Dr Raj Persaud: mind games

Conversational analysis is a research technique where conversations are videotaped then analysed rigorously to understand what is really going on in interactions between people.

It is beginning to be widely employed in medicine in an effort to try to gain some insight into why certain things happen, or do not happen, in consultations with patients.

For example, despite the publication of innumerable guidelines encouraging them to do so, GPs often do not raise the issue of giving up smoking with patients during consultations, or if they tackle the subject it is often not done effectively.

One theory about why this happens is that GPs are avoiding broaching certain subjects, such as smoking cessation, because they are afraid of opening a can of worms.

They believe that talking about certain subjects risks lifting the lid on a whole slew of troubles with the potential to overwhelm the person who started levering away at the top of the tin, in this case the busy GP.

Another key belief behind this 'can of worms' perspective is that people have problems because of certain personality traits, such as a tendency not to take responsibility for their actions, poor motivation or simply having more pressing goals. The perceived risk of confronting these perhaps intensely personal issues is that it may damage the therapeutic relationship.

Confidence in the effectiveness of your own communication skills and general abilities can be enormously helpful in situations where you are dealing with difficult subjects.

The art is in helping your patient, or perhaps your colleague, to examine their damaging behaviour or problems in a more productive light.

People often come asking for assistance and the best guidance of all is probably in leading them to see what it is they might need to do to help themselves.

Although almost never a popular approach for doctors or managers, it is better that reality is confronted and dealt with rather than leaving those worms in the can.

Dr Raj Persaud is a consultant psychiatrist at South London and Maudsley trust and Gresham professor for public understanding of psychiatry.