(Un)shared realities of psychosis treatment: An ethnographic study of (mis)alignment between psychiatrists and patients experiencing psychosis

Delivering effective, compassionate psychiatric care that emphasizes meaningful exploration of patient perspectives remains a challenge for modern psychiatry. Despite the development of certain modalities that seek to improve understanding of patients with psychosis, many individuals experiencing psychosis continue to report feeling misunderstood or misrepresented by psychiatrists. Drawing upon the theoretical frames of subjectivity and intersubjectivity, this work seeks to explore how the perspectives of psychiatrists and patients may align or misalign during psychiatric treatment, and if and how diverging perspectives of patients are explored during treatment. This study involved 11 months of ethnographic fieldwork within multiple clinics under a major US healthcare system that offer specialty psychosis care in the southeastern United States. Findings revealed that psychiatrists and patients often markedly differed in their subjective conceptualizations of the meaning of the illness, the goals of the treatment encounter, and the desired relational dynamics within the treatment encounter. In many of the observed psychiatrist-patient dyads, patients felt pressured, often in subtle ways, to conform to the psychiatrist’s subjective perspective. Alternatively, in certain relationships, the psychiatrist demonstrated more flexibility and harmonization towards the patient’s perspective. Furthermore, numerous structural factors, such as time constraints, insurance restrictions, and the biomedical emphasis of care, led to limitations on the possibilities for exploration of patient perspectives during treatment. The findings indicate important implications for psychiatric care for those experiencing psychosis, and suggest possible paths forward for improved understandings in psychiatric treatment. • Many persons receiving treatment for psychosis experience misrecognition • This ethnography explores psychiatrist-patient interactions in treatment • Patient perspectives are often not explored or given equal weight • Subtle coercion dynamics shape what patients feel they can express during treatment • Flexibility and attunement improve recognition of patient subjectivities