福祉の更なる改革に向けて
http://www.mhlw.go.jp/shingi/2009/09/dl/s0924-2a.pdf

 大まかな流れでは、イギリスの保健省が発表しているものと大きな差はないのかもしれない。ただし、一つだけ、欠落がある。それは心理カウンセリングへの国としての取り組み。

Talking therapies: A four-year plan of action
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123985.pdf

 これは、2007年から始まった、Improving Access to Psychological Therapies (IAPT)という心理カウンセリングを第一医療現場でもっと活用するというプロジェクトの、2010年から4年間の取り組みをまとめたもの。
 CBTに偏っているという点、医療現場のあり方の違いという点はあるにしても、国を挙げて医療現場での心理カウンセリングへのアクセスともっと増やす取り組みは日本の文書からは見出せない。IAPTについては検索すれば沢山文書が見つかるはずなので、興味をもたれた方はご自分でどうぞ。ひとつ、このIATP取り組みのきっかけの一つになった、レポートだけ。

The Depression Report
http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_LAYARD2.pdf

 これは先日、日本人の心理学者のとんでもないリサーチで名が出てしまったLSEレイヤードさんが、精神医療現場を改革してうつ病にかかる人を減らせば、国家予算がこれだけ助かるという経済的見地からのレポート。今でもかなり影響力のあるレポート。

 現連立政権が発表した精神医療についての政策は以下の二つで。

No Health without Mental Health
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124058.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124057.pdf

 僕には、構成が読みにくいことこの上ないけど、予想に反して使われている英語はかなり平易。英語の長文を読みなれていれば、かなりさくさく読めるはず。日本の新しい政策はいつ出るのだろう。

http://loveandhatelondon.blog102.fc2.com/blog-entry-1002.html

 僕個人にとって、画期的だった資料はこれ。

The management of patients with physical and psychological problems in primary care: a practical guide
http://www.rcpsych.ac.uk/files/pdfversion/cr152.pdf

 これも、病名の英語表記にはひるむけど、明瞭な英語で書かれている。内容は、実際の医療行為についてではなく、イギリスにおける第一医療現場であるGPにおいて、これまで積極的に取り組んでこられなかった、もしくはどのように取り組むべきが指針がなかった、精神医療に関する姿勢を向上させるためのガイド。画期的だと思ったのは内容についてではなくて、一般人に過ぎない僕がこのような資料を自宅のPCでたやすくダウンロードできたこと。日本で同様の資料があったとして、一般人が簡単にアクセスできるのだろうか。

 文化やこれまでの取り組みが違うのだから、日本とイギリスがどう違うのかをすぐに論じることは難しいだろう。ただ、最近イギリスで、というかイギリスが結果として巻き込まれしまった、精神疾患の患者によって引き起こされた悲しい事件があったばかり。

Tenerife beheading suspect had been treated in UK and released
http://www.guardian.co.uk/uk/2011/may/19/tenerife-beheading-suspect-treated-uk

 このような事件を完全になくすことは、おそらく不可能だろう。でも、その確率を減らすために国として精神医療の現場をどのように向上させ、どのような結果が見込めるかを国民に知らせようとする意思は感じられるかな。

http://loveandhatelondon.blog102.fc2.com/blog-entry-1374.html

精神医療のプロフェッショナルが語ったこと:言葉の重要性、その変遷

2011.05.09
ロンドン、信じられないほどの好天続き。しかも暑くもなく寒くもなく、空気は爽やかさに溢れていて、ロンドンではないみたいです。これも、若い二人のおかげかな、と。

 本題に行く前に。今日、5月9日付のガーディアン紙に掲載された、東日本大震災に関する記事です。

'Do not cry': a nurse's blog brings comfort to Japan's tsunami survivors
http://www.guardian.co.uk/world/2011/may/08/japan-tsunami-nurse-blog-comfort-survivors

 世界は今も、日本を襲った自然災害のことを忘れていないことを知るのは、心の底から嬉しいです。

 昨年の秋から参加している、「地域社会における精神医療」についての講習会で短いですが、とても興味深い講演があったので、自分のための記録として短く紹介します。現在、コースワークことので頭がいっぱいですので、英語と日本が混ざり合うことを先に断っておきます。

 4月上旬、精神医療のプロフェッショナルではないのですが、旧ユーゴ・スラヴィア分割に伴う紛争後のクロアチアで、人道支援のNGO立ち上げに携わった男性による「Psychosocial intervention, war torn zone and PTSD」という短いレクチャアがありました。
 日本でも、観光地として人気が高まっているらしいクロアチアですが、この国が紛争地帯であったのはそれほど昔ではないこと。4月、旧共産圏やバルカン地域で働いた経験のある友人がロンドンに来たときに話題になったのは、僕たちの世代くらいまでは「バルカン」という言葉になじみがあるだろうけど、今「バルカン」といってどの地域が該当するのかをすぐに思い浮かべる人は少ないのではないかということ。かく言う自分も、ロンドンに来て数年たった頃、「ボスニア人」と称する人に生まれて初めてあったとき、「ボスニアって、地球上の国か?」というていたらく。
 レクチャアの冒頭で男性講師が言ったのは、「PTSDという言葉は、メディアで使われすぎている」、という意見。僕も、この意見には大賛成です。いろいろな症状(symptoms)を鑑みて「PTSD」と言う診断が考慮されるべきであろうに、「PTSD」が先にありきというのは、人々を苦しめている症状を見逃してしまうのではないだろうか、といつも思います。この点については意見が別れると思いますので、これ以上は進みません。講師の方が言ったことをノートに書きなぐったいくつかのことを。

PTSD is a normal reaction to abnormal situation.

In Croatia, psychologists and psychiatrists wanted to label people as suffering from PTSD, instead of providing social & psychological supports.

As a result of being labeled by psychologists, psychiatrists and even politicians, the people were divided, which they did not expect, ie a group of the people was provided support, but the other not.

Without careful consideration, questioning the victims will only affect the reality of what PTSD should be.


 東日本大震災が起きてちょうどひと月ほどの頃だったので、紛争と震災という違いはあれど、日本から入ってきる情報にいらいらしていたこともあって、考えることが沢山ありました。レクチャアを聞いて直後の感想は、「PTSDって、本当に良くできたキャッチ・フレイズだけど実際の現場とメディアの間の差が大きすぎてまるで別物みたい」。

 先週、クリニカル・サイコロジストの大御所、Dr Dorothy Roweの特別講義がもうけられました。昨年の秋のはこちらに:http://loveandhatelondon.blog102.fc2.com/blog-entry-1274.html

 レクチャアの冒頭、ドロシィがまず言及したのは、例えば20年位前、depressionなんて言葉は誰も普段の生活では使わなかった。社会が大きく変化したと感じるのは、多くの人(全員ではない)ががんについて話すことが普通に感じられるようになったのと同様、depressionという言葉を多くの人が日常会話の一部としてまで使うようになったこと。
 でも、精神医療、そしてカウンセリングの場で、言葉の重要性を忘れてはいけない。例えば、現在では、「I am now feeling depressed because I forgot to take my umbrella today」のようにとてもカジュアルに使う。
 雨が降ってきたのに傘がないことをdepressといえるかもしれない。でも、クリニカルの現場から見ればそれはunhappyというべきではないか。Unhappy does not mean being depressed, being depression is not unhappiness.

 この、言葉の持つ意味が、市民権を得ることで変遷していくことへの彼女の危惧は理解できます。しかしながら、depressionについては現在のように、とりわけイギリスでは偏見の壁が低くなってきたことと感じられる要因のひとつは、言葉の特異性が薄まってきているからかな、と。ただし、先のPTSDのように、日常で人々がきちんとした理解のないまま使う「PTSD」と、精神医療やカウンセリングの現場で考えられる「PTSD」との間にある溝と同様のものが、「Depression」にも当てはまるのではないかと考えます。ドロシィは以下のように続けました。

Our language creates reality. Be aware of the importance of language.

 レクチャアの後半に、ドロシィは心理ケアの場でそのケアを提供する側にいる心理学者やカウンセラーが常に配慮すべきであろう点をいくつか挙げました。

Treat a patient/ client as a human being. Do not assume what you can see is not the same what your patient/ client is seeing.

 そして心理ケアの場で大切なことのひとつは、コミュニケイションを生み出すために、どのような質問がされるべきなのか。

Do you like yourself?
Do you care of yourself?
Do you value yourself?
How do you judge yourself?
How did this happen? Why did this happen?


 言わずもがなですが、このような質問を心理学者やカウンセラー側の都合で矢継ぎ早にするべき、またはしても差し支えない、ということではありません。このようなとても簡便な、でもいざしようとしてもタイミングが難しいこれらの質問をどうして自分がするのかを理解するために考えておいてもいいことは、

Thinking about the importance of what you are listening for? Why is it important to your patient, not to you? By Dorothy Rowe.

精神医療啓蒙ポスターの一例

2011.04.14
知的財産権、著作権を悉く無視しているので、絶対に転載しないでください。場合によっては削除もありえます。



 2010年秋から参加している精神医療のワークショップで出された課題の一つが、ポスター製作。パブリッシャーと格闘することトータル10時間。嬉しいことに、かなり高い評価をもらえました。このような感じのポスターが日本でも普通に受け入れられるようになればとの希望を込めて。

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