Research on the Influence That Communication in Psychiatric Encounters Has on Treatment

Over the past 30 years, few medical specialties have changed so dramatically with respect to clinical practice as psychiatry. The changes have been fueled by advancements in psychopharmacology and the emergence of managed care and managed competition as the principal driving forces in mental health service delivery (1,2,3). As a result of these forces, the technical aspects of the psychiatric encounter have changed. The psychiatrist has become principally a psychopharmacologist and secondarily a manager of care (3). This change in role definition raises concerns about the nature and purpose of the psychiatrist-patient relationship: how important to treatment outcome is the therapeutic alliance between psychiatrist and patient? What must a psychiatrist do and say within the psychiatric encounter to optimize treatment outcome? What influence do social and health policy, reimbursement schemes, and organizational systems have on psychiatrist-patient relationships? It is our contention that to achieve optimal treatment outcomes for our patients in the present mental health care environment, psychiatrists must possess a unique communicative skill set that has yet to be defined.

The purpose of this article is to inform mental health professionals about the empirical literature describing medical and psychiatric encounters and the influence of communicative behaviors on specific encounter outputs and treatment outcomes. In addition, we argue for a research and training agenda to identify communicative skills of psychiatrists that improve treatment outcome and to train present and future psychiatrists in those skills.

Key concepts in the area of health communications research bear reviewing. Health communications research uses observation instruments, also called interaction analysis systems, to methodically identify, categorize, and quantify the salient features of physician-patient communications. Most employ an exhaustive taxonomy for classifying verbal—and, with some instruments, nonverbal—events and verbal utterances. A verbal utterance is defined as "the smallest meaningful and distinguishable speech segment, conveying only one thought or relating to one item of interest" (4). Two types of interaction analysis systems have been identified: "cure" systems and "care" systems (5).

Cure systems are meant to capture instrumental (task-focused) behavior, and care systems are meant to measure affective (socioemotional) behavior. Instrumental utterances can be defined as "technically based skills used in problem solving, which compose the base of 'expertness' for which the physician is consulted" (6). Utterances defined as instrumental include behaviors such as giving information, asking questions, counseling, giving directions (7), identifying future treatment or tests, discussing side effects of tests or treatment, and discussing test results with patients (8). Affective behaviors have been defined in various ways—for example, as verbal statements with explicit socioemotional content, ratings of the affect conveyed in voice quality, and counts of speech errors indicative of anxiety (6), behaviors directed by the physician toward the patient as a person rather than a case (9), and behaviors designed to establish and maintain a positive relationship between the physician and the patient (10).

The Roter Interactional Analysis System is an example of an interaction analysis system that is both a cure and a care system (8). This system codes verbal utterances into 34 mutually exclusive and exhaustive categories that directly reflect the content and context of the physician-patient dialogue. Categories can be logically grouped to avoid excessive analysis. Verbal behavior is coded directly from audiotapes rather than from transcripts. An assessment of the tonal qualities transmitting the emotional context of interaction is therefore possible.

Methods

A comprehensive and systematic review of the medical and psychiatric literature from 1950 to 2001, using MEDLINE and PsycINFO electronic databases, was conducted to identify relevant literature on communication skills of psychiatrists and other physicians. For the medical literature, the search terms were "medical encounter," "content analysis," and "interactional assessment"; individual searches were conducted with each term. For the psychiatric literature, search terms were "psychiatry," "psychiatric," or "psychopharmacology" in combination with "content analysis," "interviewing skills," "interactional assessment," "communication skills," "treatment analysis," and "psychiatrist-patient relationship." These searches yielded five articles of interest in medicine and 6,409 articles in psychiatry. The searches were then augmented by personal correspondence with experts in practice pattern changes in psychiatry and in medical and psychiatric communications research. A review of references within each article and the experts identified other relevant articles. The search was then narrowed to include reports of studies that used any of the following: structured written instruments that captured relevant physician and patient perceptions of the physician-patient relationship, content analysis of audio- or videotapes of communication in medical or psychiatric encounters, or interaction analysis systems used to categorize audio- or videotaped communicative behaviors in medical or psychiatric encounters. Our method yielded 25 articles in medicine and 34 articles in psychiatry.

Results

In medical specialties other than psychiatry, the communicative aspects of the medical encounter have been empirically evaluated since the late 1960s (11). Medical communication researchers have shown associations between communicative skills of the physician and patient satisfaction (12,13,14,15), adherence to treatment recommendations (16,17,18), treatment outputs (14,15,18,19), and willingness of the patient to file malpractice claims (20,21). Additionally, it has been shown that primary care physicians can be more responsive to patients' concerns without lengthening visits (22).

The relevant literature in psychiatry, which is summarized in Table 1, can be conceptualized as representing four discrete categories of research: negotiated treatment and the customer approach, therapeutic alliance, Gottschalk-Gleser content analysis of patient speech, and content analysis of interviews.

The following discussion summarizes the pertinent findings from these lines of research, with emphasis on studies that associate communicative behaviors with specific encounter outputs or treatment outcomes.

Negotiated treatment and the customer approach

The work of Eisenthal and Lazare (23,24,25,26,27,28,29,30) explored the applicability of the "customer approach" to the conduct of the initial psychiatric interview in a walk-in clinic. The initial evaluation was viewed as a process of negotiation between the clinician and the patient. It was assumed that patients had one or more clinical requests or perceived needs for help. The clinician's task was to empathically elicit these requests, collect other data necessary for a clinical formulation, and then enter into a negotiation in which patient and clinician simultaneously attempted to influence each other, leaving the clinician better educated to make a more valid formulation and leaving the patient more willing to consider the clinician's suggestion (24,25).

The negotiated consensus model described by Levinson and colleagues influenced the "customer approach" (31). Eisenthal and Lazare used this interview model as the ideal template for the interaction between clinician and patient in an initial interview in a walk-in clinic. Eisenthal and Lazare viewed the initial psychiatric interview as a set of transactions between the clinician and the patient, which, if performed to the satisfaction of the participants, would create the context necessary for optimal treatment outputs. To ascertain the effect of this approach on clinician and patient satisfaction, the researchers developed written questionnaires for both clinicians and patients to complete before and after the encounter, to report their expectations and the results of the encounter. In addition, Eisenthal and Lazare developed the Patient Request Form (PRF), a 75-item self-report questionnaire designed to assess the degree to which patients want each of 15 categories of services. The categories were derived from interviews of 200 patients on their first visit to a walk-in clinic by asking them what type of help they wanted. The PRF was used to assist clinicians in conducting the psychiatric interview (24,25).

Eisenthal and Lazare reported three salient findings about shared decision making. First, clinicians saw the value for the patient and themselves of initiating the disposition discussion in an open and democratic manner. Second, clinicians associated patient satisfaction with having the recommended treatment plan match the patient's request—a match the clinicians did not connect with their own satisfaction. And third, clinicians failed to realize how important it was for the patient to engage with the clinician in a mutual sharing of power in terms of the clinician-patient relationship.

In a study of 120 patients who were referred for further treatment from an acute psychiatric service, Eisenthal and Lazare found that 41 percent of the patients kept the referral appointment (30). Patients who did so were distinguished from those who did not by their endorsement of statements related to participation in disposition planning and by clinicians' understanding of their requests. Patients who endorsed the statement that the clinician provided a diagnostic understanding of their symptoms were no more likely to adhere to referral appointments than those who did not endorse this statement. However, diagnostic understanding was associated with patient satisfaction, feeling helped, and feeling better. In addition, adherence to referral appointments was related to a problem- or task-centered, rather than a feeling-centered, approach to the conduct of the initial interview. These findings led Eisenthal and Lazare to conclude that the customer approach could be shaped to fit a diverse patient population, resulting in greater adherence to treatment recommendations (30).

Eisenthal and Lazare's work was limited in its the characterization of the psychiatric encounter, because it focused only on negotiated transactions and not on other aspects of the encounter that are considered valuable to the development of a trusting professional relationship—for example, the verbal and nonverbal communication cues of the clinician, and the clinician's ability to balance data acquisition for diagnostic purposes with socioemotional inquiry and support to build rapport. Eisenthal and Lazare's work was done in the 1970s, and its applicability to the psychiatric encounter in today's mental health systems has not been tested. Their work addressed only initial interviews in walk-in clinics, and therefore the generalizability of their findings to follow-up appointments, initial appointments in other settings, and specific diagnostic groups at particular times in the course of illness has not been tested.

Therapeutic alliance

The literature on therapeutic alliance addresses the therapist's ability to develop the context necessary for treatment to be beneficial. This line of inquiry has a rich history dating back to the 1950s, principally focusing on therapeutic alliance issues in psychotherapy (32). In a review of psychotherapy research, Krupnick and Pincus (33) highlighted the importance of identifying the active elements that make psychotherapy effective. Within these complex treatment procedures, they noted that the influence of therapist variables on treatment effectiveness and the therapeutic alliance is particularly important.

In the context of psychotherapy research, therapist variables refer to the competency of the therapist in adhering to a particular method of psychotherapy. Crits-Cristoph and colleagues (34) reanalyzed data from ten psychotherapy outcome studies. This meta-analysis revealed that therapist effects vary considerably and at times are large and significant. In psychotherapy research, therapist variables are controlled through the use of manual-driven psychotherapeutic interventions. Videotaped observations of treatment sessions and measures of adherence to the manual are used throughout the study to monitor fidelity (35). The term therapist variables, however, does not capture other important aspects of the therapist that potentially play a significant role in treatment: the therapist's capacity to show warmth and empathy, the therapist's ability to develop an open interpersonal dialogue, therapist demographic variables, personality characteristics that may either enhance or limit openness in the therapeutic setting, and so forth. These variables have not been thoroughly studied and may be important to the development of a therapeutic alliance.

As early as the mid-1970s, Borden (36) identified the therapeutic alliance as an important avenue of investigation. Since then, at least six different measures have been developed to assess the role of the relationship variable on outcome. In the largest study in which the efficacy of different psychotherapeutic approaches for the acute phase of depression were tested, the Treatment of Depression Collaborative Research Program of the National Institute of Mental Health, the therapeutic alliance was found to account for more of the variance in outcome than the specific technical approach that was employed (37). Other researchers in psychotherapy outcome studies have noted this finding as well (38,39,40,41,42,43,44). Other important findings from this line of research are summarized as follows. The patient's subjective evaluation of the relationship, rather than the therapist's actual behavior, has the greatest impact on psychotherapy outcome (32,38). The most reliable estimates of the quality of alliance are those based on patients' reports; the next most reliable are those of outside raters (32). Attention to the here-and-now aspects of the relationship was more likely to produce beneficial results than clinician's interpretations linking the patient's current relational crises to their past experiences (39). Neither gender combination nor androgyny appear to have a statistically reliable impact on the quality of the alliance (32). Finally, training aimed specifically at helping therapists develop better alliances with their patients has been less successful than anticipated (32,38,45).

Although the bulk of the alliance literature focuses on the therapeutic alliance in psychotherapy, research by Frank and Gunderson (46) and by Weiss and colleagues (47) addressed the role of the therapeutic alliance in the pharmacological treatment of schizophrenia and chronic depression, respectively. Frank and Gunderson examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients diagnosed with schizophrenia who were followed for two years. Assessments of alliance were obtained from the Psychotherapy Status Report, a 15-item questionnaire that therapists completed monthly (48). The Psychotherapy Status Report included six Likert scales pertaining to the patient's in-therapy behaviors that the clinical and research literature suggested would be indicative of an alliance in any form of psychotherapy. Each scale had five levels defined by clinical descriptors. Ratings on the six scales were highly intercorrelated and were combined to form a single measure of the alliance that was termed active engagement. Treatment utilization and medication compliance patterns were obtained from therapist reports (collected monthly), patient reports (collected every six months), and medical records (reviewed on an ongoing basis). Changes in patient functioning were obtained every six months from seven instruments that were administered by trained raters who did not know the patients' identities and three self-report instruments that were administered to the patients.

Results revealed that patients who were rated as having a good alliance with their treatment provider at six months were less likely to drop out of treatment subsequently, showed a greater acceptance of pharmacotherapy, and had better functional outcomes than those who were not rated as having a good alliance. In addition, the alliance accounted for 11 percent of the variance in outcome at two years, after the association between outcome and alliance at six months was controlled for.

Frank and Gunderson's study results were limited in their generalizability to typical clinical treatment settings, because study participants were recruited from a sample involved in an ongoing research study. The study measured alliance effects on treatment outcome, based on monthly appointments—not on the longer intervals between appointments typical of many of today's psychiatric treatment settings. Additionally, because of the research design, the influence of reimbursement schemes and managed-care models of service delivery could not be ascertained. Finally, the influence of demographic differences between psychiatrist and patient on alliance development and treatment outcome was not addressed.

Weiss and colleagues (47) studied the influence of the therapeutic alliance on the efficacy of pharmacotherapy for depression. They posited that the relationship between alliance and outcome might be more powerful in depression than schizophrenia, because the hopelessness, poor self-esteem, and self-blame that are characteristic of depression are sensitive to therapist interventions, even when these interventions are framed as education about the disorder within a pharmacotherapy context. From this position they hypothesized that even pharmacological management with medication is a type of "therapy" and that it might have many of the same process mechanisms as other psychotherapies. They further hypothesized that therapists' and patients' perceptions would correlate with outcome in the pharmacological treatment of depression.

In Weiss' study, 31 patients who met DSM-III-R criteria for major depressive disorder and had a score of 14 or greater on the 17-item Hamilton Rating Scale for Depression (HAM-D) were included. Potential participants were excluded if they had suicidal intent requiring hospitalization, organic mental disorder, substance abuse, psychosis, mania, or severe eating disorders. Patients were treated with imipramine, starting at 75 mg a day with the dose increased by 25 mg every three days as tolerated. Patients were seen weekly during initiation of medication, then every two weeks until stable, and then monthly during maintenance. Medication was gradually discontinued when patients had been in remission for at least four months. Patients were seen weekly during discontinuation of the medication and then were followed for two more monthly visits. Alliance was measured by the California Pharmacotherapy Alliance Scale, patient and therapist versions (unpublished scale, Gaston L, Marmar CR, 1991). Outcome was measured objectively by the clinician with the HAM-D and subjectively by the patient with the Beck Depression Inventory. A multiple time-series design was used to investigate the alliance-outcome association within patients over time as well as across patients.

Results revealed that the alliance in pharmacotherapy was highly correlated with outcome. Overall, 41 percent of outcome variance was explained by therapists' ratings of alliance and 25 percent by patients' ratings when alliance scores were averaged across treatment sessions.

The results of the study by Weiss and colleagues stand in marked contrast with findings on alliance and outcome in psychotherapy. Weiss and colleagues found that treatment providers' perception of the alliance best predicted outcome, and the alliance ratings they observed were lower than those seen in psychotherapy. Because the study was conducted in Canada, the study's generalizability to health care systems driven by managed care and managed competition is uncertain. Also, the study measured alliance effects for monthly appointments, not appointments that may be once every three months, a common schedule in many managed care systems. Finally, the study did not assess the influence of demographic differences between psychiatrist and patient and their effect on alliance and treatment outcome.

In conclusion, although the alliance literature addresses the association between a mental health professional-patient relationship and specific treatment outputs—such as patient satisfaction, outcome of psychotherapy and pharmacological treatment, and adherence to appointments—it is not clear whether these results are generalizable to today's psychiatric encounter within managed care and managed competition systems or various reimbursement schemes and whether the research is applicable to clinician training. Also, the influence of demographic differences between psychiatrist and patient on communicative behaviors within the psychiatric encounter and their effect on encounter outputs and treatment outcomes has yet to be explored.

Gottschalk-Gleser content analysis of patient speech

The work of Gottschalk and colleagues (49,50) on the content analysis of patient speech in psychiatric research used small samples of speech, as brief as two or five minutes, to provide objective measures of various psychological dimensions. This research demonstrated that the major part of the variance of an immediate psychological state of a person could be accounted for by variations in the content of verbal communications (49). The Gottschalk-Gleser method of content analysis involves scoring typescripts of verbal samples by breaking the text down into grammatical clauses (the coding unit) and coding those clauses that fall into the thematic content of verbal behavioral categories that make up each of several different scales devised by the researchers. A score is obtained by multiplying the number of scoreable clauses by the weights assigned to each verbal category, dividing the sum of these products by the total number of words in the speech sample, and multiplying the quotient by 100 to produce an index of the amount of each psychological dimension per 100 words (50). The speech samples can be obtained in the course of psychotherapeutic interviews or with the following standardized instructions: "This is a study of conversational habits. I have a microphone here and a tape recorder, and I would like you to talk for five minutes about any dramatic or personal life experiences you have had. If you finish telling one experience, you should continue on to another experience until the five-minute period is over. While you are speaking I would prefer not to reply to any questions you have until the five minutes have elapsed. Do you have any questions? If not, I will tell you when to start and when to stop. You may start now" (51). This method has been used to investigate specific psychophysiological processes (52,53) and treatment effects of both pharmacological and psychotherapeutic interventions (54,55,56,57,58,59).

Because of its focus on the patient's utterances alone and the small sample of speech used for scoring, the Gottschalk-Gleser method does not lend itself to an in-depth inquiry into the communicative behaviors within a psychiatric encounter and their association to specific treatment outputs.

Content analysis of interviews

The work of Cox and Rutter in the late 1970s and early 1980s used audiotape and videotape recordings of initial psychiatric interviews with parents of children referred to an outpatient child psychiatric clinic at Maudsley Hospital in London (60,61,62,63,64,65). A three-phase research strategy was used. In the first phase, appropriate measures were developed and their interrater reliability was assessed. In the second phase, a naturalistic study of 36 interviews, conducted by psychiatric residents, were used to determine the range of approaches ordinarily followed in routine clinical practice, to learn whether the psychiatrist's style was consistent over different interviews, and to identify associations between these styles and the informant's response, as reflected in the factual information given and the feelings and attitudes shown. The third phase consisted of the comparison of four different interview styles that were developed from the findings of the naturalistic study and that were close to styles recommended by influential teachers and practitioners in psychiatry.

Cox and Rutter's research revealed the following findings. Most mothers who sought help with their children's problems mentioned most of the key issues without the need for standardized questioning. The authors concluded that it is desirable to begin clinical diagnostic interviews with a lengthy period that features little in the way of detailed probing and in which informants are allowed to express their concerns in their own way (64). In addition, it is desirable to ask certain specific questions about key issues when it is crucial to know whether or not a particular symptom or problem is present; interviewers must be sensitive and alert to factual cues and choose their probes with care and attention, so that there is a focus on the essential issues identified in the informant's spontaneous comments. Systematic questioning is not perceived as unduly intrusive or lacking in understanding (64). Specific feelings-oriented techniques on the part of the interviewer—for example, direct requests for self-disclosure by the participant, use of interpretations and expressions of sympathy, and the use of open rather than closed questions—are valuable in eliciting feelings (65). Finally, the gathering of good factual information is compatible with the successful eliciting of emotions and feelings; however, the two aims require rather different communicative methods (65).

Cox and Rutter's research findings did have limitations. Results were obtained from interviews of parents, not of identified patients, so the results may not be generalizable to mentally ill patient populations. The results focused on interviewing techniques, independent of the results of the interview's association with specific outcome measures. Cox and Rutter did not address the effect of psychiatrist-patient demographic differences on research findings. Finally, their findings may be specific to the United Kingdom's socialized mental health service delivery system and therefore may not be generalizable to other systems or settings.

Harrison and Goldberg (66), recognizing the advances in training medical students and general practitioners in interviewing skills in Great Britain and the limited research in training psychiatric residents, began a course in interviewing skills for first-year psychiatric residents at the University Hospital of South Manchester. The course ran for ten weeks; teaching was in small groups with feedback from the first author of the paper and peer trainees on a series of videotaped recordings of real patient interviews. The topics covered in the program included a detailed analysis of segments of the interview that encouraged certain types of questions and behavior from the patient and discouraged others; the important aspects of particular sections of the interview, such as the presenting complaint; and attention to overall style—controlling the interview, empathy, and so forth.

For the purposes of the study, 20 first-year psychiatric residents were asked to make three videotape recordings—one before training, an interim recording made during the interview course, and one after training. The pretraining and interim recordings were used for teaching purposes. Patients were unknown to the trainees and had a variety of presenting complaints but were not acutely disturbed. Each recording was 20 minutes long, with about ten minutes devoted to eliciting the presenting complaint and ten minutes to the mental status examination. Each separate segment of the resident's speech was defined as a specific type of utterance: compound question, leading question, closed question, multiple-choice question, neutral question, no-question, and open or directive question. Each segment of speech was also defined as a specific type of good behavior: a request for clarification, supportive remark, summarizing statement, transition statement, response to nonverbal communication, delayed verbal cues, or understanding of verbal cues. For the previously defined segments of the interview, each category of utterance and good behavior was rated on a 3-point scale from 1, not used, to 3, definitely used. The ratings were made after completion of the course by the first author, who was blind to pre- and posttraining status. Using similar, unrelated recordings, interrater reliability was performed by two raters, one blind rater who rated the study videotapes and another who did not. Agreement was between 70 and 100 percent. Rater reliability was also measured by repeating the ratings for the first ten recordings after a two-month interval. This gave a Cohen's kappa value of .85 for the utterance ratings and agreement between 70 and 100 percent for good behaviors.

After the training, the residents used more closed questions and showed an increase in the use of supportive behaviors. They were significantly better at establishing the onset of the presenting complaint, identifying precipitating factors, clarifying the main complaint and other complaints, summarizing the problems, appreciating the nature of depression and suicidal ideas, clarifying psychotic symptoms when present, using directive questions appropriately, and establishing the patient's view of their illness.

Harrison and Goldberg were able to show that the use of interaction analysis systems in psychiatric residency training is helpful in changing the types of questions posed to patients and improving the gathering of relevant historical information about the course of the presenting illness. Whether these changes positively influence specific encounter outputs and treatment outcome is left to be explored. Because of the focus on initial evaluations, the content analysis technique used in this study may not be applicable to follow-up appointments, emergency and inpatient appointments, or other psychiatric specialty evaluations. Because acutely disturbed patients were excluded from the study, the generalizability of the study's findings to acute care assessments is questionable. Also, because only 20 minutes of speech was analyzed, rather than the entire interview, important communicative behaviors within the interview process may have not been identified for analysis. Finally, the study did not address resident and patient demographic differences or personality characteristics that might influence the development of a therapeutic alliance.

In conclusion, health communications research in mental health has assessed the influence of communicative behaviors on negotiating a treatment plan, patients' following through on treatment recommendations, outcome of treatment from either a satisfaction or a symptom-reduction perspective, informing providers about the communicative utterances that help in assessment or developing a therapeutic alliance, and whether interaction analysis techniques can be used to improve psychiatric residents' interviewing skills.

Much of this research was carried out from the 1960s to the early 1990s, before the significant changes in psychopharmacology and the shift to managed care models of service delivery and capitative reimbursement schemes. Therefore, its relevance to the communicative skill set necessary for a psychiatrist practicing in today's mental health care systems is limited.

The research to date implies the existence of a universal communicative skill set that can be applied to all psychiatric services within different service settings. But is the communicative skill set necessary for the evaluation of a suicidal patient in the emergency department the same as the evaluation of a patient in a walk-in clinic? Is the communicative skill set necessary for the psychiatric assessment of a seriously and persistently mentally ill patient within a program for assertive community treatment team (PACT) the same as the assessment of the same patient in a private office setting? Is the communicative skill set that a psychiatrist uses when treating a patient with borderline personality disorder the same as the communicative skill set used when treating a person with paranoid schizophrenia?

Most clinicians would agree that the communicative skill set used in each case is dissimilar. Clinicians typically possess an array of communicative styles that have been formed through experience in evaluating patients under various conditions. The communicative style used is based on the unique characteristics of the psychiatrist and the patient, as well as the context and purpose of the evaluation. Identification of the ideal communicative skill set in every varied scenario in which psychiatric services are provided—and training residents and practitioners in those communicative skills, taking into account the practitioners' unique individual characteristics—has not been attempted.

Discussion and conclusions

Before the recent advances in psychopharmacology and the introduction of managed care and managed competition, the goal of the psychiatric encounter was to create the context necessary to help the patient through a psychological journey of self-discovery and change (67). Now the goal of the psychiatric encounter is to assess symptom severity, educate the patient about the nature of his or her illness, negotiate a treatment plan, provide psychopharmacological treatment, and coordinate the treatment provided by multiple caregivers (1). The psychiatrist attempts to balance data gathering functions with the development of a trusting, caring, and participatory relationship with the patient and other treatment providers (36,68). Along with the change in the goal of the psychiatric encounter and the change in the psychiatrist's role in treatment, a change in the technical skill set of the modern psychiatrist is needed. Regestine (68) has proposed that "to relieve behavioral dysfunction, today's psychiatrist may prescribe medical or behavioral treatments to control appetite, induce physical fitness, or increase prescription compliance." This view of the role of psychiatrists in mental health service delivery is consistent with the paradigm shift that mental health services have gone through over the past two decades—that is, from a focus on healing to one on disease management and rehabilitation. As this shift in treatment paradigm progresses, the psychiatrist-patient relationship will become increasingly similar to the typical physician-patient relationship in other medical specialties.

The role of the psychiatrist in the psychiatrist-patient relationship has changed not only clinically but also politically. Previously the psychiatrist was seen as the treatment advocate for the patient. Now this role has been complicated by the psychiatrist's contractual relationship with managed care organizations that increasingly rely on the psychiatrist to manage the organization's financial risk. With the introduction of prepaid reimbursement, today's psychiatrist must balance the ethical obligation to "do no harm"—including the obligation to protect the confidentiality of patient records—with the need to control treatment costs. It is said that trust in physicians is a social good that is compromised if physicians divide their allegiances between their patients and the insurer (69). Consequently, patients' ability to trust that their psychiatrist will not breach the confidentiality of what is discussed within their relationship to a third party and that their psychiatrist's treatment decision making is always in their best interest is now in question.

When viewed at the level of the typical psychiatric encounter, these clinical, administrative, and political changes have had content and process effects on the interaction and transactions that occur within the psychiatrist-patient relationship. Although these effects on the psychiatrist-patient relationship are being discussed in many forums—such as casual conversation among psychiatrists, formal conferences, trade newspapers, and professional journals—little effort has been made to rigorously study these phenomena. By addressing these phenomena, research could guide the clinical psychiatrist who is interested in ensuring that encounters maintain confidentiality and achieve patient satisfaction, cost containment, and optimal treatment decision making.

Changes in practice patterns

The psychiatrist's public persona is still as a psychotherapist or verbal healer. The shift from a healing to a disease management model as the theoretical paradigm dictating the psychiatric encounter (36,70) has caused an identity crisis within the psychiatric profession. Now the centrality of the relationship between psychiatrist and patient in mental health service delivery is debatable. Evidence of the change in the identity of psychiatry can be found in most medical schools and psychiatric residency training programs throughout the country. Psychiatrists used to be the faculty sought after to teach communication skills in medical student training. Now, faculty from family and community medicine provide much of this training (personal correspondence, Gordon G, Oct 2000). Additionally, in psychiatric residency training programs, we have seen a minimization, or even a devaluation, of teaching how to "know" and "be with" the patient (1).

To assess the changing role of psychiatrists in mental health care, Pincus and colleagues conducted an observational study in 1997, collecting detailed information from 417 psychiatrists on the demographic, diagnostic, clinical, and treatment characteristics of a systematic sample of 1,228 patients (71). Overall, 943 patients (79.7 percent of the sample) were seen as outpatients, 225 (15.1 percent) as inpatients, and 53 (5.2 percent) in partial, intermediate, or residential settings. Of the outpatients sampled, 37.6 percent received services from another provider in the past 30 days in an outpatient setting. The data from this study as well as previous professional activities surveys done in 1974 (72) and 1989 (73) also suggest a gradual shift in psychiatric practice. Pincus and colleagues (73) concluded that the results suggest that "psychiatrists have shifted toward a more pharmacologic treatment orientation over the past two decades."

With this shift in focus and purpose of the psychiatric encounter, the duration of encounters has become shorter. Olfson and colleagues (74), using the data set from the National Ambulatory Medical Care Survey, reported that the mean duration of psychiatric visits declined from 42.8 minutes in 1985 to 38.1 minutes in 1995. The number of visits of less than ten minutes' duration increased from 2.9 percent in 1985 to 12.1 percent in 1995, along with a significant decrease in the proportion that were 41 to 50 minutes long (55.6 percent in 1985 versus 43 percent in 1995). Patients who did not receive a prescription for psychotropic medication had the greatest reduction in visit time (46.7 minutes in 1985 to 41 minutes in 1995). From a financing-of-care perspective, the largest reductions in duration of visits occurred with privately insured fee-for-service patients and those in health maintenance organizations or prepaid plans. With expanding enrollments in prepaid plans and more restrictions on what privately insured fee-for-service plans will pay for, we suspect that these trends are ongoing.

With managed care principles and prepaid reimbursement schemes being used more in mental health care in both the public and private sectors, treatment interventions have come under intense scrutiny by payers of mental health services (75). The developments within the health care system can lead to benefits such as a broad orientation to standards of care and access to treatment, more thoughtful use of inpatient treatment, a continuum of care that engages patients and their families in treatment that is less fragmented and more community-based, and a focus on behavioral and functional outcomes as the operative goals of treatment. However, mental health professionals see potential problems. The advantages of being less restrictive and more community-based may be offset by discontinuity and brevity of the therapeutic relationship and by capitative reimbursement models disrupting the therapeutic alliance (75).

Although payers have closely scrutinized treatment interventions recommended by psychiatrists, no attention is being paid to how a psychiatrist gathers information, develops a relationship with the patient, and ultimately negotiates a treatment plan. It is critical for psychiatrists to define empirically the importance of the psychiatrist-patient relationship at this time, because of the mounting pressure that managed care has applied on mental health service providers to improve their efficiency and effectiveness.

The relationship psychiatrists establish with their patients is fundamental to the definition of psychiatry as a distinct health care specialty. Psychiatrists have long recognized the importance of the psychiatrist-patient relationship in achieving optimal treatment adherence as well as symptom reduction and improved functional outcomes. By systematically quantifying the influence psychiatrists' and their patients' communicative behaviors have on specific treatment outcome variables, we can identify communicative behaviors that are essential to efficient and effective care. Psychiatry, through an empirical validation of the importance of the therapeutic relationship, can maintain this core aspect of its identity in today's mental health care system.

Another important reason to empirically define the psychiatrist-patient relationship is that in the next ten to 15 years more health care will be delivered through the Internet and videoconferencing, including broadband video in the home environment and other easily accessible settings (76). The lack of studies providing basic information about how the psychiatrist-patient relationship affects treatment outcome and about the influence of videoconferencing on this relationship limits providers' and policy makers' ability to ensure effective use of telepsychiatric services (77).

Changing trends in psychotherapy research over the past three decades have turned psychotherapy from "a somewhat mysterious art to a quantifiable science" (33). Through the employment of the scientific method to treatment—for example, use of control groups and randomization—the validity of specific psychotherapeutic treatment interventions with specific psychiatric disorders is being elucidated. The effects of specific interventions on outcome measures important to the public taxpayer and policy makers—for example, cost-effectiveness and improvement in social and work functionality—are now being addressed. Psychotherapy research has identified the importance of the therapeutic alliance and therapist variables in achieving particular treatment outcomes. However, present psychotherapy research tools—for example, self-rated and face-to-face measures of patient improvement along with measures of therapist adherence to specific psychotherapeutic modalities—provide indirect measures of the actual interchange that occurs between the therapist and the patient. These tools are limited in their ability to capture salient aspects of the therapeutic alliance and therapist variables that may be central to encounter outputs or treatment outcomes. Interaction analysis systems, however, provide more direct observations of the communicative behaviors used by therapists and patients. These communication research tools are capable of quantifying verbal and nonverbal communicative behaviors that contribute to the influence of the therapeutic alliance on encounter outputs and treatment outcomes. Through translating communication, psychotherapeutic, and health services research methods and measurement tools for the exploration of present psychiatric practice within the varied treatment settings in which psychiatrists practice, we can begin to standardize and thus validate the communicative behaviors of psychiatrists.

A research and training agenda

We believe that a research agenda designed to systematically analyze the communicative behaviors within the psychiatrist-patient relationship and their influence on specific appointment outputs and treatment outcomes is as necessary as research into the varied treatment modalities we provide to patients. We propose a research strategy grounded in three types of analysis, which Inui and Carter (78) refer to as involving, respectively, developmental or descriptive, subexperimental or etiological, and interventional studies.

The purpose of developmental or descriptive studies is to expand the repertoire of theories, measures, and experience available to serve as the basis for empirical research. Studies of this nature rely on observation, interviews, archival analysis, and in-depth description. As such, developmental studies provide empirical data unconstrained by existing categories of communicative behaviors. They can be used to substantiate or adapt existing communication categories to the psychiatric contexts and to develop new ones when appropriate.

In this phase of the research agenda, a hierarchical model will be developed of how social and health care policy, the organizational structure of mental health systems, and provider agencies of mental health services, as well as the settings in which services are provided, influence the psychiatrist-patient relationship and the treatment decisions that the psychiatrist-patient dyad makes.

An interaction analysis system that captures both "cure" and "care" utterances within the psychiatrist-patient relationship will be developed, as well as measurement tools to assess the influence of the hierarchical variables previously described on the communicative behaviors within the psychiatrist-patient relationship, their influence on the array of treatment options available for decision making, and ultimately these hierarchical variables' effects on encounter outputs and treatment outcomes.

Other measurement tools will have to be developed or identified as well to collect relevant characteristics of both psychiatrists and patients that may influence communicative behaviors and treatment decision making—for example, demographic characteristics of both psychiatrists and patients, patient diagnoses and symptom severity, and psychiatrists' and patients' personality characteristics.

The developed psychiatric interaction analysis system and measurement tools can then be used to undertake subexperimental or etiological investigations. These types of investigations are generally cross-sectional and rely on frequency distributions, correlations, and regression for analysis. Through characterizing the psychiatrist-patient communicative process and assessing cause-and-effect theories linking psychiatrist and patient communicative behaviors to policy and organizational influences, demographic and personality differences between the psychiatrist and the patient, and patient diagnoses and symptom severity, the influence of psychiatrist-patient communicative behaviors on encounter outputs and treatment outcomes can be ascertained.

These subexperimental or etiological investigations will then help in the development of interventions aimed at improving psychiatrist-patient communication. These interventions can include educational strategies such as teaching, instructions, or information; behavioral strategies, such as skill building or reminders; and affect-oriented strategies, such as relationship building. The strategies that are identified will then be assessed by randomized controlled clinical intervention trials. These trials will use psychiatric practitioners and residents crosscut by different patient diagnoses, symptom severity, and demographic characteristics within different treatment settings.

Medical communications researchers Roter and Hall (79) remarked that "talk is the main ingredient in medical care and it is the fundamental instrument by which therapeutic goals are achieved." We in the psychiatry field are participating in a dramatic transformation of the identity of our profession. Clinical practice is moving toward psychopharmacological evaluation and treatment monitoring as the principal role for psychiatrists in direct service provision. These changes in role definition have led to reductions in the time spent and services directly provided by psychiatrists to patients. As managed care organizations attempt to provide evidence-based treatment interventions in a cost-effective manner, the current model of psychiatrists primarily providing psychopharmacological interventions and treatment monitoring to patients may have an adverse impact on the psychiatrist-patient relationship, with subsequent undesirable effects on service satisfaction, treatment outcomes, and cost-effectiveness of care. We propose that through a thorough analysis of what psychiatrists and patients say and do in their interactions, we can identify the most effective forms of verbal and nonverbal communicative behaviors and train present and future psychiatrists to use them.

Acknowledgments

The authors thank Joel Yager, M.D., Howard Waitzkin, M.D., Ph.D., Mary Ann Cook, Ph.D., Debra Roter, Dr.P.H., and Stephen J. Cole, M.D., for their input as expert researchers in the specialty topics investigated in this study.

Dr. Cruz and Dr. Pincus are with the department of psychiatry at the University of Pittsburgh School of Medicine. Send correspondence to Dr. Cruz at the Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, Pennsylvania 15213-2593 (e-mail, [email protected]).

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