The role of therapist self-disclosure in psychotherapy: A qualitative review

Over 90% of therapists self-disclose to clients (Mathews, 1989; Pope, Tabachnick, & Keith-Spiegel, 1987; Edwards & Murdock, 1994), however, the implications of therapist self-disclosure are unclear, with highly divergent results from one study to the next. The goal of this paper was to review the empirical literature relevant to therapist self-disclosure, and provide the reader with a comprehensive understanding of the factors that affect, and are affected by, therapist self-disclosure. Findings are organized into an integrated model examining the who, what, when, why, and how of therapist self-disclosure. In addition, training implications and suggestions for future research are provided.     

The role of self-disclosure by peer mentors: Using personal narratives in depression care

ObjectiveSelf-disclosure is recognized as an important aspect of peer support, but little is known about its use by peers. This study aimed to qualitatively understand peer self-disclosure in the context of depression care delivery to older adults.Methods69 audio-recordings of peer-client meetings were coded for self-disclosure using the Roter Interaction Analysis System (RIAS). Peer self-disclosure was defined as a statement describing personal life experience with physical and/or emotional relevance for the client. A total of 3421 discrete statements were organized into 770 disclosure episodes. The episodes were qualitatively analyzed to identify themes related to the content and function of self-disclosure within the peer-counseling context.ResultsPeer self-disclosure was used to 1) counsel through reframing perspectives, modeling positive behaviors, offering coping skills, and sharing mental health resources and health information; 2) establish rapport by emphasizing similarities unrelated to depression; and 3) show empathy and understanding of personal struggles. In addition, self-disclosure rarely only focused on the peer experience without relevance for the client.Conclusions & practice implicationsPeer self-disclosure can be purposively used in depression care delivery with older adults. Training and supervision in appropriate self-disclosure should be provided to peers to ensure purposive use.     

Assessment of surgeon communication skills from the patient perspective: A national evaluation using the Communication Assessment Tool

ObjectiveThe Communication Assessment Tool (CAT) has previously been translated and adapted to the Italian context. This national study aimed to validate the CAT and evaluate communication skills of practicing surgeons from the patient perspective.MethodsCAT consists of 14 items associated with a 5-point scale (5 = excellent); results are reported as the percent of ‘‘excellent’’ scores. It was administered to 920 consenting outpatients aged 18–84 in 26 Italian surgical departments.ResultsThe largest age group was 45–64 (43.8%); 52.2% of the sample was male. Scores ranged from 44.6% to 66.6% excellent. The highest-scoring items were “Treated me with respect” (66.6%), “Gave me as much information as I wanted” (66.3%) and “Talked in terms I could understand” (66.0%); the lowest was “Encouraged me to ask questions” (44.6%). Significant differences were associated with age (18–24 year old patients exhibited the lowest scores) and geographical location (Northern Italy had the highest scores).ConclusionCAT is a valid tool for measuring communication in surgical settings.Practice ImplicationsResults suggest that expectations of young people for communication in surgical settings are not being met. While there is room to improve communication skills of surgeons across Italy, patients highlighted the greatest need in the Central and Southern regions.     

Physician and patient perceptions of the physician explanations in medical encounters

Although, in actual practice, physicians have to subjectively judge the level of the explanation that they provide, little is known about this judgment. Therefore, making use of 630 physician-patient pairs in Japan, we investigated the association between patient and physician evaluations of physician explanations of medical test results and diagnoses. We found that the physician's judgment does not always agree with that of the patient, with regard to the level of explanation necessary. In addition, we first identified factors relating to the accuracy of physician judgments with regard to their explanations to patients. More studies will be necessary to verify the present findings.     

Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement

Objective

To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure).

Methods

We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations.

Results

Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior.

Conclusion

For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations.

Practice implications

To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.     

Patient affect,physician liking for the patient,physician behavior,and patient reported outcomes: A modeling approach

ObjectiveTo determine associations between patient affect and physician liking of the patient, and their associations with physician behavior and patient-reported outcomes.MethodsStructural equation modeling based on coding of 497 videotaped hospital encounters, with questionnaires assessing pre-visit patient affect, post-visit patient affect and encounter evaluations, and physician liking of the patient, involving 71 physicians.ResultsIn first visits, patient reported outcomes were strongly correlated with physician behavior and less so with physician liking, while in later visits, patient reported outcomes were directly related to physician liking and not mediated by physician behavior. Physician liking predicted physician behavior, more for female physicians in first visits. Patient negative affect before the visit was negatively associated with male physicians’ liking. When acquainted, both patient positive and negative affect were associated with physician liking.ConclusionPhysician liking of the patient plays a dynamic role in a consultation, is influenced by patient pre-encounter affect, and influences physician behavior. The dynamics are different in first and later visits, and influenced by physician gender.Practice implicationsPhysicians should be aware how patient affect influences their behavior, and administrators should take any prior relationship between patient and physician into account when evaluating patient reported outcomes.     

The impact of residents sitting at the bedside on patient satisfaction during team rounds

ObjectivesPatient satisfaction ratings are a priority for academic medical centers. Sitting during patient encounters has been recommended as a “best practice.”¹ A prior study showed that hospitalists had higher-rated communication skills when sitting compared to standing at the bedside during rounds.² It is unclear whether the same is true of resident-led team rounds.MethodsWe performed a cluster-randomized crossover trial assigning 18 internal medicine residents to sit or stand at the bedside during rounds.ResultsA total of 347 patients were surveyed to assess physician communication skills. Standing residents received higher ratings than sitting residents on 2 of 5 survey items and rounding duration did not differ. These results differ from prior work that suggests sitting is superior to standing^2–6.ConclusionWe suspect that one rounding member sitting, while all others stand, is not enough to impact patients’ perceptions. These results suggest that initiatives to optimize patient satisfaction on resident-staffed units should be focused elsewhere.Practice implicationsPatients do not have better impressions of physician communication skills when one team member is sitting and the rest are standing.     

Talking about depression: An analogue study of physician gender and communication style on patient disclosures

Objectives

To disentangle the effects of physician gender and patient-centered communication style on patients’ oral engagement in depression care.

Methods

Physician gender, physician race and communication style (high patient-centered (HPC) and low patient-centered (LPC)) were manipulated and presented as videotaped actors within a computer simulated medical visit to assess effects on analogue patient (AP) verbal responsiveness and care ratings. 307 APs (56% female; 70% African American) were randomly assigned to conditions and instructed to verbally respond to depression-related questions and indicate willingness to continue care. Disclosures were coded using Roter Interaction Analysis System (RIAS).

Results

Both male and female APs talked more overall and conveyed more psychosocial and emotional talk to HPC gender discordant doctors (all p < .05). APs were more willing to continue treatment with gender-discordant HPC physicians (p < .05). No effects were evident in the LPC condition.

Conclusions

Findings highlight a role for physician gender when considering active patient engagement in patient-centered depression care. This pattern suggests that there may be largely under-appreciated and consequential effects associated with patient expectations in regard to physician gender that these differ by patient gender.

Practice implications

High patient-centeredness increases active patient engagement in depression care especially in gender discordant dyads.     

The medical interview satisfaction scale: Development of a scale to measure patient perceptions of physician behavior

Patient satisfaction is a variable of increasing interest to researchers, clinicians, and medical educators. Of several studies reviewed, only a few have shown evidence of careful methodology. Most surveys have focused on general evaluations of doctors and/or health care services or of a particular facility. The present article reports the development of a scale to measure patient satisfaction with an encounter with a physician or other primary care provider. Methods of item generation and pretesting are detailed. The overall reliability of the scale (Cronbach's coefficient) is 0.93. The distribution of satisfaction scores is broader than that reported for other scales and approaches the normal in shape. Clinical and research applications of the scale are suggested.This project was supported by Grant No. HS 01971 to the Health Services Research Center of the University of North Carolina at Chapel Hill from the National Center for Health Services Research, Health Resources Administration, DHEW.     

Culture and nonverbal expressions of empathy in clinical settings: A systematic review

ObjectiveTo conduct a systematic review of studies examining how culture mediates nonverbal expressions of empathy with the aim to improve clinician cross-cultural competency.MethodsWe searched three databases for studies of nonverbal expressions of empathy and communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peer-reviewed, experimental or observational articles. Sixteen studies met inclusion criteria.ResultsNonverbal expressions of empathy varied across cultural groups and impacted the quality of communication and care. Some nonverbal behaviors appeared universally desired and others, culturally specific. Findings revealed the impact of nonverbal communication on patient satisfaction, affective tone, information exchange, visit length, and expression decoding during cross-cultural clinical encounters. Racial discordance, patients’ perception of physician racism, and physician implicit bias are among factors that appear to influence information exchange in clinical encounters.ConclusionCulture-based norms impact expectations for specific nonverbal expressions within patient-clinician dyads. Nonverbal communication plays a significant role in fostering trusting provider-patient relationships, and is critical to high quality care.Practice implicationsMedical education should include training in interpretation of nonverbal behavior to optimize empathic cross-cultural communication and training efforts should accommodate norms of local patient populations. These efforts should reduce implicit biases in providers and perceived prejudice in patients.     

Intensity of exposure to a patient activation intervention and patient engagement in medical visit communication

ObjectiveWe examined associations between intensity of exposure to a community health worker (CHW) delivered communication activation intervention targeting low-income patients with hypertension.MethodsWe analyzed question-asking behaviors of patients assigned to the intervention arms (n = 140) in a randomized controlled trial. Intensity of exposure to the intervention was operationalized as the duration of face-to-face coaching and number of protocol-specified topics discussed. Mixed effects models characterized the relationship between intensity of exposure and patients’ communication in a subsequent medical visit.ResultsThe number of topics discussed during the coaching session was positively associated with patients’ asking psychosocial-related questions during their visit. The duration of the coaching session was positively associated with patients’ use of communication engagement strategies to facilitate their participation in the visit dialogue. Exposure to a physician trained in patient-centered communication did not influence these relationships.ConclusionsA dose-response relationship was observed between exposure to a CHW- delivered communication activation intervention and patient-provider communication.Practice implicationsThis study supports the use of CHWs in activating patients toward greater communication in the therapeutic exchange.     

Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

ObjectiveCommunication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists.MethodsParticipants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication.ResultsThe intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found.ConclusionThis QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes.Practice implicationsThis QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.     

The hospitalized psychiatric patient and the primary care physician

Patients admitted to a general hospital psychiatric service were divided into two groups depending on whether they had primary care physicians. Significant differences were found in age, sex, psychiatric diagnoses, and incidence of active medical problems. The primary care physicians said they were aware of these patients’ psychiatric problems and had treated them in their offices, but were reluctant to participate in medical care during psychiatric hospitalization. The reasons for this are dis cussed, and a model for collaborative treatment by primary care physicians and hospital-based psychiatrists is presented.     

Development and validation of a patient measure of doctor-patient caring

Objective

Conceptualising the doctor-patient relationship as a ‘window mirror’ exposes care delivery from doctor to self, doctor to patient, patient to self, and patient to doctor. These directions have not been measured concurrently. We aimed to develop and validate a patient questionnaire informed by this model.

Methods

A modified-Delphi exercise was conducted to develop, and face and content validate, the questionnaire. Stage 2 surveyed 495 patients in general practice to assess the internal consistency and construct validity of the questionnaire.

Results

The questionnaire is face and content valid. Its internal reliability and construct validity appear good. Patients who care more about their doctor also care more about themselves. A patient or doctor who cares about the other person is associated with increased self-care by that person.

Conclusions

Further development and testing of the patient questionnaire is warranted to validate measurement of how patients perceive the caring they and their doctor give, and receive from, each other.

Practice implications

From the patient perspective the questionnaire may increase awareness of the importance of family doctors and patients caring about each other and themselves. It may inform and evaluate medical students, educational programmes and caring in doctor-patient relationships.     

Agreeable patient meets affiliative physician: How physician behavior affects patient outcomes depends on patient personality

Objective

This study tests whether the personality trait of agreeableness in simulated patients moderates their reactions to the physician's behavior. We predicted that the more agreeable the participants, the more positive the interaction outcomes when they see a high affiliative physician as compared to a low affiliative physician.

Methods

Participants (60 students) watched videotaped excerpts (2 min each) of 4 physicians exhibiting a high affiliative behavior and of 4 physicians exhibiting a low affiliative behavior. Participants reported after each physician their satisfaction, trust, determination to adhere to the treatment recommendations, and their perception of the physician's competence. They also completed the agreeableness scale of the NEO-PI-R personality questionnaire.

Results

The higher the agreeableness scores of the participants, the higher was their trust with the high affiliative physicians as compared to the low affiliative physicians, their perception of the physician's competence, and their determination to adhere to the treatment.

Conclusion

Results confirmed that the more agreeable the simulated patients were, the better they reacted to a physician behavior that was high rather than low in affiliativeness.

Practice implications

These results suggest that the more agreeable patients are, the more important it is that physicians adopt a high affiliative behavior.     

大学生异性关系信念与恋爱行为的相关研究

目的 :研究异性关系信念对大学生恋爱关系建立和维持的影响。方法 :采用异性关系信念量表 ,从大学 1～ 4年级本科生中抽取 5 6 8人进行异性关系信念测验 ,并对其恋爱经历进行调查。结果 :对有无恋爱经历的大学生的得分进行t检验时 ,只在“对默契的需求”一个维度上有显著性差异 (P <0 .0 1) ,χ2 检验显示 ,“对默契的需求”(P<0 .0 1)和“对分歧的容忍”(P <0 .0 5 )两个维度存在差异。对有无失恋经历的大学生得分进行t检验时 ,只在“对分歧的容忍”一个维度有显著差异 (P <0 .0 1) ,χ2 检验显示 ,“对分歧的容忍” (P <0 .0 1) ,“对默契的需求” (P <0 .0 5 )和“对两性差异的认同”(P <0 .0 5 )三个维度存在差异。结论 :异性关系信念与大学生恋爱关系的建立和维持关系密切。