In the Lancet, the author argues poignantly and persuasively, that the one to one relationships in psychiatry matter as much as the more funded and popular research which prioritise quantity. November 2020.
Author : Dariusz Galasiński
Psychiatry is qualitative. In contrast to the probable assumptions and dominant research practices of the readers of this Comment, I would like to not only make a case for a greater presence of qualitative research in psychiatry, but also highlight that it is qualitative research that speaks to the core of psychiatric practice.
There is no doubt that the foundation of modern medicine, including psychiatry, is what is normally referred to as evidence-based medicine (or, more widely, health care). It is as Trisha Greenhalgh states, “the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients.”1
Modern medicine is primarily about numbers. And yet, I would argue that the very essence of clinical psychiatry is the meeting of, normally, two individuals. One of them is a clinician and the other is a patient, who, by communicating, establish a clinical relationship. Therefore, it is important that psychiatry as a field recognises that mental illness is contextual,2 and that there is no single, generalisable, experience of conditions such as schizophrenia.3, 4And so, psychiatrists’ professional organisations (eg, the Royal College of Psychiatrists, World Psychiatric Association, American Psychiatric Association, and American Board of Psychiatry and Neurology) emphasise the ability to create clinical relationships through communication as one of the most important aspects of psychiatric care and a core competence a psychiatrist should have. This aspect of practice is further supported by some psychiatric literature, which sees the ability to offer a patient the space to talk and share their experiences as key in clinical communication.5, 6
Only a conversation that allows an understanding of the patient and their problems is clinically valuable.Therein lies the paradox of psychiatry. Psychiatry is underpinned by quantitative research on population samples, yet its core is a unique clinical encounter, a highly contextual conversation about sometimes dramatically difficult experiences, which cannot and probably should not be underpinned by such research. And although several attempts are made to posit what good communication in psychiatry is,7 the contextual uniqueness of the clinical encounter in which psychiatry is practised cannot be overstated.
This is probably why poor communication continues to be one of the main reasons for complaints in mental health care.And here we come to my initial proposition: psychiatry is qualitative. It is qualitative research that offers insight into the complexity of clinical communication, the here-and-now of the clinical encounter in which a complex interaction with a multitude of communicative and social goals is happening. This is because qualitative research tells us about the way we experience the world; it looks at our life-worlds from the point of view of those who participate.8
It offers us insight into the meanings we exchange in the variable contexts of our social lives.Qualitative research does not, of course, give definitive answers. In contrast to a plethora of communication guides, and institutional or clinicians’ recommendations on how to speak and write in clinical contexts,9 qualitative research tells us that the clinician is largely on their own in their encounter with a patient. But what qualitative research does is offer insight into the nuance of clinical interaction. And it is that nuance that individual clinicians can reflect upon in their practice. Through qualitative research, light can be shed onto how clinical practice works (or does not work) in the real world.10
In addition, it is qualitative research that offers psychiatry the understanding of its social contexts, its difficult history, and its political framing. In a nutshell, qualitative research is the kind of research that holds up a mirror in which psychiatry can look at itself and ponder what it is all about.In 2019, I attended the International Congress of the Royal College of Psychiatrists. I talked to more psychiatrists than I care to remember, and if there was one common theme of those conversations, it was precisely that of psychiatry’s contact with people, individuals, who suffer.
I do not know how common this concern for the individual is among psychiatrists, but this message is what I took from the Congress. It was heartening.But then came a reflection. If you as psychiatrists are so concerned with the experience of suffering, where is the qualitative research at the Congress or in the numerous psychiatric journals? Why does this Comment even need to be written?
You all seemed so convinced of the need to understand the individual. One of the most wonderful and poignant comments I heard was this: “If I ever stop crying at least once a week, it will be time to quit psychiatry.” It is qualitative research that will offer understanding of why a psychiatrist should say this.