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Chapter 23 - Medication Interest Model

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Chapter 23 - Medication Interest Model

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Medication Interest Model (MIM): Moving From Mere 'Adherence' to Genuine Interest and Effective Use: Introduces the concepts behind the Medication Interest Model (MIM) and its implications for improving patient adherence through increased interest and involvement in treatment.
References: Provides a comprehensive list of references used throughout the book, supporting further research and validation.
Conclusion to the Book: Summarizes the key insights and recommendations from the book, reinforcing the role of MIM in improving medication practices.

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CHAPTER 23
Medication Interest Model (MIM):
Moving From Mere “Adherence” to
Genuine Interest and Effective Use

Physicians are confronted by the particular souls of the individuals and families before them
… People want to know that their opinions and concerns are worthy of interest and response.
Robert Schuman, EdD
The Psychology of Chronic Illness1

INTRODUCTION
When patients are facing potentially devastating psychiatric disorders such as schizophre-
nia, bipolar disorder, and major depressive disorder, medications are often life
transformative or, in some cases – where suicidal ideation has arisen – even life saving.
Unfortunately, it can be a difficult decision to try a medication and to, subsequently,
tolerate its side effects while determining an effective fashion for controlling an illness.
Nevertheless, no matter how understandable the factors may be that are at play, we are
left with the disturbing fact that the number one reason for treatment failure in people
coping with major psychiatric illnesses is the fact that their medications are not taken as
prescribed or, in some instances, not taken at all. Such is the case with non-psychiatric
diseases as well, from diabetes and asthma to hypertension, cancer, and acquired immu-
nodeficiency syndrome (AIDS). As former Surgeon General C. Everett Koop, MD, ScD,
so elegantly quipped, “No medications work inside a bottle. Period.”2 It is hard to argue
with Dr. Koop on this one.
The amount of human suffering – to our patients and to those who love them – caused
by this lack of what is traditionally called “medication adherence” is truly staggering in
the field of mental health. At times it even leads to the end of our patient’s life – suicide.
Consequently, it is of immense importance to address this issue in any book on clinical
interviewing, for I believe the words that we use in talking with our patients about their
medications is one of the keys to transforming this complex problem. The Director of
the Colorado Health Outcomes Program, John Steiner, provocatively captures this fact
by reminding us “that our words are as important a part of the pharmacopoeia as the
medications themselves.”3

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e240 Specialized topics & advanced interviewing

The Medication Interest Model (MIM) directly addresses the above daunting challenge
to healing. The MIM has been evolving for over 20 years. It includes more than 50 behav-
iorally well-defined interviewing techniques. These interviewing techniques are housed
within a conceptual framework – the Choice Triad – which provides a reliable, logical,
and simplifying structure for understanding the many complexities of how patients
decide to try a medication as well as how they decide to continue or discontinue it. The
Choice Triad, which is easily utilized by both experienced clinicians and trainees, pro-
vides a platform for clinicians to rapidly and sensitively explore the thought processes
and emotional responses patients experience when using medications.
Moreover, transforming medication nonadherence has a lot more to do with our
patient’s souls, as our opening epigram hints, than is usually ascribed. By soul, I simply
mean “what makes our patients tick” psychologically and spiritually. Moreover, whether
we are psychiatric nurses or nurse clinicians, psychiatrists, psychiatric physician assistants,
clinical pharmacists, or case managers, we reach our patients’ souls through the power
of our relationships with them as forged by our words and nonverbal communications.
Thus, the resolution of the problem of nonadherence, to a large extent, ultimately comes
down to how we talk with our patients about their medications.
The MIM is a prototypic person-centered model of interviewing. If one were forced
to proffer one word that lies at the center of the model it would be the word “choice.”
Every single interviewing technique of the MIM is designed to enhance the patient’s
ability to consider whether the use of medication is the right choice for himself or herself,
and, if so, how to choose a particular medication and how to use it most effectively.
From the perspective of the MIM, the practice of “choice” and the issue of “trust” often
go hand in hand, leading directly to the heart of the therapeutic alliance. The patient’s
trust of any given clinician is frequently partially, and sometimes substantially, based
upon the patient’s observations of how the clinician discusses the use of medications.
This state of affairs is particularly accentuated if the clinician is expected to make a
medication recommendation by the end of the initial meeting. Obviously, in such
instances, the quality of the therapeutic relationship created during the earlier aspects of
the initial interview may greatly determine the likelihood that the patient will be inter-
ested in following the clinician’s recommendations. But, not so obviously, the reverse
may be equally true – the discussion about medications may determine the robustness
of the overall therapeutic alliance.
One can argue that, concurrent with the development of the overall “therapeutic alli-
ance,” a prescribing clinician must also develop a “medication alliance.” One can further
argue that this “medication alliance” may have a greater impact on the overall “thera-
peutic alliance” than vice versa. I would go so far as to assert that the fashion in which
a clinician handles the transaction over the potential use of medications may even deter-
mine whether or not the clinician and the patient will ever set eyes upon each other
again.
Let me be more specific. I am suggesting that the microcosm we call the “medication
alliance” may have a profound impact on, indeed may represent the primary determinant
of, the macrocosm we have traditionally in the field of mental health, and throughout
this book, called the “therapeutic alliance.” The discussion of medications in the initial

interview marks the first time that the patient and the clinician must truly arrive at a
difficult collaborative decision. In this regard, the process of this discussion represents a
pivotal database from which the patient will make a formulation of “who is this person
sitting across from me?”
From their initial discussion of medications, the patient will determine whether the
clinician is genuinely interested in various ways of approaching symptom relief or is
merely a “pill pusher.” The patient will gauge the clinician’s degree of actual concern by
how carefully and openly the clinician describes the benefits and side effects of the
medication. The patient will judge from the look in the clinician’s eyes, and from the
tone of his or her voice, whether the clinician is truly registering the patient’s concerns
about the potential side effects of the medication. Ultimately, the patient will listen to
the clinician’s recommendations in direct proportion to how well the clinician listens to
the patient’s recommendations.
If the patient leaves this first interview with a positive assessment of these clinician
characteristics, a second session will be more likely to occur. If such a meeting results,
one can bet that the process of evaluation of the clinician by the patient will continue.
This ongoing evaluation will undoubtedly be greatly based upon the dyad’s exchanges
of their opinions about medications.
The patient will determine the clinician’s ability to effectively listen by how carefully
the clinician explores the patient’s concerns about his or her side effects that have now
morphed from abstract possibilities in the first session to concrete realities in the days
preceding the subsequent sessions. It is one thing to hear about potential problems with
sleep. It is entirely a different thing to toss restlessly in one’s bed for 2 hours every night
before getting to sleep. The patient will decipher the collaborative proclivities of the
physician or nurse by whether the clinician is willing to change his or her medication
recommendations (stop a medication, lower its dosage, or switch to another medication
or, perhaps, an alternative intervention to a medication) based upon the patient’s input.
Put succinctly, exactly as Shuman emphasized in our opening epigram, “people want to
know that their opinions and concerns are worthy of interest and response.” The MIM
is all about this “listening.”
As emphasized repeatedly in this book, each patient–clinician relationship is unique.
And each patient–clinician relationship must define its own unique sets of expectations
and methods of joint problem solving. This process often begins, and sometimes ends,
over the discussion of medications. The remainder of this chapter is an effort to show a
variety of concrete techniques that can flexibly be used by clinicians to start this listening
and to enhance it with each subsequent meeting.
To accomplish this task we will divide our exploration into five parts. In Part 1, “Non-
adherence” – More Than Meets the Eye, we will better familiarize ourselves with the
characteristics and consequences of what has traditionally been called “nonadherence.”
In Part 2, The MIM: Development and Roots, we will explore the influences that impacted
on the creation of the MIM to understand how to use it more effectively. In Part 3, The
Spirit of the MIM, we will look at the underlying collaborative principles driving the
model. In Part 4, The Choice Triad: The Foundation of the MIM, we will turn our atten-
tion to understanding, at a sophisticated level, the fashion in which patients decide

whether to try a medication and subsequently stay on it. Finally, in Part 5, Practical
Interviewing Tips and Strategies of the MIM, by far our largest section, we will get down
to the “nitty-gritty,” examining in detail specific interviewing techniques that can be put
to immediate use in the hectic world of everyday practice.

PART 1: “NONADHERENCE” – MORE THAN MEETS THE EYE

Extent of the Problem
Whether one is discussing psychiatric illnesses such as schizophrenia and post-traumatic
stress disorder (PTSD) or non-psychiatric illnesses such as hypertension and diabetes,
hundreds of studies have found that patients with chronic diseases only take their medi-
cations as prescribed about 50–60% of the time.4 The actual number depends upon the
disease in question, but a large survey cited by the National Council on Patient Informa-
tion and Education aptly highlights the problem: nearly 31% of the patients had not
filled the prescription they were given, almost 24% had taken less than the recommended
dose, and 29% had stopped taking the medication before the supply had run out.5
Whether using as recommended or not, about one-third of patients with chronic illnesses
have strong reservations about the medications they are on – future examples of discon-
tinuance just waiting to happen.6
We need not look much further than the nearest mirror to see the ubiquitous nature
of what is traditionally called noncompliance or nonadherence – I, for one, know
that I haven’t always taken meds exactly the way I was supposed to take them. From
a struggling mother in a welfare line in Detroit to a wealthy e-business hotshot in a
ticket line on Broadway, from a soldier back from Afghanistan to a vacationer on a
Cape Cod beach, from a high school dropout to a Rhodes Scholar, all types and
shapes of people are guilty of “playing” with their meds. Nonadherence is everywhere,
it would seem.
Regarding psychiatric illnesses such as schizophrenia and bipolar disorder, the rate of
nonadherence is particularly striking. For instance, Lacro reviewed the literature on preva-
lence and risk factors for nonadherence in schizophrenia.7 Among the ten reports that
met a strict set of study-inclusion criteria, they reported a mean rate of nonadherence of
41%; those patients who met an even stricter set of inclusion criteria reported a 50% rate
of nonadherence.
There was some hope that the introduction of “atypical” antipsychotics with fewer
neurologic side effects would reduce rates of nonadherence to a clinically meaningful
degree, but this has not proven to be the case.8 Unfortunately, these medications have
demonstrated a new set of side effects such as weight gain and the triggering of the meta-
bolic syndrome/diabetes, which represent genuinely good reasons for patients who are
contemplating taking these medications to be hesitant to do so.
It is important to underscore that relapse is often the result of medication discontinu-
ance. Indeed, Robinson found that with patients who had been successfully treated for
their first episode of schizophrenia, discontinuing medication was the single most

powerful predictor of relapse.9 Patients who stopped taking their medication were five
times more likely to relapse than those who continued on medication.
Each relapse results in enormous personal suffering, family and community burden,
and increased health care costs. In addition, there is substantial disruption in psychoso-
cial and vocational functioning and/or interference in achieving personal goals. Psychotic
relapse is also associated with an increased risk of violence towards self or others, and
involvement in the criminal justice system.
Valenstein10 and Weiden11 have studied the impact of gaps in taking medication based
on prescription refill data in large populations of patients. They found that even a gap
in medication-taking as short as 10 days resulted in a doubling of the risk of hospitaliza-
tion. With longer gaps, the risk of re-admission to the hospital continues to rise signifi-
cantly, with gaps of greater than 30 days increasing the risk fourfold.
Indeed, discontinuation of medications can even result in the loss of our patients’
lives. In a fascinating, yet disturbing, study, Herings and Erkens reported on 603 patients
with schizophrenia in the Netherlands using a medication-dispensing and hospital dis-
charge database.12 Adjusting for age and gender, they reported that a 30-day gap in medi-
cation treatment increased the relative risk of suicide attempts a stunning 4.2 times.
(Thirty-three percent of the patients in their sample had a gap of at least 30 days.)
In contrast, utilizing medications as indicated often results in a significant decrease
in both positive and negative symptoms of schizophrenia13 as well as great relief in a
myriad of other psychiatric disorders. On a personal note, some of my most rewarding
moments in the field have been related to having patients plagued for years, even decades,
by the savage mood swings seen in bipolar disorder move into complete remissions
through the use of medications such as lithium and other mood stabilizers. Seeing people
whose lives had been ruined by bipolar process re-gain their normal personalities, poten-
tials, and dreams is an experience hard to put into words for all involved including
patient, family members, and clinician.

Nonadherence: The Nature of the Beast

It is clear from the above that nonadherence is not only common, it is commonly
devastating in its impact. The next question is, “Where does it come from?” We will spend
much of the remaining pages of this chapter exploring the answers to this question in
specific detail. For the immediate purpose of launching our discussion, it is useful to
look at the roots of nonadherence from a more general perspective.
Peter Weiden has pointed out that nonadherence tends to fall into one of two broad
categories.14,15 In the first category – “intentional nonadherence” – the patient makes an
internal active decision that he or she does not want to begin or continue with a medica-
tion as prescribed (either lowering the dose or stopping it entirely). In the second cate-
gory – “unintentional nonadherence” – external obstacles get in the way of a patient,
who otherwise wants to take the medication, from doing so. In this sense, Weiden points
out that the patient “cannot adhere.”
With regards to unintentional nonadherence, many external factors can block a
patient’s ability to utilize a medication. The problems can be as diverse as the cost of the

medications, difficulties remembering to take the medications (related to normal aspects

of forgetting or to cognitive impairments as seen in dementia and schizophrenia), the
complexity of multiple medication regimens, lack of transportation to the pharmacy,
language barriers to understanding directions for taking the medications, and interper-
sonal and cultural pressures to stop medications. Mueser has coined the term “medica-
tion follow-through” to describe the patient’s efforts to overcome these external obstacles.
He has also reviewed the psychiatric research that addresses methods for helping patients
to achieve effective medication follow-through such as mechanical timing prompters,
easier-to-use pillboxes, behavioral tailoring, dosage simplification, social skills training,
intensive psychoeducation strategies, and outreach programs such as Assertive Commu-
nity Treatment (ACT) Teams.16
All medication nonadherence can be viewed as stemming from either intentional
nonadherence or unintentional nonadherence, or some combination of the two. This
delineation allows clinicians to quickly focus upon specific internal or external factors
in an effort to transform nonadherence. Moreover, this classification forces clinicians to
always evaluate the role of patient choice as being paramount.
From its first inception, the MIM has recognized the importance of both intentional
and unintentional nonadherence. In order to avoid the negative connotations of the term
nonadherence, as well as emphasizing a positive person-centered perspective, the MIM
addresses the intentional aspects of patient choice as “medication interest” and the
ability to overcome external obstacles with the term coined by Kim Mueser “medication
follow-through.”
Indeed, the situational roadblocks to medication follow-through are not the emphasis
of the MIM, for the simple reason that the vast majority of research and innovation has
focused upon medication follow-through. In contrast, other than the pioneering inroads
made by motivational interviewing regarding medication adherence (nicely documented
but modest in results), minimal attention has been given to the topic of patient choice
in taking medications. The MIM was designed to right this imbalance. The model empha-
sizes the importance of viewing adherence as beginning with the one factor with which
the patient has direct control – patient choice – focusing upon interviewing techniques
and strategies for helping patients to make the very best choice that they can.

PART 2: THE MIM – DEVELOPMENT AND ROOTS

Development of the MIM
The MIM originated with insights gained from an “in-the-trenches” case management
team that was part of a research study sponsored by the Robert Woods Johnson Founda-
tion and led by Robert Drake from the Psychiatry Department of the Dartmouth Medical
School in the late 1980s and early 1990s. These teams were developed to help patients
with severe and chronic psychiatric disorders (all of the study patients had poorly con-
trolled schizophrenia, schizoaffective disorder, or bipolar disorder) who were also
suffering from concurrent alcohol and/or street drug abuse/dependence.17 This case

management study pioneered using Continuous Treatment Teams (CTT, often called ACT
Teams) to help the most ill of dually diagnosed patients, for all of these patients had
histories filled with suicide attempts, violent episodes, and/or multiple hospitalizations
– a cohort with traditionally minimal interest in taking medications.
I had the pleasure of developing and directing one of these teams. Our specific team
had a high success rate with medication interest and follow-through. By the end of the
4-year study, the team had decreased hospital days on average by 20 days per patient per
year,18 a result that seemed to correlate well with higher medication adherence rates.
From a concerted effort to tease out the interviewing techniques that seemed to be related
to this success (as well as asking our patients why they chose to stay on their medica-
tions), the MIM was born and evolved.
A second source for the MIM stemmed from a series of over 200 “medication interest”
workshops given by myself over an 8-year span in the late 1990s and early 2000s across
the United States and Canada. Participants representing a wide sampling of disciplines
including psychiatrists, psychiatric nurse clinicians/nurses, and other mental health pro-
fessionals as well as primary care physicians, nurses, and case managers attended. These
front-line clinicians were asked to share their best practices regarding interviewing tech-
niques that they had found to be useful in enhancing medication adherence. In the
subsequent years, and in an ongoing fashion to this day, these workshops continue, with
participants providing interviewing tips that enhance the ever-expanding and evolving
MIM. The evolution of the MIM also continues through interviewing tips given by readers
for inclusion in the “Interviewing Tip of the Month Feature”19 posted on the website of
the Training Institute for Suicide Assessment and Clinical Interviewing (TISA).20
Of particular note is the fact that over a hundred of the original workshops were limited
to primary care physicians, nurses, physician assistants, and case managers. These primary
care clinicians provided a wealth of interviewing techniques – designed to improve
adherence when treating illnesses such as hypertension, diabetes, asthma, congestive
heart failure, and AIDS – that were immediately appropriate for use with patients coping
with psychiatric illnesses. From their feedback it quickly became apparent that the theo-
retical foundation of the MIM (such as the Choice Triad) as well as its interviewing
techniques were equally applicable to psychiatric and non-psychiatric illnesses.
Consequently, the MIM was expanded for use with patients coping with all medical
disorders. It is now designed for use not only in psychiatric residency and graduate
programs in psychiatric nursing, but also as a core model of prototypic person-
centered interviewing in medical, nursing, physician assistant, and clinical pharmacy
schools. The MIM is appropriate for use in disease states ranging from diabetes,
congestive heart failure, and AIDS to depression and schizophrenia, although in this
chapter we will focus upon its use with psychiatric patients. The use of the MIM
across all common disease states encountered in primary care led to the publishing
of the book, Improving Medication Adherence: How to Talk with Patients About Their
Medications.21 This book is designed as a concise, core primer on the interviewing
techniques of the MIM for utilization in medical, nursing, physician assistant, and
clinical pharmacy schools as well as by residents and nurse clinicians across all dis-
ciplines including psychiatry.

Roots of the MIM

Pulling on Clinician Wisdom
Although motivational interviewing has made significant contributions to helping clini-
cians better understand and improve medication adherence, the MIM, hopefully, adds
a new and powerful additional approach. The MIM fully endorses the use of motiva-
tional interviewing as a tool for improving medication adherence and is in complete
agreement with the spirit of motivational interviewing as described in Chapter 22.
Moreover, the MIM agrees with, and utilizes, the general principles of motivational
interviewing such as the importance of collaboration, compassion, moving with the
patient’s concerns, and allowing the patient to discover his or her own personal reasons
for motivation.
On the other hand, the MIM did not derive from motivational interviewing. Nor did
the roots of the MIM grow from the same soil (borrowing a treatment approach from
substance use counseling and adapting its techniques and strategies to a different arena
– medication nonadherence). For the interested reader, the relationship between counsel-
ing approaches such as motivational interviewing and solution-focused interviewing
with the MIM has been nicely delineated by Cheng.22
The MIM grew from the belief that although many prescribing clinicians and case
managers encounter problems with medication adherence (and to some degree lack the
necessary interviewing skills to effectively engage patients around the use of medica-
tions), many other clinicians are talented at the process. Some clinicians are gifted at it.
Consequently, as mentioned above, the MIM was created by tapping the wisdom of these
front-line clinicians by talking with – and observing at work – mental health profession-
als such as psychiatrists, nurses, nurse clinicians, and case managers as well as subse-
quently doing the same with primary care providers.
As useful interviewing techniques were shared and delineated, an attempt was made
to see if a theoretical model of motivation would emerge (the Choice Triad) that could
be used to clarify and enhance the use of the many interviewing techniques that were
being discovered. Thus, the MIM evolved as a “bottom-up model” derived from the clini-
cians who are directly prescribing and following medication use with patients on an everyday
basis.

Pulling on the Wisdom of Educational Theory and Research

on Clinical Interviewing
Time … not enough of it. Clinicians are pushed by the pressures of contemporary practice
to move at an ever more feverish pace. In addition, less and less time and financial
support seems to be allotted to continuing education by employers and administrators.
What little time is left for education must be utilized effectively and be as productive
and enjoyable as possible. But there is a limit to the degree with which training times
can be decreased while still allowing for the effective acquisition of skills. Several
methodologies have added important gains in our abilities to train clinicians to use
interviewing skills more effectively to enhance medication interest. But such models of

counseling (motivational interviewing) and psychotherapy (solution-focused therapy,

cognitive-based therapies) are sophisticated. They cannot be learned quickly and their
mastery requires ongoing supervision and coaching.
The MIM is not a style of counseling or a psychotherapy. It is a collection of individual
interviewing techniques organized around a simplifying clinical construct, the Choice
Triad. Each technique is well defined, brief in nature, and easily taught and learned. No
doubt, one can become significantly more adept at employing the numerous interview-
ing techniques of the MIM through ongoing experiential training and supervision, but
learning even a single interviewing technique of the MIM may, in my opinion, signifi-
cantly improve a clinician’s ability to communicate more collaboratively with patients
about medications. To better understand how a single interviewing technique from the
MIM can be rapidly learned and subsequently implemented it is useful to review three
concepts discussed in our book: interviewing principles, interviewing techniques, and inter-
viewing strategies (see Glossary).
An interviewing principle is a guiding concept for approaching an interviewing task.
Interviewing principles help clinicians to recognize when to use specific techniques,
how to flexibly handle new situations, and how to be creative and “think on one’s
feet” while interviewing. On the other hand, interviewing principles do not show the
clinician concretely what words to use. Interviewing principles, because they are abstrac-
tions, are by their very nature sometimes unclear to trainees, open to interpretation,
frequently difficult to learn, and often notoriously difficult to test with regards to trainee
competence.
In contrast, an interviewing technique (which is a specific attempt to apply an inter-
viewing principle) is defined as being a behaviorally defined set of words (often a single
statement or a single question) that has been operationalized and tagged with a name.
Every interviewing principle in practice can be applied by the use of numerous interview-
ing techniques flexibly chosen to fit the unique needs of the client and the clinical task
at hand.
Consequent to their behaviorally specific nature, interviewing techniques are less likely
to be misunderstood by trainees than interviewing principles, are more easily learned, and
are quite easy to be objectively tested for competence (if asked to do so, the trainee either
does or does not use the interviewing technique required by the instructor with a patient
or role-player).
Moreover, two or more easily learned interviewing techniques can be sequenced together
to form an interviewing strategy. Earlier, in Chapter 17, we saw a nice example of a
sophisticated interviewing strategy, the Chronological Assessment of Suicide Events (CASE
Approach) designed to uncover the breadth and depth of suicidal ideation, planning,
and intent. The MIM has several short interviewing strategies.
Because the MIM focuses upon interviewing techniques, for the reasons described
above, the separate elements of the MIM tend to be easily taught, learned, and tested.
Thus the reader can learn as many or as few of the MIM interviewing techniques as is
personally desired, choosing to become proficient in those techniques that are most
natural to the reader and are most personally appealing. By becoming adept in a variety
of techniques, clinicians can learn to creatively choose the techniques that fit the unique

needs of any specific patient. The model also allows the clinician to create their own
techniques, maximizing creativity to suit the needs of the patient and the clinical context.
For readers interested in training other clinicians, as noted above, educational research
has shown that interviewing principles can be difficult to teach. In contrast, a myriad of
studies has shown that effective role-playing approaches have been developed that can
train clinicians to competency with regard to single interviewing techniques when they
are behaviorally operationalized (e.g., Alan Ivey’s “microtraining”).23–25 We have been
involved in the development of promising educational approaches that allow trainers to
teach complex interviewing strategies when they too are behaviorally operationalized
(e.g., Shea’s “macrotraining”).26 In addition, a style of group role-playing in which there
is minimal to no acting – scripted group role-playing (SGRP) – has proven to be unusu-
ally popular with workshop participants when learning both individual interviewing
techniques and complex interviewing strategies.27 Microtraining, macrotraining, and
SGRP are directly applicable for experientially teaching the clinical interviewing tech-
niques and strategies of the MIM.

PART 3: THE SPIRIT OF THE MIM

Collaborative Exploration: The Transformative Engine of the MIM
Choice. The spirit of the MIM arises with the simple acknowledgement that the decision
to put a foreign substance into one’s body – sometimes indefinitely – is not an easy
choice. Let us be blunt: many people have died from medications; vastly more have been
harmed by them. Oliver Wendell Holmes, Sr., a renowned physician from the 1800s acer-
bically wrote, “I firmly believe that if the whole materia medica as now used could be
sunk to the bottom of the sea, it would be all the better for mankind – and all the worse
for the fishes.”28 Fortunately we have a remarkably more effective and safe stable of medi-
cations today than we did in 1860, but, even today, medications must be used with
caution and respect, both for their powers of healing and for their potential side effects.
With this idea in mind, the MIM views physicians, nurses, or other prescribing profes-
sionals, as well as those who collaboratively follow medication use such as case manag-
ers, not as people whose goal is “to get” a patient to take his or her medications; rather,
their goal is to serve as knowledgeable and compassionate guides, who provide the
information that will allow patients the opportunity to make the best possible choice
for themselves. Of the prescribing dyad, only the patient puts the medication into his or
her mouth. Prescribers don’t suffer side effects, patients do.
We are reminded of a lesson we learned in Chapter 7 on treatment planning: an ideal
treatment plan that the patient will not follow is not ideal; it is foolish. In this regard,
treatment algorithms that are solely disease based (as with the patient has this disease
so this medication is the correct therapeutic choice) are prone to foolishness. In helping
the patient to choose an intervention, one must also consider contextual factors such as:
the patient’s personal beliefs, cultural beliefs, spiritual beliefs, and finances. Added to the
list are interpersonal factors such as the beliefs of family, friends, other patients, and
concurrent healers (for instance, practitioners of alternative medicine).

In fact, from the perspective of the MIM, the collaborative exploration does not begin
with the question, “Which medication should the patient choose?” It begins with the
question, “Should the first choice be something other than a medication?” Some forms
of hypertension and diabetes respond quite well to dietary changes, exercise regimens,
meditation, and deep breathing, none of which possess side effects. Many depressions
respond well to psychotherapies, changes in family dynamics, and spiritual revitaliza-
tions. Various alternative treatments hold promise, from acupuncture in pain to St. John’s
wort in mild depressions.
For a patient to trust us, we must always communicate our best-possible treatment
recommendation, which, at times, may include the use of a medication. Sometimes
patients agree. Sometimes they don’t. Sometimes patients prefer a plan of action not
involving medication use. In such instances, if we reflexively disagree with the patient’s
choice – try “to right the wrong” as motivational interviewers warned us not to do in
Chapter 22 – we may generate an unnecessarily conflictual atmosphere with the result-
ing loss of the patient’s trust. Alternatively, in many instances, we can genuinely suggest
that the patient should try his or her preferred choice. Indeed, we can enthusiastically
do our best to help the non-medication intervention to succeed in any fashion that we
can. After all, if the patient can achieve healing without a medication, so much the
better.
If, for some reason, the alternative choice fails, then the patient will discover for him-
or herself that it did not work, and is more likely to seek out the use of a medication. I
am convinced that such a process – allowing the patient to arrive at his or her personal
decision that the best intervention is a medication – is frequently, almost always, more
likely to result in enhanced interest in using and sticking with a medication. People want
relief from their pain. If they feel that a medication is the best way to get that relief, they
will seek it.
The MIM fully recognizes that a truly collaborative exploration of treatment options
necessitates an openness from the clinician that the patient is the expert of what impact
a medication is having on his or her disorder as well as upon his or her life. It is impor-
tant to carefully listen to what the patient is saying, not merely because it strengthens
the therapeutic alliance: It is important because the patient is frequently right.
In many instances, the dose is too high, the timing of the dose too rigid to allow
for effective use, the medication is not working, the medication’s side effects outweigh
its benefits, or a different medication might work better. Perhaps no medication at all
is the best course of action. Thus the spirit of the MIM is about collaborative listening.
The spirit of the MIM is about learning from the patient. Without question, if we learn
from our patients, they are much more likely to learn from us. This listening process,
this shared learning, this shared trust is at the heart of the medication alliance. The
bottom line is: Few patients will take a medication from a person unless they like that
person.

The Truth About So-Called Medication “Nonadherence”

There is a lot about nonadherence that we are not taught in our medical, nursing, and
graduate schools and in our psychiatric residencies. The nature of the phenomenon is

complex. The term itself is misleading. Indeed, in a very few pages from now, we will
abandon the word “nonadherence” altogether, replacing it with a more person-centered
term.
Here is the crux of the matter. Throughout our book we have emphasized the reality
that interviewing is a dyadic process. From a traditional perspective, medication nonad-
herence is defined as being that situation in which a clinician recommends a medication
and the patient does not do what the clinician is recommending. The patient either
refuses the medication, changes how it is taken, or stops it altogether. There is nothing
wrong with this definition. On the surface, it is exactly what happens. It is not so much
that the definition is wrong. It is that the definition is incomplete.
If one takes the time to actually watch what unfolds when a patient is concerned
about using a medication or is down-right refusing to do so, the truth of the matter
is that medication adherence requires a more complete definition. This can be stated
as, “It is when the patient is not doing what the clinician wants, and the clinician is
not doing what the patient wants.” It is a dyadic process. For every clinician thinking,
“I wish this patient would ‘get it’ that he needs his lithium to control his bipolar
disorder,” there is often a patient thinking, “I wish Dr. Shea would ‘get it’ that there
is nothing wrong with me, and I don’t want to keep talking about this stupid drug
of his.”
In essence, medication nonadherence is less something that one person does (the
patient) than it is an experience that two people share.
It is an experience that is often quite painful to both parties. We feel badly because
we know the suffering that is about to occur when our patient with bipolar disorder stops
his lithium. Our patient with bipolar disorder is pained by the fact that we do not under-
stand him for who he is, and we view him as having an illness that he feels he does not
have. We have a disagreement, a jarring one at that. The next question is, “How do dis-
agreements tend to solidify into rigid stalemates?” How does a disagreement become a
wall that separates the patient both from the clinician and from the healing options
offered by the clinician?
Let us look, for a moment, at everyday arguments that have nothing to do with medi-
cations, for they may shed light on how stalemates occur regarding medications. Truth
be told, debates tend to escalate into arguments when one of the two participants tends
to increase the push on the other, especially when that push includes a personal attack on
the other member as opposed to the other member’s beliefs. Think of politicians during
a campaign.
It is one thing to say, “I strongly disagree with you.” It is an entirely different
thing to say, “I strongly disagree with you, but that doesn’t surprise me because
you’re an idiot.” Think politicians. The fight is on. You can bet the attacked member
of the dyad is about to unload their own delightfully wicked cannon shot or tweet.
Note that often, not always, it only takes one of the two people to start the oppo-
sitional war.
Curiously, it is the same process at work when oppositional dyads settle themselves. It
does not necessarily take two to tango. Anyone who has done marital therapy knows that
two people screaming at each other do not spontaneously – at an identical moment – pull

back saying, “You know we just need to respect each other’s views, for we are both good
people.” I don’t think so.
Angry dyads tend to de-escalate when one of the two people pulls back a little. When
one of the two people decreases the push of the attack, when one of the pair softens his
or her words, sometimes just a bit, the stalemate often begins to crumble. If one of the
people in the couple says with a gentler tone, “You know I still disagree very strongly,
but I at least see where you’re coming from,” many times, not always, the other member
will reciprocate the softening with, “Well, I still feel I’m right, but I get where you’re
coming from a little better too.” At such a moment, frequently the originator of the
softening will soften even more in their next comment and the partner, too, will
reciprocate.
In short, angry dyads often de-escalate in a seesawing fashion. One person softens the
attack, the other reciprocates. The first to soften then softens even more, and the partner
once again reciprocates until the argument has cooled, and the therapist has a better shot
at getting a word in edgewise. The de-escalation often is initiated solely by one person
backing off.
Let us now return to the focus of our chapter, transforming medication nonadherence,
for it too is a dyadic process. Nonadherence is a roadblock shared by both people, indeed,
often partially co-created. Perhaps the best way to motivate patients to take medications
lies less upon focusing on how to change the patient’s beliefs and more on focusing how
to change the clinician’s beliefs or the pressure with which these beliefs are being
communicated.
According to the MIM, in many cases, a change in the beliefs (or communication
style) of only one of the two involved parties, in this case the clinician, is all that is
needed to kick-start the transformation into medication adherence. I should note that
in actuality – with the seriously ill dually diagnosed patients on our CTT – in many
instances we did not change our beliefs. I still felt that a given patient needed a mood
stabilizer, antipsychotic, or antidepressant. But what I could always change was how I
communicated my beliefs. Equally important, I could also change how I asked my
patients about their beliefs.
As clinicians, we have direct control over both our beliefs and how we express them.
As the above model suggests, on our original CTT we found that how we phrased our
questions and made our suggestions often resulted in a complementary change in how
our patients viewed the use of medication. Patients, over time, moved from disinterest
to interest, from nonadherence to adherence. What is this change in clinician
language?
In a sense, it all comes down to the following interviewing principle: Rather than
creating the sensation that we are moving “against them,” we want our patients to feel that
we are moving “with them” – that we are a team, not opposing armies. It is a principle that
reflects the process of collaborative exploration that sits at the very center of the MIM’s
spirit.
We can hold opposing views with our patients without being an opponent, depending
upon the words with which we choose to ask our questions and with which we share
our beliefs. Our words convey not only meaning. They convey relationship.

In Search of a New Word

The terms compliance and adherence should be abandoned because they subtly exaggerate
the importance of clinicians, describe behavior inaccurately, and shed little light on
motivations.29
Steiner and Earnest, 2000

As we have discovered, the single most pivotal concept of the medication interest
model is to create an atmosphere of “going with” patients as allies against their ill-
nesses as opposed to “going against” them as antagonists to their beliefs. This non-
oppositional stance is at the very heart of the model, its spirit, and, as we shall soon
see, its name.
Unfortunately, as John Steiner and Mark Earnest note in the above epigram, the most
commonly used terms – compliance/noncompliance and adherence/nonadherence tend
to set the stage for an oppositional field of communication. They also introduce other
distorting perspectives.
One of the major problems with the term “noncompliance” is that it implies that
clinicians are the ones who make decisions on treatment and that patients are merely
supposed to comply with these decisions. But there is more to the problem, for these
words also suggest that clinicians have more control over medication use than they really
do in actual clinical practice.
For example, the term compliance seems to suggest that clinicians choose medica-
tions, but clinicians do not choose medications. Patients do. And, as the sociologist Peter
Conrad pointed out, not only do patients choose which medications they want to take,
they decide exactly how they are going to take them, a process Conrad aptly calls the
patient’s “medication practice.”30 In the end, he explains, the only medication practices
that count are those practices that patients choose to do, not the medication practices
that physicians, nurses, and case managers tell them to do.
Another problem with the terms noncompliance and nonadherence is that they are
too generic, often yielding an inaccurate picture as to why the patient is not taking a
medication. These terms, which can exude a subtly pejorative undertone, are often casu-
ally applied, not only to that small percentage of patients who may be purposefully
oppositional – perhaps as the result of a personality disorder – but also to patients who
forget easily or have other external problems hindering medication follow-through. In a
similar fashion, patients who miss a dose twice a week are grouped together as being
“noncompliant” with patients who almost never take their medication. The terms are
also applied to patients who logically decide that one of the beliefs of the Choice Triad,
described below, has not been met.
According to sociologist James Trostle, who was one of the earliest pioneers in chal-
lenging the use of words such as “compliance” and “adherence” in his ground-breaking
article Medical Compliance as an Ideology,31 various alternative terms have been suggested
to replace “noncompliance” and “nonadherence,” such as “defaulting,” “self-regulation,”
and “self-management,” with some of the newest being “persistency,” and “reconcilia-
tion.” Although researchers have wisely attempted to refine these terms such that “primary

nonadherence” indicates a prescription not being filled and “persistency” refers solely to
long-term problems with use, none of these new terms seems to have caught on with
busy front-line clinicians.
Perhaps the best of the lot – “nonadherence” – is generally the most commonly used
in the parlance of today, but I believe it has a distinctly oppositional undertone. At one
level, terms such as “adherence” and “persistency” are certainly less oppositional sound-
ing than “noncompliance” and “nonadherence,” but for many clinicians they convey a
sterile and cold tone towards the patient/clinician alliance that does not reflect its warmth
in actual practice. Even the term “reconciliation” suggests that the clinician and the
patient are starting at opposite ends of a belief set and somehow resolve their views. In
contrast, the MIM suggests that from the beginning the patient and interviewer are col-
laborators, starting a joint venture.
Our original CCT was vested in finding a term that was positive in nature and that fit
a person-centered view of interviewing. We quickly hit upon the positive term “medica-
tion interest.” The term aptly captures the person-centered spirit of the entire model and
the philosophy behind it, hence the name medication interest model (MIM). The term
medication “interest” emphasizes that the goal of the clinician is not to choose the medi-
cation for the patient and subsequently make the patient comply or adhere to it; instead,
the term metacommunicates that the task is to help the patient arrive at his or her own
choice as reflected by their personal interest. As we have already noted, the patient’s
choice might even include the decision to not take the medication in the first place.
The concept of “medication interest” also emphasizes a point well acknowledged by
veteran clinicians that one of the main skills of a successful clinician is the ability to
teach. In the clinical trenches, the success of a clinician depends directly upon the clini-
cian’s ability to collaboratively explore the three steps of the Choice Triad, which we are
about to address, while providing accurate information (teaching) for use by the patient
in fashioning his or her own decision.
The case management team from which the model initially evolved found that terms
such as “noncompliance,” “nonadherence,” and “resistance” could be easily eliminated
from daily treatment planning meetings by using questions such as the following:

1. “How interested is Jim in taking his med?” (followed up with a question that provides
a concrete idea of the level of interest such as, “What percentage of the doses do you
think he is actually taking?”)
2. “If he was here, how would he list the pros and cons that have led to his low
interest?”
3. “Is his low interest related to the first, second, or third step of the Choice Triad?”
4. “Does anybody have any ideas how we could increase his interest?”
5. “How interested is his family in his taking the med?”

At last we have arrived at both a theory and a language with which to better understand
our patients’ interest in starting and perhaps continuing with their medications. We can
now turn our attention to the art of interviewing itself. It is time to move from theory
to practice.

PART 4: THE CHOICE TRIAD – THE FOUNDATION OF THE MIM

Non-adherence is rational behavior – it is driven by patient beliefs about their treatment,
disease, and prognosis as well as their objective experiences with their treatment and
disease.32
Colleen A. McHorney, PhD

In our original case management work with the seriously ill, dually diagnosed patients
(in which high rates of medication interest and follow-through were eventually achieved)
the opportunity arose to frequently ask the patients the following question, “How did
you decide to take this medication?” The question was designed to better understand the
fashion in which patients contemplate the use of medications and, once using them,
whether to stay on them. The hope was that such an understanding would lead to practi-
cal hints as to how to phrase the conversation around medications in the most collab-
orative fashion possible so as to create the sensation of “moving with” the patient. Over
the years, as the answers came in from our patients, they seemed to fall into three broad
categories.
Interestingly, as I subsequently began providing workshops for mental health profes-
sionals and primary care providers, both nationally and internationally, I had the rare
opportunity to ask the members of my audience the exact same question, for each and
every one of the audience members had been, or was currently, a patient. We may be
professional providers, but all of us have been on the other side of the stethoscope as
well. All of us have taken medications at some time, from antibiotics and cold capsules
to antidepressants, antihypertensives, and oral hypoglycemic agents. These workshops
offered a rare opportunity to hear from a large number of patients (possessing excellent
communication skills) about how people actually decide whether or not to take a medi-
cation and subsequently to stay on it. I always told my audience of professionals, “When
answering this question forget about your own patients. I want to know how you, per-
sonally, decide to take a medication. Please start your answers with the first-person word
‘I’ as in ‘I take a medication because …’”
The results have been, and still are in my current workshops on using the MIM,
remarkably consistent. Physicians, nurses, and other health care providers, both nation-
ally and internationally, tell me that they decide to take medications if the following
three broad criteria are met – the exact same three criteria the patients with schizophre-
nia, schizoaffective disorder, and bipolar disorder from our CTT study with dually diag-
nosed patients had related. People tend to take medications when they personally arrive
at the following three beliefs or steps:

Step 1: They feel there is something wrong from which they personally want relief.
Step 2: They feel motivated to use a medication because they believe it has the potential
to bring them relief from the perceived problem (or perhaps prevent a serious future
problem as with a vaccine).
Step 3: They believe that the pros of taking the medication outweigh the cons.

Nothing startling here. It appears to be common sense. In all of the workshops I’ve given,
I have never met a physician, nurse, clinical pharmacist, physician’s assistant, or case
manager who would ever take a medication (outside of “meds” such as vitamins or vac-
cines) unless they thought there was something wrong and felt motivated to get help
with the problem via the use of a medication. I have also never met a clinician who
would ever take a medication for which he or she thought the cons outweighed the pros.
Why would any intelligent person do so? And so it is with our patients.
By way of illustration, a typical 18-year-old male high school student experiencing
his first break of schizophrenia seldom believes that there is something wrong with
him (he does not accept Step 1 of the Choice Triad). If a clinician suggests taking an
antipsychotic for an illness that this 18-year-old does not believe he is experiencing, it
would be rather odd for the student to agree, would it not? Added to that, the clinician
must also alert the student that this medication might make his tongue dart in-and-out
like a lizard’s for the rest of his life, capping it all off with the following truthful state-
ment, “I might be able to reverse this but I might not.” I believe it would be odd indeed
to expect the student to reply, “Awesome Dude. Who wouldn’t want to be permanently
disfigured by a drug you want me to take for an illness I don’t even have. Sweet, let’s
do it Bro.”
I don’t see why one would expect such an answer. This student genuinely does not
believe that there is anything wrong with him. Exactly like ourselves, if we did not feel
that there is anything wrong, none of us would take a medication, especially an antipsy-
chotic that could cause tardive dyskinesia (TD) – so why should we expect a patient to
do so? I, personally, would never take a medication unless I felt there was something
wrong with me.
In this instance, refusing medications is not so much evidence of a person being
illogical, as it is evidence of a person being smart. Indeed, if he or she thinks that there
is nothing wrong, it is quite illogical to take a medication of any kind, let alone a medi-
cation that can cause serious side effects like TD or the neuroleptic malignant syndrome.
The student is making the exact same choice that I would make if I shared the same
belief. It just so happens that in this case, I don’t.
Once this insight is understood by a prescribing clinician, whether a psychiatrist, nurse
clinician, physician assistant, or other prescriber, it is a natural next step for the clinician
to develop a genuine respect for the patient’s decision-making process, for it is the same
as our own. While I may not necessarily agree with the patient’s database or the resulting
decision, I certainly agree with the patient’s logic and I respect the patient’s right to his
or her own personal beliefs.
A pioneering piece of research by Colleen McHorney, who provided the epigram at
the start of this section, retrospectively provided support for key elements of the Choice
Triad. In examining the reasons that 1072 patients stayed on medications or stopped
them, McHorney found that the three top reasons were as follows: (1) the patient was
convinced or not convinced of the importance of the medication (first and second steps
of the Choice Triad), (2) the patient worried that the medication would do more harm
than good (third step of the Choice Triad), and (3) it cost too much (one of the specific
elements of the third step of the Choice Triad).33 As we had discovered in the 1990s

through clinical interviewing, McHorney confirmed through research in the 2000s that
“nonadherence” is often a logical choice made by a logical consumer.
As we delineated in our section on the spirit of the MIM, our role becomes not one
of making a so-called “resistant” patient become compliant, but of helping a patient with
poor information become aware of the information he or she needs to make a wise
choice. We become teachers. Our goal is to increase our patients’ genuine interest in
trying a medication or staying on it once begun. It has been my experience that once
patients decide for themselves that there is something wrong that they want help with,
that a medication might provide them that help, and that the pros of the medication
outweigh the cons, they are often highly interested in taking medications. People don’t
like to be in pain. They will gravitate to whatever they feel will effectively end their pain.
I have also found that – as was the case with myself and my fellow team members on
the CTT – once psychiatric residents, psychiatrists, nurse clinicians, care managers, medical
students, and nursing students, as well as other health care providers and therapists, truly
understand this simple fact – that patients refusing medications are often making the same
decision we would make if we shared the same belief set – it is rather remarkable how deeply
it changes their attitudes towards so-called “resistant” patients. More importantly, it
changes how these providers come across to their patients, both verbally and nonverbally,
often disrupting a troublesome atmosphere of potential patient/clinician opposition
before it can become a problem. Instead, this potentially oppositional dynamic is replaced
with an evolving patient/clinician medication alliance based upon the collaborative
exploration that drives the spirit of the MIM.
I am, once again, reminded of a great quote by Armond Nicholi, Jr., that we noted
earlier in our book but is well worth repeating here:

whether the patient is young or old, neatly groomed or disheveled, outgoing or withdrawn,
articulate, highly integrated or totally disintegrated, of high or low socioeconomic status,
the skilled clinician realizes that the patient, as a fellow human being, is considerably
more like himself than he is different …34

From the perspective of the MIM, and from our understanding of the Choice Triad, con-
cerns that a patient has about medications, the unilateral changing of how a patient is
taking their medications, and a patient’s discontinuation of medications is not viewed,
with few exceptions, as oppositional behavior. Instead, it is viewed as logical behavior
based upon the fact that the patient does not believe one of the three steps of the Choice
Triad. We do not take medications unless we believe these three steps. I see no reason
why we would expect a patient to do so.
Interestingly, even if the 18-year-old from the above illustration had testily responded
to our suggestion with, “I don’t need your medication. I don’t want your medication.
I’m not going to take your medication. And I’m about to tell you where you can put
your medication [and he is not referring to a medicine cabinet here],” we would still
not view it as oppositional behavior from the framework of the MIM. He is simply
angrily responding to what he feels is interpersonal pressure to take a medication that
is patently inappropriate for him to take, for there is nothing wrong with him, therefore
it cannot help him, and it has remarkably dangerous side effects. No wonder he is angry.

Moreover, if this is the first meeting of the patient with this prescriber, he will most
likely see little reason to trust this person in future meetings, if indeed there ever is a
future meeting.
From the perspective of the MIM, the term “oppositional” is used in a specific manner.
A person is viewed as being oppositional if they are disagreeing with the clinician on
purpose because the patient wants to anger or hurt the clinician. An oppositional patient will
refuse to cooperate even if he or she agrees with the clinician’s recommendations, in this
case to begin a medication. This is certainly not the case with the student above who
genuinely feels that there is nothing wrong with him.
Oppositional refusal of medications sometimes occurs within the context of problem-
atic personality dysfunction such as seen with borderline or passive-aggressive dysfunc-
tion, but, in my opinion, such oppositional behavior is a relatively infrequent cause of
low medication interest or poor medication follow-through. In contrast, most people
who choose against using medications do so because they do not believe one of the steps
of the Choice Triad.

PART 5: PRACTICAL INTERVIEWING TECHNIQUES AND STRATEGIES FOR

ENHANCING MEDICATION INTEREST AND USE
We prescribing clinicians continue to struggle with the most basic of problems: how to get
our patients to take the pills that we think they need in the way we think they should. As
efficacious as the medications are in research reports and clinical studies, they cannot be
effective without moving from the prescription vial to the patient’s body.35
James M. Ellison, MD, MPH
Clinical Director, Geriatric Program
McLean Hospital, Belmont, Massachusetts

Building the Medication Alliance: Toolboxes for Collaborative Exploration

In Part 5, we will explore a wide variety of interviewing techniques for enhancing medi-
cation interest that address the dilemma so adroitly framed by James Ellison above. These
techniques will allow us to flexibly adapt to the unique needs of each patient we treat.
From our survey, the reader will be able to develop an individualized set of interviewing
techniques with which they are personally comfortable and which are diverse enough in
nature that the clinician can utilize them to transform the various roadblocks to medica-
tion interest that complicate everyday practice.
The reader is invited to pick and choose from the following techniques and even create
new ones that feel comfortable and provide increased flexibility. There is no “right way”
to talk with patients about their medications. But the MIM provides an avenue upon
which each clinician can create his or her own way, moving the interviewer from a merely
habitual method of discussing medications with patients to the intentional style of
skilled collaborative interviewing we have so valued throughout the pages of this book.
It is a collaborative style that can transform lives and sometimes even save them.

Each of the MIM techniques functions as a gateway to this collaborative exploration.

In many instances, the patient’s immediate response to the questions provides an accu-
rate and complete picture of the patient’s beliefs. In other instances, the gateway created
by the interviewing technique will require further collaborative exploration to better
understand the patient’s perspectives and the nuances of the patient’s beliefs. To effec-
tively accomplish this exploration, the clinician need only utilize the engaging explor-
atory techniques described in Chapters 1–4 of this book. In short:

1. Use many open-ended techniques such as open-ended questions (“What are some
of your concerns about using this medication?”) and/or gentle commands (“Tell me
more about your concerns about this medication”).
2. Appropriately utilize closed-ended questions to ensure accuracy of your understand-
ing and to improve engagement by metacommunicating a keen interest in clearly
understanding the patient’s beliefs (i.e., “How many hours is it actually taking you
to fall asleep on this medication?”, “Does your wife have some concerns about the
side effects you are experiencing?”, “Would you want to stay on this medication if we
could get rid of your side effects by cutting your dose in half?”).
3. Use empathic statements if, and when, needed to deepen engagement. (Remember
that an overuse of empathic statements can feel awkward or artificial to a patient who
is already well engaged and such an overuse can even be interpreted as patronizing.)
4. Don’t be afraid to use gentle humor in a relaxed and well-timed fashion if you feel
it will help with engagement and communicate a reassuring warmth and concern.

With the intense time limits of contemporary practice, in order to effectively utilize spe-
cific interviewing techniques for enhancing medication interest, it becomes critical that
interviewers possess a flexible framework for recognizing when to use such techniques.
Time is of the essence. In a matter of mere seconds, interviewers must be able to recognize
when their patients are experiencing concerns regarding a medication that is being sug-
gested (or that is already being used). Interviewers must subsequently be able to uncover
such concerns and possess a flexible method for sensitively addressing these concerns
on the spot in a caring fashion. This is no easy task. The MIM was designed to provide
practical help for this exact type of challenge. Moreover, the reader will find that many
of the techniques described in the following pages are also effective for communicating
with patients via e-mail or texting in today’s wired society.
Towards these goals, the Choice Triad will provide an excellent method for spotting
“where the patient is at” regarding medication interest and choice. Our understanding
of the principles of the Choice Triad will provide a reliable system for alerting us when
a psychological need or concern of a patient is about to result in refusal or discontinu-
ance of a medication, offering the clinician an opportunity to either transform the dis-
continuance before it damages the patient or, perhaps, to discover that the patient is
correct and a different medication is worth trying or perhaps an approach without a
medication is indicated.
As mentioned earlier, because the MIM emphasizes the use of “interviewing tech-
niques” (well-defined, behaviorally concrete interviewing questions or statements that

are tagged with a logical and easily remembered name), the clinician has immediate
tools from which to creatively meet the patient’s concerns. In this sense, we are not
unlike skilled craftspersons that have, over the years, created toolboxes filled with a wide
variety of well-tested tools, each of which has its specific purposes and advantages/
disadvantages. Depending upon the type of wood, or the type of structure the craftsper-
son is creating, he or she selects the most effective tools for the purpose, always working
with the medium and never forcing an ill-conceived approach that goes against the grain
of the medium.
Similarly, our goal is to help our patients to find for themselves the most effective
approach for healing that will work for them, not us. The patient’s ultimate choice may
or may not include medications. If a medication, in actuality, offers the best chance for
healing, the MIM will significantly enhance the likelihood that the patient will choose
to use a medication. And if the patient chooses medications, we will help them to choose
the best possible fit from the patient’s perspective and culture.
We will find that there are “core toolboxes” comprised of specific interviewing tech-
niques for each step of the Choice Triad. In addition, there are a variety of other “specialty
toolboxes” designed for specific clinical situations regarding medication interest such as:
first introducing our personal approach to the use of medications to a new patient,
addressing potential concerns during initial use of a medication (related to cultural
factors, the influence of the media and the web, interpersonal pressures to not use the
medication), accessing family suggestions and concerns, dealing with ongoing medica-
tion use (sensitively exploring concerns about side effects and effectively addressing such
concerns), accurately assessing the patient’s actual medication practice and the number
of missed doses. Familiarity with the various interviewing techniques from each toolbox
allows the clinician to creatively choose those techniques best suited for that particular
patient’s need and that feel the most comfortable for that particular clinician (for all
clinicians must develop their own style, picking and choosing the most personally
appealing techniques from the array available).
Two points are important to emphasize: (1) With any given patient, depending upon
time constraints and clinical context, the interviewer will use only a relatively small number
of the following tips – sometimes only one or two – in a given appointment with a patient. Other
techniques can be used in subsequent appointments as deemed useful and as time
permits. The beauty of the MIM is that even a single technique can help create a collab-
orative medication alliance that may improve medication interest and use. Flexible,
ongoing use of various techniques can create an ever deepening and powerful alliance.
(2) The MIM techniques are not used in a solid block of time during the interview. The
toolboxes are utilized throughout the initial interview and subsequent medication checks as
needed and where the individual interviewing techniques most naturalistically fit for the patient.
For instance, the specialty toolbox on understanding the patient’s general attitudes about
medications and past experiences with medications is often used in the initial interview
when expanding the past psychiatric treatment history. In contrast, the toolbox tech-
niques designed to help clinicians introduce their personal approaches to how they use
medications falls much later in the initial interview during the closing phase when col-
laborative treatment planning is occurring.

With these caveats in mind, we are ready to assemble our toolboxes. To ease our
familiarization, we will organize our study of the various toolboxes in the following sec-
tions: (1) toolbox for the first prescription, (2) toolboxes for the three steps of the Choice
Triad, (3) specialty toolboxes for difficult clinical challenges encountered in everyday
practice. Let us begin at the beginning.

Section 1: Toolbox for the First Prescription

The Medication Passport
Many of the patients entering our offices have been on a long journey regarding the
medications that they have taken for their psychiatric disorders from depression to
schizophrenia. Many patients have seen many clinicians, many offices, and, in some
instances, many inpatient units. Even if a patient is seeing a mental health prescriber for
the very first time, they undoubtedly have had a previous history with primary care pro-
viders prescribing for non-psychiatric illnesses from pneumonia to hypertension.
Some of these encounters have been good. Some, not so good. Thus patients enter
our offices with preconceptions, expectations, and fears of what, and whom, they are
about to encounter behind the office door. Sometimes they have every right to be
worried. They have encountered pill-pushers who have had little interest in what the
patient wants or believes. Other times, they have been fortunate to have met talented
clinicians, who have listened carefully and helped to relieve their pain markedly. So much
the better for us, for these patients are anticipating good care. Nevertheless, all patients
have a track record with prescribers and the medications they prescribe. Each patient
arrives at our office for a first appointment with a certain degree of attitudinal “baggage”
in tow. This baggage will often shape the patient’s level of interest in our first
prescription.
One can view this treatment journey, sometimes decades in length, as being recorded
in a psychological “medication passport” of sorts. It is useful – I would argue, critical – to
get a look at this passport before recommending a new medication or a change of medi-
cations during a first meeting. A good understanding of how the patient views medica-
tions can greatly alter how we first suggest them and even whether or not it is wise to
suggest them as a first line of intervention. A new interviewing principle has emerged
that is simple in theory and powerful in practice: Before prescribing a first medication, review
the patient’s medication passport. The following two interviewing techniques show how to
put this principle into practice. They often fit naturalistically in the section of the initial
interview when one is expanding the past psychiatric treatment history. Occasionally they
may arise naturally when expanding the History of the Present Illness:

Tip #1: Exploring the Medication Passport

“How do you feel about the current medication you are on for your depression?”

“Have there been any psychiatric medications that you either really liked or really
disliked?”

or if the patient is not on current medications:

“What are your feelings about psychiatric medications in general?”

Tip #2: Exploring for Medication Sensitivity

“When you take medications, have you generally found that you are particularly sensi-
tive to them?”

or a slightly different variation is worded as follows:

“Do you feel that you tend to get bad side effects on medications?”

In our first encounter with a patient, two opinions exist about every medication pre-
scribed: the prescriber’s and the patient’s. With regard to whether or not the medication
will ever leave the bottle, in the final analysis, only the latter opinion counts. The above
passport questions can help the clinician uncover the patient’s true opinions. They can
subsequently help us to shape the patient’s receptivity to using a medication, while
simultaneously shaping the patient’s views of us as trustworthy listeners.
If the patient describes fears of being overly sensitive or having had bad experiences
with medications, it is useful to follow up with an open-ended question such as, “What
types of bad experiences have you had?” or “What are some of the things you have
encountered that have shown you that you are overly sensitive to medications?”

Follow-Up on Uncovering the Patient’s Medication Passport

If it is clear that the patient is, indeed, sensitive to medications (each person’s body
handles medications differently, indeed, genetic and racial variations can greatly alter
blood levels at similar doses) or if the patient perceives him- or herself to be overly sensi-
tive (when he or she may not be), it makes no difference in how we approach the first
prescription. It should be approached with great caution and appropriate sensitivity to
the patient’s concerns. The patient’s perception of sensitivity (whether accurate or not) is key
to the patient’s subsequent interest in taking the medication. If the patient has concerns about
sensitivity, I have found the following interviewing technique to be useful. I use it late
in the initial interview, during the closing phase when treatment brainstorming and
recommendations are being discussed:

Tip #3: The Mini-Dose Recommendation

After starting to write the paper prescription or typing up an e-script, I pause, look up at
the patient and say something like this:
“Mrs. Jenkins, would it be okay with you if I start you off at one-half of the recom-
mended starting dose for this medication because of your history of being sensitive to meds?
I think this would be a smart way to start you off. I call this a mini-dose, and I think it
is a very gentle way to begin medications. This way, your body can get a feel for the medi-
cation first before we give you much of a dose. Any side effects, and there might not be

any with this little of a dose, will probably be much smaller in nature. Then, when you
are feeling comfortable on the medication, we can slowly increase it to get you feeling
better and better. By the way, at this tiny dose you might not get any benefits from the
medication but I just think it is a smart way to start because of your sensitivity. What do
you think?”

The above techniques, concerning our patient’s medication passports, look good on
paper, and in practice I have been pleasantly surprised just how effective they can be in
both spotting patients who have concerns about medications and in helping to ease those
concerns when present.
I vividly remember a woman who had been suffering with a major depressive episode
for years who had discontinued five consecutive antidepressants, “because they all cause
me horrible side effects.” She had also been in ongoing psychotherapy with little relief.
After exploring her medication passport carefully using the first two MIM techniques
above, I employed the “mini-dose recommendation” (at one-fourth the typical starting
dose). We gradually increased the dose over several months at tiny amounts and at her
own pace until we arrived at a therapeutic dosing. She went into a complete remission,
commenting that her psychotherapy with me seemed much more useful as well, “Because
the medication made me feel better so that I could do the psychotherapy better.”

The Past Prescribers Passport

As intimated above, during the patient’s treatment journey the patient has often encoun-
tered many prescribing clinicians. Patients may not only have experienced “problematic
drugs” but also, unfortunately, “problematic prescribers.” Thus each patient comes to our
office carrying a “prescriber passport” as well as a medication passport. If a patient has
a history of bad encounters with prescribers, it is very easy for the patient to anticipate
that we will fit the same mold. Such a projection can be devastating to future medication
interest with us. Our next interviewing principle mirrors our previous one: Before prescrib-
ing a first medication, take a look at the patient’s prescribers passport. The following interview-
ing technique, which can be worded with some degree of variation, puts the principle
to use:

Tip #4: Exploring the Prescriber Passport

“How have you felt about your previous clinicians and their medication
recommendations?”

or if the patient is a direct transfer:

“What are your feelings about your last psychiatrist (nurse clinician, physician assis-
tant, or other prescriber)?”

Introducing Your Personal Approach to Using Medications to the Patient

In the initial encounter there exists no single correct way for a psychiatrist, nurse clini-
cian, or other prescribing provider to introduce his or her approach to prescribing

medications. Each of us will vary what we say depending upon our own beliefs and the
differing needs of each of our patients. The following techniques are not presented as
the “right way” to do it, but merely emphasizes that we must all give considerable
thought to how we do it.
In the harsh time demands so common to this age of managed care, it can be easy to
omit the few minutes it takes to discuss with our patients our general views on prescrib-
ing meds. I think it is often a mistake to do so. These 2 or 3 minutes may prove to be
one of the most critical components of establishing a powerful and reassuring medica-
tion alliance. It may well set the stage for all future medication interest in our patient.
These 3 minutes, if successful, may save hours of the preventable time required for
follow-up appointments needed with a patient who is decompensating because of not
taking his or her meds. Moreover, patients who have discontinued their meds may require
hospitalization, requiring large amounts of time on the part of the treating clinician. The
interviewing principle at hand is a simple one: Before recommending your first medication,
take the time to introduce your personal approach to prescribing medications. The following
three tips provide prototypes for putting this principle into practice. Clinicians tend to
use them in the closing phase of the interview:

Tip #5: The Medication Interest Opening

“My goal as a psychiatrist (nurse clinician, physician assistant, clinical pharmacist, etc.)
is to always give you my best advice, whether that advice is to start a medication, stay
on it, or get off it. Together we want to find a medication that you are genuinely inter-
ested in taking because it makes you feel better. You’re the one who is putting the medi-
cation in your body so it’s your opinion that is most important, not mine. Obviously, as
a physician (nurse clinician, other prescriber), I have tremendous respect for medications
and I have found them to be very helpful in many patients. I also have a healthy respect
for the fact that medications can cause problems too. In my own life, I only take medica-
tions when I feel that I really need them and I feel that the benefits will outweigh the
costs. I take the same approach with my patients. So I don’t suggest a medication unless
I really have a feeling it will help you. I would never recommend a medication that I
myself would not take or give to one of my family. And I always try to fill my patients
in on any possible side effects as well as the pros and cons of using the medication. How
does that sound to you?”

With a single, elegantly effective statement –“Together we want to find a medication that
you are genuinely interested in taking because it makes you feel better” – the clinician
fosters both a sense of collaboration and spotlights the goal that such a collaboration
can achieve: relief from suffering.
While forging the initial medication alliance, it is useful to further highlight the
importance of the patient’s input. I am once again reminded of the wise words of Robert
Schuman in the opening epigram of our chapter, “People want to know that their opin-
ions and concerns are worthy of interest and response.” The following technique reas-
sures the patient that such shall be the case by stamping it into the initial bond between
the prescriber and the patient:

Tip #6: Introducing Shared Expertise

“I look at it that you and I are both experts. Hopefully, I know a lot about medications
and how different medications can help in different ways and I can call on years of experi-
ence, as well as other colleagues to help. You are the expert on your own body. The medi-
cation goes in you, not me, and so I’m totally dependent on you to tell me if it’s helping
or not and also if it’s causing any side effects. I’m counting on your input. You know your
body better than I do. And I think we can be a great team in finding a medication that
works well for you – that really makes you feel better. How does that sound to you?”

People also vary on how comfortable they feel about sharing their opinions with physi-
cians and other prescribers, especially about side effects. Some of this hesitancy has been
inculcated by long-standing but outdated cultural norms such as, “I should do as the
doctor says.” Peter Weiden, in complete resonance with the spirit of the MIM, emphasizes
that interviewers must sometimes actively help patients to move away from this “obedi-
ence mode,” as he describes it in his insightful article, “The Adherence Interview: Better
Information, Better Alliance”.36 Indeed, this process of de-activating the obedience mode
is an ongoing process that must be addressed again long after the first meeting, as we
shall see Weiden demonstrate with several specific techniques later in this chapter. In any
case, it is often expedient to start this de-activation from the very first encounter when it
comes to reporting side effects. In short, the phrase from the technique of Introducing
Shared Expertise, “The medication goes in you, not me, and so I’m totally dependent on
you to tell me if it’s helping or not and also if it’s causing any side effects” may not be
enough.

Tip #7: The “Call Me First” Invitation

“By the way, I really do mean that I want to hear about any side effects you may be
having. For different reasons, people sometimes are hesitant to let their provider know
about side effects, but I really want to know. Sometimes we can reduce them or even get
rid of them, and sometimes we may need to stop the medication. And if, for some reason,
you start getting a side effect, please call our office before you do anything. I’ll let you
know what I think is happening and you can decide what to do. Even if I’m not available,
one of our staff will talk with you and will provide advice. But try not to stop any medica-
tion without talking with me or one of my staff first. Sometimes it isn’t a side effect. And
some types of side effects even go away shortly after appearing as your body adjusts. In
any case, I really am your consultant. In the end, you’ve got to call the shots, but be sure
to use me.”

We began this section with an interviewing principle: Before recommending your first
medication, take the time to introduce your personal approach to prescribing medica-
tions. We have now looked at three interviewing techniques: the Medication Interest
Opening, Introducing Shared Expertise, and the “Call Me First” Invitation that can be
used to implement this abstract principle in the real world of a hectic clinic. If one would
choose to pair two of these techniques sequentially, or perhaps all three, one will have

utilized a specific interviewing strategy that can be easily learned and remembered for
practical use. The weaving together of the above techniques into an interviewing strategy
is given the name “Forging the Medication Alliance.” Let’s see how a clinician can effec-
tively and naturalistically use it:
We will imagine that the patient, a mid-level manager from a large retail chain, has
just moved to Manchester, New Hampshire, from Pittsburgh, Pennsylvania, secondary to
a job relocation. In this instance, the patient is being transferred from one clinician, a
psychiatrist, to another. The patient is already on an antidepressant that has been reason-
ably effective, for a moderately severe depressive disorder. The patient has had several
severe depressions in the past requiring hospitalization. We are picking the conversation
up in the closing phase of the initial interview in which the clinician and patient are
collaboratively sharing opinions on what is going on and how to proceed with treatment
planning:

Clin.: Levon, this is your first appointment here, and before we talk a little about some of
my ideas about possible treatment I’d like to talk a little bit about how I use
medications. First, let me just reassure you that unless there is an emergent reason
to do so, or unless you really want me to, I don’t make any suggestions about
changing medications in a first meeting. I would like to get to know you better and
what you are dealing with before I make any suggestions for changes, if indeed I
have any. I also know it can be a little unnerving to switch doctors. Especially if
you’ve … I see that you’ve been seeing Dr. Travis for almost 15 years. That’s a …
Pt.: Long time?
Clin.: Right.
Pt.: Yeah, I really liked her.
Clin.: I can see why. From her notes, it looks like she took great care of you. What did
you like about her? (Exploring the “prescribers passport”)
Pt.: I don’t know exactly, hmmm, she was just, I don’t know, low key, sort of an average
kind of person, but really bright. I just liked her. Felt comfortable with her. I don’t
know.
Clin.: Well, I’m hoping you’ll like me too. In fact, it’s very important to me that you feel
comfortable with me and how I use medications, so that’s why I thought I should
share with you a little bit about how I approach medications in general, because
each doctor may be a little different. Is that okay?
Pt.: Yeah, sure.
Clin.: My goal as a psychiatrist is to always give you my best advice, whether that advice is
to start a medication, stay on it, or get off it. Together we want to find a medication
that you are genuinely interested in taking because it makes you feel better. You’re
the one who is putting the medication in your body so it’s your opinion that is
most important, not mine. Obviously, as a physician, I have tremendous respect for
medications and I have found them to be very helpful in many patients. I also have
a healthy respect for the fact that medications can cause problems too. In my own
life, I only take medications when I feel that I really need them and I feel that the
benefits will outweigh the costs. I take the same approach with my patients. So I
don’t suggest a medication unless I really have a feeling it will help you. I would
never recommend a medication that I myself would not take or give to one of my

family. And I always try to fill my patients in on possible side effects and the pros
and cons of using the medication. How’s that sound to you?” (the Medication
Interest Opening)
Pt.: Sounds good.
Clin.: I look at it that you and I are both experts. Hopefully, I know a lot about
medications and how different medications can help in different ways and I can
call on years of experience, as well as other colleagues to help. You are the expert
on your own body. The med goes in you, not me, and so I’m totally dependent on
you to tell me if it’s helping or not and also if it’s causing any side effects. Make
sense? (Introducing Shared Expertise)
Pt.: Sounds good to me (pauses) … I hope you know what you’re talking about (smiles
with a joking tone of voice).
Clin.: (smiles) Yeah, let’s hope so (continues with patient’s use of humor). I’m curious,
how comfortable do you feel talking with your doctor about side effects and things
like that, because people vary on that point. (interesting variation on the “Call Me
First” Invitation, for the interviewer has decided to start the technique with a
question)
Pt.: Oh, I’ll tell you, you can count on that. I want to know what’s going on. I’m not a
big one for surprises (smiles).
Clin.: Either am I (smiles). Which brings up another point. If for some reason you start
getting a side effect, please call me, before you do anything. I’ll let you know what I
think is happening and you can decide what to do. But try not to stop any
medication without talking with me first or if I’m not available one of my staff will
be sure to talk with you, and they’re great (the “Call Me First” Invitation).
Sometimes it isn’t a side effect. And some side effects even go away shortly after
appearing as your body adjusts to the medication. In any case, I really am your
consultant. You get to call the final shots, but be sure to use me. (pause) I’ve got
some good ideas. (smiles) Deal?
Pt.: Deal.
Clin.: By the way, if we run into major problems with side effects, I’ll be the first one to
tell you to get off the medication. Our goal is to help you to find a medication that
you genuinely are interested in taking because it makes you feel better, not because
I tell you to take it. I’m always interested in your input and I have a feeling we
might be able to further help your depression. (Clinician continues with the spirit
of the MIM, emphasizing moving with the patient by indicating that she too will be
a watchdog for problematic side effects and that the interviewer’s goal is not to
keep the patient on a medication but to find a medication that the patient is
interested in keeping.)
Pt.: That would be great. I mean, don’t get me wrong, I like my med, but I’m still sort
of depressed.
Clin.: Fill me in on that a little bit more. What kind of feelings are you having about your
current medication and dosage? (Exploring the Medication Passport)
Pt.: Pretty good. Dr. Travis felt things were going pretty good, but like I said I would
like to feel a little better. I’m not feeling myself, especially at work. (pauses) I had
the feeling that Dr. Travis was thinking of maybe making a change. I don’t know.
But she didn’t get a chance to say so at the end. I transferred so quickly.
Clin.: She doesn’t mention that in her note, but maybe I should give her a call before we
meet next time. I’d like to tap her opinion more directly. (The clinician could not

give a more convincing message that she will listen carefully to the patient’s input
and act upon it. Notice that the clinician has effectively used all three of the
techniques comprising the strategy of Forging the Medication Alliance. She has
further used this gateway to continue her collaborative exploration.)
Pt.: That’s a great idea! (patient looks animated and pleased)

In the above dialogue the clinician has nicely set the stage for a true partnership. She has
deftly, yet quickly, debunked any misconceptions that she may be a “pill-pusher,” while
establishing her role as a consultant who feels comfortable with her expertise in using
medications effectively. Importantly, she sought out the patient’s ideas on his role and
clearly stated and subsequently demonstrated that she values his input. But, even more
powerfully than her statements of interest in her patient’s input, are the questions she
asks that prove her interest.
It is striking that even on topics unrelated to symptoms or diagnosis, she is clearly
interested in what Levon thinks. When he comments that he really liked his previous
physician of 15 years, our interviewer inquires, “I can see why. From her notes, it looks
like she took great care of you. What did you like about her?”
Concerning collaborative exploration, right from the first mention of medications,
this physician talks the talk and, more importantly, walks the walk. She has also managed
to match her style to the needs, educational background, and cultural feel of her patient.
She is talking with frankness to him, “manager to manager,” a style well suited to his
own. Naturally, she will adapt her style of introducing her personal approach to using
medications depending upon the unique needs of each patient. The three techniques
used in the interviewing strategy of Forging the Medication Alliance (the Medication
Interest Opening, Introducing Shared Expertise, and the “Call Me First” Invitation)
provide her with a flexible toolbox from which she can adapt her approach to the unique
needs of each patient. By previously practicing the techniques and by observing the
fashion in which different people respond to them, she has gained a sophisticated, rapid,
and sensitive fashion of forging the medication alliance.

Section 2: Toolboxes for the Three Steps of the Choice Triad

Toolbox for Step 1 of the Choice Triad
Wisdom From a Past Century
As a patient navigates each step of the Choice Triad, his or her belief in each step is not
necessarily an “all-or-nothing” process. With regard to Step 1 – the patient believes that
there is something wrong – a patient’s response may range from total endorsement of
this belief to complete rejection. Depending upon where the patient lies on this con-
tinuum, different interviewing techniques may be more or less useful.
With a patient who has come to the conclusion that he or she has a serious
mental disorder such as schizophrenia or bipolar disorder – sometimes after years
of wrestling with the idea – or a serious medical disorder such as congestive heart
failure, the clinician’s exploration of Step 1 often becomes more nuanced in nature.

It is no longer an issue of whether the patient feels that there is something seriously
wrong; he or she does. Instead, the emphasis now shifts to the equally important
task of finding out which symptoms the patient most wants relief from at this
moment in time.
To some degree, medical, nursing, physician assistant, and clinical pharmacy programs
teach clinicians to treat diseases, but people often take medications not so much because
they have a disease but to get relief from the symptoms their disease is causing. The dif-
ference in perspective is subtle, but it is real, with potentially telling ramifications for the
building and maintaining of the medication alliance.
The trust that a patient with a psychiatric disorder has in his or her psychiatrist, psy-
chiatric nurse, or case manager is often largely determined by how hard he or she feels
that the clinician is working to provide relief from that individual’s self-identified most
pressing symptoms.
The great physician Sir William Osler (pronounced with a long “O”) might be able
to provide some practical insight here. Sir William, whom we have met earlier in our
book, was knighted for his pioneering work in advancing Victorian and Edwardian medi-
cine. He was born in 1849. By the time he died 70 years later in 1919 he had left quite
a legacy, having been one of the greatest physicians to have practiced at McGill University
in Canada. He was also a founding father of Johns Hopkins University in Baltimore,
Maryland, and later retired as Regius Professor at Oxford, England. In his spare time he
managed to write one of the greatest general textbooks of internal medicine in the history
of medicine and nursing. Busy guy. But what I liked best about Sir William was the fact
that he was a bit of a renegade.
William Osler was a renegade in the sense that, in a time when the “science” of medi-
cine was all the rage, Sir William Osler always held compassion as the foremost principle
of medicine. It is said that he had a remarkable way with his patients. He was known as
much for his kind bedside manner as he was for his splendid diagnostic innovations. In
a sense, one could argue that he was the inventor of “person-centered medicine” about
100 years before it was supposedly invented. To illustrate my point we only need look
at the following oft-quoted axiom by Osler:

It is much more important to know what sort of patient has a disease than to know what
sort of disease a patient has.37

According to Osler’s perspective, each patient will uniquely view the impact and impor-
tance of his or her symptoms of an illness. A symptom (or a side effect for that matter)
that bothers one patient immensely may be perceived by a different patient as a mere
nuisance. The person’s perception of the symptom will be dependent upon who they are
as people (psychologically, spiritually, and culturally).
Patients will be motivated to stick with a medication to the degree that the patient
personally feels the medication is relieving them of their most problematic symptoms.
We need to find out what symptoms these are for each unique patient. To do so, we must
understand who the person is beneath the diagnosis, a theme we have repeatedly empha-

sized. Since Osler was an internist, we will initially look at an example from internal
medicine – congestive heart failure – that cleanly demonstrates the point.
First, let us picture a 76-year-old woman, whom we shall call Mrs. Hayes. Mrs. Hayes
presents with severe dyspnea (shortness of breath) upon exertion to the point that she
literally can barely get up the stairs to the second floor of her house. It would be easy
enough for a clinician hearing about such a disabling symptom to feel that offering relief
from it would be a powerful motivator for medication interest and use. The prescribing
clinician might say, “Mrs. Hayes, I think I may have a medication that might really help
you to get up those stairs,” thinking that the patient would find such an offer powerfully
motivating. One problem. The second floor of her house only contains bedrooms for
her children who are long gone. She never goes up those stairs.
Now picture a 32-year-old patient, Barry Mack, who suffers from equally disabling
congestive heart failure after having contracted a viral myocarditis. His new family prac-
titioner, as the initial interview unfolds, takes the time to uncover that Barry is a profes-
sional artist, at present, struggling mightily. We will soon see why he struggles so. Like
Mrs. Hayes, Barry also has debilitating dyspnea on exertion. It makes reaching his second
floor nearly impossible. And here is the catch. It is on the second floor that Barry has
built his studio. He has had huge ceiling windows installed so as to allow natural light
to flow into the room. He comments to his physician, “It’s the only place I can work, I
have to have natural light to do my painting. My career is essentially over.” Now imagine
a physician who says, “Barry, I think I may have a medication that might really help you
to get up those stairs.”
The difference in medication interest between these two patients is staggering, even
though the clinicians each pinpointed the same symptom (admittedly severe in nature
with both patients) for relief. The last clinician has taken the time to find out what sort
of patient has the disease and the first clinician has not. The last clinician, who under-
stands the needs of his artist patient, will have treatment success. The former clinician,
who does not understand the needs of Mrs. Hayes, probably will not.
Had the first physician explored Mrs. Hayes’ feelings about her symptoms he might
have discovered that, from her perspective, her most problematic symptom is not her
dyspnea on exertion. With gentle questioning she would have belatedly described her
intense embarrassment at not being able to get into her shoes because of the edema
(swelling related to fluid pooling) in her ankles and feet caused by her congestive heart
failure. Her shame has prevented her from going to shoe stores for months, a shopping
ritual she sorely misses, for she had always prided herself on having “nice, nothing fancy
mind you, but nice shoes.”
This tiny snapshot of “humanness” may seem, at first glance, mundane and unimport-
ant, but it is not. It is exactly what Sir William Osler was looking for – what kind of
person has a disease. It may, in its own unassuming way, hold the key to creating a pow-
erful and lasting alliance with this elderly patient, for if a medication can be used, such
as a diuretic, that rapidly takes away her edema, the clinician may have found a medica-
tion that the patient is probably going to want to stay on. More importantly, the patient
has found a clinician that she is probably going to want to keep. As we mentioned at

the beginning of our chapter, when one forges a sound medication alliance (the micro-
cosm) one is often simultaneously forging a sound overall therapeutic alliance (the
macrocosm).

Techniques for Uncovering the Patient’s Priorities for Symptom Relief

We can now translate Osler’s axiom into the following interviewing principle: Before
recommending a medication, directly ask patients to tell you from which of their symptoms they
most want relief. Assume nothing. Let us examine two interviewing techniques that can
allow us to more effectively apply this principle. The techniques were relayed to me by
primary care clinicians in one of my workshops so I shall continue with our elderly
congestive heart failure patient as an example:

Tip #8: The Target Symptoms Question

“Mrs. Hayes, of all of your different heart symptoms, which are the ones that you most
want me to help you with today?”

Tip #9: The Magic Pill Question

“Mrs. Hayes, if I had a magic pill – and I don’t – but if I did, and it could completely
take away just one of your heart symptoms which one would you want me to get
rid of today?”

Obviously, the above techniques are equally useful with patients coping with psychi-
atric disorders from depression, obsessive–compulsive disorder (OCD), and PTSD to
bipolar disorder. (Target Symptoms Question: “John, of all of the different symptoms
you’re having from your PTSD, what are the ones you would most like to get help
with?”)
In fact, let us see this exact technique at work with a person navigating schizophrenia.
Imagine a person who, over the years, has come to understand both the positive and
negative (deficit) symptoms of his or her schizophrenia well. Dealing with much
improved, but still disturbing, positive symptoms, such as denigrating hallucinations, a
clinician might expect the patient’s answer to the Target Symptoms Question to be along
the lines of “Do something about my voices.” Instead, the patient responds, “You know,
I can handle the voices. They are a lot better than they’ve been for years. But what I can’t
handle is having no energy. I want a job, and I really, really want a job bad. But I don’t
have the energy to get one.”
This patient’s angst, caused by his negative (deficit) symptoms, provides a wonderful
window into what Osler meant by what kind of person has the disease. Through this
window, provided by the Target Symptoms Question, the clinician may have sighted the
single most powerful motivator for this particular patient to stay on his or her medica-
tion – if the medication is one that could increase energy and perhaps lead to a job. On
the other side of the coin, if the patient perceives that his or her current antipsychotic is
hurting his energy level (“it makes me drowsy”), the risk of discontinuing the antipsy-

chotic may rise steeply, despite its effectiveness in decreasing the patient’s auditory hal-
lucinations and agitation.
The response of the above patient may suggest the choice of an atypical antipsy-
chotic that potentially may have greater efficacy for relieving negative symptoms or
fewer sedating effects. When the clinician proceeds to share, “I would like to suggest
a medication that may be particularly effective with helping with the low energy we
sometimes see in schizophrenia,” the patient will feel that he has been heard. Indeed,
he has.
Both the Target Symptoms Question and the Magic Pill Question are nice examples
of interviewing techniques (easily learned and taught questions/statements that are
behaviorally specific and tagged with a name) that were derived from a single interview-
ing principle: Before recommending a medication, directly ask patients to tell you from which
of their symptoms they most want relief. Assume nothing. The behavioral specificity of the
two techniques allows us to employ this interviewing principle in differing ways depend-
ing upon the needs of the patient. Note that these two questions are not identical in
phrasing, request, and tone. Consequently, their subsequent impact on patients is not
the necessarily the same. The Target Symptoms Question asks the patient for multiple
symptoms, whereas the Magic Pill Question requires the patient to choose a single
symptom.
Picture an elderly patient with an agitated depression who is constantly second-
guessing everything and everyone. He second-guesses every decision he makes. He hates
being asked to make decisions for he always feels he has made the wrong one, spending
hours of time ruminating about his decision. If I wanted to uncover what symptoms he
himself most wants help with, the Magic Pill Question (which forces him to make a
specific single decision) might be quite psychologically disturbing to him. He might
spend the next two days worrying, “Oh my God, I told the doctor the wrong thing to
help me with!” This patient may find the Target Symptoms Question much less threaten-
ing, for it allows him the freedom to share a variety of symptoms.
In contrast, picture a 10-year-old boy who walks into your office wearing a “magic
cape” and carrying three Harry Potter books. This 10-year-old is practically begging the
interviewer to use the Magic Pill Question, “Now if I had a magic pill, like Harry Potter
might have – and I don’t – but if I did and I could get rid of just one of your symptoms
from your OCD, which one would you like me to get rid of first?” In both of the above
instances, the clinician has matched the interviewing technique to the unique psychologi-
cal characteristics of the patient. The result may very well be more valid information, the
discovery of a more powerful personal motivator for enhancing medication interest, a
more effective use of the medication, and a significantly improved outcome for each of
the patients.
We are seeing the fashion in which the emphasis in the MIM on not only understand-
ing interviewing principles – but also developing concrete interviewing techniques for applying
those principles to unique patients – provides flexibility and creativity to each toolbox. Let
us see how this dual emphasis upon both interviewing principles and their translation
into interviewing techniques can help us with one of the most difficult of medication
interest problems, and a common one at that.

What to Do When Patients Do Not Believe They Have a Mental Illness

The Diagnostic Passport
As we have seen, in their therapeutic journey, many patients experience a bevy of both
medications and those who prescribe them. We also know that understanding the impact
of these experiences (both good and bad) can be accomplished by exploring their
so-called psychological passports regarding these issues (e.g. the medication passport and
the prescribers passport). There remains one more passport of potentially great signifi-
cance – the diagnostic passport. Patients are given many diagnoses. Many of them are
wrong. Moreover, even when they are correct and can potentially help with treatment
planning, empowerment, and self-understanding, as we saw in Part II of this book,
patients may have misunderstandings regarding their meaning and significance.
The following three interviewing techniques (although simple in nature and obvious
in name) can be helpful in exploring the patient’s views regarding his or her current and
possibly past diagnoses. These intimate, and sometimes highly charged, personal views
can greatly impact medication interest, for who would want to take a medication for a
disorder that one does not believe one has? As we have already seen, it would not be
logical to do so. The trio of techniques is as follows:

Tip #10: Inquiry into Current Diagnoses

“Have you been given a diagnosis?”

Tip #11: Inquiry into Diagnostic Understanding

“What is your understanding of what exactly that diagnosis means?”

Tip #12: Inquiry into Diagnostic Agreement

“Do you agree with that diagnosis?”

These three interviewing techniques and the collaborative exploration that follows each
of them are usually done in sequence, an interviewing strategy simply called “Exploring
the Diagnostic Passport.” As straightforward and simplistic as these three techniques may
seem, I am consistently fascinated by how often clinicians do not ask them. I have found
answers to be sometimes quite surprising and almost always important.
Patients appreciate the genuine interest in their opinions that such questions meta-
communicate. I highly recommend the employment of this three-question strategy,
which is usually done in the initial interview, often during the history of the present
illness. It is not unusual for a patient to spontaneously provide the answer (his or her
current diagnosis) without the Inquiry into Diagnosis even being asked. When this
occurs, it is quite natural to follow up with the next two questions of the strategy.
If the patient reports doubts about the diagnosis in this early part of the interview,
there is no reason to challenge this doubt at that moment, even if you agree with the
patient’s current diagnosis. First, such a challenge (another example of reflexively trying
to right a wrong) may seriously hurt the therapeutic alliance. Second, it is always wise

to arrive at one’s own diagnosis, for previous diagnoses can be inaccurate. Instead, it is
an opportune time to say something along the lines of, “One of the things we can look
at today is whether or not that diagnosis is wrong or right. At this point, I certainly don’t
know, and it would be a great thing for us to explore together today. At the end of the
appointment I’ll share with you my own ideas about your diagnosis, including whether
I think you even have one. How does that sound?”

The “Heading for Common Ground” Strategy: A Practical Approach When Patient and
Clinician Disagree About Diagnosis
The Target Symptoms Question and the Magic Pill Question offer practical interviewing
techniques for navigating Step 1 of the Choice Triad once a patient has come to the belief
that there is something wrong. But what if after the body of the interview, or after many
sessions of ongoing outreach, it becomes clear that the patient does indeed have a severe
mental illness but does not see it? In plain language, does the MIM have anything to
offer if the patient simply does not agree with Step 1 of the Choice Triad?
As experienced clinicians, we know all too well, that, especially with severe illnesses
such as schizophrenia and bipolar disorder, many of our patients are at the other end of
the continuum regarding Step 1 – they strongly do not believe that they have this illness.
Such clinical situations present us with a particularly difficult, and common, roadblock
to medication interest and use.
The MIM has no magical solutions to this conundrum, but it does offer some reason-
able options for transforming what is one of the most difficult problems with medication
interest in psychiatry. In this case, we will also have an opportunity to see how we can
weave two or more interviewing techniques into an interviewing strategy called “Heading
for Common Ground.” Before we can see the strategy at work, it is useful to more care-
fully explore the nuances of how a patient approaches Step 1 of the Choice Triad.
Obviously, stigmatization regarding severe mental disorders such as schizophrenia,
schizoaffective disorder, and bipolar disorder can play a major role in a patient’s lack of
belief in Step 1 (Step 1 being: the patient thinks that there is something wrong with them
for which they personally want relief). Not as obviously, it is important to realize that suc-
cessful navigation of this step does not necessarily demand that the patient believe that he
or she has schizophrenia, depression, or whatever other disorder may be present. Rather,
it states that the patient, under his or her own volition, has arrived at a personal conclu-
sion that there is “something wrong” from which the patient personally wants relief.
All too often, the roadblock at Step 1 becomes the patient’s belief that, “They are going
to drag me in to see a shrink who is going to try to convince me that I have a disease I
don’t have (schizophrenia) and they are going to try to drug me with medications I don’t
need or want (antipsychotic or mood stabilizer).” If a patient believes this statement, it
makes total sense that he or she should refuse medications.
Note that the core problem with the above therapeutic stalemate is the oppositional
feeling that has arisen between the patient and the prescriber and not necessarily whether
or not the patient believes that he or she has schizophrenia. The initial goal of the clini-
cian may not be to “bring insight to the patient” that he or she has schizophrenia, but
rather to help the patient independently arrive at a personal conclusion that there is

something wrong with which the patient wants help. If done well, there is no perception
by the patient that anything is “being pushed” – including the idea that he or she
has schizophrenia or the idea that he or she needs medications – because there isn’t any
such push. These beliefs will undoubtedly be shared by the psychiatrist, nurse clinician,
physician assistant, or other prescriber, but in a fashion that eliminates the sensation
of oppositional push.
Once again the goal is to create a sensation that one is “going with” the patient along
the Agreement Continuum as we discussed in our chapter on transforming anger and
potential points of disengagement. Another driving interviewing principle of the MIM
comes into play: Meet the patient at the level of his or her request. A clinical illustration can
help us to see the power of this interviewing principle to address the conundrum created
when a patient fails to see the presence of a mental illness. We will see how to apply the
principle by demonstrating the use of two new interviewing techniques (“Agreeing to
Disagree” and “Stating Shared Goals”) that, when coupled together, become the afore-
mentioned effective interviewing strategy – “Heading for Common Ground.”
Perhaps the best way to illustrate the above concepts would be to draw on a
patient example from my own practice on the CTT, the outreach team from which,
you will recall, many of the initial concepts of the MIM arose. A patient, we shall
call Jim, entered the research protocol. He had had over a decade of highly disrup-
tive episodes of schizophrenia, punctuated with acts of violence and many revolving
door hospitalizations. In the previous 3 years, he had been in the state hospital over
100 days each year and, as one can imagine, he hated medications and psychiatrists
– not necessarily in that order, I might add. He categorically denied that he had
schizophrenia.
Jim was released from the state hospital on an involuntary outpatient commitment
in which he was required to take a long-acting injectable antipsychotic, which he loathed.
In the past, every time Jim had begun to decompensate, a clinician would recommend
that he increase his outpatient antipsychotic medication, at which point he would refuse,
become agitated, and be returned to the state hospital, occasionally after a violent
outburst.
During our initial meetings, the track was taken to seldom mention medications at
all. Instead, I did everything I could to learn about Jim’s interests and current concerns.
I also chose not to wage a battle over whether or not Jim had schizophrenia. Over the
course of our meetings, I would occasionally use the following technique, a technique
utilized by therapists for decades:

Tip #13: Agreeing to Disagree

“Well, we probably disagree about whether or not you have schizophrenia, but you know,
people are entitled to their own opinions, and I respect yours.”

More importantly, over the months, I learned two things: (1) Jim strongly disliked the
sleep problems that occurred when he decompensated, and (2) Jim hated being hospital-
ized, especially at the state hospital. He stated that, “it makes me feel like I’m a caged
animal.”

After months of gentle engagement, I was able to use an interviewing technique called
“Stating Shared Goals.” Operationalized, in this technique the interviewer identifies one
or more genuinely shared goals between the patient and the clinician. These goals gener-
ally have nothing to do with accepting a specific diagnosis. Indeed, they do not always
involve symptom relief per se, but may involve getting relief from an unwanted conse-
quence of a symptom (such as unwanted hospitalization). In this sense, it is critical that
the principle of meeting the patient at his or her level of request be followed. In short,
the patient must be the first person to raise the therapeutic goal. With Jim, the technique
manifested as follows:

Tip #14: Stating Shared Goals

“You know, Jim, over the months I think you’ve come to know that I’m a straight shooter,
and I would never tell you something that I did not believe. Whether or not you have
schizophrenia, I believe that your medication is helping you. I’m convinced it helps you
with your sleep and, even more importantly, I am absolutely convinced it keeps you out of
the hospital. In fact, if your sleep gets bad again and you feel a little agitated because of
it, I truly believe if we increase the medication a bit, there is a very good chance that we
will be able to keep you out of the state hospital. I know that is what you want, and it is
what I want – to keep you out of the hospital.”

Within a matter of months, Jim’s schizophrenia began to “break through” his current
antipsychotic dose. When I first suggested raising the dose of his long-acting injectable,
he began to get agitated, but when I reminded him that the goal was to help with his
sleep (which Jim openly admitted had become a problem again) and to keep him out
of the hospital, he relented, reluctantly agreeing to take the increased dose. His schizo-
phrenia moved back into remission, both helping with his sleep and helping Jim to avoid
a trip to the state hospital. He was pleased, albeit with begrudged acknowledgement, as
was Jim’s habit. Throughout his subsequent interaction with the team, which lasted over
several years, Jim never returned to the state hospital, despite several episodes requiring
an increase in the dose of his long-acting injectable antipsychotic. Jim never fully believed
that he had schizophrenia, but he did independently arrive at the conclusion that there
was something wrong with which he wanted help (poor sleep and unwanted hospitaliza-
tions). Step 1 of the Choice Triad was effectively achieved.
Note that the interviewing principle “Meet the patient at the level of his or her request”
has been made eminently more employable by first translating it into two behaviorally
specific interviewing techniques – Agreeing to Disagree (which takes the edge off the
interpersonal field) and Stating Shared Goals (which uses the concrete stating of shared
goals to foster a collaborative stance of “us against the problems”). These two techniques
are sequentially combined into the specific interviewing strategy called “Heading for
Common Ground.”
I believe that you will find this interviewing strategy to be both useful and easy to
teach to psychiatric residents and other trainees, ranging from nursing and medical stu-
dents to residents in other disciplines, for it is always composed of sequencing the two

techniques of Agreeing to Disagree and Stating Shared Goals. Interestingly, Step 2 of the
Choice Triad was also achieved, in that Jim was motivated to use the antipsychotic
because he believed it might bring relief for a self-identified problem. Jim’s illustration
provides a natural bridge to a deeper exploration of the set of techniques that comprise
our toolbox for addressing Step 2 of the Choice Triad.

Toolbox for Step 2 of the Choice Triad

Tying Medication Use to Achieving Positive Life Goals
Step 2 of the Choice Triad – the patient believes that a medication may help provide
relief for what is wrong – is yet another gateway to understanding patient motivation.
In Step 2, for the first time the patient is considering the use of an actual medication
(in Step 1 the patient is solely preoccupied in deciding whether or not there is some-
thing wrong from which the patient wants relief). At Step 2, the interviewer is attempt-
ing to solidify the patient’s idea of relief with the promise of such relief coming
directly from a medication. In keeping with the spirit of the MIM, for the patient to
have a robust motivation to initially use and to subsequently continue to use the
medication, this conclusion must be arrived at by the patient on his or her own
terms.
As one would expect from our understanding of Step 1, one of the primary motivators
for trying a medication is the belief that the medication may remove a highly disruptive
symptom. In psychiatric disorders, a wide range of symptoms can be distressing includ-
ing hallucinations, delusions, agitation, obsessions and compulsions, suicidal ideation,
and flashbacks. In our last example, Jim wanted relief from his extreme sleeplessness
during the exacerbations of his schizophrenia. But Jim had also discovered another
motivator – staying out of the state hospital – unrelated to symptom relief directly. I
suspect that this situational motivator was an even more powerful factor in his decision
to increase his long-acting antipsychotic, a decision that would prove to keep him out
of the state hospital for as many years as I knew him.
The question then becomes, “Are there any interviewing techniques that we can pull
from our toolbox that can help patients find such situational motivators?” Translated
into an interviewing principle, this question is transformed into the following task:
Remember that the most powerful motivators patients may have for using a medication may be
directly related to gaining a positive life outcome as opposed to mere symptom relief. Helping
the patient to uncover such personalized motivators is arguably the greatest clinical task
in Step 2 of the Choice Triad. Let us explore several interviewing techniques that allow
us to translate this principle into meaningful action.
A pediatrician in one of my medication interest workshops highlighted the impor-
tance of this principle and pointed the gateway through which to achieve it. It is worth
seeing how he stumbled upon the answer with a non-psychiatric disease, asthma, for the
resulting interview strategy has powerful implications for use with psychiatric disorders.
He was a specialist in treating childhood and adolescent asthma.
Many kids with asthma resist taking their medications because they don’t like
the embarrassment of having to use inhalers in front of other kids, nor do they like

using the accompanying mouthwashes. Side effects are another major problem. In the
workshop, the pediatrician commented that one of the most powerful motivators for
these students was the obvious one: they wanted relief from their acute asthmatic attacks.
But this was only true if the patient was experiencing severe and frightening asthmatic
attacks, which many of his patients were not. He discovered that (both with patients who
had such attacks, but also with students whose attacks were disruptive but not necessarily
frightening in nature) there existed another powerful motivator. It was a motivating factor
that he found he could repeatedly tap in ongoing therapy whenever his adolescents were
having tough side effects and were having thoughts of discontinuation (common con-
cerns also often arising with the use of psychiatric medications).
What was the secret to generating such tenacious medication interest? He found that
more often than not, his patients did not so much want relief from something the asthma
had given them – symptoms – as they wanted back something the asthma had taken
from them – the ability to play a sport or “feel normal” like the other kids who didn’t
have to use an inhaler in gym class.
In many instances, whether one is talking about diseases from the non-psychiatric
arena such as asthma and congestive heart failure or psychiatric disorders such as major
depression, OCD, PTSD, and schizophrenia, patients want back their dreams, their liveli-
hoods, their peace of mind, their self-esteem, and the confidence to pursue goals without
becoming beset with self-doubts. The desire to recover these lost dreams can often
provide unusually powerful motivators that may help patients to tolerate surprisingly
unpleasant side effects.
The pediatrician had developed an interviewing tip that helped him to tap this moti-
vator in a reliable fashion. His tip, which was subsequently named, the “Inquiry into
Lost Dreams” in the MIM, was described by him in the following words as best I remem-
ber them:

Tip #15: Inquiry into Lost Dreams

I find it useful with my kids with asthma to ask them this question or a variation on it:

“Is there anything that your asthma is keeping you from doing that you really wish
you could do again?”

What I find with this age group is that there is often a quick answer to this question, and
the answer is often related to a sport – say football or soccer.

Another useful thing about this question is that it opens the door for adolescents, who by
definition are prone to form oppositional relationships with adults, to tell me what they
want me to do for them. They are calling the shots, not me. The opposition seems to dis-
solve away. Meanwhile, I gain a deeper insight into their motivation for seeking help from
their asthma that goes beyond their desire for symptom relief. I might never have known
this powerful motivator had I not asked. I can use this knowledge to enhance the adolescent
patient’s desire both to start a medication and to stay on it.

Although I never provide false hope, if I feel it is within reason I can use this newly
uncovered information immediately to help shape a shared agenda with a comment like:

“Now I can’t promise you this, but I have had some very good luck with helping
other students, with asthma like yours, to get back onto the soccer field. We have
some great medications that can help with that goal. Once again, no promises, but
I would like to work with you to see if we might be able to get you back out on that
soccer field. How does that sound to you?”

Even the pediatrician’s last phrase, “How does that sound to you?” wisely transfers the
power of the decision as to even agree upon the shared plan (using a medication to get
back onto the soccer field) over to the adolescent. This useful interviewing technique can
easily be applied in the field of psychiatry – “Is there anything that your depression is
keeping you from doing that you really wish you could do again?” Such a question can
be used to gracefully transform low medication interest by helping the patient to uncover
a personalized motivator other than symptom relief.
Imagine the power of this type of motivator for enhancing interest in staying on an
antidepressant, if, say, a grandmother suffering from a severe depression answered with,
“Yes, I’d really like to have enough energy to go visit my granddaughters in California.
I’ve promised them for years that I would take them to Disneyland,” and she felt that
her antidepressant, despite its side effects, offered her the single best chance of doing so.
The Inquiry into Lost Dreams has become one of my personal favorites in my own
practice.
In schizophrenia, the Inquiry into Lost Dreams approach is generally employed long
after patients have navigated Step 1 of the Choice Triad. At this stage of recovery, they
believe, at least partially, that they have schizophrenia and are usually already on an
antipsychotic. The question is: Will they stay on it?
The answers to the Inquiry into Lost Dreams in patients managing schizophrenia can
be diverse, including responses of a very practical nature, such as “I want to be able to
get a job,” “I want to be able to go to college,” “I just want to be able to move out of
my parent’s home and get my own apartment,” “I just want to stay out of hospitals.”
There are also responses that poignantly remind us of the devastating damage to the
soul that schizophrenia leaves in its wake, such as “I want to be able to hang out with
my family again at Christmas. I just want them to like me again.” Some of these lost
dreams may be achievable and some may not. Those that the clinician believes are rea-
sonable goals can be used as powerful personalized motivators for staying on an anti-
psychotic or mood stabilizer, even when it may be necessary to tolerate some difficult
side effects.
As Kim Mueser points out, clinicians should be careful to avoid discouraging patients
from pursuing ambitious goals that they are genuinely interested in attaining and damp-
ening their enthusiasm, as such goals have the potential to be powerful motivators for
taking medication.38 If the patient states the desire to achieve a very ambitious goal, such
as becoming a professor or an architect, rather than expressing skepticism, the clinician
can demonstrate interest in this goal by seeking to understand why it is so appealing,

and then consider some of the steps the patient could take towards achieving that goal,
such as enrolling in school to complete a degree. Medication can then be discussed as
something that could help the patient make those first steps towards the goal.
The Inquiry into Lost Dreams is very fruitful for many patients, but some may have
difficulty identifying concrete losses or changes they want to make in their life. When
working with these patients, it can be useful to rephrase the question along the following
lines:

Tip #16: Alternative History Question

“If you didn’t have schizophrenia, or you weren’t experiencing these kinds of problems,
what would you be doing, how would things be different?”

Patients often respond to the Alternative History Question with answers like “I’d have a
job,” “I’d have a girl/boyfriend,” “I’d be married/have a family,” “I’d have my own apart-
ment,” “I wouldn’t have to depend on other people, I could take care of myself,” and
“I’d be able to enjoy life more, and have the energy to do things I used to do.” These
responses provide important hints to non-symptomatic changes that patients would like
to see that could prove to be powerful personal motivators for enhancing medication
interest. This technique harks back to the miracle question (“If you would wake up in
the morning and one thing in your life had been completely changed for the better, what
would you want that thing to be?”) developed in solution-focused therapy that we dis-
cussed earlier in Chapter 2 (see page 52–54).

What if the Disorder Has No Symptoms?

In psychiatry, such a situation at first glance appears to be relatively rare. Although our
patients may not agree that they have a specific disorder or that they are having psychiatric
symptoms, they are, nevertheless, experiencing some form of symptoms, otherwise they
would not have sought our help or been brought to our attention by others. In primary
care, it is a very different “ball game.” Many of the diseases that family practitioners,
physician assistants, nurse clinicians, and case managers encounter do not demonstrate
symptoms in the early stages of the disease (e.g., hypertension, hyperlipidemia, the
metabolic syndrome). Somewhat surprisingly, two techniques shared in my workshops
by primary care providers for enhancing medication interest in symptomless diseases are
of use to us, for, with a second glance, it becomes apparent that we do indeed encounter
patients without symptoms. And we do so frequently.
In the first place, although our patients invariably present with symptomatic illness,
if we do our job well, the symptoms often disappear. Once patients are in remission, the
motivator of finding symptom relief essentially disappears. It now becomes an issue of
preventing the return of symptoms. But symptom prevention is frequently a far less
compelling motivator than symptom relief, for it is an abstraction with no immediate
pain. Second, what if a patient does not acknowledge the presence of the symptoms
perhaps secondary to psychotic or manic process? Occasionally, such patients may still
find a reason for using a medication if they feel the consequences of not doing so will

hurt the ones they love. In other instances, the patient fears losing these relationships if
medications are not used.
Since the following two techniques were first described by primary care clinicians, I
feel it is insightful to examine their use directly in the primary care setting, for it will
better illuminate the interviewing principle behind them as well as enabling us to see
how the techniques are applied with optimal skill by the people who actually developed
them. Subsequently, we will see how to adapt them for use with our psychiatric patients.
As with our grandmother above (who wanted to take her granddaughters to Disney-
land), patients can have powerful reasons for taking medications that are based primarily
upon the idea of helping others. In many instances, these interpersonal motivators can
be a great deal more compelling than simply taking a grandchild to Disneyland (impor-
tant in its own right). Sometimes a patient feels that if he or she does not take a medica-
tion, catastrophic events may befall loved ones.
It was a primary care physician from Los Angeles who shared this insight at one of
our workshops. It was an insight that also resonates with a theme that we have repeat-
edly addressed throughout the chapters of our book – understanding and effectively
navigating cross-cultural issues and divides. The clinician was white, but much of his
work was with the Latino population. He found that Latino males often didn’t want to
take medications for their symptomless diseases, such as hypertension, for “taking care
of oneself” is viewed as being self-centered. On the other hand, the Latino culture places
a profound emphasis upon family ties and responsibilities, which displays itself as an
intense belief in taking care of one’s spouse and children (as well as extended family)
no matter what the cost. Family needs first. Individual needs second. Spending precious
money on medications, when “there is nothing wrong with me (symptomless disease
such as hypertension), when I need that money for clothes and food for my kids”
simply flies against the patient’s cultural ethics. Indeed, all of the risks and dangers of
immigration are often undertaken because of profound and pressing needs to help one’s
family survive.
The family practitioner commented that convincing young Hispanic fathers to take
medications for asymptomatic illnesses was an often an insurmountable barrier to medi-
cation interest and follow-through. He related that one day he inadvertently stumbled
upon the solution when he was eliciting the routine family history during an initial
History and Physical. We will call the patient Juan. When he asked Juan whether anyone
in his family had had a heart attack or stroke, the patient commented, “Yeah, my father.
He died of a heart attack (pauses), … it was the worst day of my life. He was the greatest
man I’ve ever known.” When asked how old he was when his father died he commented,
“Way too young, I was 12.” The patient welled up with tears. At this point, the proverbial
“light bulb” went off in the clinician’s mind.
The light bulb in question can be summarized by the following interviewing principle:
Actively explore with each patient the potential interpersonal motivators for enhancing medica-
tion interest, situations in which serious problems may result for loved ones if relapse should
occur. During the closing phase of the interview when the clinician was recommending
the use of an antihypertensive, he put this principle into practice with the following
interviewing technique:

Tip #17: Tapping Family Motivators

“Juan, I know you don’t feel much like taking these medications for your hypertension,
and I understand that. There might be another reason, in addition to taking care of your-
self, why it may be very important for you to try to take them. I think they can help you
to take care of your family. You see, I don’t know if your father had high blood pressure
like you have, but it commonly runs through families from generation to generation. I
think he very possibly did. And high blood pressure is one of the number one causes of
heart attacks. I think there is a very good chance it is what caused your father to have
his. This medication can help to make sure that you don’t get a heart attack, something
that you know from your own experience would be horrible for your wife and kids. I can’t
guarantee you that it will, but I think it truly might. We need to keep you healthy, not
just for you, but for your two children. Our goal is to try to lower your blood pressure so
that we can protect your heart. And if we do this right, we might be able to prevent your
two children from going through what you went through when you were 12. (pauses) …
You know, this warning might just be the last great gift your father gave to you. What do
you think?”

To me, this interviewing exchange was brilliant. The family practitioner focused upon his
patient’s cultural matrix both in a general sense (Hispanic pride in familial responsibil-
ity) and in a personal sense (Juan’s loss of his father at an early age).
The physician commented that he had found this tip to be useful from that day
forward, with rather startling increases in medication interest in this specific popula-
tion. He uses it with asymptomatic diseases such as hypertension, hypercholesterolemia,
and diabetes. But, more importantly for us, I have found that Tapping Family Motiva-
tors can be very useful with many psychiatric patients, as we discussed above. For
instance, some patients, not all, suffering from bipolar disorder, when they move into
a strong remission have regrets about what the bipolar disorder “put my family through.”
Tapping Family Motivators can be a particularly powerful technique for use with such
patients.
This technique can also be expanded beyond family members. For some patients, such
as teachers, ministers, physicians, nurses, and social workers, it is their commitment to
their communities and to helping others that stands as a powerful motivator for them
to stay healthy and capable of helping. As one would expect, this tip is of great use not
only among the Latina/o population, but across all cultures when we find individuals
possessing a high sense of responsibility to family or mission. To optimize its power to
enhance medication interest, it is important to re-enforce it over time. Another primary
care clinician had an excellent interviewing technique to accomplish that exact task.
A nurse from Kansas, Janet Brack, suggested a clever extension of the above interview-
ing technique. She asks patients whether they might have a photograph of their children
with them. If they do, she asks to see it. Naturally, no matter what the appearance of the
child or children might be, she enthusiastically comments how cute the kids are. She
then employs the following technique, which we shall illustrate with bipolar disorder in
remission:

Tip #18: Visual Reminder for Tapping Family Motivators

“You know, some of my patients with bipolar disorder have found a neat trick that helps
them to remember how taking their medication can help them to help their families. And
I know from working with you, Mr. Timpkins, how important that is to you. They get a
picture like you have here of their kids, and sometimes they even make it bigger, if you
happen to have it on your phone or computer you can just print it out larger. They then
place their lithium or depakote bottle on top of the picture. Every time they reach for their
bottles the picture reminds them of why they are taking the medications and they say
something to themselves like, ‘I’m doing this for me and I’m doing this for my two kids.
I don’t want this mania to ever come back. I know what it does to my wife and kids. I
really do know.’ My patients tell me this really help them to stay motivated to use their
medications wisely. It even helps them to remember to look for their early warning symp-
toms every single day. What do you think?”

If safety is an issue, as it would be with lithium and two kids in the house, the photo-
graph can be taped or placed inside a medicine cabinet that is locked or out of reach of
children. With disorders that can severely disrupt family functioning such as bipolar
disorder, OCD, agoraphobia, and severe depressive disorders this ongoing re-enforcement
through the use of the Visual Reminder for Tapping Family Motivators can be surprisingly
effective, especially with patients who have a visual way of learning and navigating the
world.

Toolbox for Step 3 of the Choice Triad

By exploring steps 1 and 2 of the Choice Triad, we have gained a clearer understanding
of how patients decide to try a medication. Each patient must recognize that there is
something wrong and be personally motivated to try a medication to fix it before a
medication has a realistic chance of being taken on a regular basis.
By digging one step deeper into the patient’s perspective, we will uncover a treasure
trove of new interviewing techniques. In particular, if we turn our attention to the third
step of the Choice Triad – the weighing of the pros and cons – we will discover remark-
able differences in how individual patients go about this process.
Understanding this uniqueness is at the very heart of understanding how to increase
medication interest. There is a bottom line to medication interest. Even when a patient
feels that there is something wrong and is motivated to do something about it via the
use of a medication, if that patient is not convinced that the pros outweigh the cons, the
medication bottle will remain on the shelf. Period.
When we say that patients weigh the pros and cons – whether it is ourselves when we
take a prescribed medication or our patients when they take a medication that we are
prescribing – what exactly are they weighing? In the most basic sense, patients are weigh-
ing a surprisingly large number of individual beliefs, varying from concrete cognitions
that could be written down to more evasive “gut feelings” that elude capture by words.
Robert Horne and John Weinman have done innovative early work on clustering these
numerous belief sets. At its simplest level, they have found that patients “weigh their

beliefs about the necessity of the prescribed medication for maintaining health now and
in the future” with their “concerns about the potential adverse effects of taking it.”39
Over the years, I have found that most patients use three specific belief sets when
placing their feelings and thoughts into the categories described by Horne and Weinman.
Understanding these three belief sets can help us to determine a more valid read on any
given patient’s medication interest, allowing us to address and often transform patient
concerns before they become unfilled prescriptions.
If you will recall, more recently McHorney has delineated the three factors that she
feels are statistically most predictive of patient problems with medication interest and
follow-through.40 In our discussion of interviewing techniques designed to collabora-
tively explore the first two steps of the Choice Triad, we have already delineated flexible
interviewing techniques for exploring her first criterion – that the patient must be con-
vinced of the importance of taking the medication. Her next two predictive factors:
financial cost of the medication and fear that the medication will do more harm than
good provide excellent empirical support for the third step of the Choice Triad. As we
shall soon see, the MIM provides practical techniques for addressing both of these factors,
and many more, in a sensitive and efficient manner.
There are many other beliefs that any specific patient might weigh in addition to
McHorney’s three concerns. In actual clinical practice, one must go well beyond McHor-
ney’s three top statistical factors, for factors distinct from these three may become the
deciding factors swaying a unique patient to stop a life-saving medication (prevents
suicide) or life-transforming medication (prevents the pain of a returning mania, psy-
chosis, or disabling depression). As we discovered in Chapter 17 with suicidal intent,
medication interest is ultimately not a statistically caused event: People decide to take a
medication not because they meet a statistical threshold – they take a medication because
they choose to do so, statistics be damned. There exist a variety of beliefs, not covered
by McHorney’s trio, that patients may utilize when determining whether a medication
may cause them more harm than good.
Thus, from the person-centered perspective of the MIM, interviewers must possess a
framework that allows them to collaboratively explore all of the many different beliefs
that patients may use as they weigh the pros and cons. Towards this goal, I have found
the following three categories of beliefs seem to cover just about any perspective a patient
may be weighing during this final, and crucial, step of the Choice Triad:

1. Efficacy of the medication

2. Cost of the medication
3. Psychological meaning of the medication

Each of these three belief sets forms its own continuum. Each of our patients, as they are
sitting in our offices or hospital units, has a position along these three axes concerning
the pros and cons of the medication – toward one end or the other. For instance, con-
cerning the efficacy of the medication, each patient has a personal belief about the extent
to which a particular medication is “working.” Some patients are convinced that the
medication is helping a lot, whereas others are convinced that it is not helping at all. Of

course, many are in between. But the closer the patient is to believing that the medica-
tion is not helping, the less his or her interest will be in staying on it.
The point at which the above three axes (efficacy, cost, and meaning) intersect can
provide us with a remarkably clear idea about which way the patient’s internal committee
is about to vote. By weighing these three belief axes, our patients decide whether the
necessity of the medication outweighs their concerns about the medication. Consequently,
learning to explore all three axes is a critical skill set for any sophisticated clinician to
master, if indeed the clinician wants to enhance the medication interest of their patients.
Fortunately, there exists a toolbox for each axis of the third step of the Choice Triad.
Before addressing how to utilize these toolboxes effectively, we must examine one more
intrapsychic phenomenon.

Where Does the Patient Weigh the Pros and Cons

There exists a “catch” to addressing and transforming any concerns the patient may have
in Step 3 of the Choice Triad. A metaphor will help us understand this catch.
It is important to realize that few, if any, patients are sitting around, pencil in hand,
making lists of the pros and cons. Patient beliefs are often a somewhat chaotic potpourri
of opinions on numerous aspects of the medication, from side effects to convenience,
from financial cost to what the patient’s partner and family think about the medication.
These beliefs, some conscious, others preconscious, are all simmering in a stew from
which a decision will emerge.
In a metaphorical sense, when people (whether it is ourselves or our patients) are
weighing the pros and cons of taking a medication, there exist a multitude of beliefs to
be weighed. Each of the pros and cons is considered in the decision-making process. For
a person facing the formidable decision as to whether or not to place a foreign substance
in his or her body, it is as if the person has a committee inside his or her head. Each
member of the committee represents a differing opinion the patient holds about the
medication. For instance, if the medication in question were an antidepressant, part of
the patient might be saying, “This medication makes me feel better because it helps me
stop crying.” But another part of the patient might chime in, “Yeah, but I can’t sleep on
it.” A third member of the committee might add, “But I can get back to work again.”
This positive vote may be quickly countered by another committee member arguing, “But
this medicine is costing us an arm and a leg!” and so on and so on, until it is as if the
committee chair (the patient’s ego) suddenly says, “We’ve heard enough, let’s vote!” And
they do. The patient makes a decision – either to continue the medication or to stop it.
Here is the catch: I have found that roughly 90% of the time, when this committee
votes – i.e., the patient decides to stop the medication or continue it – the committee
votes outside of my office. In short, the patient has either stopped the medication or has
already decided that he or she does not like it before we meet again.
If the committee votes outside my office, I do not get an opportunity to sway the
committee before they vote. It’s a done deal. I generally find that if a patient has already
stopped a medication, it is frequently hard to persuade the patient to try it again. To do
so, the patient must first decide that he or she has made the wrong decision. Admitting
that one is in error is not the most natural of human strengths. Even when the clinician
has persuaded the patient to try the medication again, the reluctant patient is now

coming from a perspective of looking for slightest evidence that he or she was right in
the first place, “This medication is bad for me.” Such a patient is pre-loaded to experience
low medication interest.
On the bright side, clinicians are, by definition, important resources of information
about medications for this committee, and, at times, strong lobbyists for their use.
Patients value our opinions. Indeed, the more powerful our medication alliance, the
more our opinions are valued. Perhaps the patient stopped the medication because he
or she had some negative experiences with the medication that we could have helped
with, as with a method of decreasing an unwanted side effect. Or perhaps the patient
simply had some misinformation about the medication, perhaps discovered on the web,
that we could have clarified very easily. In any case, we can do neither of these interven-
tions if the committee has already voted.
Another interviewing principle now begins to emerge. It is a simple one. It is also one
of the most important interviewing principles that I have found for enhancing medica-
tion interest: Invite the patient’s committee to vote inside your office not outside it by asking
specific questions concerning the patient’s emerging views of the pros and cons of the medication
during each medication evaluation. Once again, assume nothing. In short, the clinician wants
to hear the patient’s various views on the three axes concerning efficacy, cost, and
meaning while the patient is sitting in their office. If possible, the clinician wants the
patient to decide to stop or to continue the medication while he or she is there, i.e.,
during the appointment itself. This interviewing principle has become one of my major
conscious goals during medication checks over the years.

Uncovering the Patient’s Pros and Cons on Axis #1: Efficacy

The most common rationales for altering medication practice are drug related: the medica-
tion is perceived as ineffective or the so-called side effects become too troublesome.41
Peter Conrad, PhD

As we continue to explore what makes patients interested in taking medications, we

inevitably must examine the issue of efficacy, because efficacy is at the very heart of how
patients weigh the pros and cons. Despite this fact, in over 20 years of clinical experience
I have yet to have a patient plop into a chair in my office and comment, “I’m having
some concerns about the efficacy of my Haldol.”
For prescribing clinicians the word efficacy has various technical connotations. Research
literature makes distinctions between efficacy (ability of a medication to achieve its goals
in more idealized settings such as research projects and academic centers) versus medica-
tion effectiveness (how well the medication is able to achieve its goals on the clinical
frontlines of community practice and outpatient clinics, where various psychological,
cultural, and sociological factors impact on the use of the medication).
From the patient’s perspective, it is a good deal simpler. As Iqbal Ahmed cogently
points out, clinicians tend to prescribe according to the “proven clinical efficacy” of the
medication as opposed to its “effectiveness.”42 For patients, there is no distinction between
efficacy and effectiveness. Instead, the patient decides upon the usage of a medication
based upon the patient’s perception of its efficacy in layperson’s terms (does it work or

not for me?). Put into even simpler terms, patients tend to perceive efficacy by asking
themselves the following question: “Does this drug make me feel better?” The patient’s
answer to this question of “efficacy” will frequently tip the scales in one direction or the
other with regard to medication interest.
As Peter Conrad suggested in the opening quote from his insightful article, “The
Meaning of Medications: Another Look at Compliance,” the answer to the patient’s ques-
tion, ultimately, comes down to whether the patient’s perception of symptom relief
outweighs his or her perception of side effect damage.
From the view of understanding medication interest, the key word in the last sentence
is perception. We often hear, both in research and clinical parlance, that a patient discon-
tinued a medication because of a side effect. No patient has ever stopped a medication
solely because of a side effect, unless the side effect killed him. Patients stop a medication
because of their perception that the costs of the side effect are not worth the benefits of
the medication, not because of the mere presence of the side effect itself. Side effects
don’t lead to discontinuation. Perceptions do.
By way of illustration, we all know patients experiencing severe side effects who, nev-
ertheless, stay on a medication because they believe that the pros of the medication out-
weigh the costs of its side effects. To make our point in the primary care arena, we need
only look at instances when patients tolerate the severe side effects of chemotherapeutic
agents for treating cancer because they believe that the agents can save their lives. In psy-
chiatry, patients with bipolar disorder in remission often tolerate the markedly unpleas-
ant side effects of their antipsychotic agents and/or mood stabilizers because these agents
have rescued them from the ravages wrought by their manias and depressive episodes.
Returning to our committee metaphor, these patient perceptions represent positive
votes in the patient’s internal poll on medication interest. As stated earlier, our goal is
to get the committee to vote in front of us. The art of securing this “in-house” vote lies
in skillfully questioning our patients about their core beliefs regarding efficacy from a
person-centered perspective.

Opening the Door to a Medication Interest Discussion

Generally speaking, one of the best ways to begin the discussion regarding the patient’s
experiences on the prescribed medication since the last appointment, telephone call, or
e-mail exchange is to ask directly:

Tip #19: The “Since Last Time” Question

“How’s that medication working out that we started up last time?”

“Since the last time we met, what have you thought about that medication we started?”

Addressing the Patient’s Concerns About Dosage: An Invitation of Sorts

As Robert Shuman so elegantly suggested in the opening epigram of this chapter, patients
want their opinions to be heard. Undoubtedly, one of the most important opinions that

patients want heard, loud and clear, is their view on whether the dosage is too high. But
all sorts of things can get in the way of this opinion being voiced or heard. The barriers
arise from both sides of the stethoscope.
From a patient’s perspective, he or she may have the misperception that the clinician
will be upset with them if they don’t like the dosage that has been suggested by the
psychiatrist, nurse clinician, physician assistant, or clinical pharmacist. In other cases,
patients may lack the communication skills or assertiveness to spontaneously describe
their hesitancies about the dose of the medication.
From the clinician’s perspective, the problems are no less significant. One problem in
particular is daunting – time – not enough of it. In the hectic rush of the clinic flow, it is
easy not to have time to sort out the patient’s opinions, even one as important to hear as
the patient’s views on current dosage. Frequently this key point is not addressed unless
the patient spontaneously raises it. And, if we are honest with ourselves, unconsciously
we might not want to hear it anyway, because if a patient does not want to advance a dose
and is still sick, new interventions will need to be found and discussed. All of this takes
time. It is so much simpler when the patient is thrilled with the medication and its dosage!
Along these lines, one of the most likely periods for medication interest to plummet
is when a prescribing provider – focusing upon inadequate relief of target symptoms –
suggests increasing a medication to a patient who already feels that he or she is on too high
of a dose but does not voice that concern to the provider. I believe that a large portion of
such patients – who do not immediately voice concerns about the suggested increase in
dosage – will be inclined to lower or stop the medication before the next session. Patients
may be hesitant to voice concerns at this juncture for a variety of reasons including: fears
of displeasing the clinician, ambivalence about the suggestion, feeling that their family
want them “to do whatever the doctor says,” etc.
This phenomenon – patients not informing clinicians that they are displeased with a
dosage increase and subsequently stopping the medication in the weeks after such an
increase has been made – is so common that it warrants a name, the “trap door effect.”
The name comes from the fact that when this situation arises, the medication interest of
the patient seems to disappear – as if a trap door had opened beneath it, resulting in
medication discontinuation.
A new interviewing principle has emerged: Ask the patient his or her opinion regarding
the current dosage – don’t assume you know it – before making a recommendation to increase
the dosage. Therefore, while performing a routine med check, in addition to wanting to
know symptom severity, amount of relief, and side effects, the clinician makes a con-
certed effort to directly uncover this critical bit of information. In this regard, the follow-
ing question provides an invitation to such a discussion:

Tip #20: Trap Door Question

“At this point in time, in your own opinion, do you feel that you are on too little, too
much, or just the right amount of this medication?”

One of the strong points of the Trap Door Question is that it inquires along a continuum
and thus does not bias the patient in any specific direction. You may discover, or may

have already found, a question that works for you, perhaps with a slightly different slant.
The important point is to directly ask for the patient’s opinion about the current dosage
before suggesting an increase. Once again, assume nothing.
If the patient responds to the Trap Door Question by sharing hesitancies or fears
about the current dose, the interviewer has an opportunity to address these concerns
before proceeding with any suggestions for an increase in dosage. At times, the Trap
Door Question also uncovers a particularly problematic side effect that, secondary to
stigmatization, the patient had never previously shared, even when the clinician had
asked about the side effect directly. I have found sexual dysfunction on antidepressants
to be such a hidden side effect, which the Trap Door Question sometimes sensitively
uncovers. In such cases, the clinician can take actions to alleviate the side effect or may
find it expedient to switch medications. I often find that patients know they are on the
wrong medication before I do, and the Trap Door Question sometimes helps me to
find out.
The Subtle Art of Exploring Side Effects
Earlier we saw with the techniques of Introducing Shared Expertise and the “Call Me
First” Invitation two effective ways in the initial interview to directly invite the patient
to share future side effects. Peter Weiden points out that this invitation is not always easy
to accept in subsequent sessions. Part of the problem lies in the very nature of the more
traditional models of “medication adherence” that sometimes, inadvertently, create an
oppositional dynamic that, as Weiden nicely states, can result in a relationship “encum-
bered by obedience issues.” These obedience issue dynamics must be dismantled quickly
if the medication alliance is to be a healthy one, in which both parties truly share exper-
tise. If the patient does not share his or her concerns about side effects, there is nothing
the clinician can do to alleviate them. Weiden proposes two techniques for dismantling
the obedience rut, which can be adapted to address side effects, as well as further
re-enforce the shared-expert spirit of the MIM and can be referred to as follows43:

Tip #21: The Hurt Feelings Observation

“Sometimes patients are nervous about telling me what is really going on about their side
effects because they are afraid of hurting my feelings or making me angry. Please always
let me know if you are having any side effects. Our goal as a team is to limit them and,
if we have to, change medications. I promise you I won’t take it personally if you decide
you need to stop the medication because its side effects outweigh its benefits for you.”

Weiden’s original technique is designed to help a patient that has already stopped a
medication to relay “the secret” with a minimum of shame and/or guilt. When used for
this purpose, it reads exactly as Weiden delineates:

“Sometimes patients are nervous about telling me what is really going on about their
side effects because they are afraid of hurting my feelings or making me angry. Although
I certainly think it is a good idea for you to stay on medication, I promise you I won’t
take it personally if you’ve stopped.”

Once again, one of Weiden’s techniques for uncovering completed discontinuance can
be adapted to spotting impending discontinuance related to the patient’s side effects
perceptions.

Tip #22: The “Let’s Get Off the Medication Together” Invitation

“If you are like many patients, at some point you might decide that you want to stop a
medication, perhaps because of its side effects. Although there might be a part of you that
doesn’t want to tell me, please do. It’s okay. I want you to tell me about any side effect
concerns, and if you feel we need to stop the medication, let’s do it together. If I know
that’s what you want to do I can help you to get off the medication in the safest possible
way. Even if we decide we have to agree to disagree about whether or not stopping the
medication is wise, (Agreeing to Disagree technique discussed earlier) it doesn’t matter,
you have to make the final decision and my goal is to make sure that whatever decision
you make, we do it safely. Hearing your concerns will also help me to make better recom-
mendations for you down the road. We are a team here.”

Recognizing the inherent hesitancies that patients may have about reporting side effects,
we come to our next interviewing principle: Always directly ask patients in each encounter
about the presence of side effects. Without asking directly about side effects, clinicians and
case managers invite misunderstanding. This misunderstanding is a harbinger of dis-
continuance. The following technique in its differing variations is the antidote to the
problem:

Tip #23: Direct Side Effect Inquiry

“Are you getting any of the side effects that we talked about last time?” or

“Are you having any problems that you are wondering whether or not they might be a
side effect?

Weiden adds the following variation:

“Are there any side effects that cause distress or discomfort?”44

Once a patient has shared a concern about a side effect, the goal is to ascertain how the
patient experiences the side effect and feels it stacks up against the benefits of the medi-
cation. The clinician should guard about pre-conceived ideas that the benefits outweigh
the cons. Once again, the ultimate decision maker (unless a medication is being court-
ordered) is always the patient. I believe this collaborative exploration of how the patient
views the personal impact of the side effect on his or her functioning is enhanced by the
number and specificity of the interviewer’s questions about the side effect. The following

amount and type of questions (regarding a patient experiencing nausea on an antidepres-

sant) metacommunicate genuine concern and interest:

Tip #24: Techniques for Conveying Concern About Side Effects

1. “Tell me about a specific time you felt nauseated and walk me through what
happened.”
2. “Just how bad does the nausea get?”
3. “How often are you feeling it?”
4. “How many days this week did you get it?”
5. “Is it making it harder for you to do anything?”
6. “On a scale from 1 to 10, with 1 meaning ‘it hardly bothers me’ and 10 meaning
‘I can’t stand this side effect,’ where would you put your nausea this past week?”
7. “I have some ideas about what to do to get rid of the nausea, but if we can’t, do you
think the nausea is bad enough that it outweighs the good things your medication is
doing, like making you feel less depressed and sleeping well again. Sometimes it’s a
tough call, but only you can make it. The bottom line is: do you think you feel better
on or off the medication at this point?”

Such questions cut to the core of the matter so that there is no miscommunication pos-
sible here between the patient and the prescriber. By understanding how problematic a
side effect is, we can help the patient weigh the pros and cons more effectively. Moreover,
the reporting of side effects that are perceived as severe by the patient may be the har-
binger of imminent medication discontinuation. Now that we have examined the issue
of common side effects, let’s take a look at one of the most difficult decisions that a
patient has to make regarding his or her perception of the potential efficacy of a new
medication.

How to Present a Medication When One of the Potential Side Effects Is Death
When clinicians propose a treatment that carries risks of dangerous side effects, they must
inform the patient of those risks.45 For instance, some medications in internal medicine
carry a distinctly increased risk of death, as is seen with chemotherapeutic agents in
oncology. These potentially lethal side effects must be discussed openly with patients.
In psychiatry, clozapine (which may lead to agranulocytosis, cardiac myopathy with
sudden death, and the metabolic syndrome and diabetes) has just such a risk attached
to its use. Although less striking in nature, some mood stabilizers also carry an increased
risk of potential lethality such as carbamazepine (agranulocytosis), divalproex sodium
(chemical hepatitis), and lamotrigine (Stevens–Johnson syndrome). How does one raise
these issues in such a way that one is effectively describing risk without generating inap-
propriate fear?
One solution lies in an interviewing technique called “Personalizing Risk.” Imagine
a clinician who has been working for years with a patient whose schizophrenia has
responded poorly to antipsychotics. They have established a robust medication and
therapeutic alliance, having navigated some rough roads together. The patient has been
doing somewhat better but is still hounded by psychotic process and disabling negative

symptoms. He has successfully embraced both Step 1 and Step 2 of the Choice Triad – he
believes he has schizophrenia and he believes that medications may help, although he
has been disappointed by their usefulness to date.
The clinician is personally convinced that clozapine could be potentially life saving
(preventing suicide) and/or life transforming. After explaining the pros and cons of
clozapine effectively, including the potential for death, the clinician might proceed as
follows:

Tip #25: Personalizing Risk

“You know, John, when thinking about using clozapine, one has to give a lot of thought
to it, because of the dangerous side effects that I mentioned. You and I have a pretty good
relationship and have known each other for a long time now, and I think we trust each
other. Considering the fact that every medication we’ve tried has failed, and this medica-
tion has a definite tendency to help when other medications have not helped with schizo-
phrenia, if I was in your spot, I would absolutely take it myself. Not only that, but the
risk of the bone marrow problems and the possible problems with your heart and diabetes
is relatively low, if we can carefully keep our eyes out for them and take protective steps
if any changes are seen. When a team carefully monitors for these side effects and, trust
me, we will, I feel very confident that this is a generally safe medication to use – so much
so that I would give it to a member of my own family if they were in your spot. I wouldn’t
say that to you unless I meant it.”

By using Personalizing Risk, based upon a genuine belief in the safe use of the medica-
tion when monitored properly, the clinician has helped the patient to address one, if not
the, most difficult decisions that a person can make in Step 3 – weighing the pros of a
medication against the possible con of death. No doubt, it is of value to hear from a
trusted clinician an honest and spontaneous sharing of the clinician’s personal opinion.
This interviewing technique can also be of use when introducing other atypical antipsy-
chotic agents, where the clinician needs to discuss potentially serious side effects such as
the metabolic syndrome and tardive dyskinesia. One can never use Personalizing Risk
unless one has a genuine belief in one’s recommendation.

Questions for Uncovering Positive Effects of Medications

As important as the task of eliciting and helping with side effects is, it is equally impor-
tant to help the patient obtain a clear picture of the medication’s benefits to feeling better,
for side effects can quickly become preoccupations that hide these benefits from the
patient’s awareness. Once again, the simplest approach is to ask directly:

Tip #26: Symptom Relief Inquiry

“Is the medication helping with any of your symptoms?”

If the patient answers “yes,” add, regarding the symptom in question, “Give me a rough
estimate; has it barely helped, helped a little, helped a lot, or totally gotten rid of the
symptom?” With sophisticated patients, one can ask them for a percentage of relief

provided by the medication from 0% to 100% relief. Repeat such questioning with each
symptom that the medication appears to be relieving.
Weiden offers the following useful questions for uncovering benefits of the medication
that are helping the patient to feel better about themselves or life itself46:

Tip #27: The “Life is Better?” Inquiries

“Is your medication helping you to feel better in any way?”

“Is the medication helping you deal with stresses or day-to-day problems?”

“Does the medication make life easier for you in any way?”

“Is the medication helping with any of your relationships?”

Before leaving the area of discussing the pros of a medication, it is useful to remember
another important interviewing principle from Peter Weiden: Don’t oversell the benefits of
a medication.47 It is important to communicate both confidence and hope regarding any
medication that one is prescribing, but it is also important that the clinician be aware of
the limitations of the medication as well. As Weiden points out, some medications may
not be curative or may not even able to restore “normal functioning.” It is important
that the patient be aware of the legitimate benefits of the medication so that he or she
is not disappointed by inappropriate expectations for relief. Such disappointments can
also deleteriously impact on the medication alliance, for the disappointed patient may
feel that the clinician is not a credible source of information or, even worse, is willing to
purposely mislead the patient.

Uncovering the Patient’s Pros and Cons on Axis #2: Cost

Cost is the second major belief set that patients weigh while deciding whether to continue
or to stop a medication. Cost is translated by most patients into a question such as, “Is
it worth it to me to take this drug?” As clinical experience suggests – and McHorney’s
research verifies – money is a major issue regarding medication interest and follow-
through. Returning to our “internal committee” metaphor, on the pro side, the patient
may have many internal committee members singing the praises of a medication, but
all one needs is one member of the committee to say, “That’s all well and good, but we
simply don’t have the money and that’s that.”
With regard to cost, money is not the only issue. There are other costs to taking medi-
cations. These psychological costs include: inconvenience, interpersonal disruptions, and
side effect concerns that hinder patient goals and dreams. We will address both types of
costs, financial and psychological, in this section.

Techniques for Addressing Financial Costs

We want to be aware of cost issues as a potential serious problem, not only because they
can lead to medication discontinuance, but also because we may be able to do something
constructive to prevent such discontinuance. Cost is a medication interest problem,

though not always easily solved, that does have a surprising number of potentially helpful
solutions, including use of generics, use of medication samples, formal use of pharma-
ceutical programs for indigent patients, and supplemental governmental programs.
Howard Brody in his book, The Healer’s Power, makes the point that not only is the
personal relationship the tool of the trade for clinicians, to use this tool effectively the
clinician’s “approach to the patient’s problems must be grounded in the way the patient
defines the problem.”48 In this regard, we need to see how each patient is defining the
problem of cost, because patients may be embarrassed by their financial situations. In
such instances, instead of viewing money as the problem, patients view themselves as
the problem for not having enough money. This type of negative self-impression can
make the topic of cost a taboo one.
If we don’t know of the problem, then there is nothing we can do about it. While
sitting in a café, busy at work with the first edition of my book introducing the MIM,49
a nurse, who happened by, provided me with our next interviewing principle: Develop
the habit of routinely asking every patient about the cost of his or her medications, because if
you don’t ask, you often will not be told.
As prescribing clinicians and as case managers, it is sometimes a sobering realization
to see the financial burdens of our prescriptions. Despite its best intentions, it is not clear
yet the extent to which the Affordable Care Act will help with these costs. Indeed, in
instances where a patient’s necessary medication is not listed on the ACA’s formulary,
insurance plans that formally reimbursed for medications may stop doing so. In such
instances, the costs of medications to some patients may skyrocket to prohibitive levels,
perhaps necessitating discontinuance of an invaluable medication for a patient. In any
case, the importance of applying this interviewing principle will probably only increase
in time. Let us look at a cluster of variations on a single interviewing technique that
effectively allows the employment of the above interviewing principle:

Tip #28: Gently Exploring Cost Issues

“Mrs. Phillips, I’m always curious about how much my patient’s medications cost. How
much did you end up having to pay for the (insert medication in question) this past
month?”

“Were you surprised by the cost?”

“How much of that did you have to pay for yourself?”

“It can be tough for anyone to pay for their medications; how much of a burden do
you think this will be for you and your family?”

Routinely asking such questions assures insight into the financial cost issues potentially
impacting on our patients’ medication interest. Using these interviewing techniques, the
clinician can gently open the door into this critical topic.
Naturally, generic medications of a certified bioequivalence are a reasonable first
answer. Another thing to keep in mind is that, especially with antidepressants, a pill that

is twice the dosage of another one may be only fractionally more expensive. In such a
case, if the pill is scored, you can write the script for pills of the double dosage and then
instruct your patient to cut the pill in half, being sure that the patient is able to do so
effectively. I sometimes have patients demonstrate in front of me how they halve the
dosage to make sure that they can do it appropriately, keeping in mind that patients with
rheumatoid arthritis or failing eyesight may have trouble with such a task.

Techniques for Addressing Psychological Cost

The Hidden Cost: Inconvenience
As noted earlier, the patient’s answer to the question, “Is it worth it to me to take this
drug?” is not always related to cost in the sense of money. In the book, The Doctor–Patient
Relationship in Pharmacotherapy, one of the contributors, James Ellison, makes the follow-
ing point that is often not given enough attention: “In general, patients should be dis-
couraged from beginning a treatment that is likely to become burdensome as a result of
inconvenience.”50 At first glance, the point seems painfully obvious, but I have been
surprised at how often I seem to ignore it.
I ignore it, not because I do not believe it, but because I am unaware just how
inconvenient this particular regimen for this particular patient has become, because I
have not asked about it directly. Once again, our interviewing principle is simple: Ask
patients directly about inconvenience, paying particular heed to hidden inconvenience created
by shame or guilt. As with financial cost, subtle taboos push patients toward silence on
this topic.
Inconvenience can manifest in many ways, and it often occurs as a daily problem.
Practical problems with inconvenience often present as two separate concerns: On one
level, there are the psychological concerns (such as shame or guilt for not “taking my
meds as I’m supposed to take them”). On another level, there are nitty-gritty mundane
problems about how to overcome the inconvenience (“How do I get a ride to the phar-
macy?”). These latter hurdles actually move into the realm of facilitating medication
follow-through and move beyond the issue of patient choice, which is the focus of the
MIM. Consequently, these problems are best addressed by the many strategies that have
been developed to help with medication follow-through for patients who have already
chosen to utilize medications (case management, smartphone prompts, easier-to-use
pillboxes, behavioral tailoring, dosage simplification, etc.). But the first concern – the
psychological aspects of inconvenience – is in the immediate purview of the MIM, for
such inconveniences can be viewed as powerful cons to taking the medication.
Moreover, whether one is addressing psychological issues associated with inconve-
nience or practical nitty-gritty issues, neither can be addressed unless the clinician is
aware that problems with inconvenience exist in the first place. It is to the initial unmask-
ing of such problems that we now turn our attention. Several problems and interviewing
techniques for uncovering them come to mind:

Tip #29: Inquiry into General Inconvenience

“Are you finding that taking the medications is inconvenient for you in any way?”

Tip #30: Inquiry into Timing Inconvenience

“Sometimes it can be hard to remember when to take medications. Are you finding that
it is hard to remember to take your medications at the times that I had suggested. If so,
we might be able to figure out better times?

Tip #31: Inquiry into Travel Inconvenience

“Have there been any problems for you in getting to and from the pharmacy for your
medications?”

The Tragic Cost: Disruptions in Relationships

Medications can have marked interpersonal costs. For instance, a patient who must hide
medication use from a boss who frowns upon “sick employees” may need to fret several
times a day as he or she sneaks off to the bathroom to quickly gulp down a tablet
or two.
Even darker in nature is the patient with an alcoholic spouse who is highly opposed
to medications. Such a spouse may push the cost situation “over the edge” with com-
ments, such as “I’m sick and tired of you and your depression. We all have to deal with
stress. Do you see me reaching for a pill that costs a fortune? Do you have any idea how
much strain your damn pills are putting on us financially? No, I wouldn’t think you
would. The only person important to you is you.” For a patient on the receiving end of
such a vicious diatribe, there will be a considerable psychological penalty paid for con-
tinuing on medication. It represents a legitimate con that could easily tip the scale toward
stopping the medication. A patient who hides the use of a medication from such a
spouse, if discovered by the spouse, can have severe complications including physical
assault.
At other times, a spouse may disagree with the use of medications because of the
impact of the patient’s medication-induced side effects on them. These side effect con-
cerns impact on the patient in a different way to those we normally discuss. The question
on this axis of belief is not, “How is this side effect making me feel?” It is, “Is the side
effect causing other people problems?” In this regard, sexual dysfunction and weight gain
can create powerful problems between a couple. To uncover such sensitive issues, Weiden
suggests the following general technique:

Tip #32: Inquiry into Med-Induced Relationship Problems

“Are there any side effects causing problems in your relationships?”

Sexual dysfunction, in my opinion, is best routinely directly asked about because of the
strong social taboo against admitting sexual dysfunction. Sexual dysfunction is often not
shared spontaneously by patients. Instead, affected patients simply stop the medication.
Once the topic has been shared, it is valuable to ask how the person’s spouse or partner
feels about the dysfunction, for his or her voice will cast a powerful vote on the decision
to continue or not on the medication.

This area of relationship-related discontinuance (and the opinions of others on

shaping the patient’s final decision in the Choice Triad) is so important that we will
devote an entire section to it in one of specialty toolboxes at the end of the chapter. In
the meantime, I have found patient’s answers to the following question particularly
revealing:

Tip #33: The Deception Inquiry

“Do you find that you need to hide your use of your medication from anybody?”

The Lost Goals Cost

As with relationships, side effects can cause problems unrelated to how they make the
patient feel physically or psychologically. Instead, the problem created by the side effect
involves impairment in the ability to achieve a much-desired life goal of the patient.
Such examples might include cognitive impairment caused by an antipsychotic prevent-
ing a patient from attending college or participating in job training, or perhaps weight
gain preventing a patient from becoming a personal trainer or model. Even a supposedly
minor side effect such as a dry mouth can become a major side effect for a teacher, min-
ister, or actress, all of whom must engage in public speaking frequently. In the same
fashion that – as Sir William Osler pointed out – it is critical to understand what patient
has a disease, for patients respond differentially to the presence of their symptoms, it is
equally important to find out what patient is experiencing a side effect.
Cross-cultural issues can play an intriguing role in how patients view their side effects.
In one study of Hong Kong Chinese patients, few of the patients complained about the
polyuria (frequent urination) and polydipsia (need to frequently drink fluids) so often
seen with the use of lithium. These side effects are commonly problematic with patients
of all races in Western countries, for they can cause significant problems in job settings
where one is expected to stay in place for hours at a time, as well as disrupting sleep. In
contrast, most of the Hong Kong Chinese patients viewed these side effects in a positive
light. They believed that water consumption and excretion are evidence that the body is
ridding itself of toxins and aiding digestion.51
A minor side effect to one patient can present as a major side effect to another and
vice versa. Peter Weiden posits a simple question for uncovering the patient beneath the
side effect:

Tip #34: Dream Destroyer Question

“Are any of your side effects interfering with any of your future goals or work?”52

“Is your [specific side effect being discussed] causing you problems at [whatever situ-
ation is appropriate, such as school, work, or recreational activities]?”

Uncovering the Patient’s Pros and Cons on Axis #3: The Soul of the Pill – Symbolic
Meaning to the Patient
It is not so much that a pill has a soul. It is that each pill has an impact on the soul of
those who take it. This impact is particularly marked with patients who are destined to

be on medications for many years, perhaps indefinitely, as is common in schizophrenia,

bipolar disorder, and recurrent major depressive disorders. If you must reach for a pill
bottle several times a day, over 700 times a year, tens of thousands of times over a life-
time, then that pill is going to assume a meaning to you, personally. The pill will become
a symbol, one that, for many patients, relates to the question, “What does it say about
me that I have to take this drug?”
Such a question moves the patient inexorably toward deeper questions concerned with
meaning – who they are, and why do they have to take this drug that other people do
not? “Do people want me to take this drug because they think I’m crazy?” “Have I become
addicted to this drug?” “Shouldn’t I be able to handle life’s stresses without needing a
crutch?” For many patients, these are disturbing questions with disturbing answers; for
others graceful resolutions exist. The former patients frequently stop their medications;
the latter patients stay on them.
Patients, family members, fellow patients, and the culture at large often attach sym-
bolic meaning to the use of psychiatric medications. Frequently this meaning is deroga-
tory or denigrating.
Many of us have been puzzled by situations such as the following, relating to a patient
in a sustained remission from bipolar disorder. We unexpectedly get a call from an emer-
gency room at 2:00 AM that our patient has presented as grossly manic and psychotic
and will require immediate hospitalization. The puzzlement arises from the fact that this
patient has been in a solid remission for over 3 years and has been a loud advocate of
medication use. It has been clear that our patient believes he or she has bipolar disorder
(agrees with the first step of the Choice Triad), feels that medications have been instru-
mental in obtaining relief from this problem (believes the second step of the Choice
Triad), is convinced that the symptomatic relief outweighs the side effects of the medica-
tion, and is fine with the costs of the medication (is comfortable with the first two axes
of the third step of the Choice Triad). Yet the patient has discontinued the medication
without warning and unilaterally. As we shall soon see, there is no need for puzzlement.
There is a very logical reason that the patient has stopped the medication. Almost invari-
ably, in these situations, it is the symbolic meaning of the medication that has led to
discontinuation. Sometimes the troubling symbolic meaning arises from a myth.
Addressing Concerns About Personal Weakness
Especially with regard to antidepressants, some patients develop the fear – and resulting
self-recrimination – that their antidepressant is an unnecessary crutch. This myth can
even be perpetuated by family members who feel that, “People should be able to handle
stress without a drug.”
After I have taken the time to provide psychoeducation with the patient about neu-
rotransmitters and how the antidepressant works, I’ll directly address the crutch myth as
follows:

Tip #35: Dismantling the Crutch Myth

“There is a common misconception that these medications are crutches, that somehow you
should be able to cope with depression without medications. But if your brain is not making
enough serotonin, it simply isn’t making enough serotonin, and you can’t just ‘will it’ to

make more, any more than a person with diabetes can will their pancreas to make more
insulin. We would never tell a person with diabetes that their insulin is a crutch because
it isn’t. We are simply getting their insulin back to the normal level that everyone else has.
“It is exactly the same with your depression. Your brain is not making enough serotonin,
and we are just going to get your serotonin back to the normal level that everybody else
has. It isn’t a crutch. It is getting your serotonin level back to normal, so that you then
have a fair chance to effectively cope with your stresses. Don’t let anyone tell you it is a
crutch, because it is simply not true.”

I will generally address the crutch myth proactively (without the patient having expressed
the fear), for it is so commonly held. As demonstrated above, it is often gracefully
addressed directly after talking with patients about the fashion in which antidepressants
increase neurotransmitters. The small amount of time it takes to use the Dismantle the
Crutch Myth can pay off in a big way. Without such proactive education, some patients
may have stopped their antidepressants by the next visit, necessitating the time-consuming
process of introducing yet another new medication. Furthermore, if, following the medi-
cation discontinuation, the patient’s depression worsens it may ultimately require more
frequent appointments or even hospitalization. Dismantling the Crutch Myth, is a win–
win–win situation (saves the patient from suffering, saves the physician time, saves the
system money).
Addressing a Compelling Paradox Arising With Remission
One of the reasons that our patient in a stable remission from bipolar disorder, used as
an illustration earlier, stopped medications may be related to a psychological dilemma.
It is a curious dilemma that patients who move into long-lasting remissions must resolve.
They need not resolve it alone. Indeed, if we don’t proactively address the issue, many a
patient will fall prey to unnecessary discontinuation with all of its potential sequelae.
Such proactive inquiry can prevent a major relapse and, in some instances, as when the
return of suicidal ideation or violent behavior is a potential aspect of stopping the medi-
cation, may even prevent a tragedy.
Peter Conrad’s work regarding the symbolic meaning of antiseizure medications sheds
light on this phenomenon.53 Conrad discovered that patients who had their epilepsy
under excellent control with minimal side effects would sometimes do exactly what
euthymic patients with bipolar disorder or schizoaffective disorder might do – abruptly
stop their medications. One of Conrad’s patients describes the experience as follows:

When I was young I would try not to take it … I’d take it for a while and think, ‘Well,
I don’t need it anymore,’ so I would not take it for … deliberately, just to see if I could
do without. And then (in a few days) I’d start takin’ it again, because I’d start passin’
out … I will still try that now, when my husband is out of town … I just think, maybe
I’m still gonna grow out of it or something.

A potentially dangerous paradox unfolds when medications are effective in relieving

symptoms. When a medication removes all symptoms, whether in bipolar disorder or a
seizure disorder, the paradox is at its maximum. If a medication successfully removes all

symptoms, it removes any ability for the patient to know whether or not the disease is
still present.
Some psychiatric diseases, such as major depressive disorder, can go completely away
to never return. With such diseases, patients can be in a bind. They may need to decide
whether to stay on a medication for the rest of their lives, despite the fact that they cannot
know for certain whether they need it. The decision is further complicated by our growing
awareness that long-term use of antidepressants may have serious adverse consequences.
So it is with patients managing schizophrenia, schizoaffective disorder, and bipolar
disorder. All of these are illnesses in which, even when some symptoms remain, the
presence of such symptoms can be easily consciously suppressed or unconsciously
repressed for what patient wouldn’t want to be free of these illnesses? The reasoning
behind why patients who are doing well may choose to abruptly discontinue their medi-
cations is no longer puzzling. It makes good sense. It is uncomfortable to not know what
is going on inside one’s body. And it is all too human to wish that such a devastating
illness no longer exists. The urge “to test” is not the hallmark of “resistance,” “opposi-
tion,” or “lack of insight.” It is the attempt to gain insight for some patients. In others,
it is the attempt to gain freedom.
I have found the following interviewing technique to be useful in short-circuiting this
dilemma before it becomes a threat to discontinuance.

Tip #36: Testing the Waters of Discontinuance

“Sophia, you’ve been doing great on your medications now for over a year. It’s wonderful
that you have your bipolar disorder (substitute whatever illness the patient is dealing with)
in excellent control. Some of my patients tell me that after a while, they wonder whether
or not they still have the bipolar disorder or even need the medications. I think that is a
natural curiosity. Do you ever have thoughts like that?”

Peter Weiden offers a subtly different version of the technique:

“When patients feel better, they may try stopping a medication to see what will happen.
They think of it as a kind of experiment. Have you tried or thought of trying that?”54

Depending upon what the patient says to such questions and, equally important, how
he or she says it, the clinician can gain insight as to whether the patient is preparing to
try a unilateral and unannounced “medication-free trial.” Sometimes the clinician can
convince the patient that such a trial is not advisable. If not, the clinician can offer to
taper the medication in the safest possible fashion as opposed to the patient unilaterally
and abruptly discontinuing the medication.

Questions for Ascertaining the Patient’s Ongoing Views About

Continuing Medications
Ultimately, with regard to Step 3 of the Choice Triad, the patient must make a decision.
The scale will tip one way or the other. Our goal is to help the patient to make the wisest

decision. Sometimes it is wisest to continue a medication. Sometimes it is not. As stated

before, this collaborative exploration of the pros and cons of a medication is truly a joint endeavor,
for the patient may show the clinician that a dosage reduction is needed, a switch to a different
medication is indicated, or no medication is needed. The questions we have surveyed in this
section can help the patient to effectively uncover his or her beliefs and feelings on each
axis (efficacy, cost, and meaning) of the third step of the Choice Triad. It is now useful
to make sure the patient’s “committee” actually votes in front of us, for only then can
we offer feedback, education, and our own opinions. The following interviewing tech-
nique and its variations can prompt a patient to consciously review the pros and cons
with us and to arrive at a decision:

Tip #37: Tipping the Scales

“We’ve reviewed some of the pros and cons of the medication; now that you’ve been
on it for a while, what do you honestly think about the medication so far?”

“Do you like the medication?”

“Do you feel that the relief you are getting from your medication is outweighing its
side effects or any of the problems they are causing, you know, like the sleepiness
the medication is causing in your classes?”

“At this point in time, do you feel that the pros are outweighing the cons with this
medication? Remember, I’m counting on you to let me know, because you are the
only expert here on how the medication feels to you. I’m not taking it, you are.”

It is important to note not only what the patient says when utilizing Tipping the
Scales, but also how the patient is saying it. Nonverbal evidence of hesitancy may be
the only indication that a more deeply rooted concern lies just below the surface of
a patient’s half-hearted, “Yeah, yeah, it’s okay I guess.” Such a response can be use-
fully explored by a simple, “You sound a little hesitant, Judy, what are some of your
concerns?”

Exploring the Choice Triad: the Importance of Sequence

Generally speaking, in order to be fully motivated to continue with a medication, people
tend to embrace the three steps of the Choice Triad in sequential order. Although this
process seems at first glance to be self-evident, in practice I have found it to be easily
missed. One of the most common stalemates that I have seen in supervision occurs when
I find a clinician vigorously attempting to convince a patient that a medication’s pros
outweigh its cons, when the patient is not yet convinced that there is something wrong
in the first place (Step 1 of the Choice Triad). In the patient’s mind there can be no pros
if there is nothing wrong. To push the point of the “pros” of the medication with such
a patient will seem, at best, annoying, and, at worst, be truly disengaging, for the patient
feels that, “this guy just doesn’t get it.” It will also appear illogical to the patient for a
simple reason. It is.

We are left with the following interviewing principle: Do not engage in frivolous attempts
to secure patient interest in any step of the Choice Triad until the previous steps have been
reasonably secured.
We had mentioned that it is useful in the initial interview to ascertain the patient’s
“diagnostic passport.” Sometimes this is not done and at other times it may change over
the course of treatment (e.g., the patient may meet someone who convinces them that
they do not have a mental disorder and/or the patient may find a website that dismisses
all mental illnesses). In any case, if you find yourself doubting a patient’s acceptance of
Step 1 of the Choice Triad, it is generally best to employ a key general interviewing prin-
ciple that we have seen attached to several of our previous principles, which warrants its
own delineation: Assume nothing. When in doubt, ask directly in a sensitive fashion:

Tip #38: Gauging Step 1 of the Choice Triad

“Do you personally believe that you have schizophrenia [or whichever disorder is
present]?”

“On a scale from 1 to 10, with 1 being ‘I’m not really sure I have schizophrenia’ to 10
being ‘I’m totally convinced I have schizophrenia’ where would you place yourself?”

Sometimes a patient’s ambivalence quickly dissipates when the interviewer provides

clarifying information. At other times, the patient, sometimes to the surprise of the clini-
cian, may be firmly entrenched in the belief that he or she does not have a mental illness.
As noted earlier, one can still instill medication interest if one can collaboratively uncover
a symptom (problems with sleep) or a situation (wants to stay out of the hospital) that
the patient acknowledges is a problem with which he or she personally wants help.
With regard to ascertaining whether or not the patient has embraced Step 2 of the
Choice Triad (the patient feels that a medication can help find relief with the identified
disorder, symptom, situation), gentle directness once again will do the trick:

Tip #39: Gauging Step 2 of the Choice Triad

“Ben, I’ve noticed that you seem a little bit hesitant about the medication, do you actually
think it will help you or are you having some doubts about that, and I really want to know,
because if you have some doubts perhaps it might not be the right fit for you?”

Section 3: Specialty Toolboxes for Difficult Clinical Challenges

As mentioned earlier, the MIM carefully delineates the use of numerous interviewing
techniques for all steps of the Choice Triad. It also provides interviewing techniques and
strategies for other clinical tasks related to medication interest. Before leaving the model,
it is useful to visit several of these toolboxes.

Toolbox for Assessing the Patient’s Actual Medication Practices

Interviewing techniques housed in this toolbox give the provider questions for ascertain-
ing, in a sensitive and non-accusatory fashion, the actual medication practices of their

patients (e.g., how often is the medication actually being taken in contrast to how it was
prescribed). Research has shown that patients do not tend to voluntarily tell their clini-
cians that they do not intend to use a medication as prescribed (or are already not doing
so).55–59 For instance, in the Laplane study, a disturbing 83% of the adult patients sur-
veyed over six U.S. states indicated that they would not tell their prescribing clinician if
they did not plan on filling the prescription that they were holding in their hands as they
walked out of the clinic door,60 an example of what has been termed “primary nonadher-
ence.”61 With regard to antipsychotics specifically, patients were hesitant to share their
changes in medication practice to their clinicians because they feared being viewed as
bad patients and as such might be reprimanded or lectured.62 Moreover, studies have
demonstrated that clinicians consistently overestimate the degree to which their patients
are taking medications as prescribed.63–65
Research by Steele and colleagues has shown that how physicians ask about missed
doses plays a significant role in whether valid answers are forthcoming.66 Their research
also showed the troubling fact that only 12% of their patients spontaneously mentioned
anything about how they were actually taking their medications during a clinic visit.
Here is an interviewing strategy for eliciting more accurate information on missed
doses that I have found to be very effective. It evolved from combining two of our valid-
ity techniques from Chapter 5 – normalization and gentle assumption. The cornerstone
of the interviewing strategy is twofold: (1) the process of missing the medications is
normalized so as to decrease shame or guilt, and (2) the clinician doesn’t ask if meds
were missed, it is gently assumed as witnessed below:

Tip #40: Normalizing Missed Doses

“Mr. Jeffers, many patients tell me that it can be easy to forget to take antidepressant at
times. (normalization) In the weeks since we last met, how many doses do you think you
might have missed per week – just roughly.” (gentle assumption)

This interviewing strategy appears to work effectively. In the research cited above by Steele
and colleagues, although they did not use the technical terms “normalization” and
“gentle assumption” they did use the actual techniques in the exact sequence described
above. They found that this combination of techniques significantly improved the accu-
racy of patient self-reporting on medication use. Personally, I have seen clinicians inquire
about missed doses with questions such as, “Have you missed any doses?” or “You’ve
been taking the meds as we discussed?” and receive assurances that all meds are on board.
A second clinician, during a later interview, will uncover numerous missed doses with
the same patient through the use of this easily learned and employed interviewing
strategy.
If, during follow-up visits, a patient spontaneously raises concerns about a side effect,
I have found that it is important to explore this side effect thoroughly. A spontaneously
raised side effect often suggests that it is causing enough problems that the patient may
be considering stopping the medication. In my experience, if a side effect is spontane-
ously raised several times, this medication is probably heading for the back shelf of the

medicine cabinet if not already there. If we have any questions about the intensity of a
patient’s misgivings, this is the time to ask and here is an effective way to do it:

Tip #41: Probing for Discontinuance

“Mary, we’ve been trying to decrease this side effect, but I know it is still a problem. What
kind of thoughts, even fleeting in nature, have you had about maybe stopping the
medication?”

I have been pleasantly surprised how, after using this technique, patients sometimes
describe serious misgivings about the medication in question. This disclosure opens the
door for a productive discussion of what to do for the side effects and whether to con-
tinue the medication, without there being any shame or guilt for the patient about having
had such thoughts. In the spirit of the MIM, we find ourselves moving with the patient
as a collaborative ally, not against the patient as an oppositional foe.
As hinted earlier, patients sometimes worry that we will be upset if they suggest stop-
ping a medication. They fear that it may look like they complain too much or don’t want
to help themselves. If they project this fear on to us – despite the fact that we, personally,
take their side effects very seriously – they may choose to say nothing. In such situations,
it is often only a matter of time before they stop the medication on their own.
One nice way of nipping this problematic process in the bud is to remind the patient
that we, too, are aggressively on the lookout for side effects. As mentioned earlier, part
of our goal is to be a watchdog that alerts our patient when it may be best to stop a
medication because the side effects are outweighing the benefits.
I have found no better way to convince a patient of my vigilance regarding side effects
than to be the first one to suggest stopping a medication. When patients repeatedly raise
a problematic side effect, one that could easily lead them to stop the medication, a
response such as the following can go a long way toward reassuring them that we, too,
share their concerns:

Tip #42 Proactively Recommending Discontinuance

“Luis, I just don’t like the problem we are having with this side effect. If we can’t get it
under control, I really think we may need to stop this med, even though I know it’s also
helping too. I’m just worried that the pros of using it are being outweighed by the cons.
What do you think?”

I, personally, have found this technique – being the first one to proactively suggest
stopping a medication – to be a very powerful tool. I use it a lot when dealing with
side effects from antidepressants.

Toolbox for Assessing Cultural Influences Upon Medication Interest

… this literature [clinical literature on culture and medication use] teaches the importance
of recognizing the multiple, often conflicting meanings of medications in clinical interac-
tions. Attention to these complexities can provide important avenues of communication

between doctors and patients. Lack of such attention increases the chances of a miscom-
munication in which the doctor and patient incorrectly think that they are talking about
the same thing when discussing medication.
Jonathan Metzl, MD, PhD, and Michelle Riba, MD67

Quietly sitting in its bottle, a medication can appear to be a simple inanimate “thing”
defined by the parameters of its color, shape, and size. But a pill is more than a mere
thing. It is a thing animated by the culture in which it lives. The surrounding culture,
whether it be Hispanic, Black, White, Asian or Native American gives each medication
its meaning, power, and appeal. In this sense, it behooves the prescriber, whether psy-
chiatric nurse clinician, psychiatrist, physician assistant, or other provider to determine
the “cultural address” of the medication about to be prescribed. With each patient, this
cultural address is unique and distinctive.
In our previous section devoted to the toolbox for use when helping patients to navi-
gate the third step of the Choice Triad, we examined the impact of the “axis of meaning”
upon the patient’s weighing of the pros and cons. Our focus was on the symbolic asso-
ciations generated by taking a medication upon issues such as self-esteem, fear of per-
sonal weakness, and thoughts of discontinuance. In this section we will expand upon
these issues, exploring the impact of other cross-cultural influences related to the meaning
of the medication that can impact upon the communication between a prescriber and a
patient. Metzl and Riba nicely highlight this by pointing out that “… understanding the
symbolic functions of medications is as important as knowing their elimination half-lives
or suggested dosing regimens.”68

Assessing the Influence of Other Healers

When we work with our patients, it is often a mistake to think we work alone. Whether
patients inform us or not, they are frequently seeing other healers associated within the
matrix of their current culture or culture of origin. Sometimes the healers are specific to
a given culture (shamans in the Hmong or First Nation Peoples). Other times, they are
a generalized movement that crosses many cultures (practitioners of alternative medi-
cine). In either case, they speak with a powerful voice to our patients. In addition, they
may have strong views about our medications, both for and against. I can think of no
instance in which it is not wise to find out what is being said by them. In most instances,
I have found them to be of great value in ongoing care. Occasionally there is a problem.
In either instance, it is important to find out what these other influences are for a given
patient. Whatever the case, the following interviewing principle guides the practice: Ask
your patients, in an open and interested fashion, if they are seeing other healers who are either
particular to their culture (as in a shaman) or generic across cultures (such as a practitioner of
alternative medicine). The following technique provides several ways in which to put this
principle into practice:

Tip #43: The Shaman Questions

“Do you visit or use a shaman?”

“Have you talked to your shaman about our work together?”

“What is your shaman’s view about our work together?”

“What do you think he [or she] will think about you starting up on an antidepressant?”

I also subsequently suggest that the patient should ask the shaman about the use of the
medication. As we saw in Chapter 6, such coordinated care can be critical to success.
With regard to generalized alternative healers the questions are basically the same,
although I soften the initial inquiry with a normalization, because many patients feel
that mental health providers have a built-in bias against alternative medicine. Some do.
I don’t. Whether you do or you don’t, the following technique can help you to assess
the presence of an alternative healer:

Tip #44: Normalizing the Use of an Alternative Healer

“It is not uncommon for some of my patients to be seeing a practitioner of alternative

medicine while they are working with me, and it’s always useful to know of such efforts
so that we can work effectively together. Are you by chance working with anyone else on
your OCD [substitute whichever disorder is relevant]?”

I believe that having a discussion between ourselves and our patients over the concurrent
use of traditional and alternative healing practices is so important that it is worth more
of our attention. In actual practice, I often have uncovered the use of alternative approaches
much earlier in the initial interview than during my discussion of my own recommenda-
tions, for I tend to make an effort during the medication history to ask about the topic
of “alternative medicines.” In other instances, patients become interested in alternative
treatments long after we have begun our relationship. Whether it is in the initial inter-
view, or during one of our ongoing sessions, I tend to use the same approach: an open
and non-judgmental interest in what the patient is doing.
The topic of alternative medicine, if not handled properly, can become a major trip
wire into an oppositional relationship instead of a partnership. Some patients are so
convinced that their physician is going to be opposed to alternative approaches that the
patients simply do not bring them up, even though they are concurrently seeing an
herbalist, acupuncturist, or chiropractor. Such a lack of openness and trust does not bode
well for a long-term partnership between a prescriber and a patient.
Fortunately, I seldom encounter a problem here, because I am genuinely open to new
ideas and feel quite certain that techniques, such as acupuncture for pain relief, can be
efficacious. This unexpected openness, once again, assures the patient that we are not
opponents – we are trusted allies. If by any chance I hear of an alternative approach that
I feel would be damaging to the patient, I would inform the patient of my opinion. To
date, I have seldom encountered this problem. Instead, the issue of damage to the patient
more often presents as the patient being told by an alternative healer to not follow my
recommendations. This relatively rare, but real, problem can be gracefully addressed, as
we shall soon see in the tip below.

In any case, if a patient unexpectedly, in ongoing therapy or in the initial interview,

comments that he or she is trying an herbal remedy or some other alternative practice,
I always ask, “Oh, do you think it is helping?” If they say it is – and I am comfortable
the alternative method is a safe intervention – I enthusiastically comment, “then by all
means you should keep using it.” Patients are genuinely pleased by this unanticipated
response on my part. I then proceed to share the following:

Tip #45: Expressing Interest in Alternative Treatments

“Some people think that all psychiatrists (substitute nurses, clinical pharmacists, or what-
ever your discipline might be) are highly opposed to alternative medicine. This is simply
not true. I feel certain there are many things that we will learn about healing from many
different systems. Indeed, digitalis, a great heart medication, was first used as an herbal
remedy centuries ago. I myself have found that acupuncture can be helpful in certain pain
conditions.
“My only cautionary note is that, in some instances, only a standard medication will, in
my opinion, provide the necessary relief or cure. In these instances, it is critical not to stop
the medication. I will always give you my best medical advice on whether you should try a
specific alternative technique. That’s my job as your clinician. Also, always let me know if
you are thinking of starting on any vitamin or herbal supplement, because these agents
occasionally can interact with medications, sometimes causing unwanted side effects.
“I am also very eager to talk with your alternative specialist to share what I am doing
and how it is helping, and to hear the same about their approaches. There are several
alternative specialists in the area with whom I have a good working relationship.
“One final thing. As you can see from my openness to alternative methods, I believe
that good healers have a keen interest in what other healers are doing. If you bump into
an alternative specialist that in any way begins to knock my medications or what I am
doing, beware of them. They clearly are not open healers. Their bad-mouthing of my
methods should alert you to go elsewhere, so that we can find someone who wants to join
our team not someone who wants to destroy it, because we’ve got a great team going here.”

I have never had this approach backfire. On the other hand, I have had some patients
switch alternative healers because they did not like the healer’s attitudes toward me. As
we can see, this non-oppositional approach, which fosters an ongoing collaborative
feeling, has transformed a potentially oppositional trap into an opportunity for an even
stronger alliance.

Uncovering Cultural Biases About Medications

Cultures can bias people either towards the use of traditional psychiatric medications or
away from their use. In his insightful book chapter, Iqbal Ahmed describes a variety of
specific beliefs that can negatively impact on medication interest and use.69 Religious
issues regarding diet can present medication interest problems that can catch an unsus-
pecting clinician off guard. Muslims may decide against using a liquid medication if they
find that it contains alcohol. Similarly, a Jewish patient may stop using a medication if

it is found to have porcine products. Outside of religious factors, but in a similar vein of
concerns, a vegetarian may very well refuse a medication if it contains animal-derived
products and an animal-rights activist could easily refuse any medication that was devel-
oped using animal experimentation.
In the past, many of these roadblocks to medication interest would have gone
undetected by patients. With the advent of the web, such information is just a click
away. Having discovered some information about their medication that causes cultural
concern, these patients may stop their medications abruptly without alerting their clini-
cian, for fear of being viewed as a bad patient. As therapy goes on, if one becomes
suspicious that the patient has developed new concerns about a medication that may
be cultural in origin, such hidden concerns can be uncovered using the following
technique:

Tip #46: Cultural Taboo Tap

“Besides side effects, do you have any concerns about this medication or how it was made
that make you feel ill-at-ease about using it or perhaps it is somehow not a good fit for
your culture or religious beliefs?”

Sometimes the cultural bias shows itself as a gentle yet pervasive hesitancy about medica-
tions as opposed to specific concerns as illustrated above. In Indochina, patients often
believe that medications should be taken only during the acute phase of an illness, being
at considerable risk for dropping a medication quickly after becoming asymptomatic.
They also fear that chronic use will result in drug dependence.70
As another example, research by Horne involving 500 undergraduate students from
the United Kingdom demonstrated such a generalized hesitancy.71 The students self-
identified themselves into two groups: students with an European background or stu-
dents with an Asian background. The Asian students perceived medications as intrinsically
harmful agents, perhaps even as addictive substances that should be avoided. These same
students were less likely to endorse the benefits of modern pharmaceuticals.
This study also demonstrates that young adults often, unbeknownst to themselves,
unconsciously adopt the belief systems current within their culture, whether determined
by folk-custom passed from generation to generation or the latest website or video that
has gone viral. No matter what age, reluctantly or not, people often absorb the beliefs
of their parents or immediate family, although many adolescents and young adults would
be loathe to admit it. Thus younger patients may more readily describe a hesitancy about
a medication stemming from such hidden, yet deep-rooted, beliefs if one invites the
patient to describe his or her parent’s beliefs as opposed to their own first. It is an indirect
way to enter the patient’s belief system through a backdoor of sorts:

Tip #47: Parental Backdoor Question

“I’m always interested in seeing how different cultures and generations view medications.
Do your parents have particular beliefs about medications, such as whether or not they
are useful or how often people should take them?”

This unassuming backdoor approach sometimes leads to unexpected answers as well as

gateways for productive collaborative exploration with an adolescent or young adult.
Such conversations occasionally present rich opportunities for enhancing medication
interest. We will see this process unfold in the following prototypic dialogue involving
a young Asian American grad student who has been participating in psychotherapy with
a Black psychiatrist over the past several months:

Pt.: Do you really think this medication might help me with my depression?
Clin.: Yes, I think there is a good chance of that, although I can’t give any guarantees. But
I am certainly hopeful it can and, if not, we will try to find one that will. (pause)
… Is there something specific that makes you a little hesitant?
Pt.: Not really, I just don’t know. I’m just feeling sort of off-balance now, and I’m not
sure what I should do.
Clin.: Perhaps a medication might not be right for you. (moving with the patient’s
concerns) We’ve been using therapy for several months, and I was just wondering if
perhaps a medication might give us a gentle advantage right now. (patient shakes
his head up and down reflectively but not convincingly) You know, Carl, I’m always
interested in getting a read on how different cultures, and even generations within
single cultures, vary on their opinions on medications. You’re a sociology grad
student and you might find this interesting as well (patient perks up a bit). Tell me
a little bit about how your parents view medications like antidepressants. They’re
still back on mainland China aren’t they?
Pt.: Oh yeah, and they’re pretty traditional if you know what I mean.
Clin.: In what sort of ways?
Pt.: My dad is really big on Taoism. You know, all that yin and yang kind of stuff. He
thinks my depression is caused by an imbalance of sorts.
Clin.: What do you think?
Pt.: I don’t really know. I’m not real into that stuff, but I have a healthy respect for it.
Clin.: I think you should. It is a very old and wise philosophy. I’m not entirely certain
how it fits into our understanding of depression, but there are some real similarities
here between that kind of model and what we are looking at with using an
antidepressant.
Pt.: How do you mean? (seems genuinely interested)
Clin.: We think the neurotransmitters we talked about earlier, and that I showed you on
the YouTube video, normally have a very delicate balance between them. Although
we are far from understanding how the antidepressants truly work, we do know
that depending on what circuit they are in and where their axons land on other
neurons, they can function as either excitatory or inhibitory. I think in your dad’s
language they would be viewed as yang or yin forces, active versus passive. This
antidepressant is designed to re-set the balance. There may be much more to it than
this simplistic view of balancing neurotransmitters, but, in my opinion, such
balancing probably plays a part in at least some depressions.
Pt.: Hmmm. That’s interesting. If it gives me bad side effects, can we stop it?
Clin.: Of course. You can stop it any time you want. In fact, unless my patients have a
serious depression that keeps returning, I don’t tend to recommend long-term use
of antidepressants, for there is mounting evidence that long-term use can have
some serious complications, which we will discuss in a little bit. But we would be

using them judiciously in the short term, with our psychotherapy, to see if we can
get you some faster relief, especially since you have some pressures on you to get
your dissertation done. In addition, if you don’t mind, we will move the dose quite
slow (mini-dose recommendation) to see if we can better find the re-set amount, to
find the right balance for your particular brain (clinician intentionally emphasizes
the concept of finding a balance).
Pt.: (student perkier now) You know, on second thought, it sounds pretty sweet. I don’t
see what I can lose, as long as we can stop it anytime I want, and I still feel pretty
depressed. I’ve really been worrying that I’m not going to have the energy to finish
my dissertation. Let’s see if we can re-set the biochemistry. I like that idea.

This interviewer has used the technique of the Parental Backdoor Question quite effec-
tively. Although the student doesn’t completely accept the cultural legacy bequeathed
by his father (Taoist medicine), the beliefs still reside comfortably within his soul. In
retrospect, the presence of his father’s beliefs within his psyche was probably leaked
by his early comment, “Not really, I just don’t know. I’m just feeling sort of off-balance
now, and I’m not sure what I should do.” The words “off-balance” may well be an
echo of the Taoist belief in illness being related to an imbalance of the universal forces
of yin and yang.
Moreover, by listening astutely with an open mind to the graduate student’s response
to the Parental Backdoor Question, the interviewer recognized a window for creating
cultural resonance between two widely disparate disease models (Taoist medicine and
empirical neurophysiology). By opening the window, the interviewer transformed an
initial roadblock to medication interest into a bridge towards culturally inspired motiva-
tion. As a consequence of the clinician’s deft use of interviewing techniques, the son
could unconsciously honor his father’s Eastern philosophy while trying something on
the cutting edge of Western medicine.
Before leaving the topic of general cultural beliefs about medications, one more
culture is worth mentioning, for its power is often missed by clinicians – the culture of
the community mental health center (CMHC) itself. CMHCs are unique cultural milieus,
with the cultures being greatly shaped by the beliefs of, and the sharing of those beliefs
by, the patients themselves. Patients share what they feel about their medications with
each other, and they share their views with a strong conviction. As informed consumers,
it makes sense to do so.
If there is a scuttlebutt at a specific CMHC about a particular medication being
“really bad to be on” (e.g., terrible side effects, “doesn’t do shit,” etc.), in my opinion
the clinician should consider recommending a different medication in the same family
and with the same efficacy, if at all possible. Prescribing a medication that fellow patients
at the CMHC feel is a bad drug is an invitation to a medication interest disaster. More-
over, if, over time, the scuttlebutt at the CMHC is, “You don’t want Dr. Harper, he
prescribes terrible drugs,” Dr. Harper’s ability to forge future alliances with patients is
dealt a severe blow. There are other “cultures within cultures” in which it is essential
to quickly uncover the scuttlebutt about a particular medication, including prisons,
hospital psychiatric units, and state hospitals. In all of these settings, the following
technique can be of use:

Tip #48: The Scuttlebutt Question

“What do other patients think about [give the exact common name of the medication in
question] around here?”

Caveats Concerning the Use of Generics

Generics supposedly possess bioequivalency (same efficacy at the same number of mil-
ligrams) when compared to brand name medications. For whatever reason, this does not
always prove to be the case. Whether related to manufacturing errors or to a decrease in
placebo effect, some generics do not work as well as the brand name version with specific
patients. In this regard, when switching from a brand name to a generic, it is important
to first reassure the patient that the medication should have the same beneficial results
while costing the patient significantly less money. At the same time, it should be added
that if, for any reason, the results are not as good, then the brand name can be re-instated
(although it must be acknowledged to the reader that one may need to battle an insurer
to do so, but it is a battle worth waging).
Harkening back to our chapter on culturally adaptive interviewing, we now come
across another fascinating cultural variable, related, somewhat unexpectedly, to the
appearance of the pills that we are prescribing. Generic medications will generally vary
in appearance (both shape and color, but especially color) from the brand name pills
they are replacing, as well as from each other. (Note that different pharmacies in the
same city may use differing generics.) Thus anytime one switches from a brand name
to a generic, there is likely to be a change in the appearance of the pill itself. Such
changes may also occur if the patient changes pharmacies or the pharmacy changes
distributors.
Research spearheaded by Aaron Kesselheim revealed some rather startling results
regarding the impact on medication interest related to these changes in appearance.72
Kesselheim looked at patients whose seizures had been stabilized on a specific brand
name antiepileptic medication and were subsequently switched to a generic brand. They
found that if the generic pill was a different color from the brand name pill, the adjusted
odds of a color change occurring immediately before a prescription was stopped was
53% greater than in controls in whom there was no discontinuance. Stated more simply,
a large number of patents stopped their medications if the generic was a different color
than the originally prescribed medication. Kesselheim has postulated that the finding
might be related to several factors, including: (1) the patient’s fear that the pharmacist
has made a mistake, (2) the breaking up of a patient’s routine for taking a medication,
and (3) the patient is experiencing a nocebo effect. If the patient had acquired a positive
placebo effect, based upon the appearance of his or her medication, the change in color
might subsequently create the opposite effect. The patient now fears that “this new medi-
cation” may not work. The following interviewing principle is pertinent here: When
switching to a generic prescription, forewarn the patient about possible changes in appearance
of the medication, while reassuring them that this change is normal and should not decrease the
effectiveness of the medication.
At the next appointment, if I remember to do so, I ask the patient how much the
generic pills cost, for I positively re-enforce any decrease in cost. Such a re-enforcement

of one of the new pros of the medication (lower financial distress) can help the patient
to keep this important factor in mind when weighing the pros and cons of taking the
medication in Step 3 of the Choice Triad. I find that this moment is an opportune time
to add the following:

Tip #49: Color Tab Question

“I’m just curious, Stephanie, like we discussed last time, is the pill a different color or
shape?”

If different in appearance, one can ask the patient if that was okay with them or if he or
she was surprised. Because of the large amount of information thrown at them in each
session, it is easy for patients to forget bits of information and some patients may have
already forgotten the previous discussion about potential changes in pill appearance with
the use of generics. If so, one can once again reassure the patient that all is well and as
was expected.

Toolbox for Assessing the Impact of the Web and Other Media on Your Patient’s
Medication Interest
The patients of today are much more informed about medication choices than patients
from previous generations. The “medication grapevine” is vastly improved. The web in
particular has transformed the grapevine. The patients of today, at a mere click, have
access to a plethora of websites, chat rooms, and blogs, both endorsing and opposing
medication use. Adding even more potent fertilizer to the grapevine, the presence of
social media has boosted the growth of the grapevine to the point where many patients
have friends scattered across the world offering both solicited and unsolicited opinions
about the medications that you and I have just prescribed. The clinician of today should
expect that a large number of his or her patients will go home to post a Facebook ques-
tion such as, “Has anyone heard anything about this drug [whatever the name of the
prescribed medication]?”
In my opinion, for the most part, this turn of events is a very good one, but there are
a few downsides as well. The internet and other popular media including television,
radio, and print sometimes contribute to the stigmatization of psychiatric medications
by presenting false and unwarranted biases against them that can lower medication inter-
est, sometimes precipitously. In this light, the following interviewing principle is an
important one: Seek out what the patient has heard about the prescribed medication from the
web, television, and other media sources. While I was delivering a workshop in Tampa,
Florida, Bruce Edson, a primary care physician, offered a nice technique for implement-
ing this principle that I call the Grapevine Question:

Tip #50: Grapevine Question

“Sometimes this medication can help with problems like you are having. Have you heard
or seen anything good or bad – on the internet or from television, radio, or magazines
– about this medication?”

By specifically mentioning various channels of cultural bias (“on the internet or from
television, radio, or magazines”), I believe the clinician increases the likelihood that the
patient will provide the whole scoop from the grapevine.
Another workshop participant, Lucius Ripley, suggests following up this technique by
providing patients with specific websites that are objective and demonstrate neither a
bias for nor against the medication in question (such as might be provided by the
National Institutes of Health or the National Institute of Mental Health). Armed first
with this factual knowledge, if the patient surfs the web and comes upon unwarrantedly
negative websites and anti-medication rhetoric (psychiatry denigrators) or potentially
unwarranted positive sites (pharmaceutical sites), the patient will be better armed to view
such information objectively.

Toolbox for Assessing the Impact of Friends and Family on Your Patient’s
Medication Interest
Like the lobbyists on K Street in Washington, DC, who aggressively push their agenda,
many people associated with the patient will forcefully express opinions as to whether
it is a good or a bad idea to take a medication. Unfortunately, many patients translate
this opinion into a reflection of their self-image as to whether they are good people or
bad people, smart people or dumb people, for having chosen “to be on meds.”
The simple truth is that we don’t so much prescribe for a single patient as we
prescribe for a single family. The opinions of the patient’s nuclear family, spouses/
partners, parents, and siblings sometimes sway the patient more than our opinions
as physicians and nurses. And their “extended families,” including intimate friends
and, as we have already observed, fellow patients at the community mental health
center, represent a powerful lobbying force. Many a patient has stopped a medication
because of the horror stories that a friend has animatedly related to them about the
medication.
Our guiding interviewing principle becomes one of: Try to remember to always ask
the patient what they anticipate their friends and family members will say about the medica-
tion. Similarly, in follow-up visits, ask what they have actually said. Oftentimes, constraints
and practicality make such inquiries difficult. Fortunately, most patients are more than
willing to fill us in on the opinions of their social supports, if we know what ques-
tions to ask:

Tip #51: Anticipating Family Response

“How do you think your spouse (partner, brother, sister, as indicated) will feel about your
starting on an antidepressant?”

A not uncommon reply is, “To tell you the truth, Charlie doesn’t really believe in this
kind of thing.” Depending upon the methods by which Charlie expresses this opinion
– ranging from mild discouragement to abusive anger – we may have uncovered a critical
roadblock to medication interest.

The process of anticipating the opinions of friends or, in subsequent visits, uncovering
their opinions may be as important a clinical task as uncovering the views of a spouse
or intimate other. On the good side of the continuum, imagine the powerful boost to
medication interest if a friend comments, “Oh my gosh, that’s the same drug I used for
my depression. It’s great. I’m not kidding you; it saved my life.” At the other end of the
continuum, contrast this with the damage done when a patient hears a best friend say,
“Oh my God! Don’t you dare take that horrible thing. I tried it once and it was horren-
dous. You’ll feel like a zombie. I’m not kidding you, I felt like I was a character on the
Walking Dead and not one of the live ones … (pause) … you know, I heard that some
people are killing people on that stuff!” In such instances, we might as well have asked
our patient to just drop off that prescription in the trash can as he or she walked out our
office door. As time permits, you may find the following question to be valuable:

Tip #52: Anticipating Friendly Fire

“Do you have any friends who have taken this medication, and, if so, what did they think
of it?”

Friends among teenagers in middle and high school represent an entirely new set of
influences. Direct peer pressure, which is a major lobbying force in this age group, is
not the only issue. Groups and cliques are so powerful, and verbal/physical abuse so
common in schools, that the mere association of the prescribed medication with a
fellow student seen as being an outcast or undesirable friend is deadly to medication
interest.
In addition, student views on the use of medications has undergone a shift with many,
not all, students. In the past, as was the case with adults, students tended to keep the use
of psychiatric medications to themselves for fear of embarrassment or stigmatization.
Although still true with some students, others have begun to announce their use. This
open sharing of the use of psychiatric medications is particularly striking with certain
medications so that one may hear a student announcing, “I’m on this or I’m on that,”
or “I’m on Ritalin. I’m selling Ritalin. Locker 287, best prices in the school district! Come
one, come all!”
As one might expect, social media has only added to the surprising lack of privacy
concerns regarding the use of psychiatric medications. Students will post their use on
Facebook or tweet it. If they dislike a student, a student might tweet the other student’s
use of the medication if they think it will be a source of embarrassment and harassment.
The bottom line is: Teenagers will often know of other teenagers who are on the medica-
tions we are prescribing.
It is important to uncover the student’s associations, which can range from, “Oh yeah,
I got a friend who is on that drug, she thinks it’s sweet,” to “Oh God, I know a kid on
that and he’s the biggest dork I’ve ever met.” Let us just say that it seems unwise to suggest
a medication to a teenager who fears it will transform him into a dork. As we’ve seen
before in such situations, if one can find a different medication from the same family
with a similar efficacy, it may be wise to change one’s recommendation on the spot before

wasting paper on a written prescription or time on a useless e-script to the pharmacy.

The following technique is of use:

Tip #53: Teenager “Bad Drug” Probe

“Do you have any friends or know anyone at school who takes this medication?”

Toolbox for Medicating an Angrily Escalating Patient Involuntarily

We will wrap up our chapter by looking at a tough scenario: talking with a patient about
the need to take a medication involuntarily. If ever there was a situation in which it might
appear that the collaborative principles of the MIM cannot be applied, the involuntary
forcing of a patient to take a medication would appear to be the one. Interestingly, it is
one of the situations in which the principles of the MIM may be most helpful.
In such difficult situations, the clinician’s language and nonverbal behaviors will
impact on the therapeutic alliance in two timeframes: (1) the long-term relationship,
and (2) the immediate, short-term relationship. In the long-term sense, as the patient
looks back upon what transpired, even though a patient may be quite angry at the
decision by the treatment team to force a medication, it is critical that the patient’s
perception be that the clinician was truly trying to help and that the clinician was not
acting from an oppositional stance. The clinician and the patient simply disagreed on
whether help was needed or what sort of help was required. It is the patient’s later
perception of the clinician’s attitudes and motivations that often determines, in the longer
term (later in the hospitalization, during treatment as an outpatient, or upon a return
admission), whether he or she will feel comfortable with the clinician’s ultimate recom-
mendations, not necessarily how upset they were at the moment of involuntary admin-
istration. In regard to long-term medication interest, the adage, “It’s a marathon, not a
sprint,” holds true.
In the more immediate sense, what often fuels the intensity of a patient’s refusal to
take a medication is sometimes not so much that the clinician is urging or even poten-
tially forcing its use, but that the patient’s perception is that the clinician is doing so
aggressively and from a point of antagonism. The patient’s perception may not be created
so much by what the clinician says, but by how the clinician says it. As clinicians, we
have already seen that we can hold opposing views to our patients without being oppo-
nents, depending upon the words chosen to share those views. We have taken note that
our words convey not only meaning; they convey relationship.
In the following illustration we will see a series of interviewing techniques woven into
an interviewing strategy called Maximizing the Alliance While Involuntarily Medicating.
Several interviewing techniques previously delineated, including Agreeing to Disagree
and Stating Shared Goals will be interspersed throughout the strategy. We will also see
two general interviewing techniques, not from the MIM per se, utilized effectively, called
Inviting a Request for Clinician Opinion and Acknowledgement of Fallibility. When
using the technique Request for Clinician Opinion, the interviewer might say something
like, “I have some thoughts that might be of value to both of us to explore, if that’s okay

with you?” In Acknowledgement of Fallibility the interviewer softens the tone of a point
by admitting – before presenting it – that he or she might be wrong as with, “I also want
you to know that I might be wrong. Naturally I believe in what I’m about to say, but I
realize that I’m not always right.”
We will also see this interviewer effectively “thinking on his or her feet” by consistently
applying the very first and over-arching interviewing principle of the MIM: Rather than
creating the sensation that we are moving “against them,” we want our patients to feel that
we are moving “with them” – that we are a team, not opposing armies. The dialogue is a nice
reminder that interviewing principles provide sophisticated interviewers both flexibility
and spontaneity if the principles are truly understood.
The interviewing strategy of Maximizing the Alliance While Involuntarily Medicating
is adapted from an approach that was shared at one of my MIM workshops by Robert
Becker, MD, who at the time was the Director of Psychiatry at the Greystone State Hos-
pital in New Jersey. Let us set the stage for its demonstration via a prototypic exchange
that is based on various interactions I’ve had with patients in this most demanding of
interviewing situations.
Imagine a patient, Mack, who has been on an involuntary commitment for 3 days,
necessitated by several acts of violence. His problems have been precipitated by a manic
episode caused by discontinuance of his antipsychotic and mood stabilizer. In the previ-
ous 3 days, the treating psychiatrist has forged a reasonable therapeutic alliance. Indeed,
both Mack and the clinician genuinely like each other, although Mack remains wary.
Mack had been doing well, until 6:00 on a Friday evening when he began to pace and
talk to himself. He quickly became irritable and yelled at another patient, “Stay the fuck
away from me!” The psychiatrist has been talking with Mack for about 10 minutes to see
what’s up and to evaluate what Mack’s potential for violence might be. We will pick up
the conversation at a point in which the psychiatrist must communicate to Mack his
decision to utilize an as-needed dose of antipsychotic, even if Mack refuses. It’s exactly
the type of interaction that, if handled well by the clinician, can result in an uneventful
calming of the patient and, if handled poorly, can result in a dangerous assault on either
staff or another patient. I have seen interviewers do it both ways. I have seen both results.
The following interviewer shows one way to do it well.

Clin.: Mack, it’s obvious you’re upset. I think I have some ideas why, but I’m not
pretending that I know for sure what’s going on. If you don’t mind, I’d like to share
my own thoughts (Inviting a Request for Clinician Opinion) because I think they
might help you to get what you want and what I want as well. (variation of Stating
Shared Goals)
Pt.: Yeah, like what? (stated testily)
Clin.: Well we both are hoping that your hospital stay, even though you are committed,
can be as brief as possible. And you’ve also made it plain that you want to be free
to be out on the ward and watching TV in the common room as much as possible.
(further use of Stating Shared Goals)
Pt.: And so? What’s your fucking point?
Clin.: Well. My thoughts are, (notice that the interviewer avoids the use of the word
“point” because people don’t generally like to have points made to them) and I

may be wrong, but it’s what I genuinely believe (Acknowledgement of Fallibility), I

think the manic symptoms, especially the irritability, are breaking through the
current dose of your medication, like I shared with you in the past they can. And I
think if we don’t raise the medication a little, the mania might trigger an angry
outburst that could lengthen your stay and limit your movements while you’re here.
I certainly don’t want that to happen and I don’t think you do either. (back to a
gentle use of Stating Shared Goals)
Pt.: What if I don’t want to take your fucking drug?
Clin.: Well, on one level I guess we’d have to agree to disagree. And we’re both entitled to
our opinions. And I respect yours. I hope you respect mine. (Agreeing to Disagree)
The catch for us right now is that I really do care what happens to you, and I
absolutely do care that you, the other patients, my staff, and even me are safe. I
can’t let the mania make you do something that I don’t think you would normally
do that might harm you or others. So I guess, I’d have to insist you took the
medication. I genuinely believe it will cap the mania and help to make sure your
time here is as short as possible. (clinician again gently utilizes Stating Shared
Goals)

At this juncture, two caveats are worth noting: (1) Although we can’t see it, part of the
effectiveness of this clinician’s intervention are related to his effective employment of
nonverbal techniques, from using a gentle tone of voice and giving the patient a wide
interpersonal space to tending to gesture with palms upwards, as were described in
Chapter 8 for de-escalating angry patients (see pages 321–322). (2) The clinician is con-
sistently following the cornerstone MIM principle to move with the patient as an ally
against the disorder. Note how the interviewer never personalizes the patient as the
problem, with words like, “You are getting out of control and need to control yourself”
or “The medication I want to give you will calm you down because you are too wound
up.” Instead, the clinician highlights the truth of the situation, that it is the mania that
is out of control, with words like, “I can’t let the mania make you do something that I
don’t think you would normally do that might harm you or others.” The clinician’s
patient use of our strategy for Maximizing the Alliance While Involuntarily Medicating
is beginning to have a beneficial impact.

Pt.: Yeah, well, I don’t know (slightly calmer). How do you want me to take this crap?
(looks over at the nurse and safety staff) I see you got your goons here. Are you
going to jam a needle in my arm?
Clin.: That’s not actually what I want to do. I’d rather offer you a choice to take the
medication as a pill. It’s the same medication you’re already on, so there’s no
surprises here. I think you’ll see pretty quickly that with the use of the pill you’ll be
able to slow down the mania, to control it better. (pauses) … Mack, you know that
I always tell you the truth. I think that’s why we’ve learned to trust each other over
the past couple of days, so I’m not going to pretend that you have a choice about
taking the medication right now, because the truth is you don’t. But you do have
the choice in how to take the medication, by mouth or by a shot. And we’ll give
you the medication whichever way you request. (Note how the clinician continues
to move with the patient as best as can be done considering the confounding fact
that the clinician must ultimately oppose the patient’s strong wish to refuse the
medication. The clinician is de-escalating the intensity of the interaction by using a

calm, non-authoritarian tone of voice, and choosing words that allow him to
non-antagonistically set a limit.) Please consider taking the medication, Mack. I
really think it will make you feel calmer and give you good control over the mania.
I also think it will avoid an incident that could lengthen your stay and limit your
freedom of movement on the unit. I think the pros of using the medication right
now outweigh the cons of not taking it.
Pt.: Oh fuck, just give me the damn shit. I’ll take your pill.
Clin.: Thanks, Mack. I’ll be around, and we’ll talk later.
Pt.: Whatever.

A job well done. I am convinced that most acts of violence triggered by patient refusal
to use an as-needed medication – for potential aggression on inpatient units and emer-
gency departments – can be avoided through the judicious use of MIM principles and
techniques. This particular interviewing strategy, Maximizing the Alliance While Invol-
untarily Medicating, will not work with every patient, but it does seem to work with
many patients. I believe the reader will be pleasantly surprised, over the years, how often
patients choose to take the oral medications when approached in this fashion, thus
avoiding the complicated confrontations that sometimes ensue with forced intramuscu-
lar dosing. In addition, this interviewing strategy conveys a caring relationship that will
probably not go unnoticed by the patient, setting a stage for future collaboration and
making the best of a most difficult encounter.
There are various ways in which to approach a patient if they persist in refusing a
medication that can be of help, such as the following technique, where the consequences
of refusal are spelled out in more detail but once again in a non-antagonistic fashion:

“I understand your hesitancy. I want to be very open with you. Our team feels so strongly
that the medication is necessary for purposes of your safety [or perhaps the safety of
others] that I have an obligation to give it to you by law. Let me explain the situation
[describe legal situation regarding involuntary commitment as it pertains to your state].
I would much prefer that you try the medication voluntarily. Even if you don’t and you
still have to take it by law, you will have a choice on how. Your nurse will offer you the
medication as a pill, which is by far the easiest way to take it [describe again the major
pros of taking the medication]. If you don’t choose to take the pill, then the nurse will
need to give you a shot, which we would definitely like to avoid if possible. Let’s see
if we can work this out so you can take the medication in the way that you feel is best
for you even though you may not want to take it.”

We have come to the close of our chapter. I am reminded of a quotation by the philoso-
pher Martin E. Marty who was emphasizing the difference between a debate and a con-
versation. Throughout our discussion of the MIM, we have emphasized that the goal is
to generate conversation, not debate, with our patients. Marty feels it should be the goal
of a true philosopher as well:

Conversation is different … The purpose of conversation is to come to know the other; to

entertain ideas that neither has explored in detail before. There is room for serendipity,

for accidental discovery. ‘You never know where it will take you.’ I make a conversational
bid and you respond, in ways that I cannot foresee. At the end we shall both have grown.
In the process there is more room for risk. We never hear someone say, ‘Boy, did I ever
win that conversation!’ or ‘He really did defeat me in that conversation.’ Conversations
may go smoothly or roughly, well or ill: but they go, while arguments end.73

In a similar fashion, when talking with patients about their medications, those clinicians
that understand the principles, techniques, and strategies espoused in this chapter will
be the clinicians that have truly learned how to converse with their patients. Perhaps the
participants of the conversation will collaboratively arrive at the decision to use a medi-
cation. At other times, it will be discovered by both parties that it is best not to proceed.
And, of course, sometimes there may be disagreement. But, always there will be respect,
always relationship. The therapeutic alliance will be the better for it, and the conversa-
tions will continue, the chances for healing greatly increased.

CONCLUSION TO THE BOOK

In closing our book, we have traveled very far. We have covered a vast amount of infor-
mation. We will be able to return to this information over and over in our careers, for
every interview holds new secrets. It is my greatest hope that the interviewing principles,
techniques, and strategies of this book will help the reader to help many people. Curi-
ously, despite the breadth of our work here, we still do not have all the answers to the
art of interviewing. There is always a subtle mystery to the healing process. The art of
healing is not, and can never be reduced to, a set of principles and techniques. I am
convinced that this remaining bit of mystery has to do with compassion. Ultimately, it
is our compassion that heals and gives power to our methods. In the last analysis, it is
also what gives meaning to our lives.

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