Communication Skills

Art by Stina Forsell & Carl Wilhelmsson, Sweden

Photos by Dr Westerlund & Wikipedia

Communication SkillsDr Marcel WesterlundConsultant Forensic & General Adult PsychiatristMRCPsych, FRSM, MD, RN

Based on the Calgary-Cambridge Guide to the Medical InterviewPostgraduate communication teaching programme

Cambridge School of Medicine & University of Calgary

Review medical values and rulesCreating a structureHow to build a relationshipExplanation and planningUnderstanding and managing relationshipsProblems affecting your clinical workCultures

You will now have a better understanding of how communication skills improve your success with clients

Objectives

Medical values and code of work ethics

• The Hippocratic oath• Hawaii declaration II (1983) ethical

guidelines for psychiatry• Madrid declaration 1996, World Psychiatric

Association• Helsinki declaration, 1964, ethical rules

about research on humans• Local ethical guide lines• Psychiatric values• Personal ethics and values

Opinions and values

Personal ideology

• Religions, politics, subcultures• Can not affect your professional conduct

Implicit values

• Convictions deeply seated in our personalities

• Social attitudes (drug users, sexuality, criminals, paedophiles etc.)

Biomedical Perspective – What is the illness?

A sequence of eventsSymptom analysisRelevant systems review

The problem

Patients perspective – I am ill

• Ideas, concerns expectations, effects on life, feelings

The problem

Background information – context

• Past medical history, family history, personal & social history, forensic history, drug & allergy

The problem

Physical & mental examination, diff diagnosis

• Explain in order to calm and gain trust. Ask for permission.

The problem

Management, conclusions, explanation

The problem

Establishing rapport • Greetings, friendliness, introduction,

consent, respect & interest• Signposting next section. Make organisation

open and observable.• Timing! Logical sequence.• If you write notes, make sure they don’t

interfere with dialogue or rapport•

Initiating the session

• Indentifying why the client is here

• Opening questions – why today? LISTEN! Confirm and screen for further problems.

• Negotiate agenda.


• Gathering information- exploring the clients problem

• Tell me! Open – closed questions. LISTEN attentively! Facilitate eg. It started with...then you.... Pick up verbal (when I went for a funeral) and non verbal cues (guarded, tense, anxious,...).

• Clarify: Following the birth of....• Summarise!• Concise and easily understood language! Talk with

farmers like a farmer!• Explain rationale for questions• Establish dates


• Clients perspective

• Ideas and concerns• Expectations• How does it affect the clients life?


Guide to the therapeutic conversation – Building the relationshipPitfall

• Poor language skills


• Fantasies about omnipotence


• Dependence


• Loss of boundaries


• Being private


• Breaking confidentiality

Pitfall• Stress and lack of time

Guide to the therapeutic conversation – Building the relationship


• Poor language skills• Fantasies about

omnipotence• Dependence• Loss of boundaries• Being private• Breaking

confidentiality• Stress and lack of

time

External structure Create structure (help client to listen to his/her own

story and to find key factors in this story)


External structure Know thyself


External structure To be concrete (clear roles, structure and boundaries)


External structure Being concrete creates focus, foster understanding and encourage the client to deal with essentialities


External structure Be aware about your clients body language (verbal/non verbal communication)


Internal structureMindful


Internal structureBe warm – empathy


Internal structureUse controlled engagement but support


Internal structureReact against content/emotions (paraphrasing, you

feel sad because your life feels miserable, I understand, tell me more, how did it feel like….., clarify, translate into something comprehensible).


Internal structureBe prepared


Internal structureBe nonjudging (internal/external realities affected)


Internal structureControl your behaviour


Internal structureBe tolerant with uncertainties


Internal structureBe sensitive with embarrassing and disturbing

information


Internal structureKeep boundaries


Internal structureUse conscious sensitivity


Internal structureFind your inner motivation


Internal structure Involve the client – share thinking


External structure Position & posture, eye contact, facial expression, movements, vocal cues Create structure (help client to listen to his/her own story and to find key factors in this story) Know thyself To be concrete (clear roles, structure and boundaries) Being concrete creates focus, foster understanding and encourage the client to deal with essentialities Be aware about your clients body language (verbal/non verbal communication)

Internal structure Mindful Be warm – empathy Use controlled engagement but support React against content/emotions (paraphrasing, you feel sad because your life feels miserable, I

understand, tell me more, how did it feel like….., clarify, translate into something comprehensible). Be prepared Be nonjudging (internal/external realities affected) Control your behaviour Be tolerant with uncertainties Be sensitive with embarrassing and disturbing information Keep boundaries Use conscious sensitivity Find your inner motivation Involve the client – share thinking


Providing the correct amount and type of information• Chunck & check

Explanation and planning

Providing the correct amount and type of information• Prior knowledge


Providing the correct amount and type of information• Extent of wish for knowledge


Providing the correct amount and type of information• What other information would help?


Providing the correct amount and type of information• Explain when it is appropriate


Aiding accurate recall and understanding• Organise explanation


Aiding accurate recall and understanding• Use explicit categorisation eg. there are two

things we need to discuss


Aiding accurate recall and understanding• Use repetition and summarise


Aiding accurate recall and understanding• Use concise and easily understood language


Aiding accurate recall and understanding• Use visual methods


Aiding accurate recall and understanding• Check understanding


Providing the correct amount and type of information• Chunck & check• Prior knowledge • Extent of wish for knowledge• What other information would help?• Explain when it is appropriate

Aiding accurate recall and understanding• Organise explanation• Use explicit categorisation eg. there are two things we need to discuss• Use repetition and summarise• Use concise and easily understood language• Use visual methods• Check understanding


Pharmacological Treatment of Bipolar Affective Disorder

SSRI SNRI Benso Carbamazepine LamotrigineSodium valproate Lithium Quetiapine Olanzapine Risperidone Aripiprazole Clozapine

Acute depression Acute depression+psychosis Recurrent depression Recurrent depression+psychosis Acute Mania

Relapse prevention depression Relapse prevention mania

Treatment resistant

Large representative population studies

Small well designed studies

Non-representative surveys, case reports or extra-polated from small well designed studies

Expert committees, clinical experience of respected authorities

AVOID

Graphic representation of possible treatments against Bipolar disorder

© Dr M Westerlund & Dr H Naijim

Achieving a shared understanding: Incorporate the patient’s perspective

Relate explanation to client’s illness framework



• Provide opportunities and encourage patient to contribute: questions, doubts etc.



• Pick up verbal and non-verbal cues eg. “well my religion...”



• Information overload.



• Distress.



• Elicit client’s beliefs, reactions and feelings re info given, terms used



• Relate explanation to client’s illness framework• Provide opportunities and encourage patient to contribute: questions,

doubts etc.• Pick up verbal and non-verbal cues eg. “well my religion...”

Information overload. • Distress.• Elicit client’s beliefs, reactions and feelings re info given, terms used


Share own thinking: Ideas, dilemmas, processes

Planning: Shared decision making

Involve patient: Offer suggestions and choices rather than directives


Explore management options


Ascertain level of involvement patient wishesA renal patient from Asia might not want to be involved


Negotiate a mutually acceptable planSignpost own position of preference


Check with patient If plans are acceptable If concerns have been addressed


Closing sessionForward planning – contract, stepsSafety net – what to do if not workingEnsuring appropriate point of closure: Summarising

briefly and clarify plan of careFinal check of agreement, comfortable with plan,

corrections, questions


Share own thinking: Ideas, dilemmas, processes Involve patient: Offer suggestions and choices rather than directives Explore management options

Ascertain level of involvement patient wishes A renal patient from Asia might not want to be involved

Negotiate a mutually acceptable plan Signpost own position of preference

Check with patient If plans are acceptable If concerns have been addressed

Closing session Forward planning – contract, steps Safety net – what to do if not working Ensuring appropriate point of closure: Summarising briefly and clarify plan of care Final check of agreement, comfortable with plan, corrections, questions


Boundaries are affected and threatened by a number of factors within the therapeutic relationship:

Transference and counter transference Dependence Identification Breaking confidentiality A desire to rescue the clientQuestionable honesty Abuse of power

Understanding and managing relationships

Problems affecting your clinical work

Gifts Humour Openness about yourself Personal style Physical contact Contact outside the clinical work Termination

Cultures

Transcultural psychiatry is very challenging. Great difference between different ethnical groups and their ways of Handling psychiatric illness and suffering

Some diseases are culturally dependent, eg. Koro, Qigong illness inAsia. Kundalini-psychosis

Review medical values and rulesCreating a structureHow to build a relationshipExplanation and planningUnderstanding and managing relationshipsProblems affecting your clinical workCultures

You will now have a better understanding of how communication skills improve your success with clients

Objectives

Thank you for listening!

Communication Skills

Education

Transcript of Communication Skills