BMJ 2002;325:1148-1151 ( 16 November )

Papers

Engagement of patients with psychosis in the consultation: conversation analytic study

Rosemarie McCabe, senior research fellow, ^a Christian Heath, professor of work and organisations, ^b Tom Burns, professor of community psychiatry, ^c Stefan Priebe, professor. ^a

^a Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Newham Centre for Mental Health, London E13 8SP, ^b Management Centre, King's College London, Franklin-Wilkins Building, London SE1 8WA, ^c Department of Psychiatry, St George's Hospital Medical School, London SW17 0RE

Correspondence to: R McCabe r.mccabe{at}qmul.ac.uk

Objective: To investigate how doctors engage with patients with psychotic illness in routine consultations.
Design: Conversation analysis of 32 consultations between psychiatrists and patients with schizophrenia or schizoaffective disorder.
Setting: Two psychiatric outpatient clinics in east London and south west London.
Participants: 7 psychiatrists and 32 patients with schizophrenia or schizoaffective disorder.
Main outcome measure: Mutual engagement in communication during the consultation.
Results: Patients actively attempted to talk about the content of their psychotic symptoms in consultations by asking direct questions, repeating their questions and utterances, and producing these utterances in the concluding part of the consultation. In response, doctors hesitated, responded with a question rather than with an answer, and smiled or laughed (when informal carers were present), indicating that they were reluctant to engage with patients' concerns about their psychotic symptoms.
Conclusions: Patients repeatedly attempted to talk about the content of their psychotic symptoms, which was a source of noticeable interactional tension and difficulty. Addressing patients' concerns about their illness may lead to a more satisfactory outcome of the consultation and improve engagement of such patients in the health services.

What is already known on this topic Patients with psychotic illness are difficult to engage in the health services No research has been published on how doctors engage with these patients in consultations What this study adds Patients actively attempt to talk about the content of their psychotic symptoms Doctors' reluctance and discomfort in engaging with this topic is apparent Addressing patients' concerns may lead to a more satisfactory outcome of the consultation and improve engagement with services

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