Assessing Clinician's Subjective Experience during Interaction with Patients

Abstract

Background: While psychiatric literature has shown renewed interest in fine psychopathological investigation, little study has been devoted to the clinician's subjective experience with the patient, which is highly valued by the phenomenological and psychodynamic traditions. We aimed at developing a valid and reliable instrument to measure such experience. Sampling and Methods: First, 104 self-report items were developed, based on daily clinical practice and references from the literature on clinician's subjective experience. Of these, 46 were retained after pilot testing and exclusion of items with poor psychometric properties. Thirteen psychiatrists and 527 first-contact patients participated in the validation study. Psychiatrists completed the ‘Assessment of Clinician's Subjective Experience' (ACSE) instrument and the Brief Psychiatric Rating Scale (BPRS) after the visit and the Profile of Mood State (POMS) before and after it. The ACSE was completed again for 60 patients with stable BPRS scores over a short retest interval. Principal component analysis with orthogonal rotation was performed. The internal consistency and test-retest stability of ACSE factorially derived scales were calculated. Convergent validity was tested by examining the correlations between ACSE scores and change in POMS scores during the visit. Results: Five factors (interpreted as tension, difficulty of attunement, engagement, disconfirmation, impotence) accounting for 57% of total variance were extracted. All ACSE scales showed high internal consistency and stability, and correlated with conceptually related POMS scales. Conclusions: The pattern of subjective experience identified by the ACSE is consistent with classical psychopathological descriptions and previous related studies. Despite limitations such as the relatively small number of psychiatrists studied and the exclusively self-report nature of the instrument, this study supports the validity and reliability of the ACSE and suggests that it may be a valuable tool for training, research and possibly diagnostic purposes.

Disturbances of Embodiment as Core Phenomena of Depression in Clinical Practice

“…They have excluded subjectivity, with serious consequences for the validity of psychiatric diagnoses, empirical research, and psychotherapeutic interventions [96] . In this context, we show the importance of reincorporating the patient's subjective experiences as well as the viewpoint of the clinician who observes the phenomenon and establishes the diagnosis [22,39,55,79,80] . Nevertheless, whereas most psychiatrists implicitly include such phenomenological data in clinical diagnosis and decision-making, it cannot be assumed that all clinicians have this intuitive skill to recognize and typify their patients in the proposed way to a similar degree.…”

“…In contrast to the concept of symptom, which designates a neutral and objective measure, the phenomenological concept takes into account the intersubjective dimension in the diagnostic process. The phenomenon is, by definition, experienced/co-constituted by the patient and clinician; it corresponds to the patient's self-experience and includes the way the patient's experience is lived by the clinician [79,80] .…”

Association between Clinician's Subjective Experience during Patient Evaluation and Psychiatric Diagnosis

“…The clinicians working in these units were asked to complete the Assessment of Clinician's Subjective Experience (ACSE) instrument [74] and the 24-item Brief Psychiatric Rating Scale (BPRS) [76,77] when they met a previously unknown patient for clinical and diagnostic evaluation.…”

“…The instrument yields scores on five scales, named tension, difficulty in attunement, engagement, disconfirmation, and impotence. These scales were factorially derived in the validation study of the ACSE [74] performed on 527 first-contact patients assessed by 13 psychiatrists. In this study, principal component analysis with orthogonal rotation was carried out, and five factors (interpreted as tension, difficulty in attunement, engagement, disconfirmation, impotence) accounting for 57% of total variance were extracted.…”

“…The main aim of the study was to investigate the value of the intersubjective field as a specific dimension of the patient's evaluation. To this purpose, we used a standardized assessment instrument that was recently developed and validated by our group, which reliably measures five dimensions (tension, difficulty in attunement, engagement, disconfirmation, impotence) underlying the clinician's subjective experience during the first interaction with a patient [74]. …”