Engagement of patients with psychosis in the consultation: conversation analytic studyCommentary: Understanding conversation
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7373.1148 (Published 16 November 2002) Cite this as: BMJ 2002;325:1148All rapid responses
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As a mental health educater with a keen interest in the experience
of, and interventions utilised in psychosis care, I am heartened by the
article and subsequent responses. The process of socialising mental health
practitioners to psychosis work remains predominantly tainted with neo-
Kraeplinian views that reinforce the dominant order of the day - non-
recovery and hopelessness should be expected. The uncomfortableness
described in the article, and captured in displaced therapist behaviour
(incongruous laughter and avoidance)is an indication of this. The
methodology utilised in the study is to be applauded, and the focus on the
use of language as a component of communication is an interesting attempt
at uncovering how power and control are invariably in the hands of the
worker. Of course this approach is not new (Watzlawick, Beavin &
Jackson, 1967) but perhaps novel.
For those stimulated to apply new research methodologies in the
exploration of conversation and power the methodology of discourse
analysis has been usefully applied by Harper (1999) to demonstrate how
medication useage in schizophrenia is constructed around a prodominantly
medical conceptualisation of 'schizophrenia'. If mental health workers
deny an individual experiencing psychosis the oportunity to develop their
own perspectives on 'self', and introduce overt medical constructions of
psychosis as 'illness' or worse 'disease' then the experience of hope, an
essential pre requisite for recovery from psychosis will inevitably be
diminished.
I would suggest that to address the question of "Whether or not one
is God?" then the worker has to adopt a broader philosophical and
psychological perspective. This of course takes time, a degree of
willingness to listen but above all an underlying positive attitude that
psychosis has meaning and function in a persons life. Whilst the call for
CBT in the NICE guidelines for schizophrenia is to be welcomed, of equal
importance is the requirement of the mental health workforce to wake up to
the fact that people with psychosis have the right to talk... and to be
properly listened to. One does not have to be a trained CBT therapist to
do so.
Watzlawick,P,. Beavin, J,. & Jackson D (1067) Pragmatics of Human
Communication: A study of interactional patterns, pathologies and
paradoxes. London: WW Norton & Comany.
Harper, D (1999) Tablet talk and depot discourse: discourse analysis
and psychiatric medication in Willig, C. (ed) Applied Discourse Analysis:
social and psychological interventions. Buckinghamshire: Open University
Press.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
The purpose of my previous letter was to stimulate a debate about the
findings of the paper presented by McCabe et al.Judging by the number of
varied responses to this study I do feel that I have succeeded in my
endeavour. This letter was not intended to defend the practice of
colleagues in their day to day work as suggested by some of the responses. It was also not my intention to criticise any of the findings but to
place the study in proper context. In this era of evidence based medicine
authors have to be prepared to have their projects critically appraised by
readers and to be able to defend their conclusions which incidentally is
also one of the aims of the Royal college of Psychiatrists as reflected in
the introduction of the critical appraisal paper in the part II exams.
After all the purpose of a study is to help people look at their
practice and to change it if necessary. Dr.McCabe's response to my
letter has been detailed and informative and the other responses have
also been useful to look at different ways of dealing with this difficult
problem, how do we engage clients with psychosis? I would also like to
convey my appreciation to the authors for this study.
Competing interests:
None declared
Competing interests: No competing interests
It comes as no surprise to read that health professionals demonstrate
discomfort with interactions around psychotic experience content beyond
its existence as a diagnostic indicator (1). The difficulty in developing
a dialogue reflects a difficulty making sense of psychotic patients’
communications. This underlies the prejudice with which society as a whole
treats people with psychosis. Traditional psychiatric teaching tells us
that these phenomena lack understandability and that there is no point
attempting to engage in a discussion about them. Consequently the people
with such experiences are qualitatively different and much biological
research has set out to prove this. Health services thus unwittingly
collude with maintaining the prejudice that blights the lives of people
with psychosis.
Yet much evidence exists that the experiences of people with
psychosis are entirely understandable. Since 1952 evidence has been
available that the therapeutic development of understanding may be
achieved using a cognitive-behavioural approach (CBT) (2). It is now
proposed that a therapist should show clear linkage between personal
experience, core beliefs (schemas) and psychotic symptom emergence (3).
Such developments have been facilitated by the understanding that there is
no qualitative difference between psychotic experiences and “normal”
experience (4). It is difficult to adequately convey the re-moralising
effect of developing a meaningful understanding of these phenomena with a
patient.
Case study material and randomised controlled trial data over the
last decade provide support for both effectiveness and efficacy. If need
is defined as the potential to benefit from the intervention, it is
enormous among this most vulnerable group of patients. The ability of
mental health staff to empathise with patients with psychosis is also
improved with a relatively small amount of training (5). The number of
staff, then, with training needs is vast. The development of interest
groups demonstrates enthusiasm of staff to work in this way with patients,
but despite this service development remains pitiful.
1 McCabe R, Heath C, Burns T, Priebe S. Engagement of patients with
psychosis in the consultation: conversation analytic study. BMJ 2002; 325:
1148-1151.
2 Beck, AT. Successful outpatient psychotherapy with a chronic
schizophrenic with a delusion based on borrowed guilt. Psychiatry 1952,
15, 305-312.
3 Brabban A, Turkington D. The search for meaning: detecting congruence
between life-events, underlying schema and psychotic symptoms. Formulation
-driven and schema focussed CBT for a neuroleptic-resistant schizophrenic
patient with a delusional memory. In T. Morrison (Ed.), A Casebook of
Cognitive Therapy for Psychosis 2000. Brighton: Psychology Press.
4 Strauss JS. Hallucinations and delusions as points on continua function:
rating scale evidence. Archives of General Psychiatry 1969, 31, 581-586.
5 McLoed HJ, Deane FP, Hogbin B. Changing staff attitudes and empathy for
working with people with psychosis. Behavioural and Cognitive
Psychotherapy 2002. 30, 459-470.
Competing interests:
None declared
Competing interests: No competing interests
The authors are to be congratulated on this study. It confirms the
findings of a number of naturalistic or 'new-paradigm' research projects
(1).
Hospitalised psychiatric patients, for example, have identified as
among their needs: a)opportunities and encouragement to make sense of and
derive meaning from their illness experiences, and, b) having time to
express feelings to staff members with a sympathetic, listening ear.
It takes skill and experience to discuss the contents of psychosis
with sufferers, and to listen with undisturbed equanimity to the
occasionally intense degrees of emotional pain that presents in close
association with them. Nevertheless, this makes an important, even
necessary contribution towards these individual's recovery and
rehabilitation, not least through the improved therapeutic relationship
that often results.
A good tip is to focus on the emotional flavour of statements and
questions about the symptoms, rather than primarily on their content. This
is commented on only obliquely in McCabe et al's paper (2), with reference
to facial expression, laughter and so on.
When someone says, 'Why don't people believe me...?' for example, it
usually helps to clarify the emotions involved. 'You seem anxious,
puzzled, angry, sad (as applicable) about that', often moves the
conversation forward in a positive and helpful way. It acknowledges and
validates at least one aspect of the communication without necessarily
negating the other, the delusional idea. 'I can see that you are confused,
irritated, upset, frightened (whichever) and would like to help you with
that'. This type of intervention can work a treat in reducing the tension
in the interview setting, sometimes even to the degree of allowing the
patient to show some insight and answer his or her own original
challenging question.
Perhaps in training psychiatrists and other mental health care
workers, we concentrate too much on knowledge and the evidence base, and
not enough on clinical skills, hopeful attitudes, traditional values and
the wisdom of experience. This study helps in restoring the balance.
(1)Culliford L. Spiritual Care and Psychiatric Treatment: An
Introduction. Advances in Psychiatric Treatment 2002;8:249-261.
(2)McCabe R et al. Engagement of patients with psychosis in the
consultation: conversation analytic study. BMJ 2002; 325: 1148-1151
Competing interests:
None declared
Competing interests: No competing interests
The results of the McCabe et al. study, that psychiatrists avoid
talking about the content of psychotic symptoms, is in my opinion in
complete accordance with everyday practice. It is not the results of the
study that I find surprising, but the reactions of Gomathinayagam and
Duffett to these results.
Their reactions are defensive. The videocamera
is blamed, and weaknesses in the study are pointed out. Clearly one
doesn’t like to discuss the content of the results.
As a psychiatrist I was trained to listen. But also not to listen. There
is little or no place for psychotic content in textbooks. These are
thought to be diagnostically of little significance and therapeutically
irrelevant. Discussing the content of delusions costs time and has no
consequences. Instead, entering in a discussion about e.g. the question
why nobody believes that the patient is God, might lead to conflict and
emotional outburst. So we are trained not to listen and avoid digging into
these subjects.
Whether this is a good strategy is questionable. The McCabe study
indicates that this common attitude is distressing for patients. They
want to discuss items that are central to their experience and of
utmost importance to them. And exactly these items are kept out of the
conversation.
The recent rise in Cognitive Behavioral Therapy for psychotic symptoms,
with very promising results, indicates that taking the contents of
psychotic symptoms seriously is not such a bad idea (see the Cochrane
library).
My own experience is that taking some time to seriously discuss the
content of delusions and the messages voices bring is highly appreciated
by patients. And believe it or not, often time saving. It taught me a lot
about these psychotic experiences that is nowhere found in psychiatry
textbooks. And sometimes fruitful dicussions are possible about the
realness of these experiences, and the way to deal with them, which has proved
to be helpful to patients.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – Doctors’ hesitation about discussing the content of
psychotic symptoms may owe a good deal to the out-patient settings studied
by McCabe et al (1). Short, one-to-one conversations, with a range of
practical issues to cover and long intervals in-between, necessarily
impose constraints on what it is possible or appropriate to explore with
psychotic patients. Experience of these limitations led to the setting up
in east London of a combined individual and group out-patient clinic
specifically for patients with long-term schizophrenic Illnesses (2) and
two such clinics have been in operation since 1985.
Individual medical interviews, by appointment or when required, are
often also attended by a CPN or another team member the patient knows
well, and are combined with a weekly group where psychotic symptoms and
other issues are addressed. Patients have proved to be extremely
considerate and helpful to each other about illness experiences and in
sharing coping strategies, and aspects that arise in the groups influence
individual interviews.
The combination has been much more comprehensive and satisfying than
the out-patient clinics the writer held previously with similar, and in
some cases the same, patients, or than a group alone. Novel out-patient
formats may become increasingly necessary to meet the expanding
expectations and horizons of psychotic patients, doctors and others.
David Abrahamson , formerly consultant psychiatrist, Newham
Rehabilitation & Continuing Care Team, Warton House, High Street,
Stratford, London E15.
E-mail Dabrah9548@aol.com
(1) McCabe, R., Heath, C., Burns, T., Priebe,S. Engagement of
patients with psychosis in the consultation: conversation analytic study.
BMj 2002, 325, l148-1151(16 November).
(2) Abrahamson D., Fellow-Smith, E. A combined group and individual
long-term out-patient clinic. Psychiatric Bulletin 1991,15, 486-487.
Competing interests:
None declared
Competing interests: No competing interests
Thanks to Drs. Gomathinayagam and Duffett for raising interesting and
valid points arising out of our study and for giving us an opportunity to
clarify some important issues. We are particularly grateful to people like
Dr. Duffett who agreed to be videod and are willing to participate in a
discussion of findings that might be perceived as criticism of their own
practice or the profession in general. We would like to emphasise that
our study was not intended to add to doctor bashing in the media. Its aim
was to analyse what happens in psychiatrist-patient consultations and to
draw conclusions from that analysis that might be used to improve
engagement in a constructive way. If the findings will not be used as a
starting point to develop better ways of engaging psychotic patients and
teaching the necessary skills to clinicians, an analytic study like this
would have little point.
They point out that the people who agreed to participate in our study
and to be videod were already engaged in treatment. This is an extremely
valid point in contextualising the findings, one which is raised in our
discussion. It goes without saying that the nature of patients’ symptoms
when they are more unwell means that they are less likely to agree to
participate in research, particularly when it involves a video camera, an
obstacle we could not overcome. We will certainly continue to struggle
with this in further studies involving other professional groups, patients
with different diagnoses and longitudinal research. Of course, the
presence of a camera may influence the subject of observation. This
concern seems to be less often raised by clinicians who have experience of
being videotaped, audiotaped or watched through a one-way-mirror.
Psychotherapists regularly have their practice recorded and anecdotal
evidence suggests that people habituate to cameras quickly. This is an
undesirable limitation of conducting such research but there is no
evidence that it invalidates the findings.
An additional piece of background information that may be of interest
in addressing how generalisable our findings are to less engaged patients
is that on an anecdotal level, the interactional tensions identified in
our analyses seemed to arise in consultations involving more symptomatic
and distressed patients. We also recorded a number of repeat
consultations, which we did not present in this paper. Preliminary
analyses of patients in repeat consultations suggested that these tensions
were not so apparent when patients were less symptomatic at the follow-up
appointment. However, an independent assessment of symptom severity
would be necessary to draw any conclusions on this.
Both Drs. Gomathinayagam and Duffett raise the issue of whether the
outpatient psychiatric consultation is the right place for the content of
psychotic symptoms to be discussed. One might wonder what the right
occasion is and whom patients should talk to about their psychotic
symptoms if not their psychiatrist. In any case, patients did use it as a
place to raise the content of their symptoms and this raised an important
question about the right way to respond to questions like “Why don’t
people believe me when I say I’m God?”. Depending on the given situation
there may be time constraints restricting the response, and there might be
different therapeutic philosophies on whether psychotic thought content
expressed by patients should be taken up or ignored. The jury is still
out on what the best way to respond is and this is a question for further
research. However, there may be a training issue if psychiatrists are
confronted with questions to which they do not know how to respond, e.g.,
“What should I say now?”. One might argue that such therapeutic skills
would be even more important in engaging more unwell, more psychotic
patients. The fact that patients present with thought disorder,
abnormalities of affect etc. is precisely why there is such a challenge in
communicating with these patients and why there might be a need for
specific therapeutic skills to meet this challenge.
Finally, with respect to the generalisability of our findings, we
consider the social and cultural diversity of the participants a strength
rather than a weakness of the study because despite these differences, the
observations were consistent across consultations.
Rosemarie McCabe and Stefan Priebe.
Competing interests:
None declared
Competing interests: No competing interests
As a consultant observed in the study by McCabe et al I read the
article on engagement of patients with psychosis with particular interest.
Overall the study seems to suggest psychiatrists are insensitive to
patients’ needs and could do better. Whilst aware that my practice could
be improved it is important that the study is placed in context.
Paradoxically the study discusses issues of engagement in a group of
patients studied were well engaged, not only attending outpatients but
also agreeing to be videoed. Psychiatrists were criticised for being
prone to smile or laugh when being asked about psychotic symptoms,
particularly if a carer was present although it was not discussed if
having a camera observe the interview has the same effect.
The authors conclude that psychiatrists should spend longer discussing
psychotic symptoms, as this would meet the immediate needs of patients.
Recalling interviews with patients who did not agree to be taped (often
less engaged or more paranoid) the discussion around psychotic symptoms
was probably more exhaustive. For patients attending outpatients for 15-
minute, three monthly, consultations, long-term management tends to be the
issue (developments over the previous 3 months and likely problems over
the next 3 months). The authors present an argument for allowing the
issue of psychotic symptoms to be discussed by patients but not that this
should necessarily be within the outpatient consultation.
Competing interests:
None declared
Competing interests: No competing interests
Editor: McCabe et al (1) have presented an interesting paper on how
psychiatrists engage with psychotic patients during routine consultations.
However the design of the study has a number of problems, which could have
compromised the conclusions. First of all the clients selected for the
study were already attending a psychiatric outpatient clinic and had
willingly agreed to participate in the study. These clients presumably
have already engaged with their respective teams and this would affect the
generalisability of the study to the non-engaged patients.
Also the very nature of the study wherein the consultation was video
taped introduces a element of subject and observer bias .The presence of
the video camera in the room has the potential to affect the nature of the
interaction between the doctor and the client and this would again affect
the generalisability of the findings to routine clinical consultations.
Given the fact that 50% of the clients were not white British the social
interaction may have been influenced by the social, ethnic and cultural
differences between the client and the doctor. . To compound this already
difficult situation clients with psychosis frequently present with thought
disorder, negative symptoms (poverty of thought) and other abnormalities
of affect, which makes the interaction qualitatively and quantitatively
different from normal conversation.
Some studies (2) have shown that patient centred skills, particularly
when giving information and counselling, are related to increased
treatment compliance, improved satisfaction, and both decreased emotional
distress and decreased burden of symptoms. Unfortunately these have been
done in primary care and may not be applicable to psychiatric
consultations. Clients at different stages of psychotic illness need
different types of consultations with the clinician having to make a
judgement about the amount of information that would be beneficial for
each individual.
This article has succeeded in highlighting the importance of the
doctor-patient consultation in engaging clients. But we have to remember
that psychiatric treatment is within a multidisciplinary team with other
agencies being equally capable of delivering information. An average
psychiatric consultation lasts only 15 minutes and it can be quite
difficult to conduct a medical review i.e. symptom control, dosage
adjustments and side effect reviews within this time .The development of
other services which can provide information to clients have impacted on
the nature of psychiatric consultations and there is a need to clarify the
purpose of the consultation. This would ensure that the consultation is
appropriately conducted for maximum benefit to the client and that the
work done by other agencies is not duplicated.
1)Rosemarie McCabe, Christian Heath, Tom Burns, Stefan Priebe, and
John Skelton. Engagement of patients with psychosis in the consultation:
conversation analytic study • BMJ 2002; 325: 1148-1151
2)Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et
al. Observational study of effect of patient centredness and positive
approach on outcomes of general practice consultations. BMJ 2001; 323: 908
-911
Competing interests:
None declared
Competing interests: No competing interests
psychosis and the consultation
The level of stigma around having had a 'psychotic' episode episode
is shown by that the person with the most to teach others, the person who
has experienced it, is ussually silenced, (or partly silenced by the need
to speak anonymously as has the respondent on March 3rd), whether by a
refusal to listen and learn in a spirit of some humility on the part of
professionals, by the way 'case studies' are written up without any
validation or verification by the person, by the covert as well as overt
ridicule experienced by those who attempt to convey the reality of the
experience etc.
By it's nature the content is often in symbolic form, is
the language of poetry rather than linear logic, and therefore needs a
particular willingness to listen deeply and attentively. It is not only
sad but a lost oppportunty to develop more humane services when so often
the relationship with practitioners is so disempowering that knowledge is
translated and skewed by simplistic diagnostic labels eg
'psychotic'. Labels can be useful but that is all. Most of what is published
about 'psychosis' in professional literature is translated into a language
based on favoured theories, it excludes the authentic voice of that
individual and the importance of what they have to teach is invalidated.
Competing interests:
None declared
Competing interests: No competing interests