- Email: [email protected]
Accomplishments of the thought disordered person: A case study in psychiatrist–patient interaction
Medical Hypotheses 77 (2011) 900–904
Contents lists available at SciVerse ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
Accomplishments of the thought disordered person: A case study in psychiatrist–patient interaction Cherrie Galletly ⇑, Jonathan Crichton Discipline of Psychiatry, School of Medicine, University of Adelaide, Northern Mental Health, Adelaide, Australia School of Communication, International Studies and Languages, University of South Australia, Australia
a r t i c l e
i n f o
Article history: Received 17 June 2011 Accepted 4 August 2011
a b s t r a c t Background: The research and clinical literature portrays the thought disordered person as incapable of meaningful social interaction. This model views thought disorder exclusively as a brain dysfunction, evidenced by dysfunctions in speech. Aims: The study seeks to address this deficit model by investigating the interactional accomplishments of thought disordered people in clinical interviews. Method: An analysis of clinical interview data. Results: We investigate (1) what thought disordered people actually accomplish in interaction, and (2) how thought disordered people and their psychiatrists routinely communicate on matters consequential for treatment. Conclusions: This paper introduces a new perspective on the interactional achievements of people with thought disorder. The skills required by both parties during routine clinical interviews have not previously been recognised or described. Ó 2011 Elsevier Ltd. All rights reserved.
Introduction People with schizophrenia sometimes communicate using a semantically disorganised style of speech referred to as ‘thought disorder’. This is regarded as a core symptom of schizophrenia, along with hallucinations and delusions. However, hallucinations and delusions are personal experiences, which can be described by the person experiencing them, or inferred from observing the person’s behaviour. In contrast, thought disorder is interactional i.e. it only exists when the thought disordered person speaks and this speech is heard by another person. In psychiatric practise this occurs when a clinician converses with a thought disordered person. Although thought disorder is reliant on communication, the literature about thought disorder focuses on only one part of the interaction – the words produced by the patient. Thought disorder is regarded as a phenomenon to be elicited, observed and measured. Generally, a speech sample is obtained by prompting the patient to talk about a series of bland topics. This sample can be rated using instruments such as the thought disorder index or the com⇑ Corresponding author at: Discipline of Psychiatry, School of Medicine, University of Adelaide, The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, Suite 13, The Adelaide Clinic Consulting Suites, 33 Park Tce, Gilberton 5081, Australia. Tel.: +61 8 8269 8144; mob: 0406 422 494; fax: +61 8 8269 6187. E-mail addresses: [email protected], cherrie.galletly@adelaide. edu.au (C. Galletly). 0306-9877/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.mehy.2011.08.006
munication disturbances instrument, and analysed with tools such as analysis of referential coherence [1] or an automated technique, latent semantic analysis [2]. These approaches reflect a ‘deficit’ model [3] that views thought disorder as a brain dysfunction, evidenced by dysfunctions in speech. Faulty speech has been linked to specific cognitive impairments such as lack of sustained attention [4], impaired executive function and poor semantic memory [5], and reduced gray matter volume in several regions of the brain [6]. Deviant verbalization has been demonstrated amongst the relatives of people with schizophrenia [7], suggesting that thought disorder may be an endophenotype for schizophrenia. Overall, there is an assumption in the research literature that thought disordered speech is a phenomenon to be observed and cannot be understood as meaningful communication. Thought disorder is also described as a disturbance of speech [8] or verbal communication [9], implying the presence of a listener. However, research on thought disorder neglects two important factors: the role of other participants in the interaction, and the interplay between the two participants. Moreover, despite the supposition that if someone has thought disorder he or she cannot be understood, psychiatrists routinely talk with thought disordered people in clinical interviews. This expertise is central to what psychiatrists do but is not reflected in publications on thought disorder or in the training literature. We argue that successful interactions between psychiatrists and people with thought disorder occur regularly in clinical practice. This raises the question of
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
what the psychiatrist and the patient bring to these conversations. We consider that the psychiatrist exercises specific interview skills and techniques to enable smooth, productive communication. These skills are generally not recognized in training materials and are therefore learnt by observation and experience. More importantly, the patient displays a series of competencies which enable useful communication but are typically not acknowledged. Our paper provides a preliminary account of the interactional accomplishments of the thought disordered person. The paper draws on an ongoing interdisciplinary collaboration between an applied linguist and a psychiatrist which explores the language used by people with severe thought disorder in interactions with their psychiatrists.
Interaction and thought disorder Communication with people with psychoses, including those with thought disorder, has evolved considerably since Kraepelin’s descriptions of the bizarre behaviour and utterances exhibited by those with dementia praecox [10]. Prior to the 20th century, asylum care was predominantly custodial, utilising a range of physical therapies. This changed as psychoanalysis, initially developed for the treatment of neuroses, was extended to the treatment of psychotic disorders [11]. Analysts attempted to understand and interpret psychotic phenomena, with the expectation that this would lead to resolution of an underlying conflict and recovery from psychosis. In the 1960s, an anthropological perspective was adopted [12]. The patient’s disordered behaviour and communication was understood as a consequence of pathological communication within the family. This concept was further developed by Laing and Esterson [13], who argued that chaotic speech could be interpreted as a sane commentary on the patient’s insane social environment. A major paradigm shift occurred in the late 1970s, as new imaging technologies were applied and it became apparent that people with schizophrenia had distinct structural and functional abnormalities of the brain [14]. Research efforts focused on the biological aspects of schizophrenia and the development and evaluation of new medications. Comparatively little was written about communication with psychotic patients, other than ratings of the nature and severity of symptoms. Unhelpful communication (high expressed emotion) by family members or carers was identified as a predictor of relapse [15,16], but the patient tended to be viewed as passively experiencing the high expressed emotion environment. A shift towards re-engagement with patients with schizophrenia occurred in the 1990s. In 1997 Fenton [17] wrote ‘‘We can talk: individual psychotherapy for schizophrenia’’, describing a successful trial of personal therapy for schizophrenia [18,19]. The reports of the trial do not mention whether patients with thought disorder were included. Subsequently, Cognitive Behaviour Therapy (CBT) has been extensively evaluated [20], although patients participating in CBT tend to have very low levels of thought disorder [21]. Whilst the dialogue between people with schizophrenia and clinicians has clearly resumed, there is very little written about communication with people with thought disorder. Qualitative research methods are being utilised more frequently in psychiatry [22], but the voices of those with thought disorder are yet to be heard. This focus on interaction is not foreign to psychiatry; thought disorder is exceptional in not having a literature on interaction associated with it. There are numerous textbooks describing the skills required to conduct psychiatric interviews, describing how to interview, assess and interact with people diagnosed with various forms of mental illness [23,24]. The doctor–patient interaction, including the doctor’s emotional reactions to the patient, is central to some therapies [25]. However, there is a lack of information
901
describing the specific skills needed to communicate effectively with patients with thought disorder. The training literature describes the phenomenology of the various types of thought disorder, but generally does not acknowledge the need to develop and practise skills for effective communication with these patients.
Interaction as an accomplishment A major theme in the literature on social interaction is that competent participation is a remarkable but usually unnoticed achievement [26–28]. This theme has been elaborated most influentially by Erving Goffman, whose work has had a profound influence on interactional studies, psychiatry and the social sciences more generally [29–33]. The value of Goffman’s work to this study lies in his [34–38] account of face-to-face interaction in which he distinguished between the self as a ‘performed character’ displayed in social encounters and the more private self as a ‘performer’, whose interests are vested in the attributes ascribed to the performed self by others. This dual account of the self provided Goffman with a way of investigating how participants (mis)manage their performances of self through the risks encountered in social interactions. At stake for participants is their ‘face’: that is, the positive attributes ascribed to their performances by others, which include their competence to participate in meaningful interaction. The cost for a person deemed incompetent is to carry a ‘stigma’ that implies social and moral deficiency [38]. That the expertise required is usually taken for granted is testament to people’s general ability to seamlessly interpret and co-ordinate each other’s performances. This expertise is exemplified by the ability to cooperate in the talk at hand. This point was highlighted in a seminal paper by Grice [39] who argued that in order to infer what a person means from what he or she says, it is necessary to assume that he or she is acting according to what Grice called the ‘co-operative principle’. This is the presumption that the person is not being obtuse, incompetent or deceptive but is willing and capable of interacting ‘such as is required, at the stage at which it occurs, by the accepted purpose or direction of the talk exchange’ (p. 45). The key point here is that if participants do not judge each other to be cooperative in this sense, they are not able to infer what they mean by what they say. This is because of the way that the co-operative principle operates in conjunction with four other expectations: that a speaker will (1) use neither more nor less language than is required, (2) be truthful, (3) be relevant to the interaction at hand, and (4) be clear. According to Grice, when a speaker’s utterance appears to flout one or more of these four expectations, the listener will, unless there are grounds to the contrary, assume that the co-operative principle applies and interpret the meaning of the utterance so as to make it consistent with this principle. In doing so the listener will look for clues to the intended meaning in the context in which the utterance was produced as well as in the listener’s more general knowledge of the world. Thus, for example, ‘It’s cold in here’ might not appear meaningful within the interaction at hand. However, on the assumption that the speaker is competent and sincere, it might elicit the response ‘Ok, I’ll shut the window’ as a way of making it so. In sum, underscored by Goffman and Grice’s work is the usually unacknowledged fact that routine interaction is an accomplishment by all concerned. For participants, this involves ongoing attention to and management of each other’s face as a condition of meaningful interaction, in which each participant infers in vivo what the other means based on the presumption of co-operation in the talk at hand. Seen in this light, we argue that meaningful interaction for participants in our study is a particularly noteworthy accomplishment, for the meetings we describe place demands on
902
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
participants in addition to the challenges posed by thought disorder. They are a specialised type of encounter, associated with norms of behaviour that need to be learned by patients and psychiatrists alike, and that vary depending on the context and purpose of the interview. Method In this paper we present a case study of a routine meeting between a psychiatrist and patient. Our aim is to illustrate the accomplishments involved in an interaction that would be recognised as typical within the profession. The value of single case studies for illuminating issues of this kind is well documented [22,40,41]. The data presented in this paper consist of the transcript of the meeting drawn from a larger collection of transcripts of routine clinical meetings between psychiatrists and patients exhibiting thought disorder. Following the meetings, discussions were held with the psychiatrists that explored their interpretation of the interaction. These particular meetings were chosen because they were thought by the psychiatrists to represent typical examples of their interactions with patients with thought disorder. This study was approved by the institutional ethics committee. Participants were provided with a complete description of the study and an information sheet. Written, informed consent was obtained. Sessions were audio-recorded by the psychiatrists and the recordings were subsequently transcribed. Pseudonyms are used for the participants and the institutions to ensure confidentiality. The analysis employs the ‘theme-oriented’ discourse analysis developed by Roberts and Sarangi [42,43] according to which ‘analytic themes’ drawn from linguistics and sociology are brought to bear on interactional data to address ‘focal themes’. These are questions of interest to the professionals and clients who engage in the interactions under scrutiny. In our study, the identification of these themes has involved a close and ongoing interdisciplinary collaboration, a process that Sarangi and Roberts have called ‘joint problematization’. Results The transcript is taken from a routine meeting between a consultant psychiatrist, P, and patient, A. The setting is a locked ward in a general hospital psychiatric unit. A has been detained in the locked ward for the previous nine weeks. There have been several episodes of aggression requiring security guards to be called. A has been P’s patient throughout the admission. They meet two to three times a week. P is the consultant psychiatrist, and has a registrar and nursing staff to assist him. However, whilst these clinicians regularly interact with A, the consultant does not delegate the above tasks to them. He meets with A himself to attend to the relationship building tasks, and to ensure that A has ongoing engagement with the consultant responsible for his care. A and P sit on either side of a table in the ward. A is upset about being in hospital and wants to go home. At this meeting P wants specifically to find out: (1) how A’s condition is progressing; (2) that A understands the purpose and outcome of his Guardianship Board hearing, held on the ward earlier that day went (this meeting was to obtain a Continuing Detention Order and to continue a Community Treatment Order, both of which were granted); and (3) how well A is tolerating Clozapine, which was recently initiated. In addressing this agenda, P’s overarching priority is to build, maintain and monitor the therapeutic relationship. His contributions to the interaction reflect this multiple agenda. For his part, A is able to competently play the role of patient in the interaction. He sits throughout the interview, taking part in the
turn-taking sequences by responding to questions and prompts according to the norms of the interview, and deferring to the power differential (as in all doctor–patient relationships). P initiates and ends the interview, and decides some but not all of the topics to be discussed and the questions to be addressed. P makes decisions (e.g. about detention orders) that directly restricts A’s freedom. At the end of the interview P is free to leave the ward but A is not. Though the meaning and relevance of A’s responses are often unclear he is consistently polite and respectful – he does not become abusive or behaviourally disturbed. He is clearly engaged in the conversational exchange, and brings his own issues to the table. P’s challenge is to ensure that A focuses on the topic of the Guardianship Board hearing and to monitor A’s condition while maintaining the trust and rapport they have established. P achieves these aims using strategies which acknowledge A as having the potential to contribute meaningfully to the interview. In doing so P attends to and realises A as a person. He shows appropriate respect and treats A as a capable person. This acknowledgement is a condition of their relationship and of the success of the interview. Central to this acknowledgment is the fact that P’s talk attends to A’s face needs by maintaining throughout the appearance that he believes that A is capable of acting in accordance with the cooperative principle. This is seen in the fact that P acknowledges A’s ‘face’ by using language which affirms the ‘positive social value’ of A as an interactant, maintaining this stance even where the conversation threatens to break down. P takes every opportunity to respond to A’s utterances as if A is interacting in accordance with the co-operative principle [39]. Examples In line 5, consistent with the co-operative principle, P’s statement invites A to infer that P wants to know how the Guardianship Board hearing went. A replies but not to P’s implied invitation. In line 7, P encourages A to elaborate but by line 9 intervenes in A’s increasingly irrelevant talk. In line 11, P repeats his original invitation but this time makes explicit the request for information. A responds appropriately in line 12 and continues to do so until line 22. In lines 33 and 35, P seeks to return A to the agenda of the meeting by inviting A to identify any issues that A would like to raise. The use of the invitations respects A’s face by not directly criticising his talk as irrelevant. Similarly in line 49, P uses language which mitigates the decision to finish the meeting and does not impugn A. In lines 53, P gives A direct feedback on his mental state in explaining why the meeting is not proceeding as he had hoped. A attempts to make a joke in response but gets tangled. P then responds sensitively to A’s face by using language which mitigates the contradiction in line 55. A then responds in a way that leads back to the topic of the Guardianship Board hearing. At the Guardianship Board hearing, it had been suggested that A may have been difficult with the workers from ACE, a community support organisation. This is important as ACE support in the community will be part of the discharge plan. In line 60, consistent with the co-operative principle, A asks directly if the ACE workers had a problem with him, and is reassured that they did not – but P also double checks this back with A and they reach agreement that there was not a problem. More generally, at numerous points in the interview P gives A information about P’s assessment of his mental state, his progress (in the light of past episodes) and what is happening in his care (e.g. lines 17, 19, 27, 47, 53, 55, 64, and 68). Besides giving information (and therefore expecting that A will listen to this information
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
and that giving this information is useful to the cooperative enterprise) this conveys that P is interested, has taken the trouble to reflect on A’s progress, and is proceeding according to a treatment plan. He confirms that he shares A’s goal of A going home from hospital. Discussion While there is a deficit model in the literature on thought disorder, in the data we find heightened, not diminished, attention to personhood. This is evidenced in the language used by the psychiatrist to address the specific clinical agenda while contributing to the overarching priority of maintaining and developing the therapeutic relationship. This language reflects sensitive attention at every point to the patient as a person, including his perceptions and feelings in a stance of ‘respectful distance’, only imposing on the conversational options available to the patient where communication threatens to break down. This stance acknowledges the ‘cooperative principle’ [39] and attends to the ‘face’ needs [35] of the patient. For his part A demonstrates that a person can be thought disordered but conversationally ordered. This is not only a matter of form but of commitment to achieving the aim of the meeting, to maintaining the relationship, and to adhering to the ‘cooperative principle’ and attending to the ‘face’ needs of the psychiatrist. There is acknowledgement of ‘personhood’ on both sides of the conversation. The patient achieves many important aspects of communication, and these interactional accomplishments tend to be overlooked in the focus on a deficit model of thought disorder. Our research suggests that it would be useful to investigate the strategies used by patients with thought disorder to mitigate their difficulties with communication. Successful strategies could be identified so that psychological treatments could be developed to address thought disorder. Psychological treatments are utilised for hallucinations, delusions and paranoia [20] and our findings suggest that a similar approach might be useful for thought disorder. There is also a need to identify the specific interviewing skills used by clinicians who have the capacity to interact effectively with thought disordered patients. Clinical training in these skills would improve the ability of clinical staff to communicate with patients with thought disorder, enabling a more accurate understanding of the patient’s current concerns, an improved therapeutic alliance, balanced negotiation of treatment options and ultimately better outcomes. Conflicts of interest statement The authors have no conflicts of interest to report.
Appendix A (continued) 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.
37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54.
Appendix A Transcript of a routine meeting between a consultant psychiatrist (P) and patient (A). 1. 2. 3. 4. 5. 6. 7. 8.
P: Hello Andrew A: 2009, December P: it is and what I want is to catch up with you this morning A: yeah P: yeah, ok, you’ve had your guardianship board hearing this morning A: I’ve got a headache and I feel sick in the stomach. P: Uh huh A: I’m about to throw up – I need some. . .an ice coffee or, or a water ‘cos they haven’t had water jugs here. They need water
903
55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65.
P: mm, can you hang on just for a moment. A: no, ‘cos jack. . .. . .ahh. . ..my. . .I’m in secretary 3 and my nurses and doctors that are brides are in room 2 P: you had the guardianship board hearing this morning. How did that go? A: well. . .. . ..good P: mm, mm A: great, they agreed to December 2009, it was all ok P: mm, mm A: I do wanna go home to see my own home, I do wanna be in my own home P: that’s our goal as well is to get you home Andrew A: yeah I know that P: we need to get you a little bit better than you are at the moment A: its day 16, . . ...3,4,5 days and 18 days behind it P: mm A: day 17 and I’ll be a mental case. . .on the tarot cards. . ..i did go through those P: mm A: the advocate, the devil’s advocate, nearly twice I went through it. . .my brother Pat’s life...he’s up the other 4 universes. . .the other life came back here. P: so A: richardsness as you know is a fool’s paradise P: in previous admissions Andrew it has taken quite a long time for you to settle down A: I usually can settle straight away, I usually just meditate, for 32 years out of my life I meditated and I am a very wise individual P: ok A: and a great artist and a critic as well. Those cigarettes you smoke, those burnt things I have forgiven all that P: ok, so A: the lady with the tape hairdo is ah the royal worker for me P: right. Now is there anything you wanted to ask me particularly this week. A: that female doctor old one she used the judges phone, can’t help he P: right, anything else you wanted to ask me A: that bloke that got the louvres and the wire he, he is down at Unley. I let Kate, the difference is that Marie Antoinette my girlfriend, my wife, my best wife, Madagascar underneath is now not an enemy P: ok A: an arch enemy of Madagascar, I met him at a Christian gathering of a club like Rotary or one of those P: ok, Andrew. Andrew we are going to have to keep going A: Mark is gonna live P: mm A: but Dave didn’t want him to. Dave’s my best mate P : ok A: anything. . .no keep asking me because P: no that will do A: I, I, I think that P: we’ve got the guardianship board’s approval through A: keep asking getting some skin graft, one of these he sits down, fucking hurt like heck P: ok, so I’m going to leave it there for the moment Andrew A: mumbling P: ok A: yeah P: I did say I would catch up with you but your thinking is still jumping around a lot and it is very hard to follow at times A: that’s because men can’t think and talk, most of them, so that when they get go through a process all men can’t quite keep up the women can think and hear at the same time P: I actually think it is more to do with the fact that you’re still quite unwell A: that’s what I told the social. . ..the Dr. . . Pete this morning P: ok A: cos I looked after, I said the guys from ACE P: right A: they are not . . .. . .advice for me are they, they never had any problem with me P: no ACE have never had a problem with you have they A: no A: did do the right thing – Simon brings me in, takes me home P: no, but you need to be here at the right A: yes I d
(continued on next page)
904
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
Appendix A (continued) 66. 67. 68. 69. 70. 71. 72. 73.
P: yeah A: but I hope not for the 17th day. P: I hope that you slowly improve A: the 17th my roster, 3, 4, 5, 3, days on 4 days off 5 days off has gone to the 15th day after that P: ok Andrew so I’m going to leave it there, thanks for talking with me A: Dave was off too P: ok A: I’ve got two shirts on
References [1] Ditman T, Kuperberg GR. Building coherence. A framework for exploring the breakdown of links across clause boundaries in schizophrenia. J Neurolinguistics 2010;23:254–69. [2] Elvevåg B, Foltz PW, Rosenstein M, Delisi LE. An automated method to analyse language use in patients with schizophrenia and their first-degree relatives. J Neurolinguistics 2010;23:270–84. [3] Candlin CN, Crichton J. Introduction. In: Candlin CN, Crichton J, editors. Discourses of Deficit. Palgrave-Macmillan; 2010. p. 1–22. [4] Docherty NM, Strauss ME, Dinzeo TJ, St-Hilaire A. The cognitive origins of specific types of schizophrenic speech disturbances. Am J Psychiatry 2006;163:2111–8. [5] Kerns JG, Berenbaum H. Cognitive impairments associated with formal thought disorder in people with schizophrenia. J Abnorm Psychol 2002;111:211–24. [6] Horn H, Federspiel A, Wirth M, et al. Gray matter volume differences specific to formal thought disorder in schizophrenia. Psychiatry Res 2010;182:183–6. [7] Levy DL, Coleman MJ, Sung H, et al. The genetic basis of thought disorder, language, communication disturbances in schizophrenia. J Neurolinguistics 2010;23:176. [8] Berenbaum H, Kerns JG, Vernon LL, Gomez JJ. Cognitive correlates of schizophrenia signs and symptoms: I. Verbal communication disturbances. Psychiatry Res 2008;159:147–56. [9] Docherty NM. Cognitive impairments and disordered speech in schizophrenia: thought disorder, disorganization, and communication failure perspectives. J Abnorm Psychol 2005;114:269–78. [10] Kraepelin E. Dementia Praecox and Paraphrenia (translated by RM Barkley). E & S Livingstone, 1919. [11] Fromm-Reichmann F. Principles of Intensive Psychotherapy. University of Chicago Press; 1960. [12] Bateson G. Steps to an Ecology of Mind: Collected Essays in Anthropology, Psychiatry, Evolution, and Epistemology. University of Chicago Press; 1972. [13] Laing RD, Esterson A. Madness and the Family. Penguin Books: Sanity; 1964. [14] Johnstone EC, Crow TJ, Frith CD, Husband J, Kreel L. Cerebral ventricular size and cognitive impairment in chronic schizophrenia. Lancet 1976;30:924–6. [15] Wynne LC. Current concepts about schizophrenics and family relationships. J Nerv Ment Dis; 1981;169:82–9. [16] Marom S, Munitz H, Jones PB, Weizman A, Hermesh H. Expressed emotion: relevance to rehospitalization in schizophrenia over 7 years. Schizophr Bull 2005;31:751–8.
[17] Fenton WS, McGlashan TH. We can talk: individual psychotherapy for schizophrenia. Am J Psychiatry 1997;154:1493–5. [18] Hogarty GE, Kornblith SJ, Greenwald D, et al. Three-year trials of personal therapy among schizophrenic patients living with or independent of family, I: description of study and effects on relapse rates. Am J Psychiatry 1997;154:1504–13. [19] Hogarty GE, Greenwald D, Ulrich RF, et al. Three-year trials of personal therapy among schizophrenic patients living with or independent of family, II: Effects on adjustment of patients. Am J Psychiatry 1997;154:1514–24. [20] Tarrier N. Cognitive behavior therapy for schizophrenia and psychosis: current status and future directions. Clin Schizophr Relat Psychoses 2010;4:176–84. [21] Evans-Jones C, Peters E, Barker C. The therapeutic relationship in CBT for psychosis: client, therapist and therapy factors. Behav Cogn Psychother 2009;37:527–40. [22] Whitley R, Crawford M. Qualitative research in psychiatry. Can J Psychiatry 2005;50:108–14. [23] MacKinnon RA, Michels R, Buckley PJ. The Psychiatric Interview in Clinical Practice. 2nd ed. American Psychiatric Publishing Inc.; 2006. [24] Hales RE, Yudofsky SC, Gabbard GO. The American Psychiatric Publishing Textbook of Psychiatry. 5th ed. American Psychiatric Publishing Inc.; 2008. [25] Yalom I. Love’s Executioner and Other Tales of Psychotherapy. American Psychiatric Press Inc.; 1989. [26] Duranti A. Linguistic anthropology: History, ideas and issues. In: Duranti A, Malden MA, editors. Linguistic Anthropology: A Reader. Wiley-Blackwell; 2009. p. 1–60. [27] Giddens A. Central Problems of Social Theory. University of California Press; 1979. [28] van Dijk T. Discourse Analysis as Social Interaction. Sage; 1997. [29] Byrne P. Psychiatric stigma. Br J Psychiatry 2001;178:281–4. [30] Jacobsen MH. Goffman through the looking glass: From ‘classical’ to contemporary Goffman. In: Jacobsen MH, editor. The Contemporary Goffman. Routledge; 2010. p. 1–47. [31] Manning P. Erving Goffman and Modern Sociology. Stanford University Press; 1992. [32] Trevino AJ. Goffman’s Legacy. Rowman & Littlefield; 2003. [33] Strong PM. Review essay: The importance of being Erving: Erving Goffman, 1922–1982. Sociol Health Illn 1983;5:345–55. [34] Goffman E. On cooling the mark out. Psychiatry 1952;15:451–63. [35] Goffman E. On face-work: an analysis of ritual elements in social interaction. Psychiatry 1955;18:213–31. [36] Goffman E. The moral career of the mental patient. Psychiatry 1959;22:123–42. [37] Goffman E. The Presentation of Self in Everyday Life. Doubleday Anchor; 1959. [38] Goffman E. Stigma: Notes on the Management of Spoiled Identity. PrenticeHall; 1963. [39] Grice HP. Logic and conversation. In: Cole P, Morgan JL, editors. Syntax and Semantics 3: Speech Acts. Academic Press; 1975. p. 41–58. [40] Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Sage; 2007. [41] Stake RE. Case studies. In: Denzin NK, Lincoln YV, editors. Handbook of Qualitative Research. Sage; 2000. p. 435–54. [42] Roberts C, Sarangi S. Theme-oriented analysis of medical encounters. Med Educ 2005;39:632–40. [43] Sarangi S. Practising discourse analysis in healthcare settings. In: Bourgeault, R DeVries, R Dingwall (ed.), Qualitative Methods in Health Research. Sage; 2010. p. 397–416.
Contents lists available at SciVerse ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
Accomplishments of the thought disordered person: A case study in psychiatrist–patient interaction Cherrie Galletly ⇑, Jonathan Crichton Discipline of Psychiatry, School of Medicine, University of Adelaide, Northern Mental Health, Adelaide, Australia School of Communication, International Studies and Languages, University of South Australia, Australia
a r t i c l e
i n f o
Article history: Received 17 June 2011 Accepted 4 August 2011
a b s t r a c t Background: The research and clinical literature portrays the thought disordered person as incapable of meaningful social interaction. This model views thought disorder exclusively as a brain dysfunction, evidenced by dysfunctions in speech. Aims: The study seeks to address this deficit model by investigating the interactional accomplishments of thought disordered people in clinical interviews. Method: An analysis of clinical interview data. Results: We investigate (1) what thought disordered people actually accomplish in interaction, and (2) how thought disordered people and their psychiatrists routinely communicate on matters consequential for treatment. Conclusions: This paper introduces a new perspective on the interactional achievements of people with thought disorder. The skills required by both parties during routine clinical interviews have not previously been recognised or described. Ó 2011 Elsevier Ltd. All rights reserved.
Introduction People with schizophrenia sometimes communicate using a semantically disorganised style of speech referred to as ‘thought disorder’. This is regarded as a core symptom of schizophrenia, along with hallucinations and delusions. However, hallucinations and delusions are personal experiences, which can be described by the person experiencing them, or inferred from observing the person’s behaviour. In contrast, thought disorder is interactional i.e. it only exists when the thought disordered person speaks and this speech is heard by another person. In psychiatric practise this occurs when a clinician converses with a thought disordered person. Although thought disorder is reliant on communication, the literature about thought disorder focuses on only one part of the interaction – the words produced by the patient. Thought disorder is regarded as a phenomenon to be elicited, observed and measured. Generally, a speech sample is obtained by prompting the patient to talk about a series of bland topics. This sample can be rated using instruments such as the thought disorder index or the com⇑ Corresponding author at: Discipline of Psychiatry, School of Medicine, University of Adelaide, The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, Suite 13, The Adelaide Clinic Consulting Suites, 33 Park Tce, Gilberton 5081, Australia. Tel.: +61 8 8269 8144; mob: 0406 422 494; fax: +61 8 8269 6187. E-mail addresses: [email protected], cherrie.galletly@adelaide. edu.au (C. Galletly). 0306-9877/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.mehy.2011.08.006
munication disturbances instrument, and analysed with tools such as analysis of referential coherence [1] or an automated technique, latent semantic analysis [2]. These approaches reflect a ‘deficit’ model [3] that views thought disorder as a brain dysfunction, evidenced by dysfunctions in speech. Faulty speech has been linked to specific cognitive impairments such as lack of sustained attention [4], impaired executive function and poor semantic memory [5], and reduced gray matter volume in several regions of the brain [6]. Deviant verbalization has been demonstrated amongst the relatives of people with schizophrenia [7], suggesting that thought disorder may be an endophenotype for schizophrenia. Overall, there is an assumption in the research literature that thought disordered speech is a phenomenon to be observed and cannot be understood as meaningful communication. Thought disorder is also described as a disturbance of speech [8] or verbal communication [9], implying the presence of a listener. However, research on thought disorder neglects two important factors: the role of other participants in the interaction, and the interplay between the two participants. Moreover, despite the supposition that if someone has thought disorder he or she cannot be understood, psychiatrists routinely talk with thought disordered people in clinical interviews. This expertise is central to what psychiatrists do but is not reflected in publications on thought disorder or in the training literature. We argue that successful interactions between psychiatrists and people with thought disorder occur regularly in clinical practice. This raises the question of
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
what the psychiatrist and the patient bring to these conversations. We consider that the psychiatrist exercises specific interview skills and techniques to enable smooth, productive communication. These skills are generally not recognized in training materials and are therefore learnt by observation and experience. More importantly, the patient displays a series of competencies which enable useful communication but are typically not acknowledged. Our paper provides a preliminary account of the interactional accomplishments of the thought disordered person. The paper draws on an ongoing interdisciplinary collaboration between an applied linguist and a psychiatrist which explores the language used by people with severe thought disorder in interactions with their psychiatrists.
Interaction and thought disorder Communication with people with psychoses, including those with thought disorder, has evolved considerably since Kraepelin’s descriptions of the bizarre behaviour and utterances exhibited by those with dementia praecox [10]. Prior to the 20th century, asylum care was predominantly custodial, utilising a range of physical therapies. This changed as psychoanalysis, initially developed for the treatment of neuroses, was extended to the treatment of psychotic disorders [11]. Analysts attempted to understand and interpret psychotic phenomena, with the expectation that this would lead to resolution of an underlying conflict and recovery from psychosis. In the 1960s, an anthropological perspective was adopted [12]. The patient’s disordered behaviour and communication was understood as a consequence of pathological communication within the family. This concept was further developed by Laing and Esterson [13], who argued that chaotic speech could be interpreted as a sane commentary on the patient’s insane social environment. A major paradigm shift occurred in the late 1970s, as new imaging technologies were applied and it became apparent that people with schizophrenia had distinct structural and functional abnormalities of the brain [14]. Research efforts focused on the biological aspects of schizophrenia and the development and evaluation of new medications. Comparatively little was written about communication with psychotic patients, other than ratings of the nature and severity of symptoms. Unhelpful communication (high expressed emotion) by family members or carers was identified as a predictor of relapse [15,16], but the patient tended to be viewed as passively experiencing the high expressed emotion environment. A shift towards re-engagement with patients with schizophrenia occurred in the 1990s. In 1997 Fenton [17] wrote ‘‘We can talk: individual psychotherapy for schizophrenia’’, describing a successful trial of personal therapy for schizophrenia [18,19]. The reports of the trial do not mention whether patients with thought disorder were included. Subsequently, Cognitive Behaviour Therapy (CBT) has been extensively evaluated [20], although patients participating in CBT tend to have very low levels of thought disorder [21]. Whilst the dialogue between people with schizophrenia and clinicians has clearly resumed, there is very little written about communication with people with thought disorder. Qualitative research methods are being utilised more frequently in psychiatry [22], but the voices of those with thought disorder are yet to be heard. This focus on interaction is not foreign to psychiatry; thought disorder is exceptional in not having a literature on interaction associated with it. There are numerous textbooks describing the skills required to conduct psychiatric interviews, describing how to interview, assess and interact with people diagnosed with various forms of mental illness [23,24]. The doctor–patient interaction, including the doctor’s emotional reactions to the patient, is central to some therapies [25]. However, there is a lack of information
901
describing the specific skills needed to communicate effectively with patients with thought disorder. The training literature describes the phenomenology of the various types of thought disorder, but generally does not acknowledge the need to develop and practise skills for effective communication with these patients.
Interaction as an accomplishment A major theme in the literature on social interaction is that competent participation is a remarkable but usually unnoticed achievement [26–28]. This theme has been elaborated most influentially by Erving Goffman, whose work has had a profound influence on interactional studies, psychiatry and the social sciences more generally [29–33]. The value of Goffman’s work to this study lies in his [34–38] account of face-to-face interaction in which he distinguished between the self as a ‘performed character’ displayed in social encounters and the more private self as a ‘performer’, whose interests are vested in the attributes ascribed to the performed self by others. This dual account of the self provided Goffman with a way of investigating how participants (mis)manage their performances of self through the risks encountered in social interactions. At stake for participants is their ‘face’: that is, the positive attributes ascribed to their performances by others, which include their competence to participate in meaningful interaction. The cost for a person deemed incompetent is to carry a ‘stigma’ that implies social and moral deficiency [38]. That the expertise required is usually taken for granted is testament to people’s general ability to seamlessly interpret and co-ordinate each other’s performances. This expertise is exemplified by the ability to cooperate in the talk at hand. This point was highlighted in a seminal paper by Grice [39] who argued that in order to infer what a person means from what he or she says, it is necessary to assume that he or she is acting according to what Grice called the ‘co-operative principle’. This is the presumption that the person is not being obtuse, incompetent or deceptive but is willing and capable of interacting ‘such as is required, at the stage at which it occurs, by the accepted purpose or direction of the talk exchange’ (p. 45). The key point here is that if participants do not judge each other to be cooperative in this sense, they are not able to infer what they mean by what they say. This is because of the way that the co-operative principle operates in conjunction with four other expectations: that a speaker will (1) use neither more nor less language than is required, (2) be truthful, (3) be relevant to the interaction at hand, and (4) be clear. According to Grice, when a speaker’s utterance appears to flout one or more of these four expectations, the listener will, unless there are grounds to the contrary, assume that the co-operative principle applies and interpret the meaning of the utterance so as to make it consistent with this principle. In doing so the listener will look for clues to the intended meaning in the context in which the utterance was produced as well as in the listener’s more general knowledge of the world. Thus, for example, ‘It’s cold in here’ might not appear meaningful within the interaction at hand. However, on the assumption that the speaker is competent and sincere, it might elicit the response ‘Ok, I’ll shut the window’ as a way of making it so. In sum, underscored by Goffman and Grice’s work is the usually unacknowledged fact that routine interaction is an accomplishment by all concerned. For participants, this involves ongoing attention to and management of each other’s face as a condition of meaningful interaction, in which each participant infers in vivo what the other means based on the presumption of co-operation in the talk at hand. Seen in this light, we argue that meaningful interaction for participants in our study is a particularly noteworthy accomplishment, for the meetings we describe place demands on
902
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
participants in addition to the challenges posed by thought disorder. They are a specialised type of encounter, associated with norms of behaviour that need to be learned by patients and psychiatrists alike, and that vary depending on the context and purpose of the interview. Method In this paper we present a case study of a routine meeting between a psychiatrist and patient. Our aim is to illustrate the accomplishments involved in an interaction that would be recognised as typical within the profession. The value of single case studies for illuminating issues of this kind is well documented [22,40,41]. The data presented in this paper consist of the transcript of the meeting drawn from a larger collection of transcripts of routine clinical meetings between psychiatrists and patients exhibiting thought disorder. Following the meetings, discussions were held with the psychiatrists that explored their interpretation of the interaction. These particular meetings were chosen because they were thought by the psychiatrists to represent typical examples of their interactions with patients with thought disorder. This study was approved by the institutional ethics committee. Participants were provided with a complete description of the study and an information sheet. Written, informed consent was obtained. Sessions were audio-recorded by the psychiatrists and the recordings were subsequently transcribed. Pseudonyms are used for the participants and the institutions to ensure confidentiality. The analysis employs the ‘theme-oriented’ discourse analysis developed by Roberts and Sarangi [42,43] according to which ‘analytic themes’ drawn from linguistics and sociology are brought to bear on interactional data to address ‘focal themes’. These are questions of interest to the professionals and clients who engage in the interactions under scrutiny. In our study, the identification of these themes has involved a close and ongoing interdisciplinary collaboration, a process that Sarangi and Roberts have called ‘joint problematization’. Results The transcript is taken from a routine meeting between a consultant psychiatrist, P, and patient, A. The setting is a locked ward in a general hospital psychiatric unit. A has been detained in the locked ward for the previous nine weeks. There have been several episodes of aggression requiring security guards to be called. A has been P’s patient throughout the admission. They meet two to three times a week. P is the consultant psychiatrist, and has a registrar and nursing staff to assist him. However, whilst these clinicians regularly interact with A, the consultant does not delegate the above tasks to them. He meets with A himself to attend to the relationship building tasks, and to ensure that A has ongoing engagement with the consultant responsible for his care. A and P sit on either side of a table in the ward. A is upset about being in hospital and wants to go home. At this meeting P wants specifically to find out: (1) how A’s condition is progressing; (2) that A understands the purpose and outcome of his Guardianship Board hearing, held on the ward earlier that day went (this meeting was to obtain a Continuing Detention Order and to continue a Community Treatment Order, both of which were granted); and (3) how well A is tolerating Clozapine, which was recently initiated. In addressing this agenda, P’s overarching priority is to build, maintain and monitor the therapeutic relationship. His contributions to the interaction reflect this multiple agenda. For his part, A is able to competently play the role of patient in the interaction. He sits throughout the interview, taking part in the
turn-taking sequences by responding to questions and prompts according to the norms of the interview, and deferring to the power differential (as in all doctor–patient relationships). P initiates and ends the interview, and decides some but not all of the topics to be discussed and the questions to be addressed. P makes decisions (e.g. about detention orders) that directly restricts A’s freedom. At the end of the interview P is free to leave the ward but A is not. Though the meaning and relevance of A’s responses are often unclear he is consistently polite and respectful – he does not become abusive or behaviourally disturbed. He is clearly engaged in the conversational exchange, and brings his own issues to the table. P’s challenge is to ensure that A focuses on the topic of the Guardianship Board hearing and to monitor A’s condition while maintaining the trust and rapport they have established. P achieves these aims using strategies which acknowledge A as having the potential to contribute meaningfully to the interview. In doing so P attends to and realises A as a person. He shows appropriate respect and treats A as a capable person. This acknowledgement is a condition of their relationship and of the success of the interview. Central to this acknowledgment is the fact that P’s talk attends to A’s face needs by maintaining throughout the appearance that he believes that A is capable of acting in accordance with the cooperative principle. This is seen in the fact that P acknowledges A’s ‘face’ by using language which affirms the ‘positive social value’ of A as an interactant, maintaining this stance even where the conversation threatens to break down. P takes every opportunity to respond to A’s utterances as if A is interacting in accordance with the co-operative principle [39]. Examples In line 5, consistent with the co-operative principle, P’s statement invites A to infer that P wants to know how the Guardianship Board hearing went. A replies but not to P’s implied invitation. In line 7, P encourages A to elaborate but by line 9 intervenes in A’s increasingly irrelevant talk. In line 11, P repeats his original invitation but this time makes explicit the request for information. A responds appropriately in line 12 and continues to do so until line 22. In lines 33 and 35, P seeks to return A to the agenda of the meeting by inviting A to identify any issues that A would like to raise. The use of the invitations respects A’s face by not directly criticising his talk as irrelevant. Similarly in line 49, P uses language which mitigates the decision to finish the meeting and does not impugn A. In lines 53, P gives A direct feedback on his mental state in explaining why the meeting is not proceeding as he had hoped. A attempts to make a joke in response but gets tangled. P then responds sensitively to A’s face by using language which mitigates the contradiction in line 55. A then responds in a way that leads back to the topic of the Guardianship Board hearing. At the Guardianship Board hearing, it had been suggested that A may have been difficult with the workers from ACE, a community support organisation. This is important as ACE support in the community will be part of the discharge plan. In line 60, consistent with the co-operative principle, A asks directly if the ACE workers had a problem with him, and is reassured that they did not – but P also double checks this back with A and they reach agreement that there was not a problem. More generally, at numerous points in the interview P gives A information about P’s assessment of his mental state, his progress (in the light of past episodes) and what is happening in his care (e.g. lines 17, 19, 27, 47, 53, 55, 64, and 68). Besides giving information (and therefore expecting that A will listen to this information
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
and that giving this information is useful to the cooperative enterprise) this conveys that P is interested, has taken the trouble to reflect on A’s progress, and is proceeding according to a treatment plan. He confirms that he shares A’s goal of A going home from hospital. Discussion While there is a deficit model in the literature on thought disorder, in the data we find heightened, not diminished, attention to personhood. This is evidenced in the language used by the psychiatrist to address the specific clinical agenda while contributing to the overarching priority of maintaining and developing the therapeutic relationship. This language reflects sensitive attention at every point to the patient as a person, including his perceptions and feelings in a stance of ‘respectful distance’, only imposing on the conversational options available to the patient where communication threatens to break down. This stance acknowledges the ‘cooperative principle’ [39] and attends to the ‘face’ needs [35] of the patient. For his part A demonstrates that a person can be thought disordered but conversationally ordered. This is not only a matter of form but of commitment to achieving the aim of the meeting, to maintaining the relationship, and to adhering to the ‘cooperative principle’ and attending to the ‘face’ needs of the psychiatrist. There is acknowledgement of ‘personhood’ on both sides of the conversation. The patient achieves many important aspects of communication, and these interactional accomplishments tend to be overlooked in the focus on a deficit model of thought disorder. Our research suggests that it would be useful to investigate the strategies used by patients with thought disorder to mitigate their difficulties with communication. Successful strategies could be identified so that psychological treatments could be developed to address thought disorder. Psychological treatments are utilised for hallucinations, delusions and paranoia [20] and our findings suggest that a similar approach might be useful for thought disorder. There is also a need to identify the specific interviewing skills used by clinicians who have the capacity to interact effectively with thought disordered patients. Clinical training in these skills would improve the ability of clinical staff to communicate with patients with thought disorder, enabling a more accurate understanding of the patient’s current concerns, an improved therapeutic alliance, balanced negotiation of treatment options and ultimately better outcomes. Conflicts of interest statement The authors have no conflicts of interest to report.
Appendix A (continued) 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.
37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54.
Appendix A Transcript of a routine meeting between a consultant psychiatrist (P) and patient (A). 1. 2. 3. 4. 5. 6. 7. 8.
P: Hello Andrew A: 2009, December P: it is and what I want is to catch up with you this morning A: yeah P: yeah, ok, you’ve had your guardianship board hearing this morning A: I’ve got a headache and I feel sick in the stomach. P: Uh huh A: I’m about to throw up – I need some. . .an ice coffee or, or a water ‘cos they haven’t had water jugs here. They need water
903
55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65.
P: mm, can you hang on just for a moment. A: no, ‘cos jack. . .. . .ahh. . ..my. . .I’m in secretary 3 and my nurses and doctors that are brides are in room 2 P: you had the guardianship board hearing this morning. How did that go? A: well. . .. . ..good P: mm, mm A: great, they agreed to December 2009, it was all ok P: mm, mm A: I do wanna go home to see my own home, I do wanna be in my own home P: that’s our goal as well is to get you home Andrew A: yeah I know that P: we need to get you a little bit better than you are at the moment A: its day 16, . . ...3,4,5 days and 18 days behind it P: mm A: day 17 and I’ll be a mental case. . .on the tarot cards. . ..i did go through those P: mm A: the advocate, the devil’s advocate, nearly twice I went through it. . .my brother Pat’s life...he’s up the other 4 universes. . .the other life came back here. P: so A: richardsness as you know is a fool’s paradise P: in previous admissions Andrew it has taken quite a long time for you to settle down A: I usually can settle straight away, I usually just meditate, for 32 years out of my life I meditated and I am a very wise individual P: ok A: and a great artist and a critic as well. Those cigarettes you smoke, those burnt things I have forgiven all that P: ok, so A: the lady with the tape hairdo is ah the royal worker for me P: right. Now is there anything you wanted to ask me particularly this week. A: that female doctor old one she used the judges phone, can’t help he P: right, anything else you wanted to ask me A: that bloke that got the louvres and the wire he, he is down at Unley. I let Kate, the difference is that Marie Antoinette my girlfriend, my wife, my best wife, Madagascar underneath is now not an enemy P: ok A: an arch enemy of Madagascar, I met him at a Christian gathering of a club like Rotary or one of those P: ok, Andrew. Andrew we are going to have to keep going A: Mark is gonna live P: mm A: but Dave didn’t want him to. Dave’s my best mate P : ok A: anything. . .no keep asking me because P: no that will do A: I, I, I think that P: we’ve got the guardianship board’s approval through A: keep asking getting some skin graft, one of these he sits down, fucking hurt like heck P: ok, so I’m going to leave it there for the moment Andrew A: mumbling P: ok A: yeah P: I did say I would catch up with you but your thinking is still jumping around a lot and it is very hard to follow at times A: that’s because men can’t think and talk, most of them, so that when they get go through a process all men can’t quite keep up the women can think and hear at the same time P: I actually think it is more to do with the fact that you’re still quite unwell A: that’s what I told the social. . ..the Dr. . . Pete this morning P: ok A: cos I looked after, I said the guys from ACE P: right A: they are not . . .. . .advice for me are they, they never had any problem with me P: no ACE have never had a problem with you have they A: no A: did do the right thing – Simon brings me in, takes me home P: no, but you need to be here at the right A: yes I d
(continued on next page)
904
C. Galletly, J. Crichton / Medical Hypotheses 77 (2011) 900–904
Appendix A (continued) 66. 67. 68. 69. 70. 71. 72. 73.
P: yeah A: but I hope not for the 17th day. P: I hope that you slowly improve A: the 17th my roster, 3, 4, 5, 3, days on 4 days off 5 days off has gone to the 15th day after that P: ok Andrew so I’m going to leave it there, thanks for talking with me A: Dave was off too P: ok A: I’ve got two shirts on
References [1] Ditman T, Kuperberg GR. Building coherence. A framework for exploring the breakdown of links across clause boundaries in schizophrenia. J Neurolinguistics 2010;23:254–69. [2] Elvevåg B, Foltz PW, Rosenstein M, Delisi LE. An automated method to analyse language use in patients with schizophrenia and their first-degree relatives. J Neurolinguistics 2010;23:270–84. [3] Candlin CN, Crichton J. Introduction. In: Candlin CN, Crichton J, editors. Discourses of Deficit. Palgrave-Macmillan; 2010. p. 1–22. [4] Docherty NM, Strauss ME, Dinzeo TJ, St-Hilaire A. The cognitive origins of specific types of schizophrenic speech disturbances. Am J Psychiatry 2006;163:2111–8. [5] Kerns JG, Berenbaum H. Cognitive impairments associated with formal thought disorder in people with schizophrenia. J Abnorm Psychol 2002;111:211–24. [6] Horn H, Federspiel A, Wirth M, et al. Gray matter volume differences specific to formal thought disorder in schizophrenia. Psychiatry Res 2010;182:183–6. [7] Levy DL, Coleman MJ, Sung H, et al. The genetic basis of thought disorder, language, communication disturbances in schizophrenia. J Neurolinguistics 2010;23:176. [8] Berenbaum H, Kerns JG, Vernon LL, Gomez JJ. Cognitive correlates of schizophrenia signs and symptoms: I. Verbal communication disturbances. Psychiatry Res 2008;159:147–56. [9] Docherty NM. Cognitive impairments and disordered speech in schizophrenia: thought disorder, disorganization, and communication failure perspectives. J Abnorm Psychol 2005;114:269–78. [10] Kraepelin E. Dementia Praecox and Paraphrenia (translated by RM Barkley). E & S Livingstone, 1919. [11] Fromm-Reichmann F. Principles of Intensive Psychotherapy. University of Chicago Press; 1960. [12] Bateson G. Steps to an Ecology of Mind: Collected Essays in Anthropology, Psychiatry, Evolution, and Epistemology. University of Chicago Press; 1972. [13] Laing RD, Esterson A. Madness and the Family. Penguin Books: Sanity; 1964. [14] Johnstone EC, Crow TJ, Frith CD, Husband J, Kreel L. Cerebral ventricular size and cognitive impairment in chronic schizophrenia. Lancet 1976;30:924–6. [15] Wynne LC. Current concepts about schizophrenics and family relationships. J Nerv Ment Dis; 1981;169:82–9. [16] Marom S, Munitz H, Jones PB, Weizman A, Hermesh H. Expressed emotion: relevance to rehospitalization in schizophrenia over 7 years. Schizophr Bull 2005;31:751–8.
[17] Fenton WS, McGlashan TH. We can talk: individual psychotherapy for schizophrenia. Am J Psychiatry 1997;154:1493–5. [18] Hogarty GE, Kornblith SJ, Greenwald D, et al. Three-year trials of personal therapy among schizophrenic patients living with or independent of family, I: description of study and effects on relapse rates. Am J Psychiatry 1997;154:1504–13. [19] Hogarty GE, Greenwald D, Ulrich RF, et al. Three-year trials of personal therapy among schizophrenic patients living with or independent of family, II: Effects on adjustment of patients. Am J Psychiatry 1997;154:1514–24. [20] Tarrier N. Cognitive behavior therapy for schizophrenia and psychosis: current status and future directions. Clin Schizophr Relat Psychoses 2010;4:176–84. [21] Evans-Jones C, Peters E, Barker C. The therapeutic relationship in CBT for psychosis: client, therapist and therapy factors. Behav Cogn Psychother 2009;37:527–40. [22] Whitley R, Crawford M. Qualitative research in psychiatry. Can J Psychiatry 2005;50:108–14. [23] MacKinnon RA, Michels R, Buckley PJ. The Psychiatric Interview in Clinical Practice. 2nd ed. American Psychiatric Publishing Inc.; 2006. [24] Hales RE, Yudofsky SC, Gabbard GO. The American Psychiatric Publishing Textbook of Psychiatry. 5th ed. American Psychiatric Publishing Inc.; 2008. [25] Yalom I. Love’s Executioner and Other Tales of Psychotherapy. American Psychiatric Press Inc.; 1989. [26] Duranti A. Linguistic anthropology: History, ideas and issues. In: Duranti A, Malden MA, editors. Linguistic Anthropology: A Reader. Wiley-Blackwell; 2009. p. 1–60. [27] Giddens A. Central Problems of Social Theory. University of California Press; 1979. [28] van Dijk T. Discourse Analysis as Social Interaction. Sage; 1997. [29] Byrne P. Psychiatric stigma. Br J Psychiatry 2001;178:281–4. [30] Jacobsen MH. Goffman through the looking glass: From ‘classical’ to contemporary Goffman. In: Jacobsen MH, editor. The Contemporary Goffman. Routledge; 2010. p. 1–47. [31] Manning P. Erving Goffman and Modern Sociology. Stanford University Press; 1992. [32] Trevino AJ. Goffman’s Legacy. Rowman & Littlefield; 2003. [33] Strong PM. Review essay: The importance of being Erving: Erving Goffman, 1922–1982. Sociol Health Illn 1983;5:345–55. [34] Goffman E. On cooling the mark out. Psychiatry 1952;15:451–63. [35] Goffman E. On face-work: an analysis of ritual elements in social interaction. Psychiatry 1955;18:213–31. [36] Goffman E. The moral career of the mental patient. Psychiatry 1959;22:123–42. [37] Goffman E. The Presentation of Self in Everyday Life. Doubleday Anchor; 1959. [38] Goffman E. Stigma: Notes on the Management of Spoiled Identity. PrenticeHall; 1963. [39] Grice HP. Logic and conversation. In: Cole P, Morgan JL, editors. Syntax and Semantics 3: Speech Acts. Academic Press; 1975. p. 41–58. [40] Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Sage; 2007. [41] Stake RE. Case studies. In: Denzin NK, Lincoln YV, editors. Handbook of Qualitative Research. Sage; 2000. p. 435–54. [42] Roberts C, Sarangi S. Theme-oriented analysis of medical encounters. Med Educ 2005;39:632–40. [43] Sarangi S. Practising discourse analysis in healthcare settings. In: Bourgeault, R DeVries, R Dingwall (ed.), Qualitative Methods in Health Research. Sage; 2010. p. 397–416.