Hilary worked as an advanced practitioner in women’s health before she became a researcher and author. Her career interest focuses on issues concerning the narrative understanding of general practice and how it happens.
As the editor of an on line journal and member of two nursing journal editorial boards she has written extensively on issues relating to advanced practice nursing, primary care, law and research. Hilary is chair of the research ethics committee (REC) within SHaW and is alternative vice chair of the Black Country NHS REC. She received her doctorate in Swansea University in 2009.
The Communication Experience of GPs with Psychiatric Patients
The Government’s mental health strategyNo Health without mental healthclearly stresses the importance and identified priority for mental wellbeing in the lives of individuals, communities and societies. This emphasis reflects mounting evidence that positive mental health within the population can reduce health inequalities and provide improved outcomes in terms of physical health, social cohesion and economic productivity. Given that the NHS sees primary care as the right place for most mental health services, it is therefore surprising that little is known as to how General Practitioners (GPs) engage with patients suffering from mental health problems. Moreover, as patient interviewing during consultations is implicitly taken to be an ‘art’ (Stanghellini, 2004), this is inevitably subject to the array of communication styles that have been formed from diverse experiences in evaluating patients under various conditions and the style used is based on the distinctive characteristics of the doctor (Cruz and Pincus 2002). The unique individual characteristics of doctors have yet to be captured in research. The communication skill set necessary for the psychiatric assessment of a seriously and persistently mentally ill patient is not necessarily the same for psychiatrists as it is for GPs. These dynamics together with the fact that medical practice itself is fundamentally linked within a complex basis of sociocultural interaction outlines the potential for many difficulties and paradoxes existing within the patient/doctor communication process.
Communication between clinicians and patients is at the heart of psychiatric practice and is said to be particularly challenging (McCabe 2008) as it influences patient outcome indirectly or can be therapeutic in its own right. Despite a large body of literature concerning the medical interview, its structure and discursive workings, there has so far been little research on its psychiatric counterpart. While the literature provides a great deal of evidence as to how to undertake general medical consultations, what models to use or framework to follow, the knowledge about what happens during consultations is minimal, particularly in terms of communication processes with patients who may suffer from a mental health problem.
Aim and Objectives
While NHS reform has closely scrutinized treatment interventions for psychiatric patients, no attention is being paid to how a GP gathers information during consultations develops a relationship with the patient and ultimately negotiates a treatment plan. It is critical therefore to define empirically the importance of the GP/patient relationship, and this is timely because of the current challenges facing GP commissioning with its requirement for mental health service providers to improve their efficiency and effectiveness.
Nyamathi (1998) argues that individuals with a mental illness have been historically considered as a vulnerable population; patients presenting with a psychotic episode may lack the ability to give informed consent and should be treated as vulnerable research participants with appropriate safeguards put in place. Given the problematic nature of using such vulnerable patients together with the short timescale and funding for this project it is was decided to only include GPs within the sample and to ask them their views.
The aim of this project therefore was to investigate the experiences of GPs when consulting patients with mental health problems and to capture their narrative stories, exploring the complexity and intricacy of human nature and behaviour, which is rooted within the qualitative paradigm.
The approach to this study was based upon the theoretical position of discursive social psychology identified by Potter and Wetherell (2005), where discourse analysis is implied as a qualitative analysis of talk and text within a social perspective, where individuals use speech to build accounts of their individual social worlds.
The words used when talking are considered to be how individuals experience themselves and others within the world, and how these experiences are interpreted, these discourses are essentially historically specific and communicative frames in which individuals interact as socially situated agents who ‘do things with words’ (Fraser 1992 p185). Humans not only learn language to express thoughts, but they also learn different ways of speaking and different discourses (Bjornsdottir 2001). Exploring these actual occurrences of talk is thought the best way to identify how individuals interacted with mental health patients.
Discourse analysis is very labour intensive and because the interest centres on language rather than the people generating the language, small samples are considered adequate in investigating a range of phenomena (Potter & Wetherell 2005). 10 interviews were carried out with GPs within the Black Country between the months of March-August 2013. The interviews lasted between 30-40 minutes and were carried out within the GP premises at a time convenient to them in order to encourage participation. When analysing the data it was considered important to read other studies first, in order to provide insights that could also be suggestive for the data collected as well as to sharpen the analytic mentality that is needed. The process of analysis followed the recommendations of Potter & Wetherell (2005) and transcripts were first read and reread. The search lay in looking first for both 'variability in differences in either the content or form of accounts, and consistency in the identification of features shared by accounts' (Potter & Wetherell 2005 p168). The second stage of the analysis involved forming a hypothesis about the effects and functions within the talk of GPs, and then a search for the linguistic evidence.
This study revealed that the GPs’ consultation with mental health patients focused around the following factors:Handling the consultation according to insight, a managing of metaphoric worlds
The assumption exists that patients suffering with mental illness have very little insight into their condition, if at all, and this alongside the fact they can typically have reduced capacity to reflect rationally on their anomalous experiences and beliefs, changes the way doctors communicate with them. Insight, as a precise acceptance of mental illness, is also related to a negative impact on identity and stigmatisation. The underpinning of any consultation related therefore to how GPs needed to manage the metaphoric worlds or realities of patients, do they play along with the patient’s world or try to bring them back to reality? as identified in the words of one respondent:
Dr I: em I normally say eh to people I'm teaching, “I have my breakfast in a world that's got one sun and one moon,” OK, “sometimes the people we're talking to have their breakfast on planets that have got three suns and four moons,” em and you've got to be able to see that they are in a completely different place than you, acknowledge it and manage the situation without managing the cure; you're not going to bring them back into your reality.
GPs tentatively do little to disturb the distorted reality of patients and often collude with them. Within any general practice consultation, there is undoubted value in gaining the confidence of patients as this strategy immediately elicits the direct means to engage with them and ultimately find out about them and assess their problems quickly. GPs run surgeries that fit with their contractual obligations, such as short appointment times and the pressures of meeting practice targets and it is not in their best interests to do anything that would aggravate their patient/doctor relationship or make consultations more protracted. As in the following interaction:
Dr A: I suppose I go along with it I mean as a GP, the reason being that, if there's someone who needs to be assessed that day, the last thing you want to do is aggravate them by saying “no, you don’t see things there.” As the GP I think it's more to get the story and to get the history, you're, you're there to get the facts from them so that you can make that decision. So for you to disagree with them, em probably isn't the right time, because you want them on-board
Consulting with mental health patients can be more challenging than normal
GPs within this study felt they had very little training in dealing with patients with mental health problems. Any training was acquired in house or from years of working with such patients. Those with an interest in this field of work tended to attract patients with mental health problems to them. Consulting with patients however as mainly challenging for GPs and often frightening; it is also not always easy to differentiate between who is hallucinating and who is not. As in this extract:
Dr R: he was actively talking to these images behind me on the trees and then, while talking to me, and then while talking to them as well, he just suddenly got up and he kind of, he, he came so close to me — and he just bowed down like this, he said “don’t worry, don't worry, I'm here, I'm here,” and I was petrified 'cause he was such a big man I thought I was absolutely about to die, I thought “oh my God, I'm just going to get smashed but then his, his mate just pulled him back and he said, no, all I was doing was trying to protect you, 'cause if you could see what's coming on to your head you wouldn’t be sitting there’
The concept of ‘knowing the patient’ helped to enhance the consultation interview
GPs followed various models of assessment specifically designed for consulting with mental health patients often depending on carers for answers if patients had limited ability to respond. This is work within a ‘pre-determined’ space in which there are certain expectations that consultations will be carried out in a customary style following specific phases of the medical consultation, explicitly maintaining their work of ‘doctoring’ (West 2006a p393). They indicated that their assessment was enriched by the fact that they got to know patients over chronological time and this also implied a sense of closeness. Knowing the patient is a concept identified in nursing (Radwin 1996) and as an essential component of clinical judgement it characterises having understanding of the patient recognising their unique individuality.
Watching for a crisis in the patient’s condition is paramount to a change of tactics
Maintaining safety for patients, carers and doctors remained paramount and GPs actively watch for a ‘crisis’, which was the time to bring in the police or refer patients on. When a crisis occurred GPs felt they were unable to manage the patient’s condition by themselves. Referral on to psychiatric services was sporadic few surgeries had good systems in place while others felt they were poor and GPs often had little confidence in psychiatrists being able to manage patients adequately.
This study while small scale, is a start in the journey towards tackling the limited research in the literature on how GPs develop a therapeutic/effective relationships with patients who have mental health problems.
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Cruz, M., Pincus, H. A. (2002). Research on the influence that communication in psychiatric encounters has on treatment. Psychiatric Services. 53(10), p10-35
Fraser, N. (1992) The use and abuse of French discourse for feminist politics. In Fraser, N., Bartky, S. (eds) Revaluating French Feminism: Critical Essays on Difference, Agency and Culture. Bloomington, Indiana University Press
Mental Health Network (2011) No health without mental health: the new strategy for mental health in England
McCabe, R (2008). Communication and psychosis its good to talk, but how? The British Journal ofPsychiatry, 192, p404-405
Nyamathi, A. (1998). Vulnerable populations: A continuing nursing focus. Nursing Research, 47(2), p65-66.
Potter, J., Wetherell, M. (2005) Discourse and Social Psychology. London, Sage Publications
Radwin, L. (1996) ‘Knowing the patient’: a review of research on an emerging concept. Journal of Advanced Nursing. 23, p1142-1146
Stanghellini, G. (2004). The Puzzle of the Psychiatric Interview. Journal of Phenomenological Psychology, 35(2), p173-195.
West, C. (2006a) Coordinating closings in primary care visits: producing continuity of care. . In Heritage, J., Maynard, D. (eds) Communication in medical care. Interaction between primary care physicians and patients. Cambridge, Cambridge University Press, p379-415