Implying implausibility and undermining versus accepting peoples' experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments.

Background: Patients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples' experiences of self-harm and suicidality are believed or not. We use an empirical method -conversation analysis - to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person's story to contest and recharacterize their accounts. Aims: To investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples' experiences of suicidal ideation and self-harm. Methods: Using conversation analysis, we micro-analyzed verbal and non-verbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants' medical records and post-visit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated. Results: When peoples' experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person's account; asked questions that implied inconsistency or implausibility ("Didn't you tell your GP that you were coping okay?"); juxtaposed contrasting information to undermine the person's account ("You said you were coping okay before, and now you're saying you feel suicidal"); asked questions asserting that, e.g., asking for help implied they were not intending to end their life ("So when you called 111 what were you expecting them to do"); and resistinged or directly questioned the person's account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person's decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn't take a more harmful medication to overdose; that self-harming behaviors were not that serious and should be in the person's control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples' experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients' accounts. Conclusion: These findings advance our understanding of how peoples' experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples' experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking.

Asking about self-harm during risk assessment in psychosocial assessments in the emergency department: questions that facilitate and deter disclosure of self-harm.

BACKGROUND: Emergency departments are key settings for suicide prevention. Most people are deemed to be at no or low risk in final contacts before death. AIM: To micro-analyse how clinicians ask about suicidal ideation and/or self-harm in emergency department psychosocial assessments and how patients respond. METHOD: Forty-six psychosocial assessments between mental health clinicians and people with suicidal ideation and/or self-harm were video-recorded. Verbal and non-verbal features of 55 question-answer sequences about self-harm thoughts and/or actions were micro-analysed using conversation analysis. Fisher's exact test was used to test the hypothesis that question type was associated with patient disclosure. RESULTS: (a) Eighty-four per cent of initial questions (N = 46/55) were closed yes/no questions about self-harm thoughts and/or feelings, plans to self-harm, potential for future self-harm, predicting risk of future self-harm and being okay or keeping safe. Patients disclosed minimal information in response to closed questions, whereas open questions elicited ambivalent and information rich responses. (b) All closed questions were leading, with 54% inviting no and 46% inviting yes. When patients were asked no-inviting questions, the disclosure rate was 8%, compared to 65% when asked yes-inviting questions (P < 0.05 Fisher's exact test). (c) Patients struggled to respond when asked to predict future self-harm or guarantee safety. (d) Half of closed questions had a narrow timeframe (e.g. at the moment, overnight) or were tied to possible discharge. CONCLUSION: Across assessments, there is a bias towards not uncovering thoughts and plans of self-harm through the cumulative effect of leading questions that invite a no response, their narrow timeframe and tying questions to possible discharge. Open questions, yes-inviting questions and asking how people feel about the future facilitate disclosure.

Talking About Things: A Patient Cue for Sensitive Healthcare Problems and Effective Physician Responses.

In routine healthcare consultations, patients often use prefaces containing the word "thing", including "the thing is", "there's this thing" or "one more thing". Although "thing" is an all-encompassing term that is used in myriad ways, in this article we show that thing-prefaces perform a specific job. This study uses Conversation Analysis to analyze 90 video-recorded primary care consultations with 14 primary care physicians in the United States. Patients' thing-prefaces mark the upcoming talk as a disclosure of sensitive information that may reflect negatively on the patient, physician or service (e.g., medication nonadherence, refill was not sent to pharmacy). Patients pursue explicit resolution of these problems (e.g., personalized recommendation, lab work, referral) despite these problems being downplayed and treated as delicate. Because patients may "talk around" these sensitive issues, thing-prefaces can be an important cue for physicians that patients are seeking resolution for a sensitive healthcare problem.

"I was gonna ask you": How patients use agency framing to display engagement in primary care.

The message that patients should be responsible for their health is pervasive. Health promotion campaigns encourage patients to "ask your doctor" about potential illnesses and treatments, preventive medicine guidelines call for patients to self-monitor to avoid future health problems, and models like shared decision-making advocate for greater patient involvement in medical decisions. Research shows that patients can participate in medical dialogue by asking questions, but that doing so is difficult due to the structure and social norms of medical visits. In this article, we ask: how can patients participate more actively in medical care? Drawing on video recordings of older patients (aged 65 and older) and primary care physicians, we use conversation analysis to describe one practice that patients use to demonstrate personal responsibility for their health; agency framing. This involves prefacing questions to the doctor with phrases that project a prior intended action, such as "I was gonna ask you", "I was gonna tell you" or "I wanted to ask you". Patients use agency framing to cast their questions as 1) independently motivated, 2) well-informed, and 3) personally responsible. Consequently, patients exert agency within the confines of the medical visit structure to resist the potential interpretation that their question was responsive to the doctor or to the local interactional context. Rather, agency framing allows patients to show that their question was considered independently. Questions designed with agency framing work to portray the speaker as a responsible patient who is not only meeting the bare minimum of expected health maintenance, but is staying ahead of medical problems. This article discusses the particular importance of this practice among older patients, for whom demonstrating a willingness and ability to cope with medical problems may be significant for maintaining independence.

Communication in youth mental health clinical encounters: Introducing the agential stance.

When young people seek support from mental health care practitioners, the encounters may affect the young people's sense of self, and in particular undermine their sense of agency. For this study, an interdisciplinary team of academics and young people collaboratively analysed video-recorded encounters between young people and mental healthcare practitioners in emergency services. They identified five communication techniques that practitioners can use to avoid undermining the young person's sense of agency in the clinical encounter. They conceptualise the use of those techniques as the adoption of an agential stance towards the young person. The agential stance consists of: (a) validating the young person's experiences, (b) legitimising the young person's choice to seek help, (c) refraining from objectifying the young person, (d) affirming the young person's capacity to contribute to positive change, and (e) involving the young person in the decision-making process.

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance.

People presenting to the emergency department with self-harm or thoughts of suicide undergo a psychosocial assessment involving recommendations for e.g. contact with other practitioners, charity helplines or coping strategies. In these assessments, patients frequently adopt a negative stance towards potential recommendations. Analysing 35 video-recorded liaison psychiatry psychosocial assessments from an emergency department in England (2018-2019), we ask how these practitioners transform this negative stance into acceptance. We show that practitioners use three steps to anticipate and address negative stance (1) asking questions about the patient's experience/understanding that help the patient to articulate a negative stance (e.g., "what do you think about that"); (2) accepting or validating the reasons underlying the negative stance (e.g., "that's a very real fear and thought to have"); and (3) showing the patient that their reasons were incorporated in the recommendation (e.g., "it's telephone support if you're a bit more uncomfortable with face to face"). These steps personalise the recommendation based on the patient's specific experiences and understanding. When practitioners followed all three of these steps, the patient moved from a negative stance to acceptance in 84% of cases. When practitioners made a recommendation but did not follow all three steps, the patient moved from a negative stance to acceptance in only 14% of cases. It is not the case that each communication practice works on its own to promote patient acceptance, rather Steps 1 and 2 build on each other sequentially to develop and demonstrate shared understanding of the patient's negative stance. In this way, acceptance and validation play an indispensable role in addressing a patient's concerns about treatment.

The conditional legitimacy of behavior change advice in primary care.

This study asks whether and when patients treat their doctors as having the right to give behavior change advice. Drawing on 171 primary care consultations video-recorded in the U.S. between 2014 and 2016, this study uses Conversation Analysis to examine physicians' behavior change advice following a patient's disclosure of medically problematic behavior such as physical inactivity. The basis on which the physician provides this advice is associated with clear regularities in patient response. Physicians may produce treatment-implicative advice that is unambiguously framed as a treatment plan for a specific health issue such as rising blood pressure. Alternatively, physicians may produce advice that is not overtly framed as treatment. This plain advice appeals to a model of care based in medical surveillance and prevention - a physician should not need to account for advising a patient to reduce risk factors. Though all advice is clinically relevant for preventing or controlling medical conditions, treatment-implicative advice is interactionally rooted in a physician's authority to treat illness. Patients show a strong social-interactional preference for treatment-implicative advice, even accepting 'behavior change' treatment recommendations at a higher rate than pharmaceutical treatment recommendations. In contrast, patients are highly resistant towards plain behavior change advice. This study explores the implications of advice formats for understanding modern orientations towards surveillance medicine in the age of preventive care.

Closing the Deal: A Cross-Cultural Comparison of Treatment Resistance.

This study investigates patient resistance to doctors' treatment recommendations in a cross-national comparison of primary care. Through this lens, we explore English and American patients' enacted priorities, expectations, and assumptions about treating routine illnesses with prescription versus over-the-counter medications. We perform a detailed analysis of 304 (American) and 393 (English) naturally occurring treatment discussions and conclude that American and English patients tend to use treatment resistance in different prescribing contexts to pursue different ends. While American patients are most likely to resist recommendations for non-prescription treatment and display an expectation for prescription treatment in these interactions, English patients show a high level of resistance to recommendations for all types of treatment and display an expectation of cautious prescribing. These behavioral trends reflect broader structural forces unique to each national context and ultimately maintain distinct cultural norms of good-practice prescribing.

Patient disclosure of medical misdeeds.

Modern patients walk a tightrope between respecting medical authority and acting as knowledgeable advocates regarding health issues, with the agency and responsibilities that come with this. This article uses conversation analysis to explore this balance in relation to patient disclosures of medical misdeeds in video-recorded primary care medical visits (e.g., taking another's prescription medication or failing to adhere to a healthy lifestyle or prescription regimen). We focus on patient-initiated disclosures. We show that disclosures are used (1) where patients are seeking physician assessment of their behavior, (2) where patients are proposing the etiology of a health problem, and (3) where patients are lobbying for a particular treatment outcome. We argue that disclosures of medical misdeeds are an important but understudied domain of conduct in which patients show awareness of their own agency over, and responsibility for, their healthcare and respect for the physician's medical authority.