PI Brief Update

Communication: Code Crimson! - Dr Mark Burgin

14/06/26. Dr Mark Burgin discusses how communication can get out of control and how disability analysts make reasonable adjustments for disabilities.

Communication breakdown can be frightening as it can be associated with threats, complaints and strong emotions. Underlying this drama can be a mixture of problems including disability, anxiety and anger with the process. The basic skills for communication are to create rapport, listen to what the person says and then understand what they mean. These can prevent most communication breakdown and avoid the need for higher level communication skills.

The first challenge is to recognise the likely cause and type of communication difficulty. This technique is about trying to get the person to speak about something that is easy for them. In young people I will often use subjects such as gaming or social media but am prepared to pivot to pets or cuddly toys if needed. Talking about what the person is interested in is a highly effective strategy.

The second challenge is to explore other areas looking for the responses and comparing with the baseline subject. A person with significant ASD will often have marked restricted social engagement but will answer all questions with the same pattern of difficulties. Disability analysis is a holistic approach so there are always opportunities to increase or decrease the sensitivity of what is being discussed. Over the course of an assessment the expert will observe the person on many different subjects and see their responses.

The third challenge is to assess the content, there will be ambiguities, inconsistencies and gaps in what has been said. There may be evidence of the limits of the person’s understanding and cognitive capacity, or that they are suggestible. There are three situations which require higher level communication skills. Dissociation, complex issues and lack of cooperation all present special difficulties and specialist techniques.

Dissociation

PTSD causes a typical pattern and the person will dissociate with detachment from reality, memory loss or emotional numbness when a trigger subject is mentioned. Normally dissociation will last a few seconds with reassurance and distraction and not require any active intervention. They can lose control and enter an automatic fight, flight, freeze or fawn state.

Deescalating techniques may be unavoidable if the person has high arousal when they arrive. The first step is to listen and reflect, as they often have pressure of speech this involves using non-verbal cues and not interrupting. In severe cases the person has kept talking continuously without stopping for 40 minutes, once simultaneously translated by an exceptional interpreter.

The second step is to validate their emotions, this means that the expert will acknowledge the emotions without criticism. The choice of phrase should be particular rather than general ‘I can see you are struggling’ or ‘that must be upsetting’ can be taken the wrong way. Focus on what the person states, use non-verbal supports and move on as soon as the person signals they are ready.

The third step is to develop rapport with the person and then engage with the task usually by saying something that they want to hear such as ‘I am here to write your story’. The person may start talking in the wrong place and I use a questionnaire to maintain structure and accuracy. This has the benefit of allowing me to make comprehensive notes and eye contact at the same time.

Communicating complexity

Working in general practice allowed me to perfect the ability to explain the most complex concepts using simple relatable narratives. Common issues such as angina, asthma, kidney failure have been practiced hundreds of times. The bits which work are kept and the bits which were confusing or did not add to the explanation are dropped. The result is a smooth clear polished description that makes sense to almost everyone. Techniques such as chunk and check or the teach - back method can assist where there are several parts or the person appears to be distracted.

Health anxiety is a condition where the person is emotionally activated by medical explanations. In severe cases they are dissociate but normally they follow up with endless questions whose purpose is to self-soothe. Sadly, the doctor’s reassurance is only short lived and they ask more questions to relieve the anxiety. The mistake is to treat the questions as logical and ignore their emotional content. By addressing the emotional driver, the doctor can break the cycle.

For some people emotional complexity is an area of blindness, they cannot process, identify or describe feelings despite having normal intelligence. They are often neurodivergent and can have a limited fantasy life. They are unable to recognise other people’s feelings even if their mirror neurons activate. People with ADHD have an attention deficit when discussing emotions whereas ASD describe their feelings as physical sensations. They can easily understand psychological explanations that are cognitive grounded. 

Lack Of Cooperation

It may not be immediately obvious why a person is not cooperating with the communication process. Possible reasons include the person has an agenda that they need to address before they will cooperate. The person may not wish to share the information that is required and will escalate the situation if pushed. The person may have anxiety or be embarrassed by the situation. They may wish to control the situation or get a reaction from the other person.

The first step is listening to what the other person has to say. This requires some patience as a person may have a lot to get off their chest. A person who repeats themselves and struggles to make progress may be intoxicated or have another reason for their lack of cooperation. It is worth trying to respond to their questions at least once before dismissing the agenda issue. If the person states something true tries to be provocative then agreeing with them may be the best approach. Anxiety can be approached in a similar way to dissociation as it shares features.

The uncooperative person will often use emotion to escalate the situation as this can cause the expert to become more amenable. If the expert stays calm and continues to engage the person may try to provoke a reaction with personal attacks. A useful approach is to ask why they are reacting in this way as it can reduce the tension. The expert needs to confirm whether the person will or won’t answer the question and should de-escalate as soon as practicable.

Conclusions

An expert trying to communicate with an agitated crimson faced person may need to consider if the expert rather than the person is the problem. Communication skills for deescalation are simple to learn and use and are highly effective. All doctors should be able to deescalate most interactions with patients or relatives. Typically, only GPs learn the specialist techniques for dissociation, complexity and lack of cooperation so lawyers should check if their expert has advanced communication skills training.

The techniques to manage dissociation, explain complex issues and address lack of cooperation require regular practice to be effective. There are a few cases where even advanced communication skills will fail. Talking to a person with depression who has lost all hope or a survivor of childhood trauma who has lost their sense of self need compassion and support.

As a doctor and medical legal expert I may have to share difficult and challenging news and I find humour can help. Saying that ‘there is a 100% chance you will die, over the next 100 years’ can help ground a discussion on serious illness. It has the advantage of helping lighten the situation and making it easier for the person to manage their anxiety. The best experts have humour in their armoury to take relieve a little of the person’s distress if required.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 01226 761937 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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