- mental health
psychological well-being.
- respect
positive attitude towards another. It involves granting another person the right to be who they want to be, and say and think what they want to say and think.
This chapter focuses on increasing your confidence in interacting with people experiencing acute emotional distress in the context of mental illness. You will learn basic principles underpinning high-quality therapeutic communication, which can be applied more widely to any professional encounter where a person is emotionally distressed.
- therapeutic communication
a technique of healing through interaction. It is the establishment of a connection which incorporates choice of words, body language and tone of voice which together demonstrate to a distressed person an attitude of respect, compassion and hope.
Introduction
When the other person is hurting, confused, troubled, anxious, alienated, terrified, or when he or she is doubtful of self-worth, uncertain as to identity, then understanding is called for. The gentle and sensitive companionship of an empathic person … provides illumination and healing. In such situations deep understanding is, I believe, the most precious gift one can give to another.
(Rogers, 1995, p. 161)
Many sectors of health care have become increasingly dominated by technologies that extend the skills of health professionals, allowing them to see inside the body, to pinpoint pathology, and to monitor vital signs. The practice of mental health care is, in contrast, a largely technology-free zone. With the exception of pharmaceutical interventions, and despite advances in genomics, the clinical practice of mental health care happens principally through interaction.
The difference between good and poor quality mental health care very often lies in the quality of the relationship between the patient and the professional (for example, Green et al., 2008; Priebe et al., 2011). Here, communication is not separate from the ‘real work’ of treatment and healing. Communication is the ‘real work’ – the main tool of treatment – for professionals working with people experiencing mental illness.
The use of principles of therapeutic communication by health and welfare professionals, whether or not they work in mental health care, can have a significant impact on people experiencing mental illness.
Preventing psychological harm means protecting the art and humanity of medicine as much as the science. It requires recognition that professional words and behaviour are potentially as toxic as therapeutic.
(Rees, 2012, p. 446)
We have two strong sources of evidence confirming the importance of appropriate communication with patients experiencing mental illness. First, interactions characterised by judgmental or stigmatising attitudes can exacerbate a person’s mental illness, erode their self-respect, and make it less likely that they will try to seek help in the future (Hansson et al., 2013; Reavley et al., 2014; Thornicroft, Rose & Kassam, 2007).
Second, people with severe mental illness have a life expectancy of between 10 and 20 years less than their peers. This excess mortality mostly stems from preventable physical illnesses that have nothing directly to do with mental illness (Lawrence, Hancock & Kisely, 2013; Nordentoft et al., 2013). This is a poor reflection on the quality of primary care and general hospital care provided to this group of people.
A further sign of failure to engage therapeutically with patients experiencing a mental illness is the fact that people who die by suicide are more likely to have had recent contact with health services (through a hospital admission for a physical health complaint or through a visit to their GP) than they are to have been in contact with specialist mental health services (Ahmedani et al., 2014; Luoma, Martin & Pearson, 2002; O’Neill, Corry, Murphy & Bunting, 2014). This research confirms the importance of communicating with such patients in ways that appropriately acknowledge their needs.
Clearly, the safety and quality of health care for people experiencing mental illness is far from optimal. Given the importance of responding to patients experiencing mental illness with appropriate communication, the way the interaction unfolds between the person and the professional plays a crucial role in determining whether health service encounters help or hinder their recovery and whether recommended treatment (whether for mental or physical health) is effective (Burgess et al., 2008; Clement et al., 2012; Sirey et al., 2001).
We now examine the principles of therapeutic communication through two clinical practice scenarios.
This example presents the perspective of a person attending a health service and experiencing distress.
I sit opposite the doctor with tears running down my face, my hands uselessly shredding tissues into little balls that fall to the floor as I try to tell her how this feels. I have never known such a complete inability to control or soothe or describe the absolute blackness inside. Three days ago, she changed my medications, and my body and mind are no longer mine. I shake, my clothes are soaked in sweat. I cannot use words. She sits impassively behind her clipboard, carefully writing notes. ‘I can’t get through this day.’ I throw this at her, again and again. She shifts in her chair, hands over a new prescription, a slightly different dose. My desperate phone messages from yesterday, never acknowledged. The too-sudden change of drugs, never discussed. I go back out onto the street, clutching the prescription. This city, my home, feels foreign. I am lost.
A different, new doctor. My friend takes me to her that same day. We sit in the waiting room for a long time. In between the procession of patients, the doctor comes over to explain – ‘I am so sorry – it’s such a busy afternoon’. At last, it’s my turn. She comes back to the waiting room, says my first name, smiles, shakes my hand, introduces herself. She smiles at my friend, asks her name. Walking to her room, she points me to a chair close to hers, asks if I like peppermint tea. She returns with two cups of steaming minty comfort, places them together on the table between us. She types notes as we talk. Between her halting two finger efforts at the keyboard, she leans towards me, her eyes meet mine: ‘You’re having a tough time of it, aren’t you. What’s happened?’
She is interested, I think. The words start to come. She takes it seriously. She nods, she frowns, her eyes radiate kindness and concern. She explains to me why I am feeling this way – what is happening in my brain and what the drugs have done. Fear and panic recede. This will fade. She seems to get how hard it is to think about the next step. She writes down what I need to do, just tonight and tomorrow morning. A list, with times and tasks. Stay with your friend. Eat something. Take this drug, this much, this time. Tomorrow, see my nurse, this time, this address. ‘I will call you first thing,’ she says. And she does.
Analysis and reflection
The differences between the two interactions in practice example 10.1 and the impacts they had on the writer of this extract illustrate important aspects of helpful, as against harmful, communication.
Note that the healing quality of the communication is, from the writer’s perspective, separate to the formal, technical tasks of psychiatry such as the mental state examination, risk assessment, and decisions about medication. Even though the first doctor may have been fulfilling these requirements, we can see that for the writer in the midst of her distress, something key to her recovery was missing. While the first doctor leaves her feeling disoriented, the second doctor makes it seem possible to ‘keep going’.
- psychiatry
a branch of medicine that specialises in the treatment of disorders such as schizophrenia and psychosis.
While the first doctor remains impassive behind a clipboard as she busily writes clinical notes, the second intersperses her note-writing with time dedicated solely to talking. In doing so – making eye contact, expressing empathy, and communicating recognition of distress – she makes the writer feel like she is being taken seriously. Empathy asks the question, ‘How have this person’s experiences led them to see/feel/think and act in the way they do?’ (Elliott et al., 2011, p. 134).
- empathy
a mental state whereby a person, experiencing compassion, shows they are affected by another person’s suffering, and takes steps to alleviate that person’s suffering.
The first doctor appears to do little to validate this person’s experience or acknowledge her pain. During the interaction, she keeps an emotional distance and the writer finds it hard to bridge the gap to express how she is feeling.
The second doctor’s initial encounters with the writer in the waiting room were important in establishing rapport. Her acknowledgement of the long wait established a frame of respectful communication, and also reduced the writer’s uncertainty about what was happening. Calling the writer by her first name only, shaking her hand and smiling, and acknowledging the presence of her friend were all acts that reduced the power differential between doctor and patient and made it clear that the doctor saw the writer as a person rather than simply a ‘case’.
The simple gesture of offering a cup of tea established a sense of comfort and security within which the interaction could proceed. While this may seem unusual in a run-of-the-mill healthcare setting, and may not be appropriate with people who are highly agitated or aggressive, in this case it was a very effective way to share a normalising experience and create a caring connection.
Imagine that you have already qualified in your chosen profession and that you encounter the person who wrote practice example 10.1. She may have come to you about some other health problem but breaks down in front of you. Or she may have come to you directly for help with her distress (for example, if you work in an emergency department).
Implications for practice
Research by and with people experiencing mental illness reveals a common set of professional attitudes and interactions that help them or harm them during times of acute distress (see for example Gunasekara et al., 2014; Noble & Douglas, 2004). Many of them will be familiar from the scenario above. Let’s spell out a few important communication principles.
Be aware of your impact on the other person: even brief negative encounters with health and welfare services can have lasting impacts on a person’s self-regard, compounding the distress caused by the illness itself (Corrigan, 2004; Hansson, Stjernswärd & Svensson, 2014; Markowitz, 1998; Rüsch, Angermeyer & Corrigan, 2005). An intelligent and articulate man living with schizophrenia told the author that he was hurt when he had called a government helpline with a question about his benefits. The person on the other end started talking loudly and slowly to him as soon as he mentioned his illness. The patient’s hurt did not register for the person on the helpline.
See the whole person: when you encounter a person experiencing distress, remember that illness is not their defining feature. They have a past, they have unique experiences, and even if they do not feel them at that moment, they have hopes, preferences and strengths. Attempting to connect with these other aspects of a person can be valuable both in creating a sense of hope and in connecting them to the ‘here and now’, particularly if they are responding to internal stimuli such as hallucinations (Bowers et al., 2009).
Think about how you can tailor your interaction so that it is appropriate to the individual. This means finding out about and considering the different needs associated with (for example) diverse cultural, religious and linguistic backgrounds and people who have experienced abuse or trauma.
Build rapport and trust: simple kindnesses are incredibly important to someone who is distressed or who has disclosed mental illness to you (Borg & Kristiansen, 2004). You can show your care by the expression on your face and the tone of your voice, just as you would with any person you care about. Depending on the circumstances, this care might involve attending to physical comfort or avoiding compromising the person’s dignity (for example, by leaving them alone and distressed in a public waiting room).
Empower the other: when someone is very distressed, they can feel as though things are getting out of their control (Goddard, 2011). It is important to offer options for next steps, and ask about preferences. This is central to a recovery-oriented model of mental health support, in which people are empowered by professionals to make their own choices and to build on their strengths and preferences to live a meaningful life with or without symptoms. It is also vital to recognise that family members and other supporters can in many cases be a resource for the person’s ongoing well-being. Loved ones can often feel excluded and ill-informed about what is happening. Only involve them if the person consents, however.
Create continuity and consistency: consistency of care is an important aspect of therapeutic interactions between services and people experiencing mental illness (Burns et al., 2009). If possible, if you have started to build trust and rapport with a person and if they will continue to access your service, try to ensure that they can speak to or be treated by the same person each visit.
Theoretical links
During recent years, the ideal of ‘person-centred care’ has become popular in health policy circles (Freeth, 2007; Stewart, 2001). The importance accorded to the individual patient’s experience is partly related to the increased role of choice in the healthcare industry, and partly to a recognition that a positive experience of treatment and care can have a significant impact on clinical outcomes. In mental health care, this principle is integral to the conduct of recovery-oriented models of care (for more information about the recovery approach, see the National Framework for Recovery Oriented Mental Health Services in the ‘Further reading’ list at the end of this chapter).
The idea is nothing new. A theory of a ‘person-centred approach’ to therapeutic interaction with people experiencing mental distress was developed by a psychologist, Carl Rogers, as early as the 1950s. Together, the principles introduced in previous sections encompass an attitude which Rogers called ‘unconditional positive regard’ (Rogers, 2007).
Unconditional positive regard is part of a theory of psychotherapy that is more complex than we can do justice to here (see Freeth (2007) to learn more about Rogerian theory). The essence of the concept is for the caregiver to hold a hopeful, calm, and respectful attitude towards the distressed person, unconditionally. It does not mean that you have to agree with what they are saying, or that you cannot set limits on acceptable behaviour. However, for the time you are interacting with them, you try to put your own judgments aside and aim for an empathic understanding of a person’s actions or words as coming from a place of fear, anxiety or unbearable pain. For many people, the feeling of being accepted despite their distress can be novel and healing (Hunter et al., 2013; Rogers, 1995).
Conclusion
To conclude, we have seen that calmly ‘being with’ someone who is very distressed, and being able to tolerate that distress for long enough to establish a connection, presents a unique communication challenge to health professionals. This is especially the case if the distress is induced by hallucinations or delusions. However, from the perspective of the person experiencing mental illness, what is often all that is needed is simply being treated and talked to as a valued human being:
For decades I waited, waited for the people who were allocated to help me, to listen. To listen with their hearts and minds, without preconceptions or judgements … Madness does not strip you of the basic human needs to be valued, treated with respect and regard, and ‘loved’. It is through thoughtful relationships with family, friends and health professionals that we seek understanding and solace.
(Debra Lampshire in Geekie et al., 2012, p. xvii).Stay updated, free articles. Join our Telegram channel
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