How pressure is applied in shared decisions about antipsychotic medication: a conversation analytic study of psychiatric outpatient consultations

Abstract

The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decisionmaking and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations.

How Psychiatrists Recommend Treatment and Its Relationship with Patient Uptake

“…The findings are discussed in terms of potential explanatory mechanisms and clinical implications, including comparisons with recommendations (for new treatments) in UK primary care (Stivers et al, in press). Our findings contribute to a small but growing literature on psychiatric communication (Angell & Bolden, 2015; Bergmann, 1992; Bolden & Angell, 2017; McCabe et al, 2013; McCabe, Heath, Burns, & Priebe, 2002; Quirk et al, 2012; Thompson, Howes, & McCabe, 2016; Thompson & McCabe, 2016). …”

“…Yet, despite these advances in mapping decision-making practices in primary care, there has been relatively less examination of actual interactions between psychiatrists and patients and their negotiation of treatment (cf. Angell & Bolden, 2015; Bolden & Angell, 2017; Kushida & Yamakawa, 2015; Quirk, Chaplin, Lelliott, & Seale, 2012). …”

Attitudes towards shared decision making in mental health: a qualitative synthesis

“…patients in acute psychotic episode) or decisional situations like hospital admission as generally unsuitable for SDM (Hamann et al, 2006;Hamann et al, 2009). This is subsequently leading to paternalistic acting or even using pressure to patients (Quirk et al,, 2012). Providing information about adverse side-effects can be a facilitator to a certain degree, but it can as well discourage patients to accept treatment (Seale et al, 2006).…”

Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

“…For example, Quirk and colleagues list a range of interactional features that contribute to a more open decision, including that 'the doctor's wishes are communicated weakly', that 'the doctor allows the patient to reformulate the decision and reconsider it once made, and immediately acquiesces to patient resistance to treatment proposals', and that 'the decision is constructed as one that will be easy to reverse if the patient experiences difficulties' (p. 110). 55 Similarly, Collins and colleagues show how, when taking a more bilateral approach, the health professional 'actively pursues [the] patient's contributions, providing places for the patient to join in, and building on any contributions the patient makes: e.g. signposting options in advance of naming them; eliciting displays of understanding and statements of preference from the patient' (p. 2625).…”

“…54 Taken together, these findings imply that the practices used by clinicians to initiate decision-making are indeed best understood as lying along a continuum with respect to how free the patient is to make a choice -just as the three main models of decision-making suggest. This has been described 55 as a 'spectrum of pressure', running from 'pressured decisions' through 'directed decisions', to 'open decisions where the patient is allowed to decide' (p. 95). Similarly, a well-cited study of UK primary care consultations about diabetes, and secondary care ear, nose and throat cancer consultations, identified a spectrum of clinician approaches to decision-making, ranging from more 'unilateral' (or clinician-determined) to more 'bilateral' 56 (or shared).…”