Change through ethical dialogue. A theoretical and qualitative study of lifestyle counselling in general practice

Many patients meet the challenge of reordering fundamental priorities in life. The reordering can entail lifestyle changes for preventing disease, carrying out extensive treatment plans, or adapting to new dysfunctions in everyday life. Adaptive change may be of crucial importance for health and quality of life, and yet involve practical, emotional and social burdens that become insurmountable obstacles for the affected individual. Being central agents in the health service, general practitioners (GPs) are confronted with the challenge of finding ways to help their patients deal with difficult adaptations to risk, illness and medical interventions, through supportive interactions that integrate biomedical and personal issues. It seems, however, that patients do not always receive the help they need. The present study explores the theory and practice of doctor-patients dialogue, using lifestyle counselling as the field of study, a field where clinical work entails complex interactional challenges for doctors and patients. When patients are advised or perceive a need to change behaviour for medical reasons, deep-seated aspects of their value-systems are stirred. Lifestyle express and are rooted in people’s values and norms, in what is tacitly considered good, right and desirable in everyday life. Lifestyle change is thus a matter of individual ethics, often entailing dilemmas where medical goals may conflict with individual perceptions of a good life. The instrumental rationality of science, including biomedicine, does not contain the conceptual tools physicians need for dealing with the highly subjective, cultural, value-laden and dynamic aspects of human thought and behaviour that characterise and constitute health and illness. Patient-centred medicine (PCM) has evolved as a loosely knit body of theory to help clinicians integrate the biomedical perspective, anchored in disease theory, with the phenomenological patient perspective, rooted in subjective, relational experiences and individual values and goals. Patient-centred medicine advocates deliberative dialogue as a general approach that may reveal and clarify patients’ practical circumstances, values and norms, and thus allow doctor and patient to reach common ground - a shared understanding of what is at stake for an individual person in a given situation of illness or health risk. Starting from the claim that PCM is somewhat under-theorised and lacking in its detailed analysis of deliberative doctor-patient dialogue, the present project examines the relevance of philosopher Jürgen Habermas’s theory of communicative action (TCA) for lifestyle consultations in general practice. Habermas’s theory is based on the assumption that human rationality is defined by our ability to let our actions be guided by a consensus that is achieved through the use of language. It claims that a person is rational when arguments are reasoned by factual or empirically-based concerns, normative concerns, or subjective feelings. The latter two categories distinguish TCA from theories where only arguments referring to empirically verifiable facts qualify as rational (“instrumental rationality”). Habermas uses the concept lifeworld to designate the objective, social and subjective circumstances of individual existence that may serve as the basis for rational arguments and decisions. The project attempts to clarify how TCA may be medically relevant, and identify adjustments needed when the principles of TCA, developed for democratic deliberation, are introduced in a dyadic helping relationship characterised by asymmetry of knowledge and power. The overarching ambition is to operationalise elements of a deliberative theory in a way that may lead to improved clinical dialogues within a PCM framework. The thesis consists of one theoretical and two empirical papers. In GP consultations, we explored physician communication patterns that enhanced or obstructed the possibilities for patients to reach good, right and practicable decisions in lifestyle counselling. In interviews, patients’ needs and preferences in consultation dialogues were explored. The study suggests that Habermas’s theory of communicative action is highly relevant for dialogues in general practice. However, the demand that dialogue partners be on an equal footing poses a challenge in the context of medical practice. The asymmetric relationship between doctor and patient necessitates adjustments to the theory, allowing the doctor to take a leader’s responsibility, based on a mandate from the patient and a professional foundation of care, respect and willingness to learn from the patient. Through a mutually respectful dialogue where the doctor is open-minded and changes his or her mind as relevant arguments are brought forth, lifeworld issues, patient values and norms can be verbalised and understood in medical dialogue, and used as anchoring points for changes and adaptations. Whereas medical counselling based on disease theory and instrumental rationality may obstruct the clarif ication of patients’ subjective values and norms, and result in frustrated efforts to change individual priorities and behaviour, the present study suggests that Habermas’s theory, appropriately adjusted, can provide GPs with communicative tools that may give rise to an expanded form of patient autonomy and produce decisions which are good, right and practicable for the patient

Change through ethical dialogue. A theoretical and qualitative study of lifestyle counselling in general practice

Many patients meet the challenge of reordering fundamental priorities in life. The reordering can entail lifestyle changes for preventing disease, carrying out extensive treatment plans, or adapting to new dysfunctions in everyday life. Adaptive change may be of crucial importance for health and quality of life, and yet involve practical, emotional and social burdens that become insurmountable obstacles for the affected individual. Being central agents in the health service, general practitioners (GPs) are confronted with the challenge of finding ways to help their patients deal with difficult adaptations to risk, illness and medical interventions, through supportive interactions that integrate biomedical and personal issues. It seems, however, that patients do not always receive the help they need. The present study explores the theory and practice of doctor-patients dialogue, using lifestyle counselling as the field of study, a field where clinical work entails complex interactional challenges for doctors and patients. When patients are advised or perceive a need to change behaviour for medical reasons, deep-seated aspects of their value-systems are stirred. Lifestyle express and are rooted in people’s values and norms, in what is tacitly considered good, right and desirable in everyday life. Lifestyle change is thus a matter of individual ethics, often entailing dilemmas where medical goals may conflict with individual perceptions of a good life. The instrumental rationality of science, including biomedicine, does not contain the conceptual tools physicians need for dealing with the highly subjective, cultural, value-laden and dynamic aspects of human thought and behaviour that characterise and constitute health and illness. Patient-centred medicine (PCM) has evolved as a loosely knit body of theory to help clinicians integrate the biomedical perspective, anchored in disease theory, with the phenomenological patient perspective, rooted in subjective, relational experiences and individual values and goals. Patient-centred medicine advocates deliberative dialogue as a general approach that may reveal and clarify patients’ practical circumstances, values and norms, and thus allow doctor and patient to reach common ground - a shared understanding of what is at stake for an individual person in a given situation of illness or health risk. Starting from the claim that PCM is somewhat under-theorised and lacking in its detailed analysis of deliberative doctor-patient dialogue, the present project examines the relevance of philosopher Jürgen Habermas’s theory of communicative action (TCA) for lifestyle consultations in general practice. Habermas’s theory is based on the assumption that human rationality is defined by our ability to let our actions be guided by a consensus that is achieved through the use of language. It claims that a person is rational when arguments are reasoned by factual or empirically-based concerns, normative concerns, or subjective feelings. The latter two categories distinguish TCA from theories where only arguments referring to empirically verifiable facts qualify as rational (“instrumental rationality”). Habermas uses the concept lifeworld to designate the objective, social and subjective circumstances of individual existence that may serve as the basis for rational arguments and decisions. The project attempts to clarify how TCA may be medically relevant, and identify adjustments needed when the principles of TCA, developed for democratic deliberation, are introduced in a dyadic helping relationship characterised by asymmetry of knowledge and power. The overarching ambition is to operationalise elements of a deliberative theory in a way that may lead to improved clinical dialogues within a PCM framework. The thesis consists of one theoretical and two empirical papers. In GP consultations, we explored physician communication patterns that enhanced or obstructed the possibilities for patients to reach good, right and practicable decisions in lifestyle counselling. In interviews, patients’ needs and preferences in consultation dialogues were explored. The study suggests that Habermas’s theory of communicative action is highly relevant for dialogues in general practice. However, the demand that dialogue partners be on an equal footing poses a challenge in the context of medical practice. The asymmetric relationship between doctor and patient necessitates adjustments to the theory, allowing the doctor to take a leader’s responsibility, based on a mandate from the patient and a professional foundation of care, respect and willingness to learn from the patient. Through a mutually respectful dialogue where the doctor is open-minded and changes his or her mind as relevant arguments are brought forth, lifeworld issues, patient values and norms can be verbalised and understood in medical dialogue, and used as anchoring points for changes and adaptations. Whereas medical counselling based on disease theory and instrumental rationality may obstruct the clarif ication of patients’ subjective values and norms, and result in frustrated efforts to change individual priorities and behaviour, the present study suggests that Habermas’s theory, appropriately adjusted, can provide GPs with communicative tools that may give rise to an expanded form of patient autonomy and produce decisions which are good, right and practicable for the patient

Quality assurance of decision-making in conversations between professionals and non-professionals: identifying the presence of deliberative principles

The ideal of dialogue is at stake in professional conversations. The aim of this study is to develop an instrument that makes it possible to compare principles of deliberation with what actually takes place in professional conversations. The developed instrument is tested on one patient's conversation with his doctor about lifestyle changes, and meetings where pupils with learning disabilities and their parents discuss further schooling with school representatives. Although in need of refinement, the conclusion is that the instrument provides meaningful insight into how much each participant 'contributes' to the decision-making process and 'behaves' during the conversation

Experiences of participating in individual placement and support: a meta-ethnographic review and synthesis of qualitative studies

publishedVersio

General support versus individual work support: a qualitative study of social workers and therapists in collaboration meetings within individual placement and support

This study aims to increase understanding of how social workers and therapists contribute to cooperation meetings within the individual placement and support intervention. The individual placement and support model of supported employment is expanding worldwide. Although several quantitative studies have shown this model`s effect, the need for qualitative studies on collaboration within this intervention is evident. The individual placement and support fidelity manual presents clear expectations to the social workers and therapist in the cooperation. Still, few previous studies investigate how these expectations are met in praxis. This study draws on sixteen collaboration meetings, recorded, transcribed, and analysed using reflexive thematic analyses. It shows that the social workers and therapists did, to a limited extent, adapting their support to the expectations of personalised work support inherent in the individual placement and support intervention. They underestimated their importance in collaboration meetings, and this limited the dialogue. Further qualitative studies are needed to understand how social workers and therapists experience their contribution to individual placement and support and their reasons underestimating their importance. Still, we suggest that more individualised work support from the social workers and therapists could help people who choose individual placement and support to succeed in work life.publishedVersio

Effectiveness of Internet-Based Cognitive Behavioral Therapy with Telephone Support for Noncardiac Chest Pain: Randomized Controlled Trial

Background: Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain. Objective:In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain. Methods: We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes. Results: In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (–3.4 points, 95% CI –5.7 to –1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (–2.7 points, 95% CI –5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions. Conclusions: This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain.publishedVersio

Present in Daily Life: Obsessive Compulsive Disorder and Its Impact on Family Life from the Partner's Perspective. A Focus Group Study

This focus group study explores the experiences of five partners of patients suffering from obsessive-compulsive disorder concerning how this disorder might influence couples’ relationships in the long-term. We find that the disorder might give rise to power struggles concerning “normality”, deprive couples of opportunities for rewarding fellowship during household chores and leisure time, and persistent analytic processes concerning predicaments of what to do. They also express a need for more help from the health services. The results might be of value to therapists in their daily work, and might have implications for future research on couple’s therapy involving this group

Effectiveness of Internet-Based Cognitive Behavioral Therapy with Telephone Support for Noncardiac Chest Pain: Randomized Controlled Trial

Background: Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain. Objective:In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain. Methods: We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes. Results: In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (–3.4 points, 95% CI –5.7 to –1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (–2.7 points, 95% CI –5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions. Conclusions: This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain