Objective

To explore the individual experiences of those who had experienced the death of a parent(s) before the age of 18, and investigate how such experiences were perceived to impact on adult life.

Design

An exploratory qualitative design using written (n = 5) and oral (n = 28) narratives and narrative analysis was adopted to explore the experiences 33 adults (7 men and 26 women) who had experienced parental death during childhood.

Setting

UK

Participants

Individuals living in the North West of England who had lost a parent(s) before the age of 18.

Main outcome measures

Views of adults bereaved of a parent before the age of 18 of impact of parental loss in adult life.

Results

While individual experiences of bereavement in childhood were unique and context bound, the narratives were organized around three common themes: disruptions and continuity, the role of social networks and affiliations and communication and the extent to which these dynamics mediated the bereavement experience and the subsequent impact on adult life. Specifically they illustrate how discontinuity (or continuity that does not meet the child's needs), a lack of appropriate social support for both the child and surviving parent and a failure to provide clear and honest information at appropriate time points relevant to the child's level of understanding was perceived to have a negative impact in adulthood with regards to trust, relationships, self-esteem, feeling of self-worth loneliness and isolation and the ability to express feelings. A model is suggested for identifying and supporting those that may be more vulnerable to less favourable outcomes in adult life.

Conclusions

The findings suggest that if the negative consequences are to be minimized it is crucial that guidelines for ‘best practice’ that recognize the complex nature of the bereavement experience are followed.

BACKGROUND

Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor–patient communication, though not necessarily patient health.

OBJECTIVE

To examine patient experiences of GPs’ attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome.

DESIGN

Qualitative study.

PARTICIPANTS

Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general.

APPROACH

Thematic analysis of in-depth interviews.

RESULTS

Potential barriers include the complexity of patients’ problems and patients’ judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution.

CONCLUSIONS

Improving GP explanation of unexplained symptoms is insufficient to reduce patients’ concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor–patient relationship in which patients can perceive psychosocial enquiry as appropriate.

Background

Previous research has not shown any significant health gain for patients as a result of providing education about depression for GPs. Reasons for this, however, are unclear.

Aims

To explore relationships between process and outcome in the setting of a randomised controlled trial of a complex educational intervention designed to provide GPs with training in the assessment and management of depression.

Design of study

Qualitative study utilising semi-structured interviews.

Setting

General practice in the northwest of England.

Method

Semi-structured interviews with 30 GPs in Liverpool and Manchester who participated in a randomised controlled trial.

Results

Three major barriers to the effectiveness of the intervention were identified: the lack of the GP's belief that he/she could have an impact on the outcome of depression, the appropriateness of the training, and the organisational context in which doctors had to implement what they had learned.

Conclusion

Attitudes toward treating depression may need addressing at a much earlier point in medical education. If students are introduced to a biosocial model of depression at an early stage, they may feel more hopeful about their ability to intervene when faced with patients who exhibit significant degrees of functional disability in the context of apparently socially determined disorders. Postgraduate interventions should be tailored to the treatment of depression as a common chronic condition and be focused at the level of the organisation, not the individual practitioner.