Letters

Engaging patients with psychosis in consultations

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7388.549 (Published 08 March 2003) Cite this as: BMJ 2003;326:549

Design of study has several problems

  1. Gomathinayagam S Rajesh, specialist registrar (general adult psychiatry) (cyberfreud{at}hotmail.com)
  1. Soho House, North Birmingham Mental Health Trust, Birmingham B23 6AL
  2. Psychiatric Hospital, GGZ Delfland, Jorisweg 2, 2311BM Delft, Netherlands
  3. The Grange, Newcastle upon Tyne NE12 9PN
  4. Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Newham Centre for Mental Health, London E13 8SP

    EDITOR—McCabe et al discussed how psychiatrists engage with psychotic patients during routine consultations.1 However, the design of their study may have compromised the conclusions.

    The clients selected were already attending a psychiatric outpatient clinic and had willingly agreed to participate in the study. These clients presumably had already engaged with their respective teams, which affects the generalisability of the study to clients who do not engage.

    Videotaping the consultation introduces an element of subject and observer bias. The presence of a video camera can affect the nature of the interaction between doctor and client, which again affects the generalisability of the findings to routine clinical consultations. Given 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 doctor. In addition, clients with psychosis often 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 have shown that patient centred skills, particularly when giving information and counselling, are related to increased compliance with treatment, improved satisfaction, and decreased symptoms and emotional distress.2 Unfortunately these studies occurred 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 judge the amount of information that would be beneficial for each person.

    This article has succeeded in highlighting the importance of the consultation between doctor and patient in engaging clients. However, psychiatric treatment is within a multidisciplinary team, with other agencies being equally capable of delivering information. An average psychiatric consultation lasts only 15 minutes, which makes it quite difficult to conduct a medical review—for example, of symptom control, dosage, and side effects. The purpose of the consultation needs to be clarified to ensure that the consultation is appropriately conducted for maximum benefit to the client and to avoid duplication of the work done by other agencies.

    References

    1. 1.
    2. 2.

    To listen or not to listen

    1. Rigo van Meer, medical director (r.v.meer{at}ggz-delfland.nl)
    1. Soho House, North Birmingham Mental Health Trust, Birmingham B23 6AL
    2. Psychiatric Hospital, GGZ Delfland, Jorisweg 2, 2311BM Delft, Netherlands
    3. The Grange, Newcastle upon Tyne NE12 9PN
    4. Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Newham Centre for Mental Health, London E13 8SP

      EDITOR—The results of the study by McCabe et al, that psychiatrists avoid talking about the content of psychotic symptoms, is in my opinion in complete accordance with everyday practice.1 It is not the results of the study that I find surprising but the reactions of Rajesh (letter above) and Duffett to these results.2 Their reactions are defensive. The video camera 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. Indeed, entering into a discussion about, for example, 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 study by McCabe et al 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 behaviour 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 discuss seriously the content of delusions and the messages that 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 found nowhere in psychiatry textbooks. Sometimes fruitful discussions are possible about the realness of these experiences, and the way to deal with them, which has proved to be helpful to patients.

      References

      1. 1.
      2. 2.

      Cognitive behaviour therapy can help end alienation of psychosis

      1. Steve Moorhead, consultant in general psychiatry and cognitive therapy (steve{at}smoorhead.fsnet.co.uk)
      1. Soho House, North Birmingham Mental Health Trust, Birmingham B23 6AL
      2. Psychiatric Hospital, GGZ Delfland, Jorisweg 2, 2311BM Delft, Netherlands
      3. The Grange, Newcastle upon Tyne NE12 9PN
      4. Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Newham Centre for Mental Health, London E13 8SP

        EDITOR—It comes as no surprise to read that health professionals show discomfort with interactions around the content of psychotic experience beyond its existence as a diagnostic indicator.1 The difficulty in developing a dialogue reflects a difficulty in 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.2 It is now proposed that a therapist should show clear linkage between personal experience, core beliefs (schemas), and emergence of psychotic symptoms.3 Such developments have been facilitated by the understanding that no qualitative difference exists between psychotic and “normal” experiences.4 It is difficult to convey adequately the remoralising effect of developing a meaningful understanding of these phenomena with a patient.

        Case study material and data from randomised controlled trials over the past 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 comparatively small amount of training.5 The number of staff, then, with training needs is vast. The development of interest groups shows enthusiasm of staff to work in this way with patients, but despite this service development remains pitiful.

        References

        1. 1.
        2. 2.
        3. 3.
        4. 4.
        5. 5.

        Authors' reply

        1. Rosemarie McCabe, senior research fellow (r.mccabe{at}qmul.ac.uk),
        2. Stefan Priebe, professor of social and community psychiatry
        1. Soho House, North Birmingham Mental Health Trust, Birmingham B23 6AL
        2. Psychiatric Hospital, GGZ Delfland, Jorisweg 2, 2311BM Delft, Netherlands
        3. The Grange, Newcastle upon Tyne NE12 9PN
        4. Unit for Social and Community Psychiatry, Barts and the London School of Medicine, Newham Centre for Mental Health, London E13 8SP

          EDITOR—Rajesh notes that the people who agreed to participate in our study (and to be videotaped) were already engaged in treatment. This is crucial in contextualising the findings, an issue we raised in our discussion. The nature of patients' symptoms when they are more unwell (such as paranoia and suspiciousness) means that they are less likely to agree to participate in research, particularly with a video camera.

          The presence of a camera can obviously influence the subject of observation. However, psychotherapists regularly have their practice recorded, and experience implies that people get used to cameras quickly. Although this is an undesirable limitation, there is no evidence that it invalidates the findings.

          With respect to the social and ethnic diversity of the participants, we consider this a strength rather than a weakness because despite these differences the observations were consistent across consultations.

          Rajesh also questions whether outpatient psychiatric consultations are the right place for the content of psychotic symptoms to be discussed. We wonder when the right occasion is and to whom patients should talk about their psychotic symptoms if not their psychiatrist. Patients did use it as a place to raise the content of their symptoms. This led to considerable interactional tension, especially in consultations with distressed patients who had symptoms. Initial analyses of repeat consultations (not presented) indicate that it was less common when patients had fewer symptoms at follow up appointments.

          This is precisely the challenge of communicating with psychotic patients: when patients are less psychotic communicating with them is easier, and when they are more psychotic successful communication becomes more difficult and engagement becomes particularly important.

          Avoiding sources of disagreement may be a useful strategy and facilitate successful communication about other business such as compliance with drug treatment. However, clinicians' willingness to participate in a conversation about the content of patients' thoughts and experiences and their emotional distress (as van Meer and Moorhead note is integral to cognitive behaviour therapy) may make it easier for patients to engage with clinicians precisely when they are psychotic.

          We talk about patient engagement with services and how certain patients are difficult to engage, yet in one to one interaction with patients, clinicians either regard proactive engagement with important patient concerns as inappropriate or are not sure how to go about it. The effective delivery of interventions in mental health care relies on identifying mechanisms of successful engagement at this core level of interaction between doctor and patient.

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