Effect of questions used by psychiatrists on therapeutic alliance and adherence

Background: Psychiatrists' questions are the mechanism for achieving clinical objectives and managing the formation of a therapeutic alliance – consistently associated with patient adherence. No research has examined the nature of this relationship and the different practices used in psychiatry. Questions are typically defined in binary terms (e.g. ‘open’ v. ‘closed’) that may have limited application in practice. Aims: To undertake a detailed examination of the types of questions psychiatrists ask patients and explore their association with the therapeutic alliance and patient adherence. Methods: A mixed methods design was employed. First, a coding protocol was developed to classify questions from 134 out-patient consultations, predominantly by syntactic form. Bivariate correlations with measures of patient adherence and the therapeutic alliance (psychiatrist-rated) were examined and assessed using generalised estimating equations, adjusting for patient symptoms, psychiatrist identity and amount of speech. A random subset of significant questions was then subjected to more detailed qualitative examination using conversation analysis. Results / Discussion: Psychiatrists used only three of ten question types regularly: yes/no auxiliary questions, ‘wh-’ questions and declarative questions. Only declarative questions predicted better adherence and perceptions of the therapeutic relationship. Conversely, ‘wh-’ questions – associated with positive symptoms – predicted poorer perceptions of the therapeutic relationship. When examined qualitatively, declarative questions were found to be frequently ‘so-prefaced’ and used to propose an understanding of patients' experiences in prior talk, in particular their emotional salience for the patient. Conclusions: A refined, more granular, defining of questioning practices is necessary to improve communication in psychiatry. The use of declarative questions may enhance alliance and adherence, or index their manifestation in talk, e.g. better mutual understanding. The function of ‘so’-prefaced declaratives, also used in psychotherapy, is more nuanced than negatively connotated ‘leading’ questions. Hearable as displays of empathy, they attend closely to patient experience, while balancing the tasks of assessment and treatment.
Research areas:
Type of Publication:
In Proceedings
Book title:
WPA XVII World Congress of Psychiatry
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