Key issues for the Elaine and Jane/John Role-Play
- Carer
- Rapport with patient
- Trust
- Headaches- Diagnostic overshadowing
- Empathy with Elaine
- Investigating social factors- not jumping to a diagnosis
- Hearing voices- Do not refer to them as ‘voices’
- Confidentiality
- Am I mad?
- Offering support and appropriate resources
- Recovery
- Holistic care
- Listen to the patient and involve them in treatment decisions
- How you act will affect the outcome of the appointment- and the prognosis of the patient
- Acknowledging Elaine’s achievement
- Offering support and appropriate resources
- Carer
Carers can be an important source of information, and listening to them does not break confidentiality. The mother in this situation is overbearing because she is very distressed and anxious about her daughter. You need to understand this and show her that you empathise. It is necessary to ask her to leave the room as Elaine may not open up with her in the room but you should do this tactfully. People may respond better if you phrase it :
- Rapport with patient - Empathy
The only way you are going to get information from a patient is by breaking down the barriers, and talking about other issues to try and get Elaine to feel more comfortable. You could ask about university or brothers and sisters.
Disclosing to a doctor about your mental health is a huge and very frightening thing to do- (you could talk about your own experiences if relevant) many people suffer for months and years before seeking help. Empathising with Elaine and showing this empathy by saying that you understand it must be frightening can help her feel comfortable. Unless someone feels comfortable and at ease they won’t tell you anything.
- Trust
The most important issue here is building Elaine’s trust. By building a rapport with Elaine and gaining her trust she is much more likely to disclose to you about what she is experiencing now and in the future. She is also more likely to listen to you and take your advice on treatment options. You will not find out all the relevant information in one session, or solve all Elaine’s problems but if you can gain her trust then you are on the way to doing both these things.
- How you act will affect the outcome of the appointment- and if Elaine gets better
If you gain Elaine’s trust and build a good rapport with her, she is more likely to tell you what she feels, and you can involve her in treatment decisions. This will mean she is more likely to stick with treatments and come to appointments.
If Elaine doesn’t feel listened to on her first appointment, it could put her off seeking help again, her symptoms could get worse and she could be more suspicious of treatment, less likely to take her medication and less likely to come to appointments in the future.
- Headaches- Diagnostic overshadowing
- Investigating social factors- Not jumping to a diagnosis
There could be lots of reasons why Elaine is experiencing these symptoms and it’s important to find out about what could be causing them.
- Asking about her sleep is important because sleep deprivation can cause psychosis
- Psychosis can also be caused by a traumatic event or severe stress
- Illicit drugs have been linked to psychosis and in particular new stronger strains of cannabis are causing this
It is important not to jump to any conclusions when it comes to diagnosis, although the parent may be pushy to know what’s wrong.It is OK to say that you need to investigate further and getting the wrong diagnosis can be very harmful.
- Hearing voices
It is important to explore this issue fully to be sure that Elaine is having sound hallucinations. There could be people talking about her at university, so we need to rule this out by finding out when and where she hears people talking about her.
It is very important to understand that to Elaine these voices are real and if you refer to them as ‘voices’ Elaine is likely to get very upset and lose all trust in your relationship. By referring to them as ‘these people that you hear’ you are not colluding by saying that they are real, but are acknowledging that they are real for her.
- Confidentiality
Elaine is over 18 and entitled to patient doctor confidentiality. Reassuring her about confidentiality may get her to open up. You will need to discuss with Elaine what you can and can’t share with her mum before you get her back into the room.
- Am I mad?
Using the word ‘mad’ back to Elaine is not useful. Instead you should acknowledge that she is experiencing difficulties, and that this is a really good time to talk about recovery and treatment. Instead you could say:
- Recovery
What Elaine is going through is incredibly scary and isolating and she may not be able to imagine getting any better. You need to reassure her that there is hope, without making false promises, for example:
- Holistic care
It’s important to remember to treat the whole person and take account of any social factors that might be influencing their symptoms. For example, if stress makes someone’s symptoms worse you can talk through how to combat stress by using relaxation techniques etc. It’s also good to talk to people about what they can do to help alleviate their symptoms. An example of this might be to talk about diet and exercise and how this can help with depression.
- Listen to the patient and involve them in treatment decisions
When talking to people about treatment, listen to what they want. The more you involve people in their treatment decisions the more likely they are to stick with their treatment.
- Acknowledging Elaine’s achievement
Just by coming to the surgery today Elaine has made a big step and now she has sought help we can start understanding what is happening and what to do about it. This must have been very hard for Elaine and you need to congratulate her on this achievement, and reassure her and her mother that she has done the right thing.
- Offering support and appropriate resources
Charities, websites, local support groups etc. can be really good sources of information and support for people with mental health issues and their carers.
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