Table 1 Illustration of the analytical process with examples of themes and categories developed during analysis

A First topic: the epistemological paradox: explaining the unexplained

 A1 Language and the dilemma of explaining the unexplained

The inherent problem in communicating inner and embodied states

Alternative approaches to communication

Using metaphors

Using visual tools

Connecting to the senses

Play

Sharing experiences

“We have tried to close in on the problems by using visual methods. (…) For example, they have taken with them a picture they have drawn or a photo, and we have looked at it together. Or we have watched film clips that sort of captures some of the things they struggle with.”

The problem of diagnosis

Nomenclature

Taxonomy

Typification

Pragmatics

Interpretation as negotiation

“It’s not so easy to create a sense of coherence and understanding that maybe I have, and make it meaningful to them.”(…) “A big challenge is to create that basic mutual understanding of what this is about”

 A2 Creating explanatory models and clinical prototypes

Clinical prototypes

The “good girl”

Personality

Lack of assertiveness

Perfectionism

Performance-oriented

Pressure to achieve

Workload

“Some of them are very focused on performance and accomplishments, trying to be perfect and live up to some sort of ideal.”

The “trauma victim”

Negative life events

Bullying

Abuse

Divorce

Poverty

Neglect

“A lot of these patients have traumatic experiences.”

Explanatory models

(Bio)psychosocial model

Vulnerability-stress model

Psychological factors

Societal factors

Acute or chronic stress

“I’ve been wondering about the school system that we have today, that there is more pressure on young people… maybe in general in our society… that we have so much to do and are so busy. I think that I have seen an increase in tired and exhausted kids the last few years.”

B Second topic: The methodological paradox: the uncertain expert

 B1 Empathy and the dilemma of clinical uncertainty

Focusing on emotions and relational aspects

Creating a good working alliance

Building on principles from patient-centred care

Believing in the patient´s story

Building trust and acceptance in clinical encounters

Working towards a common goal

“You have to believe that this is a person who really is in pain. They are really suffering. You have to believe that to create an alliance and really help them.”

Creating an in-group identity of engaged professionalism

Identity markers

Performative aspects

Advocating patient interests

Distancing themselves from biomedical parts of the health system

Connecting to like-minded colleagues

“It’s very frustrating when your referrals are declined because the person doesn’t fit the diagnostic criteria, when you know that this is a person that is suffering and could have been helped if they had been given the opportunity. That is one of our biggest frustrations. Diagnostics and the systems that we are forced into.”

 B2 The dilemma of the uncertain expert

Balancing opposing roles and tasks

Opposing roles

Opposing tasks

The gate-keeper

The expert

The caring and nurturing helper

The humble servant

“Sometimes you feel you have some sort of diamond, that they so desperately want. And then it’s sort of up to the clinician to give an approximate evaluation of whether they should have it or not. Some of them can get very disappointed, cry or make a scene if they don’t receive the diagnosis they had expected.”

Relying on knowledge and experience

Tacit knowledge

Years of experience

Clinical intuition

Knowing their own limitations

Tried techniques for themselves

Having a “tool-box” of interventions and techniques

Having seen several patients with similar problems

Being able to seek support from experienced colleagues

Being able to share responsibility with patients when appropriate

“I’m old in the game; I have a lot of experience to keep me floated. I don’t think you should start in this job as a young psychologist or doctor. That wouldn’t work.”