Digital empathy in behaviour change interventions: A survey study on health coach responses to patient cues

Introduction

Digital health coaching interventions for behaviour change (BC) are effective in addressing various health conditions. Implementing these requires accurate descriptions of components and health coaches (HC) delivery methods, alongside understanding patients' perceptions of these interactions. The HC-patient relationship significantly influences BC outcomes. Here, empathy is an important driver that enables HCs to offer tailored advice that resonates with patients' needs, fostering motivation. Yet, defining and measuring empathy remains a challenge. In this study, we draw on various BC frameworks and Pounds' empathy appraisal approach to categorise HCs responses to patient cues and explore the interplay between empathy and BC.

Methods

Using a two-round survey, we collected responses from 11 HCs to 10 patient messages from the Bump2Baby and Me trial in a simulated interaction. We analysed 88 messages to identify empathic responses and behaviour change techniques.

Results

Patients' implicit empathy opportunities showed higher response rates than explicit ones. HCs prioritised positive reinforcement and employed various strategies to achieve similar objectives. The most common empathic response was 'Acceptance' for patients' implicit positive expressions of self-judgement. HCs emphasised relatedness-support and competence-promoting techniques for implicit negative feelings and judgements, such as 'Show unconditional regard' and 'Review behaviour goals', and 'Action planning and Problem-solving' techniques to address explicit negative appreciations and feelings.

Conclusion

The use of different techniques with the same objective highlights the complexity of BC interactions. Further research is needed to explore the impact of this variability on patient outcomes and programme fidelity.

Pro-vaccination personal narratives in response to online hesitancy about the HPV vaccine: The challenge of tellability

Experimental studies have shown that narratives can be effective persuasive tools in addressing vaccine hesitancy, including regarding the vaccine against the human papillomavirus (HPV), which is transmitted via sexual contact and can cause cervical cancer. This paper presents an analysis of a thread from the online parenting forum Mumsnet Talk where an initially undecided Original Poster is persuaded to vaccinate their child against HPV by a respondent's narrative of cervical cancer that they describe as difficult to share. This paper considers this particular narrative alongside all other narratives that precede the decision announced on the Mumsnet thread. It shows how producing pro-vaccination narratives about HPV involves challenges regarding 'tellability' - what makes the events in a narrative reportable or worth telling. We suggest that this has implications for the context-dependent nature of tellability, the role of parenting forums in vaccination-related discussions, and narrative-based communication about vaccinations more generally.

Narratives, Information and Manifestations of Resistance to Persuasion in Online Discussions of HPV Vaccination

There are both theoretical accounts and empirical evidence for the fact that, in health communication, narratives (story telling) may have a persuasive advantage when compared with information (the provision of facts). The dominant explanation for this potential advantage is that narratives inhibit people's resistance to persuasion, particularly in the form of counterarguing. Evidence in this area to date has most often been gathered through lab or field experiments. In the current study we took a novel approach, gathering our data from naturally-occurring, non-experimental and organically evolving online interactions about vaccinations. We focus on five threads from the parenting forum Mumsnet Talk that centered on indecision about the HPV vaccination. Our analysis revealed that narratives and information were used by posters in similar quantities as a means of providing vaccination-related advice. We also found similar frequencies of direct engagement with both narratives and information. However, our findings showed that narratives resulted in a significantly higher proportion of posts exhibiting supportive engagement, whereas information resulted in posts exhibiting a significantly higher proportion of challenges, including counterarguing and other manifestations of posters' resistance to persuasion. The proportions of supportive versus challenging engagement also varied depending on the topic and vaccine stance of narratives. Notwithstanding contextual explanations for these patterns, our findings, based on this original approach of using naturalistic data, provide a novel kind of evidence for the potential of narratives to inhibit counterarguing in authentic health-related discourse.

Corpus linguistics and clinical psychology: Investigating personification in first-person accounts of voice-hearing

Triangulating corpus linguistic approaches with other (linguistic and non-linguistic) approaches enhances "both the rigour of corpus linguistics and its incorporation into all kinds of research" (McEnery & Hardie, 2012:227). Our study investigates an important area of mental health research: the experiences of those who hear voices that others cannot hear, and particularly the ways in which those voices are described as person-like. We apply corpus methods to augment the findings of a qualitative approach to 40 interviews with voice-hearers, whereby each interview was coded as involving 'minimal' or 'complex' personification of voices. Our analysis provides linguistic evidence in support of the qualitative coding of the interviews, but also goes beyond a binary approach by revealing different types and degrees of personification of voices, based on how they are referred to and described by voice-hearers. We relate these findings to concepts that inform therapeutic interventions in clinical psychology.

Examining the language demands of informed consent documents in patient recruitment to cancer trials using tools from corpus and computational linguistics

Obtaining informed consent (IC) is an ethical imperative, signifying participants' understanding of the conditions and implications of research participation. One setting where the stakes for understanding are high is randomized controlled trials (RCTs), which test the effectiveness and safety of medical interventions. However, the use of legalese and medicalese in ethical forms coupled with the need to explain RCT-related concepts (e.g. randomization) can increase patients' cognitive load when reading text. There is a need to systematically examine the language demands of IC documents, including whether the processes intended to safeguard patients by providing clear information might do the opposite through complex, inaccessible language. Therefore, the goal of this study is to build an open-access corpus of patient information sheets (PIS) and consent forms (CF) and analyze each genre using an interdisciplinary approach to capture multidimensional measures of language quality beyond traditional readability measures. A search of publicly-available online IC documents for UK-based cancer RCTs (2000-17) yielded corpora of 27 PIS and 23 CF. Textual analysis using the computational tool, Coh-Metrix, revealed different linguistic dimensions relating to the complexity of IC documents, particularly low word concreteness for PIS and low referential and deep cohesion for CF, although both had high narrativity. Key part-of-speech analyses using Wmatrix corpus software revealed a contrast between the overrepresentation of the pronoun 'you' plus modal verbs in PIS and 'I' in CF, exposing the contradiction inherent in conveying uncertainty to patients using tentative language in PIS while making them affirm certainty in their understanding in CF.

Illusory social agents within and beyond voices: A computational linguistics analysis of the experience of psychosis

Objectives

Psychosis has a strong social component and often involves the experience of being affected by ‘illusory social agents’. However, this experience remains under‐characterized, particularly for social agents in delusions and non‐vocal hallucinations. One useful approach is a form of computational linguistics called corpus linguistics that studies texts to identify patterns of meaning encoded in both the semantics and linguistic structure of the text.

Methods

Twenty people living with psychosis were recruited from community and inpatient services. They participated in open‐ended interviews on their experiences of social agents in psychosis and completed a measure of psychotic symptoms. Corpus linguistics analysis was used to identify key phenomenological features of vocal and non‐vocal social agents in psychosis.

Results

Social agents i) are represented with varying levels of richness in participants’ experiences, ii) are attributed with different kinds of identities including physical characteristics and names, iii) are perceived to have internal states and motivations that are different from those of the participants, and iv) interact with participants in various ways including through communicative speech acts, affecting participants’ bodies, and moving through space. These representations were equally rich for agents associated with hallucinated voices and those associated with non‐vocal hallucinations and delusions.

Conclusions

We show that the experience of illusory social agents is a rich and complex social experience reflecting many aspects of genuine social interaction and is not solely present in auditory hallucinations, but also in delusions and non‐vocal hallucinations.

Practitioner Points

The experience of being affected by illusory social agents in psychosis extends beyond hallucinated voices.

They are a rich and complex social experience reflecting many aspects of genuine social interaction.

These are also likely to be a source of significant distress and disability.

Person-ness of voices in lived experience accounts of psychosis: combining literary linguistics and clinical psychology

In this paper, we use concepts and insights from the literary linguistic study of story-world characters to shed new light on the nature of voices as social agents in the context of lived experience accounts of voice-hearing. We demonstrate a considerable overlap between approaches to voices as social agents in clinical psychology and the perception of characters in the linguistic study of fiction, but argue that the literary linguistic approach facilitates a much more nuanced account of the different degrees of person-ness voices might be perceived to possess. We propose a scalar Characterisation Model of Voices and demonstrate its explanatory potential by comparing two lived experience descriptions of voices in interviews with voice-hearers in a psychosis intervention. The new insights into the phenomenology of voice-hearing achieved by applying the model are relevant to the understanding of voice-hearing as well as to therapeutic interventions.

A linguistic approach to the psychosis continuum: (dis)similarities and (dis)continuities in how clinical and non-clinical voice-hearers talk about their voices

Introduction: "Continuum" approaches to psychosis have generated reports of similarities and differences in voice-hearing in clinical and non-clinical populations at the cohort level, but not typically examined overlap or degrees of difference between groups. Methods: We used a computer-aided linguistic approach to explore reports of voice-hearing by a clinical group (Early Intervention in Psychosis service-users; N = 40) and a non-clinical group (spiritualists; N = 27). We identify semantic categories of terms statistically overused by one group compared with the other, and by each group compared to a control sample of non-voice-hearing interview data (log likelihood (LL) value 6.63+=p < .01; effect size measure: log ratio 1.0+). We consider whether individual values support a continuum model. Results: Notwithstanding significant cohort-level differences, there was considerable continuity in language use. Reports of negative affect were prominent in both groups (p < .01, log ratio: 1.12+). Challenges of cognitive control were also evident in both cohorts, with references to "disengagement" accentuated in service-users (p < .01, log ratio: 1.14+). Conclusion: A corpus linguistic approach to voice-hearing provides new evidence of differences between clinical and non-clinical groups. Variability at the individual level provides substantial evidence of continuity with implications for cognitive mechanisms underlying voice-hearing.

Metaphors for ‘good’ and ‘bad’ deaths

This paper discusses the metaphors used by sixteen palliative healthcare professionals from around the United Kingdom in semi-structured interviews to describe what they see as ‘good’ and ‘bad’ deaths. The interviews, conducted for the large-scale “Metaphor in End-of-Life Care” project, are set against the background of contemporary practices and discourses around end-of-life care, dying and quality of death. To date, the use of metaphor in descriptions of different types of deaths has not received much attention. Applying the Metaphor Identification Procedure (Pragglejaz Group, 2007) we find that the difference between good and bad deaths is partly expressed via different frequencies of contrasting metaphors, such as ‘peacefulness’ and ‘openness’ as opposed to ‘struggle’ and ‘pushing away’ professional help. We show how metaphors are used to: evaluate deaths and the dying; justify those evaluations; present a remarkably consistent view of different types of deaths; and promote a particular ‘framing’ of a good death, which is closely linked with the dominant sociocultural and professional contexts of our interviewees. We discuss the implications of these consistent evaluations and framings in broader end-of-life care contexts, and reflect on the significance of our findings for the role of metaphor in communication about sensitive experiences.

Drowning in negativism, self-hate, doubt, madness: Linguistic insights into Sylvia Plath's experience of depression

This paper demonstrates how a range of linguistic methods can be harnessed in pursuit of a deeper understanding of the 'lived experience' of psychological disorders. It argues that such methods should be applied more in medical contexts, especially in medical humanities. Key extracts from The Unabridged Journals of Sylvia Plath are examined, as a case study of the experience of depression. Combinations of qualitative and quantitative linguistic methods, and inter- and intra-textual comparisons are used to consider distinctive patterns in the use of metaphor, personal pronouns and (the semantics of) verbs, as well as other relevant aspects of language. Qualitative techniques provide in-depth insights, while quantitative corpus methods make the analyses more robust and ensure the breadth necessary to gain insights into the individual experience. Depression emerges as a highly complex and sometimes potentially contradictory experience for Plath, involving both a sense of apathy and inner turmoil. It involves a sense of a split self, trapped in a state that one cannot overcome, and intense self-focus, a turning in on oneself and a view of the world that is both more negative and more polarized than the norm. It is argued that a linguistic approach is useful beyond this specific case.

Henry's voices: the representation of auditory verbal hallucinations in an autobiographical narrative

The book Henry's Demons (2011) recounts the events surrounding Henry Cockburn's diagnosis of schizophrenia from the alternating perspectives of Henry himself and his father Patrick. In this paper, we present a detailed linguistic analysis of Henry's first-person accounts of experiences that could be described as auditory verbal hallucinations. We first provide a typology of Henry's voices, taking into account who or what is presented as speaking, what kinds of utterances they produce and any salient stylistic features of these utterances. We then discuss the linguistically distinctive ways in which Henry represents these voices in his narrative. We focus on the use of Direct Speech as opposed to other forms of speech presentation, the use of the sensory verbs hear and feel and the use of 'non-factive' expressions such as I thought and as if. We show how different linguistic representations may suggest phenomenological differences between the experience of hallucinatory voices and the perception of voices that other people can also hear. We, therefore, propose that linguistic analysis is ideally placed to provide in-depth accounts of the phenomenology of voice hearing and point out the implications of this approach for clinical practice and mental healthcare.

The online use of Violence and Journey metaphors by patients with cancer, as compared with health professionals: a mixed methods study

OBJECTIVE

To compare the frequencies with which patients with cancer and health professionals use Violence and Journey metaphors when writing online; and to investigate the use of these metaphors by patients with cancer, in view of critiques of war-related metaphors for cancer and the adoption of the notion of the 'cancer journey' in UK policy documents.

DESIGN

Computer-assisted quantitative and qualitative study of two data sets totalling 753 302 words.

SETTING

A UK-based online forum for patients with cancer (500 134 words) and a UK-based website for health professionals (253 168 words).

PARTICIPANTS

56 patients with cancer writing online between 2007 and 2012; and 307 health professionals writing online between 2008 and 2013.

RESULTS

Patients with cancer use both Violence metaphors and Journey metaphors approximately 1.5 times per 1000 words to describe their illness experience. In similar online writing, health professionals use each type of metaphor significantly less frequently. Patients' Violence metaphors can express and reinforce negative feelings, but they can also be used in empowering ways. Journey metaphors can express and reinforce positive feelings, but can also be used in disempowering ways.

CONCLUSIONS

Violence metaphors are not by default negative and Journey metaphors are not by default a positive means of conceptualising cancer. A blanket rejection of Violence metaphors and an uncritical promotion of Journey metaphors would deprive patients of the positive functions of the former and ignore the potential pitfalls of the latter. Instead, greater awareness of the function (empowering or disempowering) of patients' metaphor use can lead to more effective communication about the experience of cancer.

Motion and conflicted self metaphors in Sylvia Plath’s ‘Smith Journal’

This paper considers how mental states can be conveyed by metaphorical expressions in texts of a personal nature. Figurative language is understood to play an important role in the expression of such complex nuanced phenomena (Lakoff & Johnson, 1999; Kövecses, 2000; Gibbs, Leggit & Turner, 2002). This study focuses on two main groups of metaphors, linked to mental states, in the Smith Journal of “The Unabridged Journals of Sylvia Plath”. ‘Mental state’ here refers to various aspects of cognitive functioning, but with a focus on mental states of affect — mental states that are intrinsically valenced (Ortony & Turner, 1990). Specifically, this paper focuses on metaphors of MOTION and SPLIT SELF. Both manual intensive analyses and automated corpus methodologies are employed in the investigation: Wmatrix (Rayson, 2009) is used to explore relevant expressions, in order to obtain a comprehensive understanding of metaphor groups. Relevant expressions are identified by an in-depth manual analysis of sample journal entries. The MIP procedure (Pragglejaz, 2007) is used for metaphor identification, and interpretations draw on research in psychology. Metaphors of mental states are analyzed in terms of their implications for conveying various aspects of mental states, such as valence and intensity.