Meaning making in psychological consultations a tape-assisted by eiv15173


									 Meaning making in psychological
consultations: a tape-assisted recall

           Chris Barker
           Marta Buszewicz
           John Cape
           Chris Dowrick
           Connie Geyer
           Sara Hutchings
           Nancy Pistrang
           Peter Salmon
First tape-assisted recall study

   Consultations about psychological problems

   Tape-assisted recall (TAR) interviews asking
    what the patient found helpful and unhelpful
Findings of the first study
   Majority of patient comments were about the
    – GP showing an interest through listening,
    – Showing understanding/ acceptance
    – Providing continuity

   Minority of patient comments were about
    – GP helping make sense of problems
    – Facilitating patient decision making
    – Supporting patient change
Overview of study

   Explore process of meaning making and
    negotiating understanding of common mental
    health problems

   Bring together perspectives of GP and patient
    about the same consultation using TAR

   Questions in GP and patient TAR interviews
    specifically focussed on meaning making
Difference from first TAR study

   TAR interviews with GPs as well as patients

   Questions about meaning making rather than
    general question as to “what was helpful?”

   RA recruits patients in waiting room

   Consultations of consenting patients are

   TAR interview with GP

   TAR interview with patient
Patient selection criteria

   Aged over 18

   Contactable by telephone

   GHQ-12 = 3+

   Consultation contains significant discussion
    of psychological problems
GP TAR interview

   GP‟s understanding of psychological problem

   How GP thought the patient understood the

   What explanations was GP trying to get

   Where in the consultation was this taking
Patient TAR interview
   Thoughts about problem before seeing GP

   Whether and how these thoughts changed
    after seeing GP

   What did GP say that helped thinking about
    problem differently

   Patients‟ thoughts on moments in
    consultation that had been identified as
    significant by GP in GP TAR

   Recruitment issues: GPs, patients, timings,

   11 complete transcript sets (consultation, GP
    TAR, patient TAR)

   Meaning making in half of these
Example 1
Pt        … horrible churning feeling in stomach… I
     suppose maybe it‟s all stress… and my heart is
     pounding… I can‟t control it… mind going into
     overdrive… think about different things… people I‟ve

GP   still grieving… and will be for a while I think, won‟t

Pt        [starts crying] uh here we go again, see? Oh it‟s
     ridiculous. I can‟t keep doing this.

GP       it‟s not ridiculous…
                                     (GP2/P14, lines 81-117)
 Consultation cont. …
Pt       I can‟t say much in front of my family because
     obviously they‟re still tearful so I don‟t like to harp on…
     Of course when I do talk about it that‟s when [laughs]
     you know

GP       yeah, yeah but that‟s absolutely normal, you know

Pt       it‟s normal

GP       it‟s absolutely normal, you know

Pt       yeah

GP     and it doesn‟t really get better. You just get used to it
  in a way if you see what I mean

GP       it‟s not so immediate, it‟s each day at a time.
                                      (GP2/P14, lines 240-252)
GP I‟m trying to get her to, you know, set
 herself a more realistic timescale and that it‟s
 not just going to switch off… people are often
 very apologetic about still feeling sad which
 always seems to me to be crazy but they
 often are and people often expect people to
 move on quicker than it‟s possible for them to
 move on and to give people permission to
 feel bad about things for a longer time.

                             (GP2, lines 249-253)
Patient TAR

[while listening to the audio-recorded section of the
  consultation above, when the GP says “…still
  grieving and will be for a while I think”]

Pt     Mhm, that‟s right. I remember that…
                            (P14, line 852-865)

[RA returns to this later in the interview and notes
  patient commented on this…]
                                            cont. …
Patient TAR cont. …

Pt       Yeah then it began to make sense really,
     yeah. That I‟ve just got to get on with it. It‟s
     hearing someone else tell you these things.
     And then you begin to think, of course you‟re
     not going to forget things so quickly. I think in
     your mind you do. You try to forget things
     quickly but the mind doesn‟t do things like
     that. It just comes around again. So I had to
     hear it. D‟you see what I mean?

                                        cont. …
Patient TAR cont. …

RA    And what impact did that have on you when you
  heard it in that moment?

Pt       Yeah cos when I came out I thought,
     yeah, well she‟s right. I‟m not going to get
     over it so quickly. So I just have to take each
     thing at a time.

RA      And how did you feel after that?

Pt I felt a bit better. I felt a bit better
  after that.
                                   (P14, lines 852-865)
Example 2
Pt       My Mum was suffering from dementia. She had a
     massive brain haemorrhage… I left her in the
     bathroom… and the next thing she‟s fallen on the floor.
     She‟s fallen over and she never really recovered. They
     said she hit her head… and then she never really
     come out of it…

GP    It‟s extremely difficult to look after people with
  dementia. I mean I think you need to speak with
  someone because I think it‟s not surprising you have
  issues about the whole thing, you know. There‟s
  probably some guilt in there, which is completely
  unnecessary but you know people do feel guilty about
  certain things…
                             (GP4/P114, lines 135-150)
RA    You acknowledged that he‟s feeling guilty and
  then you‟re saying “which is completely unnecessary,
  you know, but people do feel guilty about certain
  things” and what were you trying to achieve with that?

GP Well, that he was guilty about not being
 able to care for your mother because you‟re
 not a nurse and you know, caring is impossible
 and guilt about probably wanting her to be
 dead! Guilt from saying „don‟t operate on her‟
 when he knows it‟s absolutely hopeless. Uhm,
 and all those reasons to feel guilty maybe.
 Which is normal in a human being.
                                        (GP4 lines 453-462)
GP TAR cont. …

GP I mean hopefully, he realised that what he
 is experiencing is normal, it‟s just rather late
 because he hasn‟t allowed it or hasn‟t been
 given permission to let it out beforehand
                              (GP4 lines 914-915)

GP I was giving him permission, yeah, giving
 him permission to feel what probably his
 sibling hasn‟t allowed him to feel you know
 because he killed her, you know. Giving
 permission to feel you know, it‟s alright to feel
 that, it‟s a normal feeling
                              (GP4 lines 968-970)
Patient TAR
RA     How did you feel…………when he said “some
  guilt in there, which is completely unnecessary but
  you know people do feel guilty about certain things”?

Pt        I think he hit the nail on the head. He, and
     I think that‟s basically what it is. Guilt. I‟m
     carrying guilt over something that I shouldn‟t
     be. I think he‟s right.
                                 (P114 lines 711-717)

                                        cont. …
 Patient TAR cont. …

RA    Was that a new understanding that you got from
  the consultation that you need help in not feeling guilty
  about this?

Pt       Well, yeah it‟s new, I suppose I didn‟t really
     think about it, feeling guilty about it round the
     time, until he mentioned it. I thought the stress
     was like the agony I was going through but I
     suppose when he said, mentioned the guilt
     about it I thought he really did, I thought he hit
     home and I think he‟s right. I have been feeling
     guilty, you know. You do what you can but, as I
     said, I feel guilty over her death. I shouldn‟t
     have left her in the toilet. (P114 lines 758-766)

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