Description of the sample

Nineteen doctors took part in the study, including 11ⁱⁱ in the role of a DP and 8 TPs. There were 22 interviews in totalⁱⁱⁱ. Within the DP category, five men and six women were interviewed, aged between 32 and 54 years. DPs identified themselves as being treated by their psychiatrists for the following diagnoses^iv: depression (N=8), psychosis (N=3), bipolar disorder (N=2), generalised anxiety disorder (N=1) and polysubstance dependence (N=1). At the time of initial identification of mental health needs, two had been working in psychiatry, six in general practice, three as hospital junior medical staff, one a student and one a specialist. Four changed career direction and were working in psychiatry at the time of the interviews. The length of time off work owing to mental illness varied from less than a month to 2 years.

Eight TPs were interviewed, including five men and three women, aged between 44 and 67 years. Participants' current employment at the time of the research included full time roles in either private practice or the public sector, or a mix of both. All engaged a range of strategies in their work, including some with a focus on psychotherapy.

The culture doctors work in

Both groups of participants spoke in some depth about the culture doctors work in. Medical culture, as they described it, was characterised by explicit and implicit demands for intellectual capacity, impeccable professionalism, extensive evidence-based knowledge, respect for seniority and authority and ‘perfection’ with regard to work performance. Several described poor self-worth despite high achievement beginning in childhood, and some recounted childhood patterns of denial of painful emotion. Rigorous expectations in medical school and the bullying culture of early work years were described as having strengthened patterns of self-dissatisfaction and having instilled a relentless striving for excellence. Participants reported limited room for fallibility, vulnerability or illness—and felt that they were constantly ‘up for judgment’ (TP 1), by themselves, colleagues, the wider profession and the general public. There were no apparent differences in how this was described by men and women in this study.

DPs: taking up the patient role

Given the above, DPs described taking up the patient role as confusing, at times humiliating and challenging to their identity, eg:You get into all these sorts of confused ideas about who am I and why am I doing this and what is it about…am I a professional, am I a patient and trying to hold all of that together. (DP 1)

They spoke of the importance of being ‘open and honest’ (DP 3) but also of striving to be, and be seen to be, ‘good patients’ (DP 2–5). They were concerned about being judged by another doctor, and ‘being seen as demanding’ (DP 2). Thus, they reported that they often minimised their difficulties and distress:Giving my history in an ordered way, attending appointments as instructed…I didn't want to be troublesome. (DP 5)There's wanting to put on a good face type of situation (DP 2)

In line with this, the DPs spoke of their concern for how the interaction was for the TPs. Even when they were in positions of need, DPs were trying to manage their behaviour and take responsibility for their treating doctor. For example, when the DPs shared unsatisfactory experiences they softened their criticism, often taking the blame on themselves. Typical comments included:And I suspect it was a thoroughly horrible situation for [psychiatrist] as well. (DP 6)I didn't want to appear too assertive and too knowledgeable and too threatening. (DP 3)

DPs described their professionally acquired knowledge as sometimes unhelpful in the patient role. Some expressed a view that their training had taught them to focus on diagnosis, rather than getting to know the person or hearing their story. They described knowing how to report symptoms as patients, but lacking the capacity to fully tell their stories or articulate their subjective distress. Others reported that they found it hard to bring forward personal knowledge and experience, or that ‘overintellectualising’ got in the way of effectively engaging in care:It [training] keeps you away from a feeling state…allows you to stay even more in your head. (DP 4)You end up talking about brain biochemistry to your doctor which doesn't fix the problem at all (DP 7)I wasn't listening to the cry of my heart, I wasn't listening to my pain, I wasn't listening to the truth I knew about what had happened and who I was. (DP 3)

Relationship with the TP from the DP perspective

Forming a therapeutic relationship with a professional peer was difficult for DPs. Indeed, several participants highlighted that they did not find it helpful to engage with their TP as a colleague, but preferred them to give authoritative recommendations. While some described feeling relieved when such recommendations were given, others rejected them. However, they generally did not let the TP know of their differing views, with some reporting that they appeared compliant, but then disengaged from the therapeutic relationship:[Psychiatrist] immediately made up his/her mind that it was clearly biological cause which I totally disagreed with and that was fine, let him/her talk and ramble on. (DP 7)I'm actually not going back now, that's me, I'll just get your okay to increase my prescription and say, I'm just going to go now and I'll go to my GP, (DP 6)

For some, a reluctance to voice disagreement or dissatisfaction was because they feared losing the relationship or being pathologised if they criticised their psychiatrist:Doctors don't want to know if their patients are angry with them. Doctors want to feel really good and helpful and wonderful. (DP 3)

There were exceptions to this. One DP was comfortable openly challenging their psychiatrist, as evident in the following interview extract:I said I want another option. I have no bipolar disorder…I was very clear about it. (DP 8)

Treatment experiences

DPs' experiences of being in treatment and being diagnosed as having something ‘wrong’ with them was challenging—and the research identified a broad spectrum of responses to having their experience conceptualised within a biomedical model. Some found it helpful, some moved between accepting and rejecting it, some railed against it—and others found it unhelpful:[Psychiatrist] just said ‘you're depressed’ and started me on [medication]…it was just again that huge sense of relief that I just, I'm unwell and I'm doing something proper about it. (DP 5)I went because I thought I was having a few problems. And [psychiatrist] told me I was depressed and that I needed antidepressants and I was devastated (DP 4)

While all DPs described being prescribed medication by their psychiatrists at some stage, some initially self-prescribed (often with unhelpful effects). Again, a spectrum of responses emerged. Many experienced only temporary relief accompanied by unpleasant and distressing side effects. Some became increasingly stressed and unnerved by their non-response to medication or, at worst, to the medication's exacerbation of their distress. Some experienced immediate or gradual relief, whereas one found that being off medication altogether in the context of a therapeutic environment brought healing. Examples of comments in relation to medication included:I just take it and I don't give it much thought really. Except I know they keep me well and I don't stop. I mean I realized very quickly that they worked. (DP 9)I didn't want to be a doctor. I didn't want to be a diagnosis. I didn't want to be on medication. I wanted and needed to be me…as I learned to live with myself then I kind of…this illness thing evaporated. (DP 4)

The two people in the room

A minority of DPs reported that they were able to temporarily ‘let go’ of their doctor identity, and described this as a long and painful process, and a crucial part of healing. In the following extract, one research participant describes the experience of talking openly about the anxiety they experienced in the doctor role:I'd never talked to anyone about it before in my life. I didn't know you could, thinking back, I just didn't know you could do that… (DP 10)

DPs described how much they appreciated the TP being available to them as a person, and demonstrating interest in their story. They highlighted the value of feeling safe to talk freely, the initially painful but ultimately positive experience of being able to ‘leave the white coat at the door’ (DP 4), let go of the doctor role and be themselves with their vulnerability, often more readily with a senior clinician:Not bound by ‘I’ve got to fill in my risk assessment documents and I've got to give you a diagnosis’. It just felt like, actually ‘I’m here and I'm listening to you and I’m going to do whatever I need to.’ (DP 6)

When TP's engaged in a more personal way it sometimes created anxiety or raised concerns for DPs. For example, when TPs asked about colleagues they knew in common, one (DP 5) felt concerned about adequate attention to confidentiality. Others described feeling uncomfortable when TP's were open about a lack of diagnostic clarity (DP 7) or rang them at home (DP 6).

TP's: providing ordinary care in the context of the medical culture

A recurring theme for TPs was the desire to provide ‘ordinary care’ (TP 2–5). They described working to provide the same level of intervention and professional relationship that they would for any other patient. This included screening, treating and charging DPs in a standard manner. TPs described feeling connected to DPs and aware of the risk that collegiality might compromise care.

TPs generally reported that they enjoyed working with DPs, given that they were a resourceful group, with potential for good treatment outcomes. Some TPs spoke of DPs being no different from other educated, high-functioning patients. They described the experiences they both have, and common identities as doctors as increasing empathy and facilitating rapport. In this way, some viewed the DPs' medical knowledge as helpful, and providing a connection between the two parties. There was also a sense that this could be happening to them, ‘there but for the grace of God…’ (TP 5, 6). Overall, interviews with TPs showed a sense of their warmth, generosity and goodwill towards doctors presenting with mental health issues, and a strong desire to contribute to their well-being:I'm a doctor and I care about doctors, yeah, part of it's about treating your own kind, like helping people in your own family. (TP 2)

Despite the intention to provide ordinary care TPs described making themselves more available to DPs and taking extra measures to maintain confidentiality.

Challenges from the TP perspective

All TPs described challenging aspects of working with DPs, and some experienced particular discomfort or distress if they found engagement with the DP difficult. For example, it was reported that a tendency for DPs to minimise their concerns led to late presentation and created challenges to assessment and care. Moreover, once in treatment, some DPs demonstrated an ‘impression of cooperation’ (TP 7) which often turned out to be false. TPs also spoke about a loss of connectedness following disclosure of certain aspects of the DP's personal life (eg, domestic violence).

TPs highlighted that the collegial relationship which ‘sits in between’ (TP 4) could make interactions during treatment difficult. They were treating a colleague, and did not want to jeopardise the relationship. They described both ‘over-reacting and under-reacting’ (TP 4) or overcompensating in terms of informed consent, and being slower to push for particular interventions. This was most acute when facing the possibility of compulsory hospitalisation:I think if s/he’d been a lawyer or a policeman or a teacher I might have sectioned him/her…s/he did not get best service because of being a doctor I was so reluctant to section him/her. (TP 6)

TPs spoke of heightened self-monitoring or a desire to impress, given that they were being observed by another doctor. Most described feeling that they were vulnerable to criticism by the wider medical community, should adverse events occur (eg, suicide of a DP).

Overall, the experience for the TP appeared to be heightened positively and negatively when the patient is a doctor. Of note, some TPs highlighted that variable behaviour was common among DPs, which meant that treating this patient group could range from very satisfying to extremely challenging:Ranged from being extremely enjoyable, rewarding, interesting, worthwhile to being one of those things I had to do but wanted to get out of (TP 2)They're either being good patients or being really difficult and foul and revolting. (TP 6)

Good patient behaviour was noted by some TPs but the striving of DPs to be seen as good patients was not described by TPs even when asked about it.

What facilitates an effective psychiatrist–patient relationship from the TP perspective?

A number of issues were highlighted when discussing factors that had facilitated an effective relationship with DPs. For example, TPs talked about how helpful it was to be older and/or more senior than the doctors they were treating, or to have previous experience in treating DPs. Engaging in supervision with colleagues with experience in this area was particularly beneficial.

Some TPs highlighted the value of their own therapy or illness experience. This included, for example, a greater understanding of the challenges involved and the need to take time off work, as well as the significance of no longer having to report to the Medical Council as an impaired professional:It's brilliant, I really love the fact that I've been depressed….It stinks as an illness but it's a great extra dimension as a psychiatrist. (TP 5)I feel really comfortable to talk about [taking time off work] because it's part of my experience and I talk about how I push myself to work, even though I know probably that it would be better for me to take some time out…I find that easier really because there's a bit of a connection yeah. (TP 5)

In contrast, another TP described how the increased understanding of the DP's situation could increase their awareness of the complexity of giving appropriate advice:I should probably have taken time off….But I didn't so I know how hard it is to. That's the other thing—well if I can do it they can do it….There's also the—well I shouldn't have done it and maybe if someone had told me really firmly you shouldn't do it…. (TP 6)