Effect of questions used by psychiatrists on therapeutic alliance - - PowerPoint PPT Presentation

Effect of questions used by psychiatrists on therapeutic alliance and adherence

Christine Howes Laura Thompson, Rose McCabe 10th October 2017

Christine Howes2015

1

Background

2

Method

3

Results

4

Conclusions

Christine Howes2015

1

Background

2

Method

3

Results

4

Conclusions

Christine Howes2015

Background

Psychiatry is inconceivable without clinician questions Questions are the mechanism for:

achieving clinical objectives: history taking, reviewing symptoms and deducing diagnostic hypotheses managing the formation of therapeutic alliance – known to impact on treatment decisions and patient adherence

(Thompson and McCabe, 2012)

in the case of schizophrenia, psychotic symptoms may problematise interaction

(McCabe et al., 2002)

Christine Howes2015

Background

Advice to psychiatrists is often generalised:

in general try to use open questions rather than leading questions or closed questions

(Burton, 2010)

But ‘open’ and ‘closed’ questions encompass numerous question types – with different interactional consequences

(Heritage, 2010)

Aims: (1) What types of questions do psychiatrists ask patients in routine consultations? (2) Do particular question types predict better therapeutic alliance and treatment adherence?

Christine Howes2015

1

Background

2

Method

3

Results

4

Conclusions

Christine Howes2015

Data

UK MRC study (collected 2006–2008)

(McCabe et al., 2013)

31 psychiatrists from 3 centres Patients meeting DSM-IV criteria for schizophrenia or schizoaffective disorder Consent obtained from 138 (of 579; 40%) Consultations audiovisually recorded 134 verbatim transcripts of verbal dialogue annotated using Dexter

(Garretson, 2006)

Christine Howes2015

Questions coding

Christine Howes2015

Questions coding

Question type Example from data Yes/no Do you ever feel someone is controlling your mind? Wh- Where was that done? Declarative So you feel anxious a bit anxious? Tag You’re on 10mg of olanzapine, aren’t you? Lexical tags I’ll write a letter to your GP , okay? Incomplete Your keyworker is? Alternative Do you feel better having stopped it or worse? Check Yeah? Wh-in-situ He did what? OCRI Pardon?

Christine Howes2015

Questions coding

Question type Example from data Yes/no Do you ever feel someone is controlling your mind? Wh- Where was that done? Declarative So you feel anxious a bit anxious? Tag You’re on 10mg of olanzapine, aren’t you? Lexical tags I’ll write a letter to your GP , okay? Incomplete Your keyworker is? Alternative Do you feel better having stopped it or worse? Check Yeah? Wh-in-situ He did what? OCRI Pardon? Syntactic

Christine Howes2015

Questions coding

Question type Example from data Yes/no Do you ever feel someone is controlling your mind? Wh- Where was that done? Declarative So you feel anxious a bit anxious? Tag You’re on 10mg of olanzapine, aren’t you? Lexical tags I’ll write a letter to your GP , okay? Incomplete Your keyworker is? Alternative Do you feel better having stopped it or worse? Check Yeah? Wh-in-situ He did what? OCRI Pardon? Lexical

Christine Howes2015

Questions coding

Question type Example from data Yes/no Do you ever feel someone is controlling your mind? Wh- Where was that done? Declarative So you feel anxious a bit anxious? Tag You’re on 10mg of olanzapine, aren’t you? Lexical tags I’ll write a letter to your GP , okay? Incomplete Your keyworker is? Alternative Do you feel better having stopped it or worse? Check Yeah? Wh-in-situ He did what? OCRI Pardon? Intonational

Christine Howes2015

Questions coding

Question type Example from data Yes/no Do you ever feel someone is controlling your mind? Wh- Where was that done? Declarative So you feel anxious a bit anxious? Tag You’re on 10mg of olanzapine, aren’t you? Lexical tags I’ll write a letter to your GP , okay? Incomplete Your keyworker is? Alternative Do you feel better having stopped it or worse? Check Yeah? Wh-in-situ He did what? OCRI Pardon? Open Closed

Christine Howes2015

Symptoms

Positive and Negative Syndrome Scale (PANSS)

(Kay et al., 1987)

Rated from audiovisually recorded interviews POSITIVE delusions, sensory hallucinations NEGATIVE blunted affect, emotional withdrawal, alogia GENERAL anxiety higher scores = greater severity

PANSS mean (s.d.) POSITIVE 13.1 (5.9) NEGATIVE 12.5 (5.8) GENERAL 28.8 (9.6)

Christine Howes2015

Therapeutic Alliance

Helping Alliance Scale (HAS)

(Priebe and Gruyters, 1993)

Psychiatrist rated post-consultation Five items rated 1-10 interpersonal variables e.g. mutual understanding, rapport lower scores = poorer therapeutic relationship

Christine Howes2015

Measures and outcomes

Adherence to treatment

Psychiatrist rated 6 months after consultation (1) Adherence to treatment in general (% of

• ccasions that scheduled appointments were

kept and non-medication recommendations were followed) (2) adherence to medication (% of medication taken)

1 > 75% 2 25 − 75% 3 < 25%

lower score = better adherence

Christine Howes2015

1

Background

2

Method

3

Results

4

Conclusions

Christine Howes2015

Questions used

Per consultation Per 1000 words Question TypeTotal Mean (s.d.) Rng Mean (s.d.) Rng YN 2362 16.5 (12.2) 57 12.0 (6.0) 30 Wh- 1700 12.7 (10.4) 63 8.5 (4.8) 23 Declarative 1648 11.0 (8.3) 47 9.0 (8.0) 40 Tag 528 3.9 (4.5) 25 2.3 (2.1) 11 Lexical Tags 496 3.7 (5.2) 29 2.0 (2.2) 11 Incomplete 196 1.5 (1.7) 8 1.1 (1.8) 12 Alternative 159 1.2 (1.5) 10 0.8 (1.2) 9 Check 85 0.6 (1.4) 7 0.4 (1.2) 6 Wh-in-situ 47 0.4 (1.0) 10 0.2 (0.6) 5 OCRI 35 0.3 (0.7) 4 0.2 (0.6) 4 Total 7570 51.7 (32.1) 165 35.0 (16.0) 93

Christine Howes2015

Questions used

Per consultation Per 1000 words Question TypeTotal Mean (s.d.) Rng Mean (s.d.) Rng YN 2362 16.5 (12.2) 57 12.0 (6.0) 30 Wh- 1700 12.7 (10.4) 63 8.5 (4.8) 23 Declarative 1648 11.0 (8.3) 47 9.0 (8.0) 40 Tag 528 3.9 (4.5) 25 2.3 (2.1) 11 Lexical Tags 496 3.7 (5.2) 29 2.0 (2.2) 11 Incomplete 196 1.5 (1.7) 8 1.1 (1.8) 12 Alternative 159 1.2 (1.5) 10 0.8 (1.2) 9 Check 85 0.6 (1.4) 7 0.4 (1.2) 6 Wh-in-situ 47 0.4 (1.0) 10 0.2 (0.6) 5 OCRI 35 0.3 (0.7) 4 0.2 (0.6) 4 Total 7570 51.7 (32.1) 165 35.0 (16.0) 93

Christine Howes2015

Correlations with outcomes

YN Qs Wh Qs Declaratives r p r p r p PANSS Symptoms General 0.130 0.138 0.152 0.082 0.133 0.131 Positive 0.054 0.052 0.182 0.037 0.028 0.747 Negative 0.182 0.036 -0.008 0.927 -0.010 0.911 Therapeutic Alliance HAS Score 0.030 0.732 0.099 0.259 0.282 0.001 Adherence 0.043 0.636 0.033 0.718 -0.204 0.022

0.00 Correlation is significant at the p < 0.05 level 0.00 Correlation is significant at the p < 0.01 level

Christine Howes2015

Generalised Linear Mixed Model

Mixed model statistical method Gamma distribution with a log link function Control for within-individual correlations of psychiatrist Random variables = 3 symptom scales (using a scaled-identity covariance matrix) Fixed variables = 3 question types per 1000 words

Christine Howes2015

Therapeutic Alliance

more declarative questions = better psychiatrist ratings of therapeutic alliance more wh- questions = worse ratings

Christine Howes2015

Adherence

more declarative questions = patients more likely to adhere to their treatment

Christine Howes2015

Declaratives

So what is it about declarative questions? Detailed examination of 210 declarative questions from 30 consultations

1

Checklist type (16/8%) Doctor: Sleeping okay?

2

Verbatim repeats (23/11%) Patient: I’ve had some side-effects. Doctor: You’ve had some side-effects?

3

Inferential/abstract (171/81%) ‘So-’ prefaced inferences (90/53%) Doctor: So you feel a bit anxious?

Christine Howes2015

So-prefaced declaratives

Patient: It’s just that sometimes in the afternoon I get like, you know, I get the feeling that it’s going to happen to me, I will end up in the hospital. Doctor: Okay. Patient: And, er, Doctor: So you feel a bit anxious? Patient: Yeah. Patient: Yeah, I like to chill out in the house, Doctor, you know, I watch telly and then cook something and then washing and tidy the house up, you know? Doctor: Yeah. So you’re quite happy being on your own? Patient: I’m quite happy, Doctor. Yeah, yeah.

Christine Howes2015

So-prefaced declaratives

devices for suggesting “something implicitly meant by the client”

(Bolden, 2009)

display understanding, cooperation and engagement

(Antaki, 2008)

also serve clinical objectives, as summaries

• f therapeutic interpretation

micro-level formulation

(Summers et al., 2017)

resource to display sensitivity to the emotional implications of delusions, while avoiding collusion or confrontation

Christine Howes2015

Summary

Psychiatrists used three question types regularly: yes/no, wh- and declarative Declaratives predicted better adherence and perceptions of the therapeutic relationship wh-questions – associated with positive symptoms – predicted poorer perceptions

• f the therapeutic relationship

Declaratives can propose an understanding

• f patients’ experiences, in particular their

emotional salience

Christine Howes2015

1

Background

2

Method

3

Results

4

Conclusions

Christine Howes2015

Conclusions

Specific questioning practices can improve communication in psychiatry Declarative questions may enhance alliance and adherence, or index their manifestation in talk, e.g. better mutual understanding ‘So’-prefaced declaratives, function in a more nuanced way than ‘leading’ questions They are hearable as empathetic and attend to patient experience, while balancing the tasks of assessment and treatment

Christine Howes2015

Thanks!

Any questions?

Christine Howes2015

References I

Antaki, C. (2008). Formulations in psychotherapy. In Perakyla, A., Antaki, C., Vehvilainen, S., and Leudar, I., editors, Conversation analysis and psychotherapy, pages 26–42. Cambridge University Press. Bolden, G. B. (2009). Implementing incipient actions: The discourse marker ‘so’ in english conversation. Journal of Pragmatics, 41(5):974–998. Burton, N. (2010). Psychiatry. Wiley Blackwell, Oxford. Garretson, G. (2006). Dexter: Free tools for analyzing texts. In Actas de V Congreso Internacional AELFE, pages 659–665. Heritage, J. (2010). Questioning in medicine. In Freed, A. and Ehrlich, S., editors, Why Do You Ask?: The Function of Questions in Institutional Discourse, pages 42–68. Oxford University Press. Kay, S., Fiszbein, A., and Opfer, L. (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia bulletin, 13(2):261. McCabe, R., Healey, P . G. T., Priebe, S., Lavelle, M., Dodwell, D., Laugharne, R., Snell, A., and Bremner, S. (2013). Shared understanding in psychiatrist-patient communication: Association with treatment adherence in schizophrenia. Patient Education and Counselling, 93:739.

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References II

McCabe, R., Skelton, J., Heath, C., Burns, T., and Priebe, S. (2002). Engagement of patients with psychosis in the consultation: conversation analytic studycommentary: Understanding conversation. Bmj, 325(7373):1148–1151. Priebe, S. and Gruyters, T. (1993). The role of the helping alliance in psychiatric community care: A prospective study. Journal of Nervous and Mental Disease, 181(9):552–557. Summers, A., Boland, B., Dave, S., Gill, H., Ingrams, C., and Saju, P . (2017). Using formulation in general psychiatric care: good practice. Occasional paper, Royal College of Psychiatrists. Thompson, L. and McCabe, R. (2012). The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review. BMC psychiatry, 12(1):87.

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