Communication and psychosis: it's good to talk, but how?

Communication between clinicians and patients is at the heartof psychiatric practice and particularly challenging with psychoticpatients. It may influence patient outcome indirectly or betherapeutic in its own right. Appropriate conceptual models,evidence on effective interventions and specific training arerequired to optimise communication in everyday routine practice.

INTRODUCTION

TOP

INTRODUCTION

View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]

Clinicians communicate with patients. In psychiatry, this isarguably the main part of what they do in their daily practice.Yet, does it matter how they communicate? Both the GeneralMedical Council and the Royal College of Psychiatrists highlightthe role of good communication in achieving therapeutic relationships.Effective communication, and the related construct, the therapeuticrelationship, may have an impact on patients' engaging in treatmentin the first place, following treatment suggestions, satisfaction, symptom severity, referral to other services and willingnessto file lawsuits.¹ It may even be therapeutic in its own right.The therapeutic relationship is negotiated and reflected inpatient–clinician communication and appears to predictoutcome in different samples and settings across mental healthcare.²If communication may be influential in patient outcome, thereis a challenge to understanding how these processes work inpsychiatry. This may feel especially difficult when communicatingwith patients with psychosis whose contributions may appearto be inappropriate both in their content and placement in the interaction. The first step is good research.

Studying communication

TOP

Studying communication

Communication is difficult and cumbersome to study. A typicalapproach involves recording the interaction. Videotaping onesession can be the minimum. This is easier in a clinic settingthan in various community settings. Audiotaping alone is problematicgiven how much information is contained in non-verbal aspectssuch as posture and gaze. A long gap in a consultation hasa different meaning if the clinician is writing notes in that gap or has eye contact with the patient and is not respondingto a patient's question. Most methods involve transcription,ranging from basic (content only) to highly detailed transcripts(content plus intonation, pauses, overlap, gaze, etc.) followedby time-consuming and labour-intensive analysis; linking one-offconsultations with long-term clinical outcome is inappropriate given the complexity of treatment processes. It is likely thata series of consultations need to be studied to establish factorsthat have an impact on clinical outcomes. Simpler methods mayneed to be developed to capture intermediary outcomes of communicationso that they can be assessed in pragmatic studies with sufficientlylarge samples.

Setting aside the methodological problems, a key conceptualissue is that, even in the social sciences, there is no definitivemodel of `good communication'. A focus of positive communicationthroughout healthcare is patient-centredness. One componentis shared decision-making. People with schizophrenia have aslightly stronger preference for shared decision-making thanprimary care patients.³ Among those with schizophrenia, youngerpeople and those with more negative views of medication wantmore participation.³

Some research has been carried out on shared decision-makingin relation to antipsychotics. Seale et al audiotaped psychiatricconsultations and interviewed psychiatrists about their negotiating styles.⁴ In interviews, psychiatrists were committed to achievingconcordant relationships with patients although they felt therewere obstacles particular to psychiatry, mainly if the patientwas deemed too ill to make decisions and the patient's honestyabout their medication use. Analysis of the consultations themselvesshowed how side-effects may remain unaddressed (by offeringno response, changing the subject or disagreeing with the patient's interpretation of the experience) or be acknowledged throughsympathetic and supportive listening.

What should I say now?

TOP

What should I say...

In a detailed study of how psychiatrists and patients communicateabout psychotic symptoms in out-patient consultations, patientsrepeatedly attempted to raise the content and emotional consequencesof their hallucinations and delusions.⁵ Psychiatrists frequentlyavoided engaging with these concerns, leaving both patientsand doctors very uncomfortable. One patient asked `Why don'tpeople believe me when I say I'm God?' to which the doctor,after initial avoidance, replied `What should I say now?' In`normal' interaction, avoiding sensitive issues that mightexpose conflicts of opinion is typically a good strategy. Thismight also apply here where the clinician avoided a confrontationabout beliefs on which agreement was unlikely to be reached.Yet, in interactions with patients with psychosis, initialavoidance by clinicians seems to lead to explicit confrontationand disagreement about the very reason the patient is there.With patients who are not well-engaged, this might lead to further disengagement during treatment.

Despite the fact that communication about psychotic symptomsis a frequent challenge and regarded as fascinating by manyclinicians, there is little systematic, theoretically informedtraining on how clinicians should respond. Many state thatthe recommended approach is not to `encourage' the patient to talk about their symptoms because it amounts to inadvertentcollusion about the illness. Because the patient is uncertainabout reality, the clinician might feel that they should befirmly rooted in reality and respond to the God question with`because it is not true'.

There are alternative ways to respond. For instance, a client-centred approach might respond to the emotional content of the patient'sstatement with `You feel misunderstood and puzzled by it'.A cognitive approach might ask for evidence about the belief.One could take the patient's perspective with a response like`Why should people believe you? They did not believe Jesuseither'. Further responses are possible using other therapeutic approaches. Yet, most psychiatrists are not specifically trainedin this nor is there much theoretical debate on such a coreaspect of everyday communication with patients with psychosis.

Communication is not only technical. It also involves emotions, particularly when communicating about profoundly disturbingexperiences. Jaspers⁶ discussed the challenge of communicatingwith another person whose experience is so remote from the`normal' realm to render it `non-understandable'. However, in order to establish `non-understandability' the clinician firsthas to try to understand the patient's experiences, which requirescommunication about symptoms, emotions and their meaning forthe patient. Clinicians themselves may need to be supportedin their response to patients' disturbing experiences.⁷

Communication involves at least two people and so far we haveconsidered only the role of the clinician. However, doctorsand patients construct the interaction together so how arepatients with psychosis communicating? It is clear that patientsare representing concerns that have been discussed many timesbefore. They raise the same issues time and time again, oftenexpecting that the clinician will disagree.⁸ It may be importantto understand if (and how) patients are breaching `normal' communicativepractices both for understanding the disorder and identifying appropriate ways to respond.

Interventions to improve communication

TOP

Interventions to improve...

In medicine generally, alerting clinicians to the patient's concerns/emotions and changing clinicians' beliefs about communicationhave led to communication change. However, interventions toimprove communication, and in turn outcome, in psychosis arerare. A simple communication checklist completed by patientsbefore seeing their clinician improved communication and resultedin treatment changes.⁹ An intervention structuring patient–keyworkercommunication elicited the patient's satisfaction with a rangeof life domains, their needs for care and wishes for differenthelp. Patients receiving the intervention had a better qualityof life, fewer needs for care and higher treatment satisfactionafter 1 year.¹⁰ It remains unclear, however, whether the structuring,focusing on the patient's view, the forward-looking emphasison treatment changes or a combination of these factors wascrucial to the intervention's success. Finally, an interventionto increase shared decision-making with in-patients with schizophreniadid not take up more of the doctor's time, increased the uptake of psychoeducation and increased involvement in medical decisions.¹¹As in medicine generally, different approaches have been triedon a more or less ad hoc basis without explicit theoreticalframeworks specifying key communication processes and the pathwaythrough which they may influence health outcomes.

The current state of the art cannot begin to address the question`Does one size fit all?' (which is unlikely). Different cliniciansmay have different communication styles and strengths whichmight have to be enhanced rather than eradicated. Also, a particularclinician's communicative style may suit one patient and notanother. Future research might address matching the right patientwith the right clinician to achieve the best possible communication.

Concluding remarks

TOP

Concluding remarks

If psychiatrists want to make better use of everyday communicationas a core component of their trade, the ambition must be todevelop better competence and skills to maximise its therapeuticeffect, preferably based on sound conceptual models and evidencederived from them. Some of the required skills may be generic,whereas others are likely to be specific to communicating withpatients with psychosis. Jaspers⁶ stated that `the ultimatething in the doctor–patient relationship is existential communication, which goes far beyond any therapy, that is,beyond anything that can be planned or methodically staged'(p. 798). Thus, not all aspects of how psychiatrists and patientscommunicate might be identifiable in research and teachablein the classroom or individual supervision. Yet, the challenge is to advance the state of the art to reveal as much as possibleso that patients benefit from communication that is, eitherindirectly or directly, therapeutic. Clinicians may also benefitfrom enriching their therapeutic options and professional expertise.

REFERENCES

TOP