Communicating clearly in mental health

Reading an article in Medscape.com about the misappropriation and misinterpretation of scientific research has got me thinking about the importance of getting our messages across clearly in the clinical context as well.

A story about “medical misadventure”

Recently my sister was started on a new medication. It’s a very toxic medication called methotrexate that’s used in a wide range of conditions from rheumatoid arthritis to certain cancers. It needs to be taken once a week with a follow-up “rescue” medication a day later to prevent toxicity. Because the consultation was so complex, rushed and emotionally charged, my sister left the consulting room not entirely sure about what she’d been told. Two weeks later she was in hospital seriously ill. She had taken both medications every day and the methotrexate had poisoned her.

Medication mix-ups are just the beginning and prescribers are lucky that many problems are avoided by the checks and balances put in place via the pharmacy. However, there are many other things we need to communicate clearly, in order not just to avoid negative consequences but to ensure we make a positive difference.

Does it matter if it’s not about medications?

In mental health we try to teach people strategies to manage their emotions to enable to think clearly enough to solve the problems in their lives. We know that problem solving is less effective in the context of high anxiety. If we try to teach relaxation strategies without explaining why we are doing it (in the context of all their other more pressing issues) people will often go away dissatisfied and certainly not put what we have taught them into practice. It pays to spend the time explaining why we are encouraging them to meditate, practice controlled breathing or do relaxation exercises up front.

We need to empathise and validate, but I wonder sometimes if the lack of time to provide clear unambiguous explanations about management suggestions, is why time-poor clinicians complain that they have little success with CBT-based strategies.  

Is the problem just lack of time?

I don’t think so. I think it is also partly due to making assumptions about what people do and don’t know. My sister didn’t understand why she was taking the drug once a week – after all that’s not what happens with most medications. She assumed the pharmacist had made a mistake and just did what she thought was right. We can do better!

With things like CBT skills, its also about having the right words readily available and pitching the explanations to suit the understanding of the person we are talking to. That requires a bit of practice and maybe even listening to someone else do it so that we can explain things in a way that encourages compliance - easily, efficiently and in simple terms.

Take controlled breathing exercises for example

Why would any ordinary person understand that controlled breathing exercises might help them with their emotions? Sure, if you have panic disorder you are aware of the connection between your anxiety and your breathing, though you may not be clear about whether the anxiety makes you breath faster or the fast breathing makes you anxious. If your anxiety is not associated with changes in your breathing pattern (that you are aware of), why would breathing exercises help? 

The explanation is not difficult and not especially time-consuming but it is important, because without that understanding, compliance is unlikely.

Learning from others

My colleagues and I have been presenting a series of half-hour webinars examining some simple CBT skills and discussing how to teach them effectively and efficiently, in the context of a consultation. As it happens, the most recent webinar was about “Explaining and Teaching Controlled Breathing”. You can watch these webinars on demand on the Black Dog Institute website. Please take a look and see if there is anything that interests you.

We are hoping that looking at the way others do things can help you understand whether you are doing a good job of unambiguous communication in your mental health consultations.