Categorizing what patients with psychosis say in clinical interactions: the development of a framework informed by theory of mind, metacognition and cognitive behavioral theory

Abstract

Background

Many patients with psychosis are socially isolated and struggle to maintain or establish satisfying social relationships. This has been explained as resulting from a reduced ability to understand one’s own mind, others’ minds, and how these interact. This understanding of one’s own and others’ minds is the foundation of many different theories and models from developmental to cognitive psychiatry. Increasing this ability is the goal of many therapeutic approaches and may facilitate establishing a positive therapeutic relationship. Although much interest has focused on what clinicians say in clinical encounters, few scales exist to categorize the content of patients’ communication.

Aim

Theoretically founded in literature on metacognition, theory of mind and cognitive theory, the aim of this study was to create a framework to capture and quantify how patients with psychosis talk about their own and others’ thoughts, feelings and behaviors in clinical interactions.

Method

A two-stage iterative process of analysis, refinement and reliability testing was undertaken. In the first stage, thematic analysis, using a combined inductive and deductive approach, was carried out on 14 Italian transcripts of real clinical encounters in acute setting. An initial framework was developed from Italian transcripts, refined, translated and then applied to a sample of 15 English transcripts of real clinical encounters. The framework was further refined, finalized and concordance between independent raters was calculated.

Results

A framework comprised of 8 categories was developed to categorize verbal displays in which patients recognize and communicate their own emotions, mental states, desires and plans, relevant narratives of their own life and experiences as expressed in routine clinical interactions. Good reliability was obtained in both English (k = 0.87) and Italian transcripts (k = 0.90).

Conclusion

Patients’ thoughts about their thoughts, feelings and behaviors, and others’ can be reliably assessed in routine clinical encounters using this newly developed framework. Future research should broaden the scope of this research to explore how the questions asked by psychiatrists may influence how patients talk about their thoughts, feelings and actions, and if/how they are correlated with the therapeutic relationship and clinical outcomes.

Keywords:

• Clinical interactions
• patients' communication
• ToM
• CBT
• metacognition informed framework

Author contributions

AZ and SP were involved in the conception and design of the study. AZ and RM participated in the transcripts collection. AZ drew the first list of the categories of the framework. AZ, FC and MC conducted the transcript analysis in English and in Italian, and worked on IRRs in both languages, with regular input from RM and SP. All the authors participated in the iterative processes involved in creating the final framework. AZ and MC wrote the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors are grateful to the researchers at the Unit for Social and Community Psychiatry (Queen Mary University of London) who contributed to the group discussions.

Disclosure statement

No potential conflict of interest was reported by the author(s).