Communication skills models

Clinical communication models describe consultations with respect to stage, tasks and skills. McWhinney's disease–illness model (Levenstein Reference Levenstein, McCracken and McWhinney1986) reflects the two separate agendas of the doctor's ‘disease framework’ and the patient's ‘illness framework’. Bird and Cohen-Cole's three function model (Bird Reference Bird and Cohen-Cole1990) divides the interview into three components: building the relationship, assessing and understanding the patient's problems, and collaborating to manage these problems.

The widely used Calgary–Cambridge (Silverman Reference Silverman, Kurtz and Draper2013) framework divides the consultation into six tasks: initiating the session; gathering information; building the relationship; giving information; explanation and planning; and closing the session. It also includes providing structure and building the relationship as ‘continuous threads’ throughout the consultation. The NWL CST programme draws heavily on this model, its comprehensive set of evidence-based communication skills (Silverman Reference Silverman, Kurtz and Draper2013) and the associated teaching guide (Kurtz Reference Kurtz, Silverman and Draper2005).

Communication skills training

There have been relatively few studies of the impact of CST within psychiatry, of which we list only a selected minority. According to Wilson (Reference Wilson2018) ‘Communication skills training is still too often regarded as better suited to physical health consultations than more complex psychiatric interviews’.

Harrison & Goldberg (Reference Harrison and Goldberg1993) evaluated a training programme to improve the interviewing skills of psychiatry trainees. Videotaped analysis revealed improvements in responding to verbal cues and establishing the patient's view of their illness. Following a survey of one UK rotation which found that 42.8% of core trainees had no previous CST, Kowalski & Sathanandan (Reference Kowalski and Sathanandan2015) developed an advanced CST programme to improve confidence in managing difficult situations at work. All trainees involved felt that their communication skills had improved.

Evaluation of a communication skills framework found that trainees using it were significantly more confident in communicating a schizophrenia prognosis (Ditton-Phare Reference Ditton-Phare, Sandhu and Kelly2016). McCabe et al (Reference McCabe, John and Dooley2016) developed a brief CST intervention to work more collaboratively with patients with psychosis. This led to behaviour change and improved therapeutic relationships with patients in routine clinics.

The timing of the RCPsych CASC clinical exam towards the end of core training may discourage trainees from focusing on communication skills earlier on. It is therefore helpful that the RCPsych states that ‘all trainees must receive teaching in interviewing skills in the first year Core Psychiatry Training (CT1). The use of feedback through role-play and/or video is recommended’ (Royal College of Psychiatrists 2020, p. 36). In addition, it states that it is essential that trainees attend an MRCPsych course including ‘communication and interviewing skills’ (p. 37). It identifies communication skills as central to several intended learning outcomes (ILOs) with ILO13 setting out the knowledge, skills and attitudes required (Box 2).

Core communication skills

The introductory session on Paper A summarises the core communication skills as applied to psychiatry. It is important to discuss previous CST experience at the outset, including trainees’ preconceptions and concerns. Evidence of the consequences of poor clinical communication skills and the benefits of effective communication skills are outlined.

It is important to create a safe space to encourage trainees to participate fully. Ground rules are set out, including confidentiality, mobile phone etiquette and allowing equal contributions from everyone. We use the phrase ‘no idea is a bad idea’ to encourage free flow of ideas.

Tasks for different stages of the psychiatric interview are then outlined (Box 3). At the start, psychiatrists must listen attentively, without interrupting, allowing patients to describe presenting concerns in their own words. The use of non-verbal skills (posture, gestures, facial expression, eye contact, touch and positioning) is discussed. Verbal skills used in information gathering (Box 4) are explored in detail, such as how open questions allow the patient to tell their story and the interviewer to obtain more information.

As the interview progresses, there is a move to specific open and then closed questions to obtain finer details (Silverman Reference Silverman, Kurtz and Draper2013). These active listening skills allow trainees to develop an interview style that is responsive, as opposed to one we term ‘machine-gun fire’ (firing multiple questions from the doctor's agenda without responding to patients’ cues). Basic history taking is also reviewed; we find this is not always applied as rigorously to psychiatric symptomatology, such as delusional content, as to physical symptoms.

Trainees are taught to build rapport through actively showing interest, curiosity and empathy. A distinction is made between cognitive empathy and affective empathy. Cognitive empathy involves gaining a genuine understanding of the patient's condition whereas affective empathy is the ability to reflect on a patient's experienced emotions (feeling with) (Cox Reference Cox, Uddin and Di Martino2012).

When expressing empathy, trainees can rely on clichés, especially ʻThat must be very distressing for you'. If also delivered in a neutral manner, this comes across as robotic and patronising, which we term ‘empty empathy’. To highlight this, trainees are asked to think about how a friend might react to their responses in a similar situation. They are encouraged instead to use more natural sounding phrases (ʻThat must have been really tough for you') and to match the level of empathy to the specific situation. Trainees report that role-playing the patient enhances their understanding of patients’ symptoms and difficulties.

Dealing with sensitive subjects, especially risk and substance misuse, requires specific techniques, such as a graduated approach to questioning. ‘Empathic linking ‘(‘That sounds really tough – do you sometimes find you use drink to cope?’) and ‘normalising statements’ (We often find that people in your situation also feel/do … ’) are useful (Carlat Reference Carlat2016).

When note-taking by hand or electronically, it can be helpful to mention this at the start and to look up periodically. At significant moments, the equivalent of ‘putting down the pen’ emphasises giving full attention.

The acronym ICE (ideas, concerns, expectations), widely used in undergraduate and general practice CST, is especially relevant in psychiatry, where patients are often reluctant to disclose sensitive topics: ‘Balancing a patient's agenda, ideas, concerns, and expectations with the clinician's is a tricky but skilful task. Done well, it flows like a guided conversation; done badly it is stilted and jars’ (Wilson Reference Wilson, Coll, Papageorgiou and Stanley2012: p 11).

We find that certain difficulties with communication skills frequently occur, especially talking excessively, using multiple closed questions, and failing to clarify symptoms and concerns. Additionally, trainees do not always enquire adequately about the impact of symptoms on various aspects of patients’ lives. S.M. therefore created the acronym TOE as an aide-mémoire: ‘Talk less, listen more; Open to closed questions; Explore cues’. Other common problems include the understandable urge to provide premature reassurances and solutions.

We based a light-hearted teaching strategy on the interviewing style of the popular 1970s television detective Columbo. Like detectives, psychiatrists can also have reluctant interviewees and require sensitivity in encouraging opening up. Trainees are asked to think of communication skills common to both situations, beginning with the letter C. These include: curiosity, checking, clues/cues and appearing confused (i.e. not blaming the interviewee when they are unclear or when carefully challenging discrepancies). A subsequent interviewer question might be ʻI'm sorry, I don't quite follow why you did that. Could you tell me a bit more?'

Teaching on clinical topics

Paper A includes sessions on depression, psychosis and assessing risk to self and others. Paper B includes sessions on substance misuse, providing explanations and eating disorders. Communication skills as applied to other subspecialties, such as older adult, child and adolescent, and intellectual (learning) disability psychiatry, should also be covered during general core training. During the early stages of the COVID-19 pandemic, CST was adapted for online teaching by using pre-recorded undergraduate teaching videos with professional actors.

Sessions commence with an informal, half-hour interactive presentation on a specific clinical topic. Each includes challenges of interviewing, review of relevant symptoms and phrasing of questions, plus disorder-specific communication skills strategies (the last two often lacking in postgraduate psychiatry textbooks). In our experience, this overview also enhances the trainees’ confidence to engage more fully in the role-plays.

Certain disorders require more detailed attention. Interviewing patients with psychosis can be extremely challenging owing to the influence of psychotic symptoms on patients’ ability to communicate and develop trust. Clarifying delusions requires sensitive questioning: for example, assessing insight using challenging questions too early on can risk alienating the patient. The interviewer also needs to be careful about the use of too much silence and of personal space, as these can increase paranoid thinking. Silverman et al (Reference Silverman, Kurtz and Draper2013) mention the difficult challenge of empathising with the patient but not colluding. Hamelijnk et al (Reference Hamelijnk, Tarbuck, Kajee, Coll, Papageorgiou and Stanley2012) highlight the importance of flexibility, empathy, signposting and summarising, as well as building rapport by exploring ‘external’ problems before ‘internal symptoms’.

Providing explanations

Research reveals inadequate information-giving skills of doctors (Maguire Reference Maguire, Fairburn and Fletcher1986a, Reference Maguire, Fairburn and Fletcher1986b) and poor recall of information by patients (Ley Reference Ley1998). An important skill is ‘chunking and checking’, in which information is provided in bite-size pieces and understanding is then checked. Others include: assessing a patient's starting point, categorising information, the use of signposting, repetition and summarising (Silverman Reference Silverman, Kurtz and Draper2013).

Additional areas

Advanced techniques for use in other situations are covered, including motivational interviewing for substance misuse (Rollnick Reference Rollnick, Butler and Kinnersley2010) and the chronological assessment of suicide events (CASE) framework (Shea Reference Shea1998). Especially in risk-related scenarios, trainees are repeatedly reminded not to ignore their ‘gut instinct’.

Feedback in practice

Drawing on the approaches described, we use various strategies to facilitate constructive feedback. These contribute to making the sessions interactive and engaging and promote useful learning. Box 8 lists tutors’ tasks for facilitating feedback.

Tutors initiate feedback with open questions, then enquire about specific communication skills, such as the use of questions, empathy and signposting to promote discussion of overlooked points. Socratic questioning (a series of focused, open-ended questions to encourage reflection), along with increasingly specific prompts, helps trainees to identify difficulties and find their own solutions. Questions from trainees are initially redirected back to the group to provide answers. Tutors can also ask specific probing questions to highlight the impact of a particular communication skill, for example ʻWhat was the key question that opened everything up?' Exploring the reasoning behind interviewers’ unhelpful behaviours can reveal important points. In one example, a reluctance to clarify crucial aspects of a suicide attempt uncovered underlying fears of ‘upsetting’ patients. Sample feedback questions for tutors are shown in Box 9. Dudley (Reference Dudley2012: pp 153–154) provides a more comprehensive list.

Observers are encouraged to give feedback directly to the interviewer and for it to be specific and non-judgemental (‘effective or not’, instead of ‘good or bad’). For example, ʻYou explained clearly who you were and why the patient's family were concerned', rather than ʻYou did a very nice introduction'. Descriptive feedback using verbatim examples is key and often requires prompting. As Kurtz et al (Reference Kurtz, Silverman and Draper2005: p 126) emphasise, ‘By describing exactly what you saw in the interview, you will almost always produce non-evaluative specific feedback’.

Flexibility in the order of feedback can sometimes be useful, especially if during an initial discussion of what went well an issue arises that would be better explored there and then. This is especially so in the second year of the MRCPsych course, when trainees are more experienced and familiar with each other.

An important tutor role is to get the whole trainee group involved in discussions. This is achieved by the use of eye contact, verbal invitation and sensitively managing dominating participants. Responding encouragingly by finding value in almost all answers also helps promote interaction. Trainee interviewers can be overly self-critical, requiring prompting to recognise what they did well. Conversely, observer peers’ feedback can be overly positive. We find that interviewers accept constructive criticism more readily from their peers, underlining the importance of ensuring trainees deliver much of the feedback.

Feedback from the trainee playing the patient is particularly influential in providing the patient's perspective. In one instance, the group perceived an interviewer as empathic but the ‘patient’ disagreed as no empathic statements were expressed. Feedback can be in role, out of role or in a neutral role (in character but without strong emotions). We follow Dudley's (Reference Dudley2012) recommendation of allowing both in-role and out-of-role feedback.

Following feedback, the interviewer is given an opportunity to put the learning into practice by rehearsing (replaying) part of the interview. Even a brief replay, for example illustrating the positive difference of responding to a previously ignored cue, can provide effective teaching points and also leave the interviewer with a sense of achievement. Finally, the tutor asks the group to identify take-away points both for the interviewer and for the rest of the group.

Individual assessment of communication skills

The usefulness of WPBAs has been questioned. A survey of trainers and trainees highlighted problems and negative attitudes (Menon Reference Menon, Winston and Sullivan2009). Many of the feedback strategies described above can also be applied successfully in one-to-one situations such as WPBAs and when assessing medical students.

Videotaped feedback

Video recording and feedback are utilised extensively in undergraduate CST using simulated patients. There are many advantages: trainees can view their non-verbal behaviour, more accurate descriptive feedback can be given and the recording can be paused at key points. Disadvantages include trainees’ anxiety at being recorded and difficulty rehearsing suggestions arising from the feedback.

Cultural differences

Silverman et al (Reference Silverman, Kurtz and Draper2013) list common issues and barriers in cross-cultural communication relating to language, non-verbal communications and cultural beliefs, and where relevant, CST tutors introduce discussions on the influence of cultural factors on both clinical presentation and on the interviewing process itself.

Use of interpreters

Interpreters play an important role in psychiatric interviews. Wherever possible, especially if not an emergency, an impartial professional interpreter should be used rather than family, carers or acqaintances. It is crucial that the correct information is relayed to the interviewer without distortion. Raval & Tribe (Reference Raval and Tribe2014) make a number of recommendations: holding a pre-consultation meeting between the interpreter and the health professional; translating speech verbatim (to avoid missing important aspects such as thought disorder and swearing); and for the interviewer to talk to the patient and not the interpreter.

Interviewing informants

Some of the role-play scenarios involve interviewing family/carers, for example explaining a diagnosis of schizophrenia or a treatment such as electroconvulsive therapy. Other related points can be brought up and explored during teaching. One important example is of trainees feeling uncomfortable in asking carers to ‘wait outside’ while they interview the patient, not fully realising how vital, sensitive information could easily be missed.

Joint interviewing

Clinical assessments are increasingly carried out with other members of the multidisciplinary team. It is important to discuss beforehand who will take the lead and how they will collaborate throughout the interview. We recommend that, following joint assessments, trainees ask their colleagues for informal feedback on their communication skills. According to Poole & Higgo (Reference Poole and Higgo2017), the lead interviewer should periodically invite the other interviewer's observations or comments; breaks can allow discussion of difficult decisions (such as legal detention) and planing in case the patient reacts badly.

It can also be useful to run interprofessional CST sessions. S.M. set up the Communication and Assessment Skills Training (CAST) project for ward-based and community mental health teams (CMHTs). Involvement of different disciplines brought a useful range of different professional perspectives.

Telephone interviews

Since the advent of COVID-19, CMHTs have increasingly used telephone interviews. The absence of visual cues has a negative impact on developing rapport and on eliciting adequate information and can generate misunderstandings. There is therefore a much greater emphasis on verbal facilitation, which should be enhanced. Silverman et al (Reference Silverman, Kurtz and Draper2013) advocate careful active listening, the crucial importance of discovering the patient's ICE and frequently checking for understanding. To simulate telephone consultations during CST, we ask the interviewer and patient role-player to interact while seated back-to-back. Observers can also be similarly ‘masked’.

Remote interviewing using video

The use of video consultation in medical practice is also increasing, especially since COVID-19. Johns et al (Reference Johns, Tan and Burhouse2020) outline a step-by-step guide for clinicians on using video consultations in mental healthcare, for which there is a growing evidence base demonstrating suitability, acceptability and satisfaction. They list key considerations such as ‘legal and ethical issues, such as defining and documenting patient's suitability and the role of the clinician, risk assessments and contingency planning, privacy, confidentiality, security and consent’.

Although preferable to telephone interviews, disadvantages remain. Technology can be a challenge for some patients, owing to either ability or availability. Some patients find it acutely uncomfortable to see their own faces on screen. For others, the use of cameras may compound persecutory ideation. In addition, as cameras usually only show a patient's face, other non-verbal cues may be missed. S.M. ran a Supported Return to Training Course in which psychiatry trainees assessed simulated patients in video consultations and reported this experience to be very useful in increasing their confidence.