When talking is difficult
• Structured rather than open questions can be easier to answer
• Careful use of gathering threads can be powerful

For people whose cognitive processes are so disorganized in the context of psychotic thinking language based approaches are of limited benefit. The principles of Johnella Bird’s work:

support the 'being with' which is needed.

For people with prominent negative symptoms, limited spontaneous speech and motivation to engage with other people, the attention to questions which are easy to answer supports their verbal engagement. Open questions are often quite unhelpful in this context. They leave the responsibility for the content and focus of the verbal production with the person answering the question, with all the attendant possibility of 'getting it wrong'. Carefully constructed questions around activities such as getting out of bed, engaging in a conversation or going out of the house can bring forward a surprising amount of agency, values and intentions:

Once people who have difficulty generating talk have responsed to an inquiry the process of gathering threads can be particularly valuable. Given that the verbal production of ideas is so limited, care in enabling them to hear the themes and ideas they have brought forward spoken in the context of the power relation with a focus on agency in their own words, can be an important experience.

Compulsory Care
• Maximize the person’s agency within limits
• Embody decision to coerce

Undertaking compulsory care is particularly challenging in the context of a commitment to work collaboratively. At least in the moment this comprises a gross limitation on the person’s agency. Conversations and care can be conducted in a way to maximize the person’s agency within limits. Careful listening to support inquiry and gathering threads in relational language focusing on agency and resource can still be possible. A social constructionist epistemology supports our awareness that our assessment that compulsory care is necessary is just that, our assessment, from our frame of reference with the knowledge, skills and information we have. It is not a disembodied statement of truth. It can be presented explicitly as this:

“From what I know about the experiences you have been having and how your thinking is working, I have come to the belief that leaving hospital at the moment would put you at risk. I am aware that the idea you hold about this is very different. It is also possible that you could be right and I could be wrong. However, in my position here I am held responsible for making this call. In that position I am also supported by the law and the police. For the mean time you have no choice but to stay here. You can apply for a review of the decision I am making by …”