The effect of questions used by psychiatrists on therapeutic alliance and adherence

Abstract

Background Psychiatrist questions are the mechanism for achieving clinical objectives and managing the formation of a therapeutic alliance - consistently associated with patient adherence. No research has examined the nature of this relationship and the different practices used in psychiatry. Questions are typically defined in binary terms e.g. ‘open’ vs ‘closed’ that may have limited application in practice. Aims To undertake a detailed examination of the types of questions psychiatrists ask patients and explore their association with the therapeutic alliance and patient adherence. Method A coding protocol was developed to classify questions from 134 outpatient consultations, predominantly by syntactic form. Bivariate correlations with measures of patient adherence and the therapeutic alliance (psychiatrist-rated) were examined and assessed using Generalised Estimating Equations, adjusting for patient symptoms, psychiatrist ID and amount of speech. Results Psychiatrists used a small subset (4/10) of question types regularly 1) yes/no auxiliary questions 2) wh questions 3) declarative questions and 4) tag questions. Only declarative questions predicted better adherence and perceptions of the therapeutic relationship. Conversely, wh questions - associated with positive symptoms – predicted poorer perceptions of the therapeutic relationship. Declarative questions were frequently used to propose an understanding of patients’ experiences, in particular their emotional salience for the patient. Conclusions A more granular definition of questioning practices is necessary to improve communication in psychiatry. The use of declarative questions may enhance the alliance and adherence - or index their manifestation in talk e.g. better mutual understanding. The function of ‘soprefaced’ declaratives, also found in psychotherapy, are more nuanced than negatively connotated ‘leading’ questions. Hearable as displays of empathy, they attend closely to patient experience, while balancing the tasks of assessment and treatment.