A Mixed-Method Study of Healthy Lifestyle Talk in Everyday Practice in Mental Health Treatment

Background and Purpose:  Recent evidence reveals that people with serious and persistent mental illness have alarmingly high rates of disease morbidity and mortality, much of which is attributed to potentially modifiable lifestyle factors such as obesity, exercise, smoking, and lack of access to medical care.  Thus, integration of health and mental health care has been deemed a major service delivery priority, and mental health providers are increasingly urged to view health promotion as an element of mental health recovery and to integrate healthy lifestyle programming into their services.  Such integration requires not only the addition of expertise from physicians and nurses to the mental health team, but also the involvement of mental health clinicians in promoting and supporting healthy lifestyle behaviors in their practices with consumers.  Research to inform clinicians in enacting competent strategies for healthy lifestyles are, therefore, critically needed.  The purpose of this study is to examine how clinicians in assertive community treatment address healthy lifestyle issues in everyday practice.

Method:  Using data from a study of communication in assertive community treatment, we present analysis of audiorecorded sessions between 36 consumers and their psychiatrists and case managers (a total of 72 recordings), and analyzed using two methods:  the Roter Interactional Analysis System (RIAS), used to code medical interactions; and conversation analysis (CA).  Whereas the RIAS provides a synopsis of the proportion of talk featuring particular topics or interactive strategies, CA is a qualitative method which examines sequences of talk (e.g., question-answer, proposal-response, complement-acknowledgement) to identify how institutional practices are constituted by linguistic practices.  Conversation analytic methods were used to examine, via sequences of interaction, instances of healthy lifestyle talk initiated by either providers or consumers and describe variations in uptake from the recipient of the talk (consumer or provider).

Results:  RIAS analysis showed that “health talk,” defined as discussions of any topic related to physical health, comprised 15% of case manager talk and 39% of psychiatrist talk.  However, case managers were significantly more likely than psychiatrists to ask questions, give information, and provide counseling related to lifestyle issues in particular.  CA analyses showed that both types of providers responded to consumer-initiated discussions of healthy lifestyle by “upgrading” the consumer’s own appraisal statements to provide encouragement and motivate the consumer to engage in healthy lifestyle behaviors.  When lifestyle talk was initiated by providers, however, they often employed various politeness conventions to introduce and discuss the topic in a delicate manner, perhaps in an effort to avoid offending consumers. Thus, activation was taken up at a greater rate in consumer-initiated as opposed to provider-initiated talk sequences.

Conclusions:  Efforts are underway to effect a greater integration of primary care services into assertive community treatment and other intensive mental health services.  This study shows, however, that there are also ample opportunities to address modifiable risk factors in communication between mental health providers and consumers.  Implications for training providers in effective communication related to health promotion will be discussed.