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Article  in  Australasian Psychiatry · June 2009

DOI: 10.1177/103985629901700303

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CORRESPONDENCE
The doctrine of integration in
psychiatry and the pre-Socratics
DEAR SIR,
It always takes a measure of courage to
speak against the trend of the group,
as Michael Plastow has done in his
analysis of the question of ‘integra-
tion’ in psychiatry.1
As Plastow states, ‘‘The move towards
Australas Psychiatry Downloaded from informahealthcare.com by Austin Hospital on 09/12/12
integration in psychiatry has become
so accepted, so implicit and so preva-
lent that it is difficult to question’’.
Plastow not only risks challenging
what has become a kind of psychiatric
orthodoxy, but he also offers an ana-
lysis that is lucid, cogent, and compel-
ling. Perhaps because of his apparent
wide knowledge of philosophical
thought, Plastow brings a grasp of
conceptual logic to a discourse which,
For personal use only.
at least in psychiatry, is more often
than not characterized by the absence
of rigorous analysis.
This absence is epitomized in the
misuse of Descartes philosophy that
Plastow draws attention to. As he says,
Descartes is often condemned as ‘‘the
root of all evils that plague psychia-
try’’. The philosophical mind/body or
mind/brain problem lies at the heart
of the difficulty of integration in psy-
chiatry, and it has become common-
place in the psychiatric literature to
somehow attribute the existence of
the conceptual division of ‘body’ and
‘mind’ to Descartes, who is held re-
sponsible for creating a dualistic mis-
representation of reality. There is no
recognition of the fact that a dualistic
experience of reality is inherent in the
human condition; it would seem to be
an inevitable consequence of the
development of human self-awareness
and the capacity for self-reflection.
As Plastow suggests, Descartes is set up
as a ‘‘straw man who can then be
burned on the pyre . . .’’. Having sum-
marily dispensed with Descartes, these
authors usually proceed to offer an
‘integrated’ view, based on the claim
that neuroscience has somehow
solved the problem, and that the con-
ceptual gulf between physical pro-
cesses in the brain and mental
processes in the mind has miracu-
doi: 10.1080/10398560902866625
# 2009 The Royal Australian and New Zealand College of Psychiatrists
lously disappeared. Almost invariably,
they proceed by assertion rather than
the construction of an argument. Of-
ten there is nothing to suggest any real
acquaintance with the literature of the
philosophy of mind, let alone any
familiarity with Descartes thinking.
REFERENCE
1. Plastow M. The doctrine of integration in psychiatry
and the pre-Socratics. Australasian Psychiatry 2009; 17:
1
5.
Paul Schimmel
Sydney, NSW
DEAR SIR,
Michael Plastow’s provocative critique
of the ‘doctrine’ of integration in
psychiatry1 rightly appeared under
the section heading, ‘Viewpoint’.
Whether one sees the wood or the
trees
or both
is certainly a matter
of viewpoint. Wholes consist of parts
and to see the whole is not to devalue
the parts. Indeed at my time of life, the
parts, as they steadily drop off, are
sorely missed by the diminished
whole.
It makes a parody of the goal of
integration in psychiatry to conflate
it with a mystical Platonic, or Neopla-
tonic, concept of a Oneness in which
all division is abolished. Nor, I believe,
does Plastow do justice to what Plato
meant by Idea (or Aristotle by Form).
True, Aristotle’s definition of the Soul
as the Form of the Body might today
be more usefully translated, ‘‘Mind is
the Pattern of Neural Activity’’. We
could add that subjective experiences
represent variations in the pattern. On
this issue, I commend the Canadian
philosopher Albert Shalom. He ques-
tions the Body/Mind framework and,
after 500 pages of exploring the age-
old issues, in a surprise ending comes
out as an Aristotelian.2
Dare we hope, though, that in ques-
tioning integration Plastow was con-
cealing a subtle and truly Socratic
irony? The poet Sappho, whose dates
are impeccably pre-Socratic, well un-
derstood irony when she hymned
another abstraction, perhaps over-
valued: 3
Virginity! Oh my virginity!
Where will you go when I lose you?
I am off to a place I shall never come
back from.
Dear bride, I shall never come back to
you. Never! (p.32)
REFERENCES
1. Plastow M. The doctrine of integration in psychiatry
and the pre-Socratics. Australasian Psychiatry 2009; 17:
1
5.
2. Shalom A. The Body/Mind Conceptual Framework and
the Problem of Personal Identity. Atlantic Highlands:
NJ. Humanities Press International, 1985/1989.
3. Sappho BM. A New Translation. Berkeley and Los
Angeles: University of California Press, 1958.
John Parkinson
Wollongong, NSW
The Adolescent Intensive
Management Team
DEAR SIR,
A 100% retention rate of adolescents
with complex social, emotional and
mental health needs, described in a
recent article in this journal,1 is im-
pressive. The authors state that such a
high score is possible in a flexible and
multi-system approach to service pro-
vision. I work with Evolve Therapeutic
Services (ETS) in Logan, Queensland.
ETS is a state-wide service that, simi-
larly to the Adolescent Intensive Man-
agement Team (AIM), caters for
children of high risk, with complex
needs and emotional and behavioural
disturbance and often also the diag-
nosis of formal mental disorders. ETS
is different from child and youth
mental health services (CYMHS) in
the way that all our clients have to
be in the care of the Department of
Child Safety.
I am used to working with the most
difficult multi morbidity CYMHS cli-
ents and I am aware how difficult it Australasian Psychiatry . Vol 17, No 3 . June 2009
can be to engage them. Thinking of a
service like ETS, or AIM, I would not
have expected a 100% rate for involve-
ment. The usual length of involve-
ment of our service is for at least an
assessment period which rarely lasts
less than 3 months; often we see the
clients for more than 1 year. ETS
clinicians also have a relatively low
caseload of six clients. Not infre-
quently, we have to work very hard
to keep the clients involved.
I notice in the paper that at the start of
AIM the minimum involvement was
245
 stipulated for more than 6 months.
The authors state that involvement
ranged from 1 month to 32 months.
Mean duration was 9 months. Further-
more, the authors state that at the end
of March 2004, 20% were recent
referrals that had been seen for up to
3 months, 25.7% for 4
6 months.
I would be curious to learn more about
the clients at AIM that had the briefest
involvement (i.e. less than 6 months)
and in particular the client that was
involved for 1 month only. I would be
curious to learn why this client and
the other clients were closed to AIM
prior to the stipulated 6 months.
Although I feel very enthusiastic about
the data presented, to my mind the
data presented as they are do not
Australas Psychiatry Downloaded from informahealthcare.com by Austin Hospital on 09/12/12
necessarily suggest 100% involvement
with AIM. I wonder whether it would
be possible to obtain more informa-
tion about the clients and individual
presentation, particularly the client
that was involved for 1 month only.
It might be a welcome addendum to
confirm that criteria for involvement
have not been changed for clients
while involved with AIM.
For personal use only.
REFERENCE
1. Assan B, Burchell P, Chia A et al. The Adolescent
Intensive Management Team (AIM): an intensive out-
reach mental health service for high-risk adolescents.
Australasian Psychiatry 2008; 16: 423
427.
Klaus Martin Beckmann
Logan, QLD
RESPONSE
It is pleasing to know that there are
similar services to ours attempting to
work with this challenging group of
young people. As suggested, there are
Australasian Psychiatry . Vol 17, No 3 . June 2009
differences with your service. All our
clients are referred internally from the
CAMHS community outpatient and
inpatient teams and therefore are
familiar to our service. As a voluntary
service, the young person or their
carer also has to agree to our involve-
ment.
Statutory clients like the ones you
mainly see, present an extra set of
challenges. They often feel under dur-
ess to engage with services. This group
make up less than half (42%) of our
sample. Similarly, they tend to have
the longest involvement with us.
246
Our focus with this group is to put our
energy into containing the systems
that are involved with them. We see
our role as working to generate a
therapeutic response from the systems
surrounding the young person. These
systems may include school liaison,
family work and parental/carer sup-
port, including after hours phone con-
tact and training. We have given this
approach the working name of Inten-
sive System Therapy (IST).
Referrers are required to provide a
service plan indicating potential areas
for the AIM team’s attention, with the
agreement of the client and/or carers.
All separations from the service during
the study period were negotiated. The
stipulated time of involvement stated
in the paper is the maximum duration
and not the minimum. As stated, our
experience shows that most of our
clients needed more time with the
service.
Brief intervention is usually because
AIM has been involved to support a
transition. For example, a client with a
1 month involvement required sup-
port for transition to school following
a considerable stay in the residential
unit. A planned, gradual and graded
time at school in consultation with all
parties, as well as intensive work with
school and family and availability to
school for a prompt response if there is
crisis resulted in a successful return to
school.
To appreciate the level and flexibility
of involvement, it is important to note
that this involved pick up from home
to transport to school several days a
week. A successful return to school led
to easy transfer to the regional out-
patient team.
There was no change in the criteria,
which are very clear and specific.
Ben Assan
Melbourne, VIC
Recruitment and retention of
psychiatrists in a rural health
service
DEAR SIR,
We wish to advise readers of Australa-
sian Psychiatry of a study undertaken
to identify the positive and negative
factors that influenced the recruit-
ment and retention of psychiatrists,
the majority of whom were interna-
tional medical graduates (IMGs). A
literature review showed that there
was little information on psychiatrist
recruitment and retention or IMG
education programs. However, the
limited evidence did indicate Australia
was dependent on IMGs as an essential
component of the medical workforce.1
The study was undertaken in 2005 at
Latrobe Regional Hospital (LRH), a
rural health service located in Victoria.
LRH provides mental health services
across 40 000 square kilometres and a
population of 220 000. Prior difficul-
ties had been experienced in the
recruitment and retention of psychia-
trists.2 By 2005, the situation was
vastly improved with the equivalent
of 11 full-time psychiatrists employed.
Approval of the study was obtained
from the LRH Human Research Ethics
Committee. Psychiatrists employed by
LRH since 1994 were contacted and
invited to participate in individual
semi-structured interviews undertaken
by an independent research assistant.
Factors were identified from the inter-
view transcripts and grouped into
broad themes. This allowed focus on
areas requiring improvement and re-
inforcement of other areas with posi-
tive results.
Of a possible 21 psychiatrists, consent
was received from 14 (67%). From the
remaining seven (33%), there was one
(5%) who declined to participate,
three who were not able to be con-
tacted (14%), one (5%) who was de-
ceased and two (9%) who did not
return completed consent forms.
While the small sample and general-
ization of results does impose some
limitations on the degree to which
these findings can be applied, the
findings nevertheless highlight key
factors that influenced the psychia-
trists’ time at LRH.
Feedback was sought on the initial
contact that psychiatrists had with
LRH prior to their commencement.
This was generally perceived very po-
sitively. Regular contact and prompt
responses were common themes. Clear
communication was felt to result in
visas and medical registration being
organized quickly and without diffi-
culty.
Participants were asked about the time
immediately following their com-
mencement at LRH. The most com-
mon issue of concern raised by four
participants (28%) was a lack of cross-
 cultural issues being addressed. It was
indicated that more time on these
issues would lead to an easier transi-
tion into the Australian workforce.
More information on Australian rural-
ity, community psychiatry and the
role of the psychiatrist within the
Australian service model was also felt
to be required.
The results highlighted the need for a
comprehensive and thorough orienta-
tion program with eight (57%) parti-
cipants identifying a strong theme of
inadequate information. Suggestions
on improving orientation included
staggering orientation, a cross-cultural
focus, explanation of case manage-
ment, overview of the Australian legal
Australas Psychiatry Downloaded from informahealthcare.com by Austin Hospital on 09/12/12
system, introductions to senior staff,
restricting driving requirements and
debriefing after the commencement
of clinical work.
Professional support was rated as pre-
dominately ‘average’. This can be seen
as indicative of the requirements of a
predominantly IMG workforce work-
ing diligently to achieve Fellowship
with the RANZCP. Combined with
the degree of isolation associated
For personal use only.
with a rural based service, significant
room for improvement was identified.
A key initiative resulting from this
study was the development of the
LRH Psychiatrist Training Initiative,
an educational program described in
more depth in Haines and Oakley
Browne.3
Two main themes emerged when
participants were questioned about
improving professional support. Net-
working and external professional de-
velopment received a response rate of
64% (nine participants). Attendance at
external courses or conferences, visit-
ing other services and observing other
psychiatrists’ clinics were identified as
areas that would improve professional
support.
The second main theme was related to
peer supervision, with five (36%) par-
ticipants identifying that this could be
improved. Suggestions included devel-
oping peer review circles, timetabling
of peer review, and peer review being
prioritized within professional devel-
opment.
Participants were then asked to pro-
vide an overall rating of LRH and
identify positive and negative experi-
ences. Results varied considerably.
Three participants (21%) rated LRH
very highly, indicating that they were
very happy with their time at LRH. A
further four participants (28%) indi-
cated that their opinions over the time
varied, mainly due to changes in se-
nior staff. A further seven participants
(50%) rated LRH as average.
The study identified positive and ne-
gative aspects impacting on recruit-
ment and retention at LRH. It led
to increased importance being given
to the orientation program, cross-
cultural issues, peer supervision and
peer review programs, professional de-
velopment activities and external net-
working.
REFERENCES
1. Barton D, Hawthorne L, Singh B, Little J. Victoria’s
dependence on overseas trained doctors in psychiatry.
People and Place 2003; 11: 54
64.
2. Wilks C, Oakey Browne M, Jenner B. Attracting
psychiatrists to a rural area
10 years on. Rural
and Remote Health 2008; 8; 824. Available online at:
http://www.rrh.org.au/articles/subviewnew.asp?Article
ID824.
3. Haines M, Oakley Browne M. Developing an educa-
tional framework for international medical graduates in
rural psychiatry: The Psychiatrists Training Initiative.
Australasian Psychiatry 2007; 15: 499
503.
Catherine Wilks, VIC
Maryellen Haines, VIC
Mark Oakley Browne, VIC
Designing a referral form
DEAR SIR,
General practitioner (GP) referral of
patients for specialist opinion or care
is common. The latest BEACH study
(2004
2005) reported that patients
were given at least one referral in
10.9% of all GP encounters.1 This
same study reported that referrals to
psychiatrists and psychologists com-
bined accounted for 4.8% of all refer-
rals.1 This rate will no doubt have
risen in light of the recent introduc-
tion of the Better Access to Psychiatrists,
Psychologists and General Practitioners
through the Medicare Benefits Schedule
by the Australian Government in late
2006.
Referrals between GPs and specialist
are of a written form. Referral letters
containing clear and relevant informa-
tion are of great importance in deter-
mining the most appropriate section
of a service for the patient, the struc-
ture of the assessment and patient
management. A high-quality referral
letter may save time for clinicians and
patients, reduce unnecessary repeti-
tion of diagnostic investigations, and
help to avoid patient dissatisfaction
and loss of confidence in medical
practitioners.2 Furthermore, it aids
mental health practitioners prepare
for the assessment, facilitating both
the systematic collection of clinical
information and helping the pattern
recognition process that takes place in
clinical decision-making.3
In a quality assurance exercise con-
ducted by the Inner South East Pri-
mary Mental Health and Early
Intervention Team (PMHEIT) in Mel-
bourne, a new referral form was
devised for the service. The PMHEIT
is a service that works closely with GPs
in providing mental health assess-
ments to provide diagnostic clarifica-
tion and treatment recommendations
for anxious and depressed patients.
The assessment is mostly a ‘one-off’
clinical interview, and it is thus of
upmost importance that the referral
letter from the GP provides pertinent
patient information in order to guide
the focus of the assessment.
Psychologists and psychiatrists at our
Area Mental Health Service were
posted information outlining this pro-
ject, a consent form, and a question-
naire asking ‘‘When receiving a
referral for a one-off psychiatric assess-
ment, what are the key pieces of infor-
mation you would like to know?’’.
The questionnaire had potential for
10 responses. Subsequently, we de-
signed a new GP referral form based
on the above responses.
A questionnaire, along with the re-
designed referral form, was posted to
the top referring GPs to the PMHEIT
service, asking three questions:
Australasian Psychiatry . Vol 17, No 3 . June 2009
1. Do you think this form is func-
tional? Please list reasons why or
why not.
2. What suggestions do you have for
improving the form?
3. Do you have any other com-
ments?
Thirty-five psychiatrists and 19 psy-
chologists were approached for their
views on items of importance in refer-
ral letters from GPs. Thirteen psychia-
trists (37%) and 10 psychologists (53%)
responded to the mailed questionnaire.
Their responses were analysed thema-
tically.
247
 A new referral form was designed
(available at www.tinyurl.com/3n5
tyr), based on the psychiatrists’ and
psychologists’ feedback. The layout/
style of the form was designed to
maximize GP responses to important
items, with the use of tick boxes and
logical information flow.
A copy of the form was sent to the top
20 referring GPs to the service for
feedback. Twenty GPs were selected
based on the referral of greater than
three patients over the course of
1 year, one GP had moved, and nine
(47%) responded. The majority of GP
comments were positive. Representa-
tive critical comments were ‘a bit
busy’, ‘small spaces’ and ‘the form is
Australas Psychiatry Downloaded from informahealthcare.com by Austin Hospital on 09/12/12
of no value to GPs if not compatible
with medical software’. We acted upon
the suggestions received.
In summary, we were keen to re-design
our referral form as on review of our
previous, less structured form, there
was often important information
missing. As part of the process we
involved psychiatrists, psychologists
and GPs.
We have extended upon previous stu-
For personal use only.
dies by including psychologists and
gathering opinions from GPs. In addi-
tion, we have expanded the desired
quantity of data on referral in an effort
to design a comprehensive referral
form for use in the Australian context.
For ease of completion, the paper
Australasian Psychiatry . Vol 17, No 3 . June 2009
248
View publication stats
version of the referral form was kept Fiona Foley
to one page in length and the form is Melbourne, VIC
also available as a Medical Director
template. To encourage the referrer Rob Selzer
to consider important issues and to Melbourne, VIC
aid completion, the form contains
numerous tick boxes. Michael McGartland
Melbourne, VIC
The form is now in use and we have
had positive comments from staff
members receiving referrals about its Ode to the Committee revising
ease of use and utility. Indeed, other
parts of the service are now using the
DSM IV
form. We believe that the form will be
a ‘living’ document, able to be chan-
ged at regular review. We encourage
other services to develop referral forms
It is my wont to wonder why
drawing on the opinion of end-users.
The biopsychosocial cry
We are grateful to Terry Murphy from Has blitzed the field and by and by
South City GP Services for producing Come to eclipse biology.
the Medical Director template, and Thus ‘‘psychosocial’’ seems to be
Beyond Blue for their support of the The essence of PT-SD
research.
Socio this and psycho that
Is not where trauma’s really at
And so, physicians, let’s agree
REFERENCES
The prime place of biology:
1. Britt H, Miller GC, Knox S et al. BEACH (Bettering the A toast! A New Year’s resolution

Evaluation and Care of Health)
General Practice
Activity in Australia 2004
2005. General Practice
‘‘Zoology and evolution!’’
Series 2005; 18: 92
93.
And pray the APA may settle
2. Tattersal MHN, Butlow PN, Brown JE, Thompson JF.
Improving doctors’ letters. Medical Journal of Australia The ungrasped psychosocial nettle.
2002; 177: 516
520.
Paddy Burges Watson
3. Roter DL, Hall JA. Doctors Talking with Patients/
Patients Talking with Doctors: Improving Communica- Kettering, TAS
tion in Medical Visits, 2nd edn. Westport, Connecticut:
Praeger Publishing, 2006.