Enhancing Clients’ Communication Regarding Goals for Using Psychiatric Medications

Clients with serious mental illness are often passive in their interactions with professionals, even though they frequently disagree with their providers regarding treatment goals (1–4). Enhancing communication therefore necessitates client activation, which can improve person-centered care (5), including shared decision making (6), satisfaction with process (7), and outcomes (8).

Psychotropic medications often support clients’ recovery (9), yet prescribing in routine practice often falls short of person-centered care (10,11). Psychiatric care providers often evaluate symptoms and side effects without inquiring about the context of personal goals, values, and preference (12). Evaluating symptoms and side effects out of the context of clients’ lives and life goals can result in an emphasis on symptom relief and medication adherence as endpoints, rather than as a means to achieve clients’ goals for treatment (13,14). Time constraints have further jeopardized communication and are unlikely to expand (15). Thus, approaches that facilitate communication and person-centered care in routine practice without requiring more time, such as using aids to help clients communicate their goals for medication prior to the consultation, are critically needed.

Power statements are a novel approach that enables clients to communicate their goals for medication treatment by preparing clear and concise statements prior to a medication visit (16). The purpose of this exploratory study is to describe the power statement method and analyze the content of these statements thematically to understand clients’ goals for using psychiatric medications.

Methods

Power statements are part of CommonGround, a Web application that enables people with serious mental illness to participate in shared decision making and supports their recovery (17). Peer staff, case managers, and therapists are trained to support clients in creating power statements in the waiting area of public mental health clinics by using a worksheet that guides users in filling out a two-part stem: “I want you to help me find a medication that will help me . . . so that I can. . . .” Completed power statements are added to the Web application and appear on the health report that is reviewed by psychiatric care providers at each visit. With support from peer staff, clients update their power statements prior to appointments as needed, for instance when clients’ goals for treatment have changed. Power statements—typically two or three sentences saying something about the client as a unique individual— state how she or he wants psychiatric medication to help and invite clinicians to help achieve these goals for medication treatment. These statements amplify the client’s voice and sense of control, while communicating concisely the client’s specific goals for using psychiatric medications. Toward the beginning of the appointment, psychiatric care providers often read the power statement aloud and ask, “Is this still the goal for our work together?” Clients and psychiatric care providers have reported that the process enhances communication (18).

Participants

A total of 17,385 clients with serious mental illness seen across 69 community mental health settings, including public mental health clinics (N=50) and assertive community treatment teams (N=19), around the United States were using the CommonGround Web application during the period of this study. Background data on a sample of 5,581 participating clients obtained from a convenience sample of 20 community mental health settings showed a range of demographic and clinical characteristics. On average, 2,991 (54%) of CommonGround users were female, 949 (17%) were Hispanic, 4,275 (77%) were European American, 832 (15%) were African American, and 474 (9%) were other race or multicultural. The mean±SD age was 40.9±13.2 years. Common diagnoses for CommonGround users were schizophrenia/schizoaffective disorder (N=1,808, 32%), major depressive disorder (N=1,630, 29%), bipolar disorder (N=525, 9%), and anxiety disorder (N=396, 7%). A total of 1,619 (29%) clients in the sample had co-occurring substance use disorder diagnoses. The Dartmouth College Committee for the Protection of Human Subjects approved this study.

Procedures

We randomly selected from the CommonGround database a sample of 300 power statements from unique clients for the period of January 2011 through October 2013 and redacted the statements by hand to remove any identifying information. We also queried the CommonGround database to determine the percentage of distinct users, across the 69 sites, who had entered a power statement into the Web application.

We used methods in content analysis for analyzing and interpreting textual data (19). Initially, three of the authors (PED, EC-S, and RED) independently reviewed random selections of the statements to inductively derive the categories for the codebook, meeting regularly to discuss and refine categories, and producing a draft codebook. These same three authors then independently rated random selections of power statements to test the comprehensiveness and usefulness of the draft codebook, discussed ratings and coding discrepancies, and iteratively refined the codebook by adding or collapsing codes, resulting in 15 codes.

We trained two research assistants to independently rate the power statements. The two raters proceeded with coding in a two-stage process. The raters could use up to five codes for each part of the two-part stem template for the power statements to provide a more fine-grained summary of the statements by using subcategories. For example, the raters were able to use multiple codes to describe the same part of a participant’s power statement in order to allow for multiple possible interpretations. The two raters proceeded with coding in a two-stage process. First, to establish rating reliability, the two raters coded 10% of the data (30 statements per rater). The reliability of ratings across raters was assessed by using Cronbach’s alpha (20) and Stata 12’s alpha procedure (21). We obtained a Cohen’s kappa statistic of .97, thereby demonstrating high interrater reliability. We resolved discrepancies between raters for the 10% sample through team discussions and consensus. Second, the two raters independently coded the remaining 270 power statements. Descriptive statistics were used to summarize the results of the qualitative coding process. The analysis included participants who completed either or both parts of the power statement stem template.

Results

Our CommonGround database query found that 13,734 (79%) of 17,385 distinct users across 69 sites had entered power statements into the Web application. We rated 277 of the original 300 randomly selected power statements. We deemed the remaining 23 statements not ratable because their content was unrelated to psychiatric medication use. Not all participants completed both portions of the template; there were 272 responses to the first stem and 230 responses to the second stem. Of the 272 statements with ratings for the first stem, 150 (55%) received one code, 110 (40%) received two, 11 (4%) received three, and one (<1%) received four. Of the 230 statements with ratings for the second stem, 114 (50%) received one code, 81 (35%) received two, 26 (11%) received three, seven (3%) received four, and two (1%) received five.

Table 1 presents the distribution of goals for using psychiatric medications. In completing the first stem, clients most commonly identified wanting psychiatric treatment to help control symptoms (56%) and improve functioning (54%). For example, a client who wanted help controlling symptoms wrote: “I would like to work with the doctor to control my issues with anxiety and depression.” A client who was interested in improving functioning wrote: “I would like my medications to help me maintain stability so that I can find a job or find better housing.”

Many clients (N=83, 31%) also expressed specific medication goals, such as lowering dosages or switching or stopping medications. For example, “I want to work together with you to find the least amount of medicines at the lowest dosage.”

In completing the second stem, clients expressed the reasons why their specific medication goals were important, that is, the broader reasons for participating in psychiatric treatment. More than one-half of the clients (51%) identified improving or maintaining social relationships as a goal for using medications, for example, “so I can function like a normal mother.”

Achieving or maintaining well-being was another commonly expressed goal for treatment (32%), for example, “so I can deal with life.”

Many clients also described self-sufficiency (23%), employment (19%), and engaging in hobbies (15%) as goals for treatment. Examples of statements in these categories include “so I can keep up with my responsibilities” (self-sufficiency),“so that I can continue to work” (work), and “I enjoy reading short stories” (hobbies).

Some clients (10%) expressed their desire for self-improvement by continuing to progress in their recovery as a goal of treatment. For example, one client wrote, “I have come a long way in my life (really progressed) and want to continue to do better.”

Examples of complete power statements with both parts of the stem template are listed in a box on page XXX. These examples reflect many of the common codes used during the content analysis.

Discussion

Power statements potentially provide a scalable intervention in routine community mental health care settings. By using a brief prompt and minimal assistance, nearly 14,000 (79%) clients across 69 programs developed statements regarding their personal goals for using medication. The majority identified symptom control in the service of specific functional goals. Clients expressed a range of goals, reflecting the importance of relationships with friends and family, personal well-being, maintaining self-sufficiency and independence, pursuing work or school, participating in hobbies and leisure activities, and engaging in self-improvement. There is overlap between psychiatric care providers and clients in wanting to focus on symptom control and medication adjustment. However, the area of novelty is that power statements help clients link these clinical goals with personal goals such as social relationships and employment.

When empowered to communicate, clients express diverse and very personal goals for using medication that extend beyond symptom management. For most, using medication to control symptoms was not an end in itself but a means to an end that includes improved relationships, work, and other aspects of a meaningful life in the community. As more health care providers move toward measurement of treatment outcomes to monitor response to care (14), client input on those outcomes is beneficial and may improve the process. Power statements potentially enable clients to communicate these goals clearly and concisely.

Anecdotally, we have found that psychiatric care providers have a range of responses to power statements. Some report that power statements are unnecessary because they have known their clients for a long time and already know the context of clients’ lives. Others report they are surprised at the new information power statements reveal about people they have worked with. One psychiatrist working on an assertive community treatment team gave a lecture on his use of CommonGround and had this to say about power statements: “Power statements are really important because they rapidly summarize the patient. They rapidly present specific, powerful, self-worded representations of self. The self-worded part of it is like an automatic trigger for the patient. (When read aloud) suddenly the patient says, ‘Yeah, that’s me. That’s exactly what I want to do. Doctor you really get me.’ And remember, this is happening on day one, not a year after I’ve known the patient.”

Power statements appear to allow efficiency in helping psychiatric care providers understand clients’ goals from the beginning of treatment without requiring longer visits (22). In turn, these goals help to define treatment success. For instance, if a young man’s power statement communicates that he wants medicine to help him focus on his work at a pizza shop, rather than on auditory hallucinations, the psychiatric care provider and client have a shared understanding that could help guide treatment. Reduction in auditory hallucinations is not the only outcome that matters.

Health care providers, including those in behavioral health, struggle to integrate the practice of person-centered care and shared decision making in routine clinical settings. Practicing person-centered care means that psychiatric care providers must learn to ask, “What matters to you?” as well as “What is the matter?” (23). In an interesting twist, power statements may empower clients to be change agents in helping to make person-centered care happen. Through power statements, clients proactively communicate “what matters to me” and invite psychiatric care providers to support personal goals.

Power statements are relatively simple to teach and deploy, but they are not simple psychologically. They can have a powerful effect on both the client and the psychiatric care provider. For the client, power statements teach a specific method for becoming active in care. A clinic that supports using power statements implicitly communicates to clients that they are important, that they are partners in care, and that supporting the achievement of personal life goals is the point of treatment. Power statements also remind the provider of this: in a power statement, clients explicitly invite psychiatric care providers to partner together in achieving personally meaningful goals. This overture from clients may set the psychiatric care provider in a more responsive and receptive state of mind.

All psychiatric service providers are trained in communication and the importance of creating a strong alliance with clients in order to get the best treatment outcomes. However, the demands of routine medication appointments—symptom and side effect checks, substance use screening, laboratory tests, and documentation—can compete with the priority for communication of even the best intentioned psychiatric service providers (15). Power statements can help by providing a standardized and reliable way of communicating that can be embedded in the care pathway. Power statements can be created with pen and paper and do not necessarily require the use of the full CommonGround Web application.

Several limitations to our study warrant mention. Clients in the current investigation were actively engaged in mental health services, and our results may not generalize to those who do not use services or are tenuously engaged. Clients were also engaged in using CommonGround, a larger process that provides structure and peer support, which may perhaps be necessary for the use of power statements. In addition, staff in mental health clinics that have adopted CommonGround may be predisposed to value clients’ perspectives and shared decision making to a greater extent than those in clinics that have not adopted this application. With regard to our study methods, our use of content analysis techniques for interpreting the meaning of power statements may not have fully captured the individual goals and intentions contained within each statement. Last, given the exploratory nature of the current study, it was not possible to determine whether use of power statements contributed to improvement in communication or outcomes among clients. Future large-scale controlled studies are necessary to assess whether power statements improve communication and shared decision making between clients and psychiatric care providers in community mental health settings, and whether power statements are associated with outcomes that are meaningful to clients, including improved community functioning and ability to pursue life goals and interests.

Conclusions

Clients with serious mental illness typically viewed psychiatric medications as a means to pursue meaningful life goals, including social relationships, independence, and fulfilling responsibilities associated with roles such as worker, student, and parent. Power statements appear to be a simple, scalable, and highly promising technique to enhance patients’ communication of their goals for medication treatment, thus affording new opportunities to further the achievement of person-centered care in routine clinical practice.