State of the art speaker at ESCAP 2017 – Professor Sartorius’ fight for the improvement of child psychiatry
A question like “What is the way of securing continuity of care?” is typical for professor Norman Sartorius. He is the Nestor of those psychiatrists who are – in his words – “fighting for a better world”. Dr Sartorius founded Action for Mental Health (AMH), the Association for the Improvement of Mental Health Programmes, because he thought that some important issues in psychiatry were undervalued and did not get the deserved attention.
After a long and successful career of researching and teaching at the Universities of Zagreb, London, Geneva and other, and leadership positions at the United Nation’s World Health Organization (WHO) and the World Psychiatric Association (WPA), Dr Sartorius now devotes his energy – and certainly his heart – to policy matters around psychiatry that he finds indispensable in the fight for a better future.
Keynote in Madrid
Sartorius’ Action for Mental Health returned to child and adolescent psychiatry in 2014 by playing a key role in the organization of the youth mental health coference, titled: ‘From Continuity of Psychopathology to Continuity of Care’ (Venice, December 2014) and of course by his brilliant, eye-opening keynote lecture at the ESCAP Congress in Madrid (June 2015). Norman Sartorius returns to the ESCAP Congress in 2017 as a state of the art speaker on Comorbidity of mental and physical illness: a major problem for the medicine of the 21st Century (view Box 1 on the bottom of this page).
Action for Mental Health:
three main topics
Norman Sartorius: “After I finished my term of presidency at the World Psychiatric Association and the Association of European Psychiatrists, I saw numerous opportunities to address important but neglected problems. Thus our Association concentrated on three of those topics: the comorbidity of mental and physical illness which we feel is a growing problem particularly in the older age, but in fact at all ages. The second topic is on stigma, a follow up of the Open-the-Doors Programme that I launched during my time at the WPA and the third programme is directed at the provision of leadership and professional skills of young psychiatrists. Fifty per cent of young psychiatrists in Europe are scoring high on the burnout scales and it is worse in other countries. So the question was: what can we do to help them to make progress in a healthy way? Our answer is to train them in professional and leadership skills an area of education neglected in postgraduate education. We have organized more than a hundred symposia and courses in different parts of the world that deal with the structural lack of leadership skills amongst young psychiatrists” (read more about these three projects, at the bottom of this page).
In addition to these three main lines, as time went by, Action for Mental Health has added other activities such as the participation in the global child mental health programme, set up by professor Ahmed Okasha during his presidency of the WPA and in a new programme known as ‘The Weakest Link – Strengthening Transition from Child to Adult Mental Health Services’ (STraMeHS). Coming December this ambitious project will hold a conference in Venice, specifically on adolescent and child mental health in Europe, funded by the European Community and in partnership with the World Health Organization.
Sartorius: “The initiative for this project was born in a course with young psychiatrists and it directs to a very specific problem: What is the way of securing continuity of care? Here we find at least three transitions: from paediatric care to child psychiatry, from child psychiatry to adolescent psychiatry and finally from adolescent psychiatry to adult psychiatry. These interactions can be improved by administrative interventions and education of people who do it. It will be of great interest to hear about the experience that people have in making the transition smoother and ensuring that there is a continuity of care.”
Since its founding in 2004, AMH focused on policy related issues in general psychiatry. This will be the first project with a broad view on child and adolescent psychiatry. Professor Sartorius likes to put matters into perspective and waves the importance of establishing youth psychiatry as a separate discipline. He broadly smiles as he says: “Maybe this will not make me very popular in the community of child psychiatrists, but I think that child psychiatry, like general psychiatry, has everything to gain from joining general medicine. It would be extremely important to make child psychiatrists work hand in hand with paediatricians, with general practitioners, and so on. Working as a separate discipline in fact does isolate the mental health problems from the rest. Beside that, this rigid separation of disciplines contains the risk of bringing stigma into play.”
Amount of attention
“Once we have accepted that mental health is just as important as the physical health, one would hope that – even in places where there are no child psychiatrists – children will be given appropriate attention if they have a mental health problem. Our goal should be to provide appropriate care, not to protect interests of medical disciplines.
“Children have problems. Sometimes mental, sometimes physical, sometimes both and sometimes it is not quite clear which it is. Until now the neglect of child psychiatry has not allowed people who have been trained as paediatricians or GP’s to really pay attention to mental health problems. So it is very often very late that they start paying attention to mental health problems which are often recognized much too late. And then in many cases they send the child away to see a specialist service. We have to realize at that stage that a child receives a stigma when he goes to a psychiatrist regardless of what the child psychiatrist finds. The fact that he has been sent to a psychiatrist or a psychologist may be stigmatizing. We have to think about ways of making sure that this child is helped, without stigmatizing him or her in any way.”
Changing the system
To involve child psychiatrists actively in policy matters such as the advocacy of mental health is clearly very important to Dr Sartorius. Creating conditions for better treatment and the necessary research is something that child psychiatrists should see as a priority, he says. “We should be working on changing the system rather than only helping the individual child. What child psychiatrists do for the individual child is clearly very important and immensely useful. But what they should be doing in addition, is asking themselves: How could I influence the training of medical students? How could I start convincing the government that children also have mental health problems? Child psychiatrists should become advocates for a greater part of their time. If they would help fewer children on a day-to-day basis, they could create a brighter future for many of them. That is where the education of young psychiatrists comes in: we should not only train them about treating patients, but also about influencing politicians. They are not only doctors; they are also fighters for a better future. To be equipped for that, we must spend at least a third of their education as a child psychiatrist on training for advocacy teaching them how to speak to people, how to convince journalists. These are skills that one can learn easily. Sure, there will always be a proportion that does not want to be involved in policy and that will always hide in their treatment quarters, one-on-one with the children and their parents. I accept that – let them be. But I do hope that a majority of modern child psychiatrist will wake up and see that the policies that may create better conditions for their treatment are at least as important. If they refrain from paying attention to policy formulation, they are neglecting the important ethical objective in health care, that of achieving distributive justice. Because as a group they would be concentrating an immense capacity to a very small number of people.”
“Among the most important principles of ethics is distributive justice: you must do with what you have as much as you can for everybody - not just for the selected few. By concentrating on the selected few and not entering into the field with the aim to help everybody, you are in fact not behaving as you should be.”
Real soldiers and
their chief enemies
On the step-by-step strategy that should be undertaken, Professor Sartorius likes to speak in terms of winning a war. He would wish to recruit some one fifth of child psychiatrists as soldiers who will fight to open the eyes of society to child mental health problems. “The first step should be to recruit an army of people who will speak up for child psychiatry”, he says. “And it should be the child psychiatrist investing themselves in this, not waiting for others to do it. Mind you, we have to accept that we will not be seeing results tomorrow. Whatever we do will have to be a somewhat slow, but a continuing process over a number of years. To make this army grow and be effective you will have to start with education, particularly of the newly qualified child psychiatrists but also of those currently in service, giving them opportunities to do other things beside treating individual patients. They need time to learn new things, not always medical matters, and they need to learn and understand the mechanisms of policies around their profession. Not everybody will do it, okay. But if only twenty per cent of child psychiatrist for twenty per cent of their time were to become fighters for the acceptance and development of child and adolescent psychiatry, in general medical education and in society, this would be an immense progress.”
Easy ways to help
millions of children
“Here you should also keep in mind that many of the children that receive no treatment at all today, suffer from problems that are easy to treat. Many of us spend an enormous amount of time on treatments that have a significant but relatively minor effect. Let us look more at problems that are less significant but enormously frequent.”
“Let us take Pakistan as an example. If you take a look at the eyesight of the tens of millions of children that live there, you will see that ten to fifteen per cent have less than fifty per cent vision in one or both eyes, for a corrigible reason. In other words: if you give them glasses, they will be for a hundred per cent corrected. A pair of glasses will now cost less than a bottle of Coca Cola. Mass printed, plastic glasses that don’t break and that are cheap. At present most of those short sighted kids are at high risk of becoming drop-outs from their schools. They end up in the streets. And they also end up as being considered mentally retarded because uncorrected poor vision prevented them to follow school and they are not given a chance in life.”
“So if child psychiatrists were to insist that teachers ask the children to read a few letters from a distance of two meters, and tell those that cannot read them to go and get glasses, they would make life different for millions children in Pakistan. And we could give you hundreds of examples like this. Some of them everybody can do, others depend on specific skills. What can and should be done varies from one setting to another. Global policies are generally of little use. Child psychiatric fighters for a better world should therefore look at the situation close to them: what will have a maximum effect in a minimum amount of time? This could be very different from one country to another and from one region to another. It is important to get on with it because we need examples that will show what can be achieved. Examples will convince people to also do something.”
ESCAP: army unit of
“ESCAP could contribute to this by producing a consensus document about a well-balanced training for child and adolescent psychiatrists. ESCAP should ask itself: what knowledge is necessary? Not only for child psychiatrists, but for varied types of personnel that are involved in children’s mental health. ESCAP could be the army unit of knowledge logistics, and should not share this knowledge only internally. Not in isolation, but in collaboration with allied professions, parents and everyone involved. What should the teachers know about child psychiatry? What should the nurses know? Not the nurses in psychiatry, but the general nurse! What should the nurse do when a child is in a state of anxiety? And so forth. As a first step this will take five years or more, so you will be busy at ESCAP!”
Dr Sartorius: “Little is done about comorbidity of mental and physical disorders. It is becoming gradually recognized as being a problem, but that is going very slowly. We have now published nine books on that looking at different aspects of comorbidity: schizophrenia and physical illness, depression and cancer, depression and diabetes, depression and heart disease, et cetera. The public health significance of comorbidity is enormous. People with mental illness die sooner, and comorbidity worsens the prognosis of all the diseases present. There is no service that is currently dealing with these problems in a good way. There is a lot of uncertainty on who should take the primary responsibility. General practitioners often do not want to treat mental illness, diabetologists do not know about psychiatry, psychiatrists know little about internal medicine… The problem grows along with the fragmentation of medicine into numerous sub-disciplines. Everybody is dealing with diseases in their speciality but there are very few dealing with all the problems that a patient may have.”
Dr Sartorius: “As society becomes more open en more knowledgeable, you would expect the stigma of people with a mental illness would diminish. But this assumption was not confirmed by recent studies. In fact stigma in most parts of the world even in highly developed countries is growing and getting more severe. There are many reasons for this. One of them is that by and large most jobs require more and more sophistication. So the ones who are impaired in one way or another are less able to perform well in a job. Also, people are afraid of dealing with the mentally ill because they have no competence in dealing with them.”
What could be done against stigma concerning children and adolescents?
“Probably the most powerful and maybe the only way to diminish stigma is social contact. Contacts with people for instance that have experienced mental illness themselves and with whom one can speak about it can have a very positive effect. Boys and girls in schools will be amazed if somebody comes along and tells them the story of his life. Telling these stories in a manner that is appropriate to them, will make children change their opinions. And not only that: they will take this story home and they will insist that their parents change their opinion: “Look mummy and daddy, I have spoken to someone today who suffers from epilepsy or depression… He looked perfectly fine. There’s no problem with him and I now understand what his illness is about.” So a single contact could already be very helpful.”
“The other thing one could do is to ‘build in’ the anti-stigma activity in the normal occupation or preoccupation of children. You can’t give them an abstract talk about stigma. They will not understand. But you can very well teach them how to be more friendly and more accepting to people with disabilities. Whether it is a mild mental disturbance or somebody who is not very clever in one thing, but plays football very well… They will gradually start seeking what is positive in a person, instead of seeing what is negative.”
How could ‘social contact’ do good to children with autism, since social contact is mostly part of their problem?
“Children with autism of course are not necessarily the best communicators. They frighten children away because they seem to be different from them. But here too, perhaps starting in a slower pace, we have to make children accept that not everybody around them is the same. Some speak a great deal and others do not. They should learn thus the fact that someone is shy does not mean that he is bad or without value. Teaching children and to accept those that are different is important but neglected. Even young kids of six years old can learn to accept the disability in others. To them, their distinction between good and bad or between healthy and not healthy depends on what their parents and teachers tell them. They do not have a concept of mental illness. If you tell a child not to play with someone because he is a Muslim or a Sikh or different from the average, they will not play with them. If we help them to accept others this will help a great deal to open the door to a more intensive programme against stigma. It important here not to focus education on how to recognize a certain disability, but on what to do when you meet someone with a disability.”
Dr Sartorius: “Most psychiatrists have poor leadership skills and postgraduate training does not make them acquire them. If you ask a young psychiatrist: Has your boss asked you to make a presentation of your paper for the next congress before the department, so that you can be corrected and improve your presentation? Have you learned how to speak on television or how to write a proposal for funding? Have you been trained how to present yourself in an interview for a job? Is there any training to write your curriculum vitae? How to produce a poster? All these skills are elementary and you can learn them quite quickly. But there is little attention given to post-graduate training. So outstandingly able young people ruin their reputation by making lousy presentations, by making poster that nobody wants to look at, they don’t even know how to introduce themselves to others. These are very simple skills that may be provided in a couple of days. And they are essential in everybody’s career. If you offer young psychiatrists an opportunity to acquire such skills they are delighted – it is not that they are more shy or introverted than others.”
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