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Letter to the editor
What does ‘a Multidisciplinary Approach’ Mean in British Psychiatry?
I am pleased about having this opportunity to share some of my experiences as a psychiatrist practicing in Great Britain with my colleagues in South Korea. I am aware that my professional background as a psychiatrist could give readers the impression that I am limiting my topic to psychiatry only. However, this is not the case because psychiatry and its development in Great Britain can not be discussed without considering its involvement with other mental health professions and public services. Interestingly, this issue may provide a good starting point to explore the differences in the mental health services between Great Britain and South Korea. It is not my intention here to focus on the differences between the two countries in detail, but I will briefly compare the two different systems for the purpose of providing brief overview of the current situations, especially in relation to the issues associated with the multidisciplinary approach. I would reiterate though that there are more similarities than differences in the methods used to help those who suffer from mental illnesses.
As mentioned earlier, in my view, psychiatry in Great Britain is closely related to other disciplines. In other words, psychiatrists are always ready to work with other professionals. It is my impression that in Britain, psychiatrists often find it impossible to work without support from other agencies such as social services, housing department, schools, etc. When I first started my psychiatric practice in England, one of my greatest difficulties I faced with was to understand the different roles of each mental worker and service. For example, during the first psychiatric seminar I attended at Tavistock Clinic in North London, the term ‘social services' was mentioned more than a hundred times. It took me years to grasp all the different meanings associated with this particular word. It was also difficult to accept the fact that psychiatrists did not spend the majority of their time working directly with patients, their parents or their families. This was because my previous understanding of the role of a psychiatrist was to make a diagnosis, prescribe medication, and decide on his or her patient's admission. These basic role is probably the same in both countries but the way psychiatrists approach clinical as well as managerial matters in Great Britain is often completely different. For example, it was not considered that the role of a psychiatrist included communicating or coordinating with other services when I worked in Korea in 1990's and my conversation with my colleagues in South Korea over the last seven years indicates nothing has changed significantly in this area. Involuntary admission is one of the areas where there are numerous differences between the two countries. In Great Britain, detaining a mentally ill patient is quite complex and requires a legal procedure. When I worked in Korea, it was comparatively simple to lock up patients against their will and the procedure involved did not need a social worker who was specially approved by the government. In Great Britain, it is the approved social workers who hold the legal power to decide on the detention of a patient with recommendations from two approved psychiatrists. These approved social workers also play a role as patients' carers. They collect bills which are posted to the patients' empty properties if patients have no family and deal with some practical issues on the patient's behalf. The social workers sometimes have to find cares who look after patient's children. In this context, psychiatrists and social workers in Great Britain are in a relationship to discuss how to support patients before and after their discharge let alone manage their psychiatric symptoms. In the past, many British psychiatrists asked me how Korean psychiatrists operated without social workers. I answered that Koreans often had an extended family who was more than willing to give support for their relatives. However, nowadays, I wonder myself for how long Koreans will be able to cope without any formal statutory support.The issues pertaining to multidisciplinary approach become even clearer in the practice of child and adolescent psychiatry. In England, it is accepted as ‘standard practice' for child psychiatrists to work in conjunction with school teachers, who often hand over medication to patients in school. Young students who have difficulty concentrating often receive extra support from their school and are allowed to have more time for certain exams, thanks to their teachers knowledge about their clinical conditions. Clinical psychologists, child psychotherapists, and child psychiatrists exchange their opinions and psychiatrists are often asked to listen to other professionals' particular concerns. However, it was not my impression during my recent visit to Korea that there was always a line of communication open between psychiatrists and other professionals.
I suspect this lack of communication is rooted in Korea's culture and tradition rather than in its training, medical insurance system, etc. One of interesting episodes in my career as a trainee psychiatrist in England was that I was really shocked when my English consultant served a cup of tea for me on the very first day of my training. We were sitting on similar chairs, calling each other by our first names. It was a little bit weird but made it easier to communicate with her and it was convenient that English language did not require me to use a particular way of speaking to my boss (!). This less hierarchical setting helped me get on with other professionals in the team. In fact, all of the psychiatrists including myself formed just one group of discipline in a big community mental health team, not superior nor inferior to other disciplines. Everybody felt free to speak their views and each person was well respected. It was what they said, not their badges or positions, which mattered. Looking back on my training and experience as a consultant in general adult psychiatry in Korea, I feel that we functioned in a much more hierarchical system and I believe this is still the case. One of the reasons for this phenomenon is that our interactions are based on Confucianism as a belief system. Since a long time, Confucianism has been widely accepted both consciously and unconsciously and it affects the way how people interact with each other. Therefore, we naturally expect other people to behave in such a way. When some people resist employing this belief system, they are often marginalised and bullied both at home and at work. Having a hierarchical structure sometimes helps us save a lot of time and allows teams to work more effectively and quickly. However, it also has many disadvantages. One of them is the failure to communicate and this often results in patients being neglected and misled.
Personally, I do not see the hierarchical system as a ‘problem' to be fixed. It is my strong view though that some mental health services that Koreans are trying to import from Western countries do not fit in with their culture and, consequently, these services will fail sooner or later. It is often helpful for improving the quality of care and developing new services to explore differences in each system and try out new systems with regular reviews. Therefore, Korean psychiatrists will be better able to contribute to the development of Korean mental health services if they had more opportunities to see and learn new ideas and skills by having their own experiences of working in other countries.

Dr. Ieehyok Woo, MD
Specialist Registrar in Child and Adolescent Psychiatry

Kingston Child and Adolescent Mental Health Service
Woodroffe House Tolworth Hospital, Red Lion Road, Tolworth Surrey KT6 7QU, UK

E-mail: wooieehyok@msn.com


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