Establishing mutual understanding in interaction: an analysis of conversational repair in psychiatric consultations

The therapeutic relationship is the greatest predictor of treatment outcome, yet its relationship to communication is largely unevaluated. This study explored how psychiatrists and people with a diagnosis of schizophrenia establish mutual understanding in naturalistic communication, and associations with the therapeutic relationship, patient satisfaction and symptoms. In conversation analysis, the concept of repair focuses on how participants in interaction create mutual understanding and address misunderstanding. A standardized protocol measuring the frequency of repair was applied to 15 outpatient consultations. Correlations between repair and the therapeutic relationship, patients' experience of the consultation and symptoms were explored. Patients made most effort to make their contribution understandable, whereas psychiatrists made most effort to repair misunderstandings. The more positively psychiatrists rated the relationship, the more effort they made to understand patients. Although psychiatrists' efforts were not associated with patients' overall view of the relationship, patients felt better emotionally, despite, feeling less understood. Psychiatrists used fewer repairs when patients were more symptomatic. Both parties prioritized understanding similar topics but psychiatrists focused more on medication and patients on voices. Quantifying repair offers a new way of analyzing how mutual understanding is established in interaction, and links communication processes with treatment outcomes.