A new paper, published in Sociology of Health and Illness, describes the findings of a study that examined conversations between psychiatrists and clients to understand better how clients initiate attempts in session to change their medication regimens. The results of this conversation analysis, conducted by Dr. Galina Bolden and a team of researchers, revealed that clients have few opportunities to explicitly voice preferred changes, a structure that undermines a collaborative decision-making approach to treatment.
“Previous research suggests that clients hesitate to assert themselves in clinical encounters out of deference to clinician authority,” the authors write. “It is not enough, therefore, to exhort psychiatrists to listen to their clients’ preferences when they express them; rather, it may be necessary to train them to create explicit openings for their clients to articulate their experiences, such as, for example, explicitly raising medications as a discussion topic.”
The recent emphasis on client-centered care has focused on interventions that allow clients to direct treatment decisions. Traditional understandings of decisions around psychiatric medication management have been oriented around the psychiatrist as the professional, who holds the expertise to make decisions regarding a client’s care. However, the movement toward Shared Decision Making (SDM) focuses on treatment decisions made in collaboration across practitioners and clients.
Previous studies have observed conversations that occur between psychiatrists and clients. These findings provide insight into how psychiatrists go about making treatment decisions. First, it has been noted that the structure of the conversation is set up such that the psychiatrist is positioned as making the treatment recommendations. In these discussions, they do not tend to invite medication requests from clients. This is noteworthy because, Bolden and colleagues note, “there is no structurally provided place for patients to make such requests.”
In addition to this, the analyses of conversations demonstrates that treatment decisions, particularly those around medication, are structured around the idea that it is the psychiatrist who holds expertise on the subject, “which means that if patients are to solicit a medication, they are normatively expected to design their inquiry so as to respect the boundaries of medical authority,” write Bolden and co-authors.
For this same reason, although patients might have information about their experience with medication, their opinions may not be viewed as legitimate by providers. It is unsurprising that in this context research has found it is rare for patients to request a treatment explicitly. Some research does indicate that rather than explicitly seeking treatment or treatment changes, patients engage in a variety of implicit strategies including:
- “Producing a candidate diagnosis (e.g., ear infection) that implies a certain treatment;
- Stating their preferences, making inquiries, mentioning prior experiences with particular treatments;
- Emphasizing the severity of their symptoms;
- Citing precedents, third parties, or praising other providers who prescribed the desired treatment.”
By deploying these strategies, patients balance respecting the authority and expertise of the psychiatrist with their personal advocacy and desire to express treatment changes or preferences. A significant downside to understanding the structure of these conversations is that the existing research of in-session treatment discussions has focused on examining how psychiatrists navigate them. Bolden and colleagues write:
“By focusing on the communicative work psychiatrists do to promote their treatment decisions, this research has provided an important but limited insight into shared decision-making processes.”
Therefore, Bolden and researchers sought to investigate conversations in which clients solicited changes in their medication regimens. Examples of instances in which clients would be soliciting changes include requests to lower dosages, eliminate medication, and prescribe a new drug.
“The present study thus advances our understanding of patient advocacy in mental health settings, adding to a small but growing body of conversation analytic literature on psychiatric interactions.”
Bolden and colleagues analyzed “medication check” appointments at an assertive community treatment center. These appointments featured psychiatrist-client negotiations of changes in medication type and dose that occur in an ongoing fashion alongside other services offered including “training in everyday life tasks, supportive psychotherapy, and assistance with gaining disability benefits and housing.”
Their findings resembled earlier studies and offered further evidence that patients implicitly communicate medication preferences in psychiatry sessions. However, there were instances in which patients made explicit requests. Even still, the tendency to design requests to defer to the psychiatrist’s authority and expertise persisted and these requests were often initiated only after the psychiatrist had brought up the issue of medication.
Some patients openly demanded a medication change (e.g., “I want my meds lowered”). The researchers’ analysis details how these different types of requests correspond to varying levels of pressure that get placed on the psychiatrist.
Bolden and colleagues describe this point:
“First, when clients report problems they experience, the psychiatrist is put in a position to propose a treatment to address the problem. Second, when clients attribute a problem to a particular medication, in addition to offering a solution, the psychiatrist has to either accept or reject the client’s attribution. Finally, when the client requests or demands a medication change, the psychiatrist’s response is normatively constrained to either granting or rejecting the client’s request.”
A deeper dive into the results of this analysis demonstrates that there are different “phases” that occur throughout a typical “medicine check” appoint. The first phase involves the psychiatrist asking questions to assess the patient’s functioning. This data gathering stage is not an assessment of whether or not the patient has a diagnosis, the authors explain. They write, “The clients in this dataset have had a psychiatric diagnosis for a long time, so the issue is not whether they have a particular psychiatric condition but how well the condition is being managed by the current medications.”
Ultimately, this initial phase is to “evaluate how the current medications are working.” This is followed by an assessment of the client’s clinical state and then, a discussion of the treatment plan, including possible changes that could take place. Interestingly, the researchers found that clients initiate medication-related discussions during “activity boundaries”—in other words, at the transition points between these conversation phases.
In addition to this, client-initiated discussions manifested in a variety of ways:
Reporting a physical problem without attribution to medications. This strategy involves a client discussing a physical issue that they are experiencing that can be understood as a side effect of a drug. However, they do not mention the medication specifically.
Reporting a medication problem. In this strategy, clients discuss a particular physical problem and attribute the problem to current medication. This exerts a higher pressure on the psychiatrist than the first strategy, explain Bolden and colleagues. They write:
“When clients attribute a problem they experience to a particular medication, they constrain a range of appropriate responses, and thereby exert more pressure on the psychiatrist. Now rather than simply offering a solution to a problem, the psychiatrist is expected to validate (or reject) the client’s attribution and to grant (or reject) the implicit request for a medication change.”
Explicitly requesting a medication adjustment. In this approach, clients are openly asking for a medication change. However, this request is often crafted through what the researchers referred to as an “’I was wondering’ format.” They describe this to serve the function of conveying the “client’s low entitlement to making the request and a high contingency of the requested outcome. This format underscores the delicacy of the action and displays an orientation to respecting the psychiatrist’s professional authority on the matter.”
Demanding a medication adjustment. Through this approach, clients overtly express a preference or desire for something to be done regarding a medication change.
Bolden and colleagues discuss these findings within their context. For example, they note that the more indirect ways of approaching a medication change, such as reporting a problem, are commonly used and have the “advantage of preserving the boundaries of medical authority and expertise.” This form of initiation also fits more seamlessly into the structure of the session conversation in that it fits as a response to a “How are you doing?” question.
On the other hand, direct requests for medication changes put more pressure on the psychiatrist to respond by either granting the request or denying it. Clients tend to convey these requests in a way that presents low entitlement to the request alongside “high contingencies in it getting granted.” Direct requests are more likely to occur if an indirect request proved unsuccessful or if the psychiatrist has verbalized potential issues with the medication.
As they summarize their findings, the authors write:
“Initiating a medication discussion is an interactionally delicate task for at least two reasons: first, clients need to find a way to raise the issue without there being a systematic opportunity to do so within the organization of a routine appointment and, second, they have to articulate their medication preferences in ways that are sensitive to the fact that medical providers have the institutional authority to make (and in this psychiatric context, enforce) treatment decisions.”
They continue, “These difficulties are further exacerbated for patients suffering from a severe mental illness since they may be seen as not having sufficient insight into their illness and because they may resist taking psychotropic medications, many of which have uncomfortable side effects.”
Given this analysis, Bolden and researchers stress the importance of training psychiatrists to create conversation structures that invite explicit opportunities for patients to voice their concerns, experiences, and treatment preferences.
Bolden, G. B., Angell, B., & Hepburn, A. (2019). How clients solicit medication changes in psychiatry. Sociology of health & illness. doi: 10.1111/1467-9566.12843 (Link)