Communication in youth mental health clinical encounters: Introducing the agential stance

Abstract

When young people seek support from mental health care practitioners, the encounters may affect the young people’s sense of self, and in particular undermine their sense of agency. For this study, an interdisciplinary team of academics and young people collaboratively analysed video-recorded encounters between young people and mental healthcare practitioners in emergency services. They identified five communication techniques that practitioners can use to avoid undermining the young person’s sense of agency in the clinical encounter. They conceptualise the use of those techniques as the adoption of an agential stance towards the young person. The agential stance consists of: (a) validating the young person’s experiences, (b) legitimising the young person’s choice to seek help, (c) refraining from objectifying the young person, (d) affirming the young person’s capacity to contribute to positive change, and (e) involving the young person in the decision-making process.

Implying implausibility and undermining versus accepting peoples’ experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments

“…It also may lead to people being distrustful and unwilling to share what they think and feel with mental healthcare practitioners if they fear being misunderstood based on previous experiences, making it harder to identify optimal support. Some people may avoid seeking help if they have had a difficult interaction with practitioners, and will then miss out on attaining further support at times of future crisis ( 42 ). This is consistent with well-established evidence that positive therapeutic relationships predict better treatment engagement and treatment outcomes ( 56 ).…”

“…Poor communication can leave patients questioning whether adverse mental health experiences were “all in your head” or “not true” ( 42 ), as these recharacterizing communication practices can be subtle and difficult for patients to recognize and contest. Hence, the impact on the person may go beyond claiming that the person does not need further professional support; it conveys that the person has a misplaced understanding of their own adverse experiences as “worse than they really are.” There is an inherent power imbalance and the potential for patients to accept practitioners’ claims at face value.…”

“…Laura minimally agrees (lines 26 and 30) and the practitioner requests re-confirmation that she has no plans to harm herself (lines 31–34), a leading question that is designed for Laura to confirm she does not have plans to harm herself ( 39 – 41 ). This all works to build a case that the Rapid Response Team is not needed [see Anonymized ( 42 )].…”

Phenomenology, delusions and justice

“…To the helpful discussion of the normativity of science, I would add mention of J. Sadler's seminal linguistic analysis of the values guiding DSM 8 . Moreover, since "embodied/4E" is described as representing mental disorders as "disruptions to sense-making", I would suggest an emphasis on the challenge of "delusion", memorably described by the British philosopher of mind N. Eilan as the challenge of "solving simultaneously for understanding and for utter strangeness" 9 .…”

“…Epistemic injustice provides a rich set of conceptual tools to help us as philosophers of psychiatry and practitioners to understand why the voices of those subject to intersectional marginalization are silenced 8 , and importantly, ways to ameliorate that, scaffolding people's ability to be active and valued knowers in their interactions and to maximize their agency in clinical consultations 9 . This area of philosophy is one that we have brought into close proximity with studying real therapeutic encounters, and the experience of young people with mental health problems, and with work covering a range of areas of health care, with important implications for training and education of clinicians.…”