Annette Sofie Davidsen

Phenomenological Approaches in Psychology and Health Sciences

A whole family of qualitative methods is informed by phenomenological philosophy. When applying these methods, the material is analyzed using concepts from this philosophy to interrogate the findings and to enable greater theoretical analysis. However, the phenomenological approach represents different approaches, from pure description to those more informed by interpretation. Phenomenological philosophy developed from a discipline focusing on thorough descriptions, and only descriptions, toward a greater emphasis on interpretation being inherent in experience. An analogous development toward a broader acknowledgment of the need for interpretation, the influence of the relationship and the researcher, and the co-construction of the narrative is mirrored in qualitative analytic theory and the description of newer analytic methods as, for example, Interpretative Phenomenological Analysis and Critical Narrative Analysis, methods which are theoretically founded in phenomenology. This methodological development and the inevitable contribution of interpretation are illustrated by a case from my own research about psychological interventions and the process of understanding in general practice.

A systematic review of controlled interventions to reduce overweight and obesity in people with schizophrenia

Overweight and obesity are generally found among patients with schizophrenia. This may lead to serious implications for health and wellbeing. The aim was to review controlled intervention studies on reducing overweight/obesity and/or reducing physical illness in patients with schizophrenia.

Improving the physical health of long-term psychiatric inpatients.

Background: Patients with psychiatric illness have increased somatic morbidity and increased mortality. Knowledge of how to integrate the prevention and care of somatic illness into the treatment of psychiatric patients is required. The aims of this study were to investigate whether an intervention programme to improve physical health is effective. Methods: An extension of the European Network for Promoting the Health of Residents in Psychiatric and Social Care Institutions (HELPS) project further developed as a 12-month controlled cluster-randomized intervention study in the Danish centre. Waist circumference was a proxy of unhealthy body fat in view of the increased risk of cardiovascular diseases and type 2 diabetes. Results: Waist circumference was 108 cm for men and 108 cm for women. Controlled for cluster randomization, sex, age, and body fat, the intervention group showed a small, but not significant, reduction in waist circumference, while participants in the control group showed a significant increase in waist circumference. Conclusions: The intervention had a positive effect on the physical health of the patients measured by a reduction in the increase of waist circumference.

Narratives about patients with psychological problems illustrate different professional roles among general practitioners

General practitioners are not trained in psychotherapy. They are, however, experienced in hearing people’s stories. This qualitative interview study aimed to explore the stories GPs recounted about psychological interventions with patients. It showed that the GPs had recounted very different types of narrative, and that the same GP recounted the same type of narrative throughout the interview. Some told detailed narratives including the patient’s life situation, whereas others kept to biomedical matters. Co-creation of patients’ narratives had a therapeutic function, and patients obtained agency and power in these stories. The narrative style reflected the professional identity of the GP.

The excess mortality of patients with diabetes and concurrent psychiatric illness is markedly reduced by structured personal diabetes care: A 19-year follow up of the randomized controlled study Diabetes Care in General Practice (DCGP).

OBJECTIVE To assess the effectiveness of an intervention in Type 2 diabetic patients with concurrent psychiatric illness (PI) and compare this with the effectiveness in patients without PI. METHOD In the Diabetes Care in General Practice trial, 1381 patients newly diagnosed with Type 2 diabetes were randomized to 6 years of structured personal diabetes care or routine diabetes care (ClinicalTrials.gov NCT01074762). In this observational post-hoc analysis, the effectiveness of the intervention for diabetes in 179 patients with concurrent PI was analyzed. RESULTS During the 19-year follow-up period, patients with PI in the structured personal care group experienced a lower risk for all-cause mortality [105.3 vs. 140.4 events per 1000 patient-years; hazard ratio (HR): 0.63, P=0.023, multivariably adjusted], diabetes-related death (66.0 vs. 95.1; HR: 0.57, P=0.015), any diabetes-related endpoint (169.5 vs. 417.5; HR: 0.47, P=0.0009) and myocardial infarction (54.1 vs. 104.4; HR: 0.48, P=0.013), compared to patients with PI in the routine care group. This translates into a number needed to treat over 10 years of three or lower for these outcomes. CONCLUSION These findings suggest that in primary care, structured diabetes care allowing for individualization was highly effective among diabetic patients with co-occurring PI.

‘It takes some time to get into the rhythm - and to slow the flow of thought’: A qualitative study about experience of time and narrative in psychological interventions in general practice:

General practitioners (GPs) treat more than 90 per cent of patients with mental disease. Time restriction is often seen as a hindrance to their engagement in psychological treatment. This study aimed to explore GPs’ experiences of time when delivering ‘talking therapy’ and to analyse how time influenced the treatment of emotional problems in routine consultations. A qualitative approach was chosen, the data consisted of interviews with 14 GPs and observation of consecutive consultations in four of the participants’ practices. Analysis was made by Interpretative Phenomenological Analysis. Eleven participants delivered talking therapy, five (therapeutically minded participants) often. Three aspects of time emerged: (1) the chronological time of the schedule; (2) the inner time with another rhythm and flow of thought; (3) the longitudinal time where meeting repeatedly for short consultations promoted a trusting relationship where problems were disclosed gradually and a narrative was created. With therapeutic participants the same aspects of time could be identified in routine consultations. Stress and a heavy workload counteracted the perception of inner time. Theories of time and narrative from psychotherapeutic thinking could be applied, form links to the unconscious and the narrative time and could possibly be made more explicit in general practice. Awareness of the different time aspects is necessary for improving the treatment of mental health in primary care. Political and organizational willingness to secure the necessary working conditions is, however, equally important for optimal treatment.

Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review

BackgroundCollaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression.MethodsWe developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT).ResultsWe included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers.ConclusionsThe following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK.

What is depression? Psychiatrists’ and GPs’ experiences of diagnosis and the diagnostic process

The diagnosis of depression is defined by psychiatrists, and guidelines for treatment of patients with depression are created in psychiatry. However, most patients with depression are treated exclusively in general practice. Psychiatrists point out that general practitioners’ (GPs’) treatment of depression is insufficient and a collaborative care (CC) model between general practice and psychiatry has been proposed to overcome this. However, for successful implementation, a CC model demands shared agreement about the concept of depression and the diagnostic process in the two sectors. We aimed to explore how depression is understood by GPs and clinical psychiatrists. We carried out qualitative in-depth interviews with 11 psychiatrists and 12 GPs. Analysis was made by Interpretative Phenomenological Analysis. We found that the two groups of physicians differed considerably in their views on the usefulness of the concept of depression and in their language and narrative styles when telling stories about depressed patients. The differences were captured in three polarities which expressed the range of experiences in the two groups. Psychiatrists considered the diagnosis of depression as a pragmatic and agreed construct and they did not question its validity. GPs thought depression was a “gray area” and questioned the clinical utility in general practice. Nevertheless, GPs felt a demand from psychiatry to make their diagnosis based on instruments created in psychiatry, whereas psychiatrists based their diagnosis on clinical impression but used instruments to assess severity. GPs were wholly skeptical about instruments which they felt could be misleading. The different understandings could possibly lead to a clash of interests in any proposed CC model. The findings provide fertile ground for organizational research into the actual implementation of cooperation between sectors to explore how differences are dealt with.

Intervention to promote physical health in staff within mental health facilities and the impact on patients’ physical health

Background: Patients with severe mental illnesses have an increased physical morbidity and premature mortality on account of somatic diseases. Patients with mental illness are nursed and cared for by the staff, who may acts as role models for the patients. Aims: The study tested the efficacy of an intervention programme for improving physical health in staff working in long-term psychiatric treatment facilities. Furthermore, the paper measured the association between staffs changes in physical health and the patients’ changes in physical health. Methods: The study was a cluster randomized controlled 12-month intervention study, and the intervention was active awareness on physical health. Results: In the intervention group the staff reduced their waist circumference by 2.3 cm (95% CI: 0.3–4.4) when controlling for gender, age and cigarette consumption. In the control group, the staff changed their waist circumference by − 2.1 cm (95% CI: − 5.6–1.5). The staff in the intervention group experienced a significant reduction in diastolic blood pressure of − 5.9 mmHg (95% CI: − 9.5 to − 2.3, p = 0.009). The study indicated an association between the staff average change in each facility and the individual patients changes in health parameters (body mass index, total body fat and quality of life). Conclusion: The staff in the intervention group showed a significant reduction of waist circumference, while staff in the control group showed a non-significant increase. Furthermore, a significant reduction in the diastolic blood pressure was seen. Indications that staff acted as positive role models for the patients’ physical health were seen.

Grasping the process of implicit mentalization

Mentalization has developed through different waves and its definition has gradually changed. Through this process mentalization theorists have not taken a particular position on the philosophical underpinnings of the understanding of others, except that Theory of Mind (ToM) is referred to as a commonsense and underlying theoretical basis. It is apparent that ToM does not explain all dimensions of Mentalization Theory (MT), especially implicit mentalization, and theorists do not account for how implicit mentalization can be captured in interaction. In this article we explain the divergence between MT and ToM and the lack of a philosophical basis for the process of understanding others in MT. We show that conversation analysis (CA) can be used to capture implicit mentalization in interaction. We argue that MT needs a theoretical and philosophical formulation about what constitutes intersubjectivity and the process of understanding others. We suggest that phenomenology could inhabit this space.