Effect of questions used by psychiatrists on therapeutic alliance and adherence

Thompson, Laura and Howes, C. and McCabe, R. (2016) Effect of questions used by psychiatrists on therapeutic alliance and adherence. The British Journal of Psychiatry 209 (1), pp. 40-47. ISSN 0007-1250.

Abstract

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. Method: 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. Results: Psychiatrists used only four of ten question types regularly: yes/no auxiliary questions, ‘wh-’ questions, declarative questions and tag 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. Declarative questions were frequently used to propose an understanding of patients' experiences, in particular their emotional salience for the patient. Conclusions: A refined 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. Psychiatry is inconceivable without clinician questions. They are the mechanism for achieving clinical objectives: history taking, reviewing symptoms and deducing diagnostic hypotheses. Questioning also manages the formation of a therapeutic alliance, the benefits of which include concordant treatment decisions and patient adherence.1 Developing evidence-based interviewing techniques to improve these outcomes is crucial, particularly in the case of schizophrenia where psychotic symptoms may problematise interaction.2 A conceptual issue hinders this in practice – there is no definitive model of ‘good’ communication.3 Instead, it is viewed more generically through the ideology of ‘patient-centredness’, i.e. accounting for the patient's psychosocial context, preference and experience. Although questions are the mode of eliciting this experience, advice in psychiatry textbooks is often limited and generalised, e.g. ‘in general try to use open questions rather than leading questions or closed questions’.4 In practice, ‘open’ and ‘closed’ categories encompass numerous linguistic question types, each of which may have different interactional consequences.5 No research to date has examined the actual questions – by means of a sensitive, utilitarian classification – that psychiatrists deploy in clinical encounters and how they are linked to the therapeutic alliance and treatment adherence. To specify training and improve these outcomes, we must first explore two research questions, the aims of this study: first, what types of questions do psychiatrists ask patients in routine consultations, and second, do particular question types predict better therapeutic alliances and treatment adherence?

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