Positions in doctors' questions during psychiatric interviews

What to take up from the patient's talk? The clinician's responses to the patient's self-disclosure of their subjective experience in the psychiatric intake interview

During psychiatric diagnostic interviews, the clinician's question usually targets specific symptom descriptions based on diagnostic categories for ICD-10/DSM-5 (2, 3). While some patients merely answer questions, others go beyond to describe their subjective experiences in a manner that highlights the intensity and urgency of those experiences. By adopting conversation analysis as a method, this study examines diagnostic interviews conducted in an outpatient clinic in South Finland and identifies sequences that divulge patients' subjective experiences. From 10 audio-recorded diagnostic interviews, 40 segments were selected where patients replied to medically or factually oriented questions with their self-disclosures. The research focus was on the clinicians' responses to these disclosures. We present five sequential trajectories that the clinicians offered third-position utterances in response to their patients' self-disclosure of subjective experiences. These trajectories include the following: 1) the clinician transfers the topic to a new agenda question concerning a medical or factual theme; 2) the clinician presents a follow-up question that selects a topic from the patient's self-disclosure of a subjective experience that may orient either towards the medical/factual side or the experiential side of the patient's telling; 3) the clinician provides an expert interpretation of the patient's self-disclosure of his or her subjective experience from the clinician's expert perspective; 4) the clinician gives advice that orients mainly to a treatment recommendation or to another activity; and 5) the clinician presents a formulation that focusses on the core of their patient's self-disclosure of his or her subjective experience from the patient's perspective. In addition, we present what these responsive practices invoke from the patient in the next turn. We argue that an awareness of these strategies facilitates both the diagnosis and an appropriate therapeutic relationship during the psychiatric assessment interview. Finally, we discuss the clinical significance of our results regarding the patient's agency and the clinician's more conscious patient-centred orientation in the psychiatric assessment procedure.

Nurses' experiences when conducting the mental state examination (MSE): A scoping review

The Mental State Examination (MSE) is an assessment framework used to facilitate the collection of subjective and objective data about a person's current mental state. There is a lack of understanding of nurses' experiences when conducting the MSE. The aim of this scoping review is to identify, examine and summarize the available literature relating to nurses' experiences when conducting the MSE. A scoping review was conducted using Arksey and O'Malley (2005) framework to review, examine and synthesize the available literature on nurses' experiences with the MSE. A PRISMA flow diagram was used to describe the systematic literature search. Six databases (APA PsycInfo, CINAHL, MEDLINE, PubMed, ProQuest, and Scopus) were searched including reference lists of eligible sources. Google Scholar, Trove and Proquest Dissertation and Thesis were searched for grey literature. Twelve articles included in this scoping review considered nurses experiences when conducting the MSE. The principles of thematic analysis were used to synthesize the studies. Three distinct themes were identified from the literature: (i) Nurses' role and the MSE, (ii) Nurses' competence and knowledge when conducting the MSE, and (iii) Nurses' confidence when conducting the MSE. The results of this scoping review identified the MSE as a component of the mental health nursing role and a core competency of mental health telephone triage services. The MSE was used by nurses in the Emergency department (ED), acute in-patient and community mental health settings, including mental health telephone triage services. Nurses working in EDs and acute in-patient mental health settings experienced a lack of confidence and competence, including a knowledge deficit in conducting the MSE in comparison to nurses working in community mental health settings. Community mental health nurses identified the importance of conducting an MSE higher than acute in-patient mental health nurses. This review identified the need for evidence-based research related to the MSE and its application in nursing practice. Evidence-based research will inform the development of MSE guidelines and policies, thus, enhance mental health nursing practice related to the MSE, including improving and strengthening consumer-nurse therapeutic alliance in acute in-patient mental health settings.

'Is it in your basic personality?' Negotiations about traits and context in diagnostic interviews for personality disorders

What does it mean to claim that somebody's personality is disordered? The aim in this paper is to examine how the process of diagnosing personality disorders (PD) unfolds on a practical level. We take an in-depth look at PD interviews, paying close attention to the occasional discrepancies in the clinicians' and the patients' approaches to generalising the behaviour of patients to describe their personality. Clinicians are guided by the medical model and structured interviews in their approach. We regard the interview situation as interplay between the institution, the clinician and the patient - and the final diagnosis as an interactional construction between them. Our data consists of video-recorded interviews in Finland with 10 adult patients and three psychiatric nurses. The collection was compiled from 22 excerpts in which the participants orient differently to the generalisability of personality traits. Our observations show that, in these interviews, patients frequently make sense of their behaviour differently from what is expected - not as a reflection of their personality traits, but as an outcome of many situational factors. Our understanding leads us to emphasise the importance of making visible the practices that shape the diagnostic process in psychiatry.

Modes of Interaction in Naturally Occurring Medical Encounters With General Practitioners: The "One in a Million" Study

In this article, we qualitatively explore the manner and style in which medical encounters between patients and general practitioners (GPs) are mutually conducted, as exhibited in situ in 10 consultations sourced from the One in a Million: Primary Care Consultations Archive in England. Our main objectives are to identify interactional modes, to develop a classification of these modes, and to uncover how modes emerge and shift both within and between consultations. Deploying an interactional perspective and a thematic and narrative analysis of consultation transcripts, we identified five distinctive interactional modes: question and answer (Q&A) mode, lecture mode, probabilistic mode, competition mode, and narrative mode. Most modes are GP-led. Mode shifts within consultations generally map on to the chronology of the medical encounter. Patient-led narrative modes are initiated by patients themselves, which demonstrates agency. Our classification of modes derives from complete naturally occurring consultations, covering a wide range of symptoms, and may have general applicability.

Looking Through Dementia: What Do Commercial Stock Images Tell Us About Aging and Cognitive Decline?

Commercial stock images are existing, artificially constructed visuals used by businesses and media outlets to articulate certain values, assumptions and beliefs. Despite their pervasiveness and accessibility, little is known about the ways in which stock images communicate meanings relating to health and illness. This study examines a broad range of common stock images that depict dementia and aging, revealing the tendency for older people with dementia to be represented in objectifying and de-humanizing terms-emphasizing disease and deficit at the expense of the whole person, whereas precluding any possibility of enduring personhood. As well as introducing a multimodal critical discourse approach that can be adopted by other researchers examining the ideological underpinnings of health and illness imagery, this study underscores the importance of critically interrogating stock photography-a much neglected, yet profoundly influential, cultural resource that can shape the ways we think about and respond to illness and disease.

Reflecting on what 'you said' as a way of reintroducing difficult topics in child mental health assessments

BACKGROUND

In child and adolescent mental health assessments, questions are integral to the process. There has been limited research focused on the assessment process, or on how questions are constructed within this clinical environment.

METHODS

We examined 28 naturally occurring initial assessments, with particular attention to how practitioners used questions in their communication with children and young people. We utilised conversation analysis to examine the data.

RESULTS

Analysis revealed a particular type of question preface used to reintroduce a prior topic. This was achieved through the use of 'you said x' as a foundation for asking a follow-up question and demonstrated active listening.

CONCLUSIONS

Arguably, this approach is a useful way of gathering assessment-relevant information in a child-centred way.

Positioning pharmacists' roles in primary health care: a discourse analysis of the compensation plan in Alberta, Canada

BACKGROUND

A comprehensive Compensation Plan for pharmacy services delivered by community pharmacists was implemented in Alberta, Canada in July 2012. Services covered by the Compensation Plan include care planning services, prescribing services such as adapting prescriptions, and administering a drug or publicly-funded vaccine by injection. Understanding how the Compensation Plan was framed and communicated provides insight into the roles of pharmacists and the potential influence of language on the implementation of services covered by the Compensation Plan by Albertan pharmacists. The objective of this study is to examine the positioning of pharmacists' roles in documents used to communicate the Compensation Plan to Albertan pharmacists and other audiences.

METHODS

Publicly available documents related to the Compensation Plan, such as news releases or reports, published between January 2012 and December 2015 were obtained from websites such as the Government of Alberta, Alberta Blue Cross, the Alberta College of Pharmacists, the Alberta Pharmacists' Association, and the Blueprint for Pharmacy. Searches of the Canadian Newsstand database and Google identified additional documents. Discourse analysis was performed using social positioning theory to explore how pharmacists' roles were constructed in communications about the Compensation Plan.

RESULTS

In total, 65 publicly available documents were included in the analysis. The Compensation Plan was put forward as a framework for payment for professional services and formal legitimization of pharmacists' changing professional roles. The discourse associated with the Compensation Plan positioned pharmacists' roles as: (1) expanding to include services such as medication management for chronic diseases, (2) contributing to primary health care by providing access to services such as prescription renewals and immunizations, and (3) collaborating with other health care team members. Pharmacists' changing roles were positioned in alignment with the aims of primary health care.

CONCLUSIONS

Social positioning theory provides a useful lens to examine the dynamic and evolving roles of pharmacists. This study provides insight into how communications regarding the Compensation Plan in Alberta, Canada positioned pharmacists' changing roles in the broader context of changes to primary health care delivery. Our findings may be useful for other jurisdictions considering implementation of remunerated clinical services provided by pharmacists.

Identifying the interactional processes in the first assessments in child mental health

BACKGROUND

A comprehensive assessment is essential to contemporary practice in child and adolescent mental health. In addition to determining diagnosis and management, it is seen as important for clinical engagement and forming a therapeutic relationship. However, there has been little research on the processes which occur during this interaction, particularly in first assessments.

METHOD

Twenty-eight naturally occurring child mental health initial assessments were video recorded and subjected to the basic principles of the conversation analytic method.

RESULTS

Several processes were identified in a typical child and adolescent mental health assessment. These included introductions, reasons for attendance, problem presentation, decision-making and session closure.

CONCLUSIONS

Initial assessments provide a platform for all future engagement with services and an understanding of the processes occurring within this setting is important for the eventual outcomes, particularly in respect to new ways of working such as the Choice and Partnership Approach (CAPA).

Question use in child mental health assessments and the challenges of listening to families

BACKGROUND

The mental health assessment is a fundamental aspect of clinical practice and central to this is the use of questions.

AIMS

To investigate the frequency and type of questions utilised within a child mental health assessment.

METHOD

The data consisted of 28 naturally occurring assessments from a UK child and adolescent mental health service. Data were analysed using quantitative and qualitative content analysis to determine frequencies and question type.

RESULTS

Results indicated a total of 9086 questions in 41 h across the 28 clinical encounters. This equated to a mean of 3.7 questions per minute. Four types of questions were identified; yes-no interrogatives, wh-prefaced questions, declarative questions and tag questions.

CONCLUSIONS

The current format of questioning may impede the opportunity for families to fully express their particular concerns and this has implications for service delivery and training.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Time and the psychiatric interview: The negotiation of temporal criteria of the depressive disorder

In this article, I am concerned with doctors’ negotiations of the temporal dimension of the diagnostic criteria of depressive disorders during the first psychiatric interview. The data come from 16 initial psychiatric interviews recorded by doctors in three psychiatric hospitals in Poland. Taking a constructionist view of discourse and psychiatric practices, I shall argue that the discursive practice related to temporal information about patients’ illnesses serves in gaining information, which is useful in the medical model of psychiatric diagnosis. The doctors positioned the patients’ experiences on the timeline when the illness history was taken and temporal information authenticated the information. Conversely, the patients’ current conditions were constructed in a limitless present, which allowed the psychiatrists to remove the relativity.

Social Positioning Theory as a lens for exploring health information seeking and decision making

In this article I use Social Positioning Theory to explore the experiences of women as they interact with and make sense of evolving health information mediated by formal and informal sources. I investigate how women position themselves within their accounts of information seeking, and the influence of positioning on interactions with health professionals (HPs). Interviewed women gathered and valued information from a range of sources, and were likely to position themselves as autonomous, rather than collaborative or dependent. Faced with evolving health information, women felt responsible not only for information seeking, but also for making sense of gathered and encountered information. Participants did, however, value information provided by HPs and were likely to view decision making as collaborative when HPs fostered information exchange, appeared to appreciate different types of knowledge and cognitive authority, and supported women in their quests for information. Implications for shared decision making are discussed.

Psychiatrists' accounts of insight

Our main aim was to examine how insight into schizophrenia is discursively represented in psychiatrists' accounts, how these accounts relate to the current psychiatric literature on insight, and their potential clinical consequences. The article is anchored in the constructionist view of discourse and is based on nine semistructured interviews with specialist psychiatrists. We discuss three dimensions of insight into schizophrenia in the data we collected: a sense of illness, criticism, and readiness to receive treatment. We argue that they are embodiments of the dominant medical perspective in the relations between patients and physicians. Whereas in the former two it is possessing and accepting psychiatric knowledge which constitutes having insight, in the latter it is unquestioning acceptance and trust in whatever treatment the doctor deems fit to administer. We conclude with a discussion of medicalization of experience of mental illness, which appears to be the preferred mode of patient narrative for psychiatrists.

The pharmacist as prescriber: a discourse analysis of newspaper media in Canada

BACKGROUND

Legislation to expand the scope of practice for pharmacists to include authority to independently prescribe medications in Alberta, Canada was announced in 2006 and enacted in April 2007. To date, very little research has explored public views of pharmacist prescribing.

OBJECTIVE

This study analyzes newspaper media coverage of pharmacist prescribing 1 year before and 2 years after prescribing was implemented.

METHODS

News items related to pharmacist prescribing were retrieved from 2 national, Canadian newspapers and 5 local newspapers in Alberta over a 3-year period after the announcement of pharmacist prescribing. A purposive sample of 66 texts including news items, editorials, and letters were retrieved electronically from 2 databases, Newscan and Canadian Newsstand. This study uses social positioning theory as a lens for analyzing the discourse of pharmacist prescribing.

RESULTS

The results demonstrate a binary positioning of the debate on pharmacist prescribing rights. Using social positioning theory as a lens for analysis, the results illustrate self- and other-positioning of pharmacists' expected roles as prescribers. Themes related to the discourse on pharmacist prescribing include qualifications, diagnosis, patient safety, physician support, and conflict of interest. Media representations of pharmacist prescribing point to polarized views that may serve to shape public, pharmacist, physician, and others' opinions of the issue.

CONCLUSIONS

Multiple and contradictory views of pharmacist prescribing coexist. Pharmacists and pharmacy organizations are challenged to bring clarity and consistency about pharmacist prescribing to better serve the public interest in understanding options for health care services.

Discourses of depression of Australian general practitioners working with gay men

The data for this article are from a primary health care project on HIV and depression, in which the prevalence, nature, clinical management, and self-management of depression among homosexually active men attending high-HIV-caseload general practice clinics were investigated. One of the qualitative arms consisted of in-depth interviews with general practitioners (GPs) with high caseloads of gay men. The approach to discourse analysis was informed by Halliday's systemic functional linguistics. GPs constructed three discourses of depression: engaging with psychiatric discourse, engaging with the patient's world, and engaging with social structures. When GPs drew on the discourse of psychiatry, this discourse was positioned as only one possible construction of depression. This discourse was also contextualized in the social lives of gay men, and it was explicitly challenged and rejected. Engaging with their patients' social world was considered vital for recognizing depression in gay men. Finally, the GPs' construction of depression was inextricably linked to social disadvantage and marginalization. Depression is highly heterogeneous and constructed in terms of social relationships rather than as an independent entity that resides in the individual. There is a synergy between GPs' constructions of depression and men's experiences of depression, which differs from conventional medical views, and which enables GPs to be highly effective in dealing with the mental health issues of their gay patients.

'These psychiatrists rate themselves as gods': disengagement and engagement discourses of people living with severe mental illness

Positioning analysis, a variant of discourse analysis, was used to explore the narratives of 40 psychiatric patients (11 females and 29 males; mean age = 40 years) who had manifest difficulties with engagement with statutory mental health services. Positioning analysis is a qualitative method that captures how people linguistically position the roles and identities of themselves and others in their day-to-day lives and narratives. The language of disengagement incorporated the passive positioning of self in relation to their lives and treatment through the use of metaphor, the passive voice and them and us attribution, while the discourse of engagement incorporated more active positioning of self achieved through the use of the personal pronoun we and metaphoric references to balanced relationships. The findings corroborate previous thematic analysis that highlighted the importance of identity and agency in the 'making or breaking' of therapeutic relationships (Priebe et al. 2005). Implications are discussed in relation to how positioning analysis may help signal and emphasize important life and therapeutic experiences in spoken narratives as well as clinical consultations.