When entering the room that the psychiatrist used for his consultations it felt like a head teacher's office. The room was small and clinically white. There was a big desk and a leather chair behind it. There were no pictures on the wall and the only decoration upon his desk was his masses of paperwork and patient files. Whilst waiting for the appointment I was left to wait twenty minutes over my appointment time and this although probably unavoidable left me with the feelings that I was not important and that I was not worthy of the psychiatrists time. This combination of unimportance and my illness left me feeling very low indeed. Upon entering the room I immediately felt disempowered. The psychiatrist had upon his wall his degree certificate and was sitting looking pristine in a suit. I was sat on a small uncomfortable plastic chair wearing whatever clothes I could manage to pull out of the wardrobe probably with dinner stains on. Initially he greeted me but could not maintain eye contact and no apology was given for the lateness of the appointment. He then proceeded to rock back on his chair with a pen in his hand and seemed to be very disinterested in anything that I had to say. He asked what was the problem and how had I been feeling since I last saw him. I told him that I did not feel that the present medication I was taking was working which then prompted him to ask me what medication was that? In my depressive state I found that question very hard to comprehend. I could not remember getting out of bed that morning let alone the name of my medication. My reply to his question was that I could not remember the name and I almost felt at that point he was sighing at me and thought of me as an inconvenience. He then promptly rummaged through the masses of folders on his desk to try and locate my file. My file was obviously not even on his desk and without saying a word he left the room to try and locate it. At this point in time I felt like I wanted to get up and run. I obviously was not even worthy of having my file on his desk let alone receive treatment from such a high powered individual. On returning to the room he chucked the file to his desk and returned back to his seat. He then asked what had been happening since my last visit to him. All the time I was talking to him he was continuously looking through my notes and adding information to them, just nodding occasionally when he deemed appropriate. On completion of my talking there was an awkward silence and the psychiatrist was busy writing away not even acknowledging my silence or distress. He then simply stood up told me that he thought I was suffering from bi-polar depression type 3 and that my meds would be altered accordingly. I left that room feeling worse than when I went in. I felt inadequate unimportant, disempowered, and very low.
According to the Oxford English Dictionary symbolic means "expressed, denoted or conveyed by a symbol". Symbolic communication, therefore, involves behaviour, actions or communications, which represent or denote something else. (Lishman 1994) As professionals we need to be aware of our symbolic communication and the signals we are giving off through our punctuality, dress, layout of our rooms and body language. All of these factors create a symbolic as well as literal meaning to our clients. In professional work the client's first contact with any service is usually the receptionist. From my own experience to be ignored at a desk while the receptionist answers the telephone, gossips to her colleagues and makes a cup of coffee all give the impression that you are not important. It conveys a lack of respect and acknowledgement of myself as a person. For myself that was already feeling a sense of shame and stigma being ignored or rudely treated symbolises a devaluing lack of respect and confirmation of my lack of worth.
Waiting rooms all vary. According to Lipman (1994) space, comfortable seating, cleanliness, fresh paint, a variety of comics, toys and magazines convey a welcome. Peeling walls, dirt, a smell of urine and broken furniture symbolises that the waiting client is worth no more than this. In comparison to this the interview room that my psychiatrist saw me in was an ideal representation of symbolic communication at its worst. Breakwell and Rowett (1982) conclude that the interview room is the professionals and not the client's territory. Clients entering a professional's rooms are expected to respect territorial rules and not to move chairs or sit on the desk. Breakwell and Robert then go on to conclude how symbolic of power and control territory is. Lishman 1994 further argues this point and concludes that even though clients generally respect symbols of authority professionals should be aware of these symbols and their meanings in terms of authority and control. The way in which the psychiatrist sat behind his desk conveyed to me his was not interested in me. It increased distance both emotionally and physically between us. Without the protection of his desk however I would have felt more equal, less threatened and less intimidated. D'Ardenne and Mahtani (1989) are also concerned with the symbolic aspects of physical space and territory. Their main argument is that a physical environment can be a powerful statement of your own transcultural viewpoint. (p.53) They go on to suggest that photographs or pictures inside an office will make the client feel more welcome. Especially those from a different ethnic background.
The psychiatrist as for mentioned wore a suit whilst I sat there in my scruffy clothes. This again created the impression of power and made me feel very scared and disadvantaged. However if the psychiatrist was dressed formally in trousers and a shirt the power imbalance would not have been so great and the symbolic communication he portrayed would have increased positively. Punctuality is the final issue that I would like to compare under the theory of symbolic communication. Left waiting in an uncomfortable waiting room for twenty minutes was very daunting. I was convinced that the reason I was being kept waiting was that I was about to be sectioned and that they were arranging my papers. " Unreliability symbolises for many a lack of genuine concern. (Rees and Wallace 1982) " It may also remind them or awaken feelings about unreliability of significant people in their life. Bowlby (1984) suggests that
"Whatever representational models of attachment figures and of self an individual builds during his childhood and adolescence, tend to persist relatively unchanged into and throughout adult life" (pg 141). As professionals we need to be constantly aware of the symbolic communication we portray when we are late for appointments and unorganised for them, (not having notes on desk).
As with symbolic theories of communication we also need to be aware of the non-verbal communication potential meanings. Psychologists for centuries have been researching the use of non-verbal communication with professionals. Sutton (1979) suggested that while spoken communication is concerned with mainly information giving, non-verbal communication is the "music behind the words" and conveys the professional's true feelings. Argyyle et al (1970) conducted a study and claimed that non-verbal communication had more significance on a person than the actual verbal and if the verbal and the non-verbal communication were in conflict the verbal tended to be ignored. Whilst non-verbal communication is important it is also open to misinterpretation. A swinging foot according to Egan (1998) can portray anger, frustration, boredom and energy. Egan then goes on to say that professionals need to be aware of the ambiguities of non-verbal communication and suggests that it is the untypical behaviour of clients and professionals that hold the most significance. Lishman (1994) divides non-verbal communication into two categories. Proxemics that is concerned with a person personal space and kinesics that refer to movements, gestures, expression and eye contact. The need for personal space differs between race, gender and classes. There are great cross-cultural differences in how close people like to be to each other, and women tend to tolerate closer physical distances than men do. (Mehrabian 1972) From further research I can see no specific rule on distance and I feel that it is a very individual choice. However I did feel that when the psychiatrist was sitting behind his desk he portrayed intimidation, confrontation and power imbalances. Nevertheless if I were sat next to him a slight angle the power imbalance would have been successfully alleviated.
As with both symbolic and non-verbal theories of communication I feel that verbal communication now needs to be considered. Whilst I was talking to the psychiatrist he never engaged in conversation with me. Good practice would state that it is crucial for probing and reflection to occur at all times whilst working with mentally ill patients. The questions I was asked were very direct and only gave me the option of replying with yes or no answers. Empathy was not shown at any time and the leaving of the room to get my notes proved a hindrance to effective communication. The use of Jargon also severally intimidated me and widened the power imbalance further. I was not aware at that time what meds were and had no idea at all what bi-polar disease was, for all I knew at that time he could be telling me that I had a sexually transmitted disease. Ley (1998) concludes that what is said by professionals to clients is frequently not understood and forgotten. This he claims is the professional's fault and not the clients.
For any professional to successfully work and maintain good communication skills with people who have mental health issues they need to completely understand what a person who is experiencing depression/psychosis is feeling. Clients suffering from depression can often appear hostile or extremely passive. They often have motivational issues such as apathy and loss of interest in everyday life. They may be feeling emptiness, resentment anxiety, shame or guilt. Their cognitive skills may also be suffering and they may have poor concentration and negative ideas about the world, self and their future. Biologically most suffers of depression also incur some periods of insomnia, loss of appetite and changes in hormones. Whilst working with a depressive person it is important to keep these factors in mind at all time. Take the lead from the client regarding personal space. Sometimes all that is needed is a hug and even though very unprofessional can be a huge relief to the client. If a client is displaying negative non-verbal communication reassurance and empathy may need to be given in order for that person to feel secure and able to talk. There have been instances where severely depressed patients put themselves into a foetal position and rock backwards and forwards. The body language being displayed is very symbolic and shows that they have little feeling of self worth. At no point should a conversation from standing be instigated by a professional. Instigating a conversation from a standing level reinforces the clients feelings of worthlessness instead observe personal space and crouch down on the floor and communicate from there. As a professional working with a depressed person I also feel that it is crucial to never tell a client that you know how they are feeling. Psychology studies have shown that a hundred people could all have been involved in an identical incident and their feelings, perspectives and coping mechanisms are all very different. (Lewis 1987) Respect and empathy needs to be shown at all times and the lead should always be taken from the client.
Due to word restrictions within this essay I feel that it is now important to bring together and conclude my findings regarding effective communication and depression. The example of my experience with the psychiatrist was a worse case scenario of communication gone wrong and basically everything that he did needs to be reversed for successful communication to take place. Needless to say when I felt better and was going through an "stable" period I demanded a change of psychiatrist and have since embarked on a university degree. Good communication skills can not however be read about or taught they are something that is practically learnt and the only way in which to monitor them is by being self analysing at all times and receiving feedback from clients and friends.
