Understanding what it is like living with psychosis is very difficult. Staff and service users often struggle to talk openly and freely about symptoms. Therefore being able to develop a therapeutic relationship is key in mental health; however, it remains poorly taught and misunderstood across all health care professionals.
This study by McCabe et al (2016) aimed to see if psychiatrists’ communication skills and therapeutic relationship could be improved by focusing on developing a shared understanding.
The study was a cluster randomised controlled trial, with psychiatrists being randomised into two groups:
- The intervention was a manualised training course of four 3-hour sessions and one feedback session. The TEMPO manual (PDF) itself covers 150 pages
- The control group delivered care as usual.
Video data of consultations were collected at baseline and follow up (five months later).
The main outcomes focused on psychiatrists attempts to establish shared understanding (self-repair) and therapeutic relationship.
- 25 out of 35 psychiatrists were randomised, however a further 4 were excluded
- There were 10 psychiatrists in the intervention group and 11 in the control
- 97 out of 407 eligible patients were recruited, 64 of which were followed up
- Psychiatrists in the intervention group used 44% more self-repair (95% CI 1.46 to 11.33, P<0.011)
- The therapeutic relationship was perceived more positively by psychiatrists (95% CI 0.03 to 0.37, P<0.022) and patients (95% CI 0.01 to 0.41, P<0.043) in the intervention arm
- Psychiatrist self-confidence in communicating with those who were psychotic increased after the training (t=5.19, 95% CI 1 to 2.04, P<0.01).
The authors concluded:
This is the first study to test an intervention for psychiatrists to enhance communication with patients with psychosis. It suggests that shared understanding, which can be challenging in the treatment of psychosis, can be targeted in training and is important for improving the quality of the communication and the therapeutic relationship.
This is a relatively small trial which focuses on improving the communication style and therapeutic relationships of psychiatrists through measuring self-repair. Whilst improving the therapeutic relationship is important, whether this brings about meaningful improvements and helps aid recovery is undoubtedly more important.
My first impression after reading this paper was surprise that improving the communication skills of psychiatrists had not been tried in this way before, indeed this was reported as the first trial of its kind for psychiatrists. For more than 30 years, there has been substantial training of health care practitioners to help them communicate therapeutically with people living with psychosis. Surely such fundamentals of good care should be a core part of training for all psychiatrists?
Readers wanting to find out more may like to explore the lessons learned from Thorn training and subsequent Cognitive Behavioural Therapy/Psychosocial Interventions for psychosis courses, which have been in existence for more than 20 years. Given the multidisciplinary nature of mental health work, more cross-discipline research in this area may yield benefits and avoid duplication of effort.
There are lots of useful resources out there to guide clinicians towards improve communication skills with someone who may be psychotic. I would recommend starting with this 2009 report called Talking with acutely psychotic people (PDF), by Len Bowers and colleagues.
McCabe R, John P, Dooley J, Healey P, Cushing A, Kingdon D, Bremner S, Priebe S. (2016) Training to enhance psychiatrist communication with patients with psychosis (TEMPO): cluster randomised controlled trial. The British Journal of Psychiatry Jul 2016, bjp.bp.115.179499; DOI: 10.1192/bjp.bp.115.179499
Bowers L, Brennan G, Winship G, Theodoridou C. (2009) Talking with acutely psychotic people. Communication skills for nurses and others spending time with people who are very mentally ill (PDF). City University, London.