To be ‘within and without’ – A trainee’s perspective of an intellectual and developmental disability consultation service

Biopsychosocial model

Engraved into us since medical school, the biopsychosocial model of health was conceptualised and popularised in 1977 by G. Engel as a paradigm shift to encompass social and psychological dimension of illness. ⁸

As I noticed myself becoming overwhelmed when I first immersed myself in the seemingly foreign territory of intellectual disability psychiatry whilst I was simultaneously attempting to take a lifetime history from grieving families and burnt-out careers and attempting to flexibly accommodate the needs of our patients who often struggled to tolerate the clinical environment, the biopsychosocial framework became my initial familiar backbone tool.

Yet, it became clear that applying this model in this setting was not linear and somewhat limited. Though this model provided a prism through which multiplicity of need could be viewed, there was lack of clarity when biological, psychological, social, cultural, and behavioural domains intersected and intertwined. Attempting to identify and differentiate a diagnosable and treatable condition became one of the primary goals as a time-limited consultation service. Yet this imperative often conflicted with the complex, interconnected nature of presenting needs that defied neat categorisation, leading to a sense of helplessness and feeling like a lost outsider to the very complexity I was trying to understand.

This invited humility and curiosity in my practice, leading to consideration of additional perspective by taking a step back to better understand the situation, and ultimately myself.

Psychodynamic lens

As the term progressed, I began to recognise how psychodynamic thinking offered a deeper layer of insight, especially around emotional resonance in consultations. There were times I found myself inexplicably drained or agitated following certain assessments. It was only when I was outside of the consultation room, typically during supervision or commute back home, that I could name these feelings as countertransference; emotional responses evoked by the patient, family, or support worker, that reflected the unconscious communication of distress.

In one case, I felt a persistent sense of unease each time we met. The patient is an older person with intellectual disability and multiple medical comorbidities, residing with an ageing family who was struggling to cope. My angst mirrored what was unspoken in the room: the fear of inadequacy, the mourning of imagined futures, and the quiet rage at a system offering too little, too late. During these moments, I found myself in the room as a recipient, identifying with the emotional narrative of the patient and their supports, whilst simultaneously repelled by my own helplessness and disappointment.

The psychodynamic lens allowed me to consider what roles I was unconsciously and consciously being asked to play. Was I the rescuer? The expert? The benign outsider? Recognising these dynamics didn’t always resolve them, but it gave me the capacity to respond with more thoughtfulness and less reactivity. It also helped me appreciate the importance of the therapeutic stance in consultation. Even when no active ongoing treatment was offered as a consultation service, the assessment process of sitting together within a space lacking clarity scaffolds an authentic sense of support.

Systems framework

Perhaps the most disorienting and illuminating realisation was that the individual in front of us was never just an individual. They were enmeshed in a system of care over which they had little control and that extended across families, disability services, NDIS structures, housing providers, and health networks. Each consultation was in fact a meeting of systems, each with its own language, priorities, and anxieties, where it became easy to lose sight of the person at the centre.

This was where the concept of being ‘within and without’ became most tangible. As registrars, we were invited into these systems, but never fully part of them. We provided assessments and recommendations, but implementation often depended on factors well outside our influence. I found this simultaneously enchanting and repelling. Enchanting as I could remain reflective and avoid being drawn into dysfunction, and repelled because I occasionally questioned and feared whether my input would make any meaningful difference.

Understanding this work through a systems framework helped me better understand the inexhaustible variety in perspective and representative from members involved. This paradigm ironically provided flexibility and freedom to better mentalise by shifting away from the dichotomy of finding a definitive solution or perceived failure.

Conclusion

The experience of being ‘within and without’ in a consultation-liaison service for individuals with intellectual and developmental disabilities encapsulates the emotional, systemic, and professional tensions inherent to psychiatric training in this field. While the trainee steps into the room as a clinician, they also witness the broader systemic factors and complexities that shape patients’ lives.

This dual perspective, simultaneously engaged and detached, serves not only as a developmental crucible for the trainee but also as a necessary stance for ethical and effective practice. Reflective supervision, an openness to psychodynamic complexity, and the capacity to tolerate systemic ambiguity are essential tools for clinicians undertaking this challenging but profoundly meaningful work.

In learning to navigate the space between ‘within and without’, the trainee can discover a professional identity rooted not in certainty or omnipotence, but in authentic presence and reflective resilience.