Examples of difficulties communicating about feelings from research

We have previously reported in detail on the complex statements one research interview respondent used to describe her feelings (Yarns et al., 2018). The following examples of patients’ difficulties in articulating feelings derive from four respondents to semi-structured interviews conducted as part of Partners in Care (PIC), a randomized-controlled trial of quality improvement for depression in 46 managed care clinics across the United States (Rubenstein et al., 1999; Schoenbaum et al., 2001; Sherbourne et al., 2001; Wells, 1999; Wells et al., 2000; Wells et al., 2004). At enrollment, all PIC participants reporting depressive symptoms on a structured instrument were randomized to a control or intervention group. Then, participants completed surveys on depressive symptoms and other factors every 6 months for 2 years then at 5- and 9-year follow-up time points. At the 10-year follow-up time point, a subsample was invited to participate in up to three semi- structured interviews over approximately three months about their illness experience. Interviews at the 10-year follow-up time point consisted of open- ended questions followed by probes that focused on the subjective experience of living with depression and the long-term effects of the study’s quality improvement interventions. Interviewers were trained for the study, and some interviewers also had clinical experience. A total of 280 respondents completed at least one interview, which was audio recorded. These interviews were of interest to us because the probes in each area contained specific questions about the respondents’ feelings.

We used purposive sampling to identify respondents who were likely to provide complex examples of their emotional experiences: respondents age 65 years and older with chronic depression, which was defined as scoring depressed on all depression screening checklists (i.e., every 6 months for 2 years then at 5- and 9-year follow-up time points). We identified five respondents who met these criteria, but one was excluded because there was only one interview, which did not provide enough examples of emotional experience. Our final sample included four respondents with three interviews. Audio recorded interviews were professionally transcribed. The Institutional Review Board (1RB) at the RAND Corporation approved the PIC study, acquisition of the PIC 10-year follow-up interviews, and our new analysis.

Across the four respondents’ interviews, 58 examples of probes for feelings were located. Most often this included questions such as, ‘'How do you feel?” or “How did that make you feel?” Respondents’ answers to these questions were often quite complex. We found only nine of the 58 examples in which respondents answered a question about how they felt with a response that referred to a specific feeling. Here is an example:

Interviewer (I) : How does that make you feel that you can't be there?

Respondent (R) : I feel so sad, so sad.

In this example, the respondent was clearly able to communicate that she was sad about the situation under discussion. If this exchange were to occur in the mental health treatment setting, the respondent’s clear communication of sadness - along with other cues such as nonverbal communication - could help the mental health professional understand that this patient needed help with her grieving and healing her sadness. Specific interventions could then be provided to allow space to explore her grief and heal it, and mental health diagnoses and unnecessary treatments could possibly be avoided.

More often, however, respondents answered questions about how' they w'ere feeling with far more complex responses. For 49 of the 58 answers to questions about how they w'ere feeling, respondents did not answer with any clear communication about how' they were feeling. In the following example, the respondent does not mention any specific feelings:

I: And emotionally, how do you feel the next day after a night like that?

R: Pretty bad. I'm not getting anything done. I don't have that much long left to go, and I' ve got a lot of stuff . It just piles up and piles up, stuff that I need to do, and I can't do it because I'm too tired to do it, because I can't sleep at night. Like last night, I didn't finally fall asleep until - I don't know - five or six o' clock, and then I sleep all day, and I' m not getting anything done . And even when I get up, I'm still tired and worn out. [italics added]

Despite the interviewer specifying that she was asking how' the respondent felt emotionally, instead the respondent used a vague phrase, “pretty bad”, and then redirected her attention toward her external circumstances, “stuff ... just piles up and piles up”, and her physical symptoms, feeling “tired” and “worn out”. For this latter respondent, these communications which relied on reporting vague and physical symptoms, rather than specific feelings, may have had treatment implications. Based on other parts of the interview, w-’e w'ere able to determine that she w--as not taking psychiatric medications or in psychotherapy at the time of these interviews. However, she was taking opioid medications for physical pain.

In other examples, respondents did not describe their experience at all. Instead, they replied with thoughts or other statements that did not answer the question directly or shed any light on what they were feeling, as seen below:

I: How does that make you feel emotionally, feeling worn out all month and having everything hurt?

R: I think, I guess that this can't go on like this.

In this example, the interviewer struggles to make an important distinction between the respondent’s emotional experience and physical experience. She asks what the respondent felt emotionally about her physical symptoms of fatigue and pain. However, the respondent replied with a thought rather than any words to describe her emotional experience.

 
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