In today’s time-pressed practice of psychiatry, with its emphasis on the brief medication management visit, clinicians and patients alike often feel that time constraints limit their ability to forge a therapeutic alliance, thereby removing an important element in effective treatment.
Patients are generally well trained to ask questions such as how a medication works, when they can expect to feel something different, and what side effects to anticipate. Clinicians, for their part, are typically trained to discuss the pharmacology of medications, and to respond to these questions. Dialogue around these questions typifies a usual brief pharmacologic intervention.
But there are deeper questions and fears that patients may harbor but not know how to ask. These anxieties, if not explored with a trusting and empathic physician, can play a significant role in the overall efficacy of the treatment. These anxieties go further than concerns about the pharmacology of medications. Taking a medication that has the potential to alter one’s mind and personality is a daunting prospect. Some of these often-unasked questions include: “Will this change who I am? Will it take away my feelings? My spontaneity? My capacity for grief or sadness? Will I be less of a person? Will I be using this as a crutch? Will I become dependent upon this medication?” Another oft-unspoken concern: “You are giving me something to affect my mind. Do you know what you’re doing? Do you think a pill cures everything?”
If we open the door to the broader impact of taking psychotropic medications, we legitimize and validate such anxieties, and bring them into the therapeutic discussion. We also engage the power of the therapeutic alliance, believed by many to be a potent aspect of the “placebo effect,” and learn how to optimize this effect for our patient as an individual.
Patients often have had multiple experiences with other doctors and medications. We may be accustomed to asking what has been your experience with meds in the past, generally and specifically. But we are perhaps less inclined to ask, “What has been your experience with the prescribing doctors? Have you felt listened to and cared for? Have you felt that you were a partner in your treatment, or like a guinea pig? Have your concerns been heard? Do you think your relationship with your doctor can affect the outcome of your treatment? What kind of relationship works better for you?”
We recommend prescribers gain a greater sense of comfort in asking the following four questions as a start to opening a dialogue with our patients and establishing a greater alliance.
1. What does it mean for you to take a medication to treat these symptoms?
2. What are your biggest fears or anxieties related to taking this medication?
3. Do you think your relationship with your physician can affect the outcome of your treatment?
4. Would you feel comfortable telling me if something I’ve said or recommended does not sit well with you so that we can discuss it?
In addition to asking questions like the ones posed above, we must remember that our honest answers about psychotropic medication often times involves a degree of uncertainty. How often do we really know what a given patient can expect in terms of a subjective effect of a particular medication? How should we approach the uncertainty of our position? Some patients want to feel that their doctor has superior knowledge and do not want to hear our uncertainty, while other patients welcome the honesty and humanity in a collaborative approach. Personally, we are most comfortable with a collaborative partnership – together, we will observe the effects of this medication, positive and/or negative, and determine whether it is right for the patient.
At the same time, we are attuned to the idea that some patients do not prefer this approach, and want their doctor to know what is best and to believe in the “magicality” of a prescription from an all-knowing physician. By recognizing this possibility, we do not impose our preference for a collaborative partnership when it might create further anxiety in a patient. But we seek to learn more from our patients in this regard, and to accept that sometimes we are not the right fit.
Dr. Ascher is clinical assistant professor of psychiatry in the department of psychiatry at the University of Pennsylvania, Philadelphia. Dr. Baurer is medical director of the Kirkbride Center, Philadelphia, and president of the Pennsylvania Society of Addiction Medicine. He also serves on the faculty at Psychoanalytic Center of Philadelphia.