In different ways, China, Vietnam and Laos have undergone major social, economic and cultural changes. Traditional values are being questioned or are disappearing, and new social values and structures have not yet been established. Despite significant increases in the wealth of the population, particularly in the cities, there have been simultaneous increases in uncertainty and in stressful living situations for a large majority of the population. As a result of these social upheavals, psychological and psychosomatic disorders and problems are on the rise [1–5].
In Southeast Asia, 11% of disability-adjusted life years and 27% of years lived with disabilities are the results of neuropsychiatric disease . Depression is the largest contributor to this disease burden . The majority of the patients who suffer from common mental disorders (CMDs), such as depressive and anxiety disorders, seek help in primary care . The point prevalence of CMDs in South Asian primary care practices varies between 20 and 45%. A review of 8 epidemiological studies of common mental disorders in South Asia showed that their point prevalence in primary care was 26.3% (95% CI, 25.3%-27.4%). Less than one third of clinically significant CMDs are recognized [6–9]. The resulting chronicity causes severe burdens on the affected families and on the health system.
In contrast, East Asia, particularly in China, has a health system that is based on high-tech Western medicine. Due to missing or insufficiently developed health insurance systems, only patients with sufficient incomes can afford this extremely expensive care. To a limited extent, the poorer classes also make use of Western medicine; however, to a large extent, they also resort to traditional medicine. Basic care is lacking for common mental and psychosomatic disorders and problems, and this care is not adequately addressed by traditional medicine. In the current medical education systems in China and Vietnam, psychosomatic or psychological content is only marginally taught [10–14]. More psychiatric education is available; however, it is taught mostly, if not always, in a biological manner, and there is a strong emphasis on psychotropic drugs and custodial care. Psychiatric resources are also lacking, which often allows the treatment of only severe cases, such as psychosis. In Vietnam, there is one psychiatrist for every 300,000 inhabitants. Only half of the eight medical schools have first-degree specialty training programs in psychiatry. Psychologists administer psychological tests and sometimes perform consultations, primarily in schools and industry [11, 12, 14]. Furthermore, education about consultation-liaison psychiatry and psychosomatics in daily clinical practice is nonexistent [9, 15]. The situation in Laos is even worse: for the entire country, there are only two trained psychiatrists in the capital, Vientiane.
It is apparent that the current medical education systems in China, Vietnam and Laos need support in different ways to develop efficient educational institutions and care structures.
From 2005 to 2008, a European-Asian cooperative project funded by the European Union was coordinated by Freiburg University (Department of Psychosomatic Medicine and Psychotherapy). The objective of the project was to support the development of psychosomatic medicine in China (Tongji University), Vietnam (Universities of Ho Chi Minh City and Hue) and Laos (University of Vientiane). In this project, a basic psychosomatic care curriculum for postgraduate medical doctors was applied. In this report, we present the results of an evaluation of the project after 3 years of implementation and describe the necessary adaptations to the respective cultures of each of these 3 countries.
Teaching and learning objectives
The theoretical basis of the curriculum is the biopsychosocial model system . This system describes the interactions among the biological, psychological and social processes that are involved, to different extents, in each disease. The content and didactic implementation of the curriculum was guided by trainers from Germany, where basic knowledge about recognizing psychological and psychosomatic disorders and problems, counseling and providing emotional support and providing referrals to health specialists are included in the training of medical students and postgraduate doctors. The objectives of the psychosomatic approach are to build bridges between the various clinical disciplines to overcome the mind-body dichotomy and to stress the importance of understanding the interactions among biology, psychology, and social factors in every patient, independent of the primary pathology that is being treated. These objectives imply both a system-based perspective and knowledge of the biological, psychological, and social subsystems and their interactions. The psychosomatic approach focuses on the doctor-patient relationship and on an integrative strategy for diagnosing and treating patients. Educating and training the somatic clinician to integrate psychosomatic aspects of medical care into his/her daily work has become a well-accepted priority for training and research.
Germany offers three levels of psychosocial medical services. The first is basic psychosomatic care, in which medical specialists (from general medicine to urology) receive training and for which they can be reimbursed by health insurance providers. The next level consists of more advanced training in psychosomatic and psychotherapeutic skills, which is open to all disciplines (e.g., general medicine, internal medicine, gynecology and dermatology). This level requires an additional two years of training beyond the usual residency training requirements. Finally, there is a third level, specialist training in psychiatry and psychosomatic medicine, both of which require five years of instruction.
Basic psychosomatic care
Basic psychosomatic care is rooted in psychosomatic medicine and has primarily been influenced by psychoanalysts and internists who emulated Balint’s approach as proposed in 1964 (Balint 1964), which stressed the integration of psychosomatic and holistic perspectives in the medical practice model. Basic psychosomatic care is not psychotherapy in primary care; rather, it is integrated, biopsychosocial treatment that includes the following advantages
The physical examination is integrated into the consulting hour. Beginning with the patient's presentation of complaints, the doctor assesses both somatic and emotional concerns. As a result, both physical and psychosocial problems are addressed in diagnosis and treatment.
Many patients do not feel as embarrassed about conversations regarding mental or interpersonal conflicts in the primary care setting as they might if referred to a mental health professional.
Conversations in the primary care setting usually occur in the context of long-standing, trusting doctor-patient relationships. Such relationships have been shown to be important factors in the healing process. Family conflicts and past crises are usually familiar to the doctor who treats the entire family. When a new conflict or symptom arises, it can be placed in a personalized context.
Objectives of psychosomatic basic care
The four targeted skills of psychosomatic basic care include the following:
Identifying stressful emotional and mental disorders and conflicts using a psychosocial anamnesis;
Promoting a helping alliance among the doctor, patient, and family members; this skill also includes identifying possible barriers on the part of the doctor, patient, or family and stressing the core skills of empathy and sensitivity;
Improving the patient’s problem-solving skills, including providing information about self-help groups, supporting the management of adverse life events (e.g., severe illness, loss, separation or divorce) and avoiding unnecessary medication, diagnostic procedures, and surgery; and
Motivating/referring patients for psychotherapy. Additional skills in this area include collaborations around consultations and case management with psychotherapists and other psychosocial service providers.
Targeted skill 1: Disease patterns
The selection of mental disease to be taught depends on the frequencies of the diseases’ occurrences in Southeast Asian countries [1, 6–9]. The following diseases have been deemed important: 1. the various forms of depression; 2. somatoform disorders; and 3. psychological reactions, such as anxiety and adaptation disorders, to severe life-threatening diseases, such as cancer. Additional modules are available with regard to anxiety disorders, post-traumatic stress disorder, addiction and dependence. Psychopharmacological treatment approaches have been integrated into the education about each disease pattern.
Targeted skills 2 and 3: Interventions
The basic therapeutic approaches integrate psychodynamic approaches, cognitive-behavioral models, systemic family therapy and communication skills, such as empathy, unconditional positive regard, and congruence, to develop good doctor-patient relationships [17, 18]. Examples of the use of cognitive-behavioral models include the vicious circle model in the area of anxiety disorders and the influence of negative thinking and avoidant behaviors in depression. In the treatment of patients with somatoform disorders, the disease model of the patient, which has traditionally focused on physical causes, is gradually expanded to include alternative concepts of illness, and the attention is refocused on potential psychosocial stressors. In systemic thinking, interactions replace reductionist notions of cause and effect.
The teaching of doctor-patient communication skills includes learning interview techniques that are both doctor-centered (setting a time frame, introducing your own themes, interrupting, and asking closed questions) and patient-centered, allowing time for the patient to talk at the beginning of the interview, not interrupting, asking open questions, offering verbal and nonverbal encouragement to keep talking, summarizing in your own words, and reflecting emotions).
An ideal method for understanding doctor-patient interactions is the Balint group, in which the focus is placed on the transference and countertransference interactions between the doctor and patient.
Targeted skill 4: Collaboration with mental health specialists
The fourth learning objective involves referrals to mental health specialists and cooperation with mental health services. Even in Western countries with well-developed support systems, these processes are not optimal. Primary care physicians have an important pilot function in the mental health care system. They must decide whether basic psychosomatic care is sufficient or expert assistance should be requested, as well as which expert is best suited to address the problem. The primary care physician should inform the patient of the need for more intensive psychotherapeutic and/or psychopharmacological treatment, should motivate him/her to accept such an offer and should refer him/her to the appropriate physician or facilities.
Guidelines and didactic implementation
The guidelines for the implementation of the new curriculum:
There is a balanced ratio of seminars, practical exercises and patient-related self-experience.
Live patient interviews provide the participants with a model for conducting interviews and interventions.
The ability to conduct therapeutic interviews and the creation of relationships are the “red thread” running through the entire training program.
The basic orientation is psychodynamic and systemic. Cognitive-behavioral techniques and the basic therapeutic attitude of psychotherapy, including unconditional positive regard and respect, empathy and the congruence of the therapist as a person, will be integrated. The family-oriented point of view will be reflected in the treatment of all problems and diseases.
The objective is the acquisition of the individual’s psychosomatic-psychotherapeutic competence for treating the emotional and psychosomatic disorders and problems that arise in the specific area of work.
Theoretical knowledge, practice in interviewing and patient-related self-experience (Balint groups) will be covered by the topics in one block.
The objective of the new curriculum is the intertwining of teaching goals with learning goals and learning content. Therefore, the following teaching methods are regularly applied.
Brief interactive lectures: This method includes practice-relevant introductions of the topics presented as PowerPoint presentations in English, with the provision of hard copies translated into the local language.
Live patient interviews, which also include the partner or family, that provide a “real-life” experience of doctor-patient communication and diagnostic-therapeutic conversations: Patients are recruited from the daily practice of the partners. The patients’ and the families’ consent (for family and couple interviews) are obligatory for these units.
Reflecting teams: Five to six participants come together to discuss their experiences during the live patient interviews and to provide emotional feedback to patients.
Role-playing to teach doctor-patient communication skills: After a short impulse lecture, two teachers engage in an exemplary role-play exercise on the topic. Subsequently, the participants practice in groups of three (doctor, patient, and observer) in alternating roles. This change of perspective facilitates the consideration of a problem or disease presentation from various angles.
Group work: Group discussions, as a didactic method of teaching, are used in small subgroups and in plenary sessions. They help to create an open climate of interdisciplinary exchange among the participants, and they provide a multi-perspective point of view of the participants’ own work. Three groups are formed prior to the live interviews, and the participants are instructed to observe the interviews with a focus on the following criteria: content, e.g., the topics that are included in the psychosocial anamnesis or the questions that are asked for the diagnostic clarification of depression; communication skills, e.g., the techniques of patient-centered and doctor-centered interviewing that are used; and doctor-patient relationships, e.g., the perceptions of the atmosphere and the level of mutual understanding, as well as the participants’ experiences, feelings, thoughts, and physical perceptions.
Video feedback: In addition to the live experience, some well-established and helpful elements of teaching include case examples of doctor patient communication, elements of the diagnostic-therapeutic process and filmed training sessions (as feedback). Ideally, these video examples are produced with local patients and doctors. Video examples with European actors can also be translated and shown. For any examples, subtitles and written translations and explanations must be prepared.
Sculpture: We use sculpture for a better understanding of the meaning of illness in a family system, in the doctor-patient relationship or among hospital staff. In the Asia-Link project, sculptures are used in the Balint groups to enable access to the complex interactions among the patient, the different doctors, the family members and the illness. The objective is to spatially depict a momentary situation to clarify the nearness and distance in a relationship. To achieve this goal, the reporting doctor selects persons from the group who are representative of the system, including himself/herself, and positions them in the room. Then, the teacher asks, “Who do you see? What do you feel while you’re doing this?” The representatives can be asked to describe their physical and/or emotional perceptions or to say words that spontaneously occur to them. The presenting doctor can also play the role of his own representative and experience this position for himself/herself in relation to the other participants. Afterwards, the representatives have an opportunity to find new positions that are more comfortable for them.
Genograms: Genograms are graphic representations of a family constellation that span several generations. They show positions in the birth order, deaths, diseases, symptoms, and other life events in a concise form and are created during medical history interviews with individuals or families.
Creating a genogram involves three steps:
All the family members and their relationships are recorded. The process begins with the children or the couple as the core family and continues with the addition of the grandparents. In total, three generations are included, if possible.
In the second step, information about the family history is added: the members’ ages, sexes, marriages, divorces, miscarriages, deaths and serious diseases, and other critical family events.
Finally, the most relevant relationships among the family members are highlighted.
Balint groups: In a Balint group, 8–12 doctors meet under the leadership of a trained Balint group leader. The presenting doctor describes the doctor-patient relationship. The participants listen to this report, provide their impressions and discuss their feelings and thoughts about what they have heard. This process results in a complex image of the doctor-patient relationship that the speaker can observe quietly and from a distance without speaking. He/she receives input for a new point of view, and blind spots are illuminated. He/she recognizes his/her effect on the patient and his/her own mode of behavior. Balint groups offer doctors a modicum of self-experience and teach them to pay attention to patients’ whole personalities, beyond their diseases. The result is that the patient and doctor are both more at ease. The Balint group is always the final activity of a course day.
All of the educational materials have been compiled in both digital and hard-copy tool books that are in both lecturer- and participant-friendly formats. Continuous updates and the ability to add one’s own materials enhance individual utility.
The training lasts one year and includes 60 hours of teaching. The 60 hours are divided into three blocks of 20 hours each.
During the first year, a team of prospective teachers was recruited for each center. The didactic elements of the new curriculum were taught to the future teachers. This was a mutual process that involved the German team teaching the teachers and adapting, modifying and redesigning the lessons within the context of the partners. Teaching the teachers served as an experimental curriculum while supporting the future independence of the partners from the assistance of the European experts. The experimental lessons followed the contents of the intended curriculum. Teaching the teachers, therefore, focused on three target areas:
teaching both the content of the biopsychosocial approach in medicine and the topics included the planned curriculum;
teaching didactic methods, strategies and skills for managing and teaching the lessons; and
adapting the teaching methods to specific contexts.
At the end of this activity, the future teachers were able to manage the pilot curriculum with the assistance of their European partners during the second year.
During the third year, the Asian partners were encouraged to organize and implement the new curriculum on their own. The results of the evaluations and the partners’ accumulated competence helped to fit the curriculum elements to the needs of the partners. The European staff provided supervision but limited their participation in teaching the curriculum (except for roles as guest lecturers on special topics). Supervisors supported the teachers’ needs in managing the courses and becoming competent trainers of biopsychosocial skills.
More information and an overview of the 3-year program, including the experimental and supervision phases, can be found in a previously published report .