Mental health providers may not consider them ideal, but patients who present with a self-diagnosis for their symptoms and a specific medication request to make them better are a reality of modern-day practice.
Where such situations can get especially sticky is when a provider disagrees with a patient’s assessment and treatment plan.
Should providers assert their expertise, confidently explain they know what’s best, and potentially lose a vulnerable patient in need of help? During his session at the virtual Psych Congress Elevate conference, Andrew Penn, RN, MS, NP, CNS, APRN-BC, suggested a more collaborative approach.
“Really, what this talk is about is power in psychiatry, and how we wield power responsibly,” said Penn, an associate clinical professor in the University of California, San Francisco, School of Nursing, and an attending psychiatric mental health nurse practitioner at the San Francisco VA Health Care System Nurse Practitioner Residency Program.
Using Motivational Interviewing
Motivational interviewing is a useful tool to reach common ground with patients and set the stage for shared decision-making, Penn advised. The technique begins with expressing empathy, and empathy begins with mindful practice—specifically, the recognition that we each have filters through which we view the world. Or, as writer Anais Nin put it, “We don’t see things as they are, we see things as we are.”
“It’s naïve to say we don’t have biases,” said Penn, a member of the Psych Congress Steering Committee. “The question is, are we willing to examine our biases and begin to dismantle them?“
Motivational interviewing also requires a willingness to roll with resistance, or to blend with conflict to avoid direct resistance. The speaker likened the practice to the Japanese martial art Aikido, in which participants seek to defend themselves while also protecting combatants from injury.
During motivational interviews, providers should work to conversationally develop the discrepancy between where the patient is and where he or she would like to be. Using dialectic methods and encouraging self-efficacy in patients are nonthreatening ways to investigate options and arrive at responsible treatment choices together.
Addressing Unreputable Sources of Information
Online sources with questionable advice are a stumbling block for some patients.
“In general, I like the idea of information being available freely,” Penn said. “But the problem is, knowledge isn’t the same as wisdom, and it’s not the same as judgement.”
If a patient’s treatment of choice is based on questionable online sources of health information, Penn encouraged attendees to keep an open dialogue.
“Disagreement can deepen, rather than end, the treatment relationship,” the speaker advised.
In such situations, the following statements and questions for patients can help guide the conversation, according to the session:
• “Tell me what you’ve learned about this disease.”
• “What are the most common treatments?”
• “Was your information from a reputable source?”
• “Was the source trying to sell you a drug, supplement, or treatment?”
Occasionally, patients may pass on a provider’s treatment suggestion and pursue an alternative path—and still improve, Penn acknowledged.
“The placebo effect is a real effect,” he said, adding the patient-practitioner relationship plays a pivotal role in outcomes as well. In a study involving placebo acupuncture, for example, placebo acupuncture delivered with warmth, affection, and confidence outperformed placebo acupuncture delivered without such qualities.
What matters is not that the patient failed to cooperate with your advice, but that the patient found a path to improvement.
Demonstrating Humility, Defusing Power
Providers should also recognize that nonadherence to advice can be a response to life adversity and trauma. By equalizing power in the provider-patient relationship, trust can grow, Penn explained.
Demonstrating professional humility, defusing professional power with statements such as “I’m not here to tell you what to do but to be a consultant,” sharing knowledge, and providing treatment choices can shift power toward the patient and ease tension. Providers can then encourage patients to research using reputable sources, make their own decisions, and take responsibility for self-care with statements like “You are the expert in you.”
That doesn’t mean that a provider should relinquish all power, of course.
Penn shared an example of a young professional requesting a prescription for a performance-enhancing stimulant, which he had been purchasing illegally, to keep up with his peers at work. The provider tactfully and professionally declined, and explained why. Frustrated, the patient stormed out of the office.
“Sometimes we just have to be unpopular,” Penn said. “We have to be courageous, and do what’s right.”
— Jolynn Tumolo
“The self-prescribing patient: how do you treat them?” Presented at Psych Congress Elevate: Virtual; July 27, 2020.