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Consumer - Provider Exchange in Assertive Community Treatment: Qualitative Methods and Discourse Analysis


Investigators: Beth Angell, Ph.D. and Colleen Mahoney, Ph.D.

Implicit in the recovery movement is research and training discourse regarding consumer empowerment: optimal treatment decisions and use involve real consumer knowledge, choice, control, and say. Although recovery-oriented discourse about treatment adherence and participation is occurring in the professional literature, little is known about the actual discourse between consumers and clinicians that is occurring in mental health service delivery. If consumer choice and the sharing of decision-making power are indeed mediators of treatment use and success, it is critical that we forge a better understanding of how they occur in clinical interactions and derive methods for measuring this communication in real-world clinical settings.


Following examples of research that examine communication and interaction between providers and patients in health care (e.g., Heritage & Maynard, 2006a; Roter & Larson, 2002), this study examines real-time clinical communication about treatment participation between consumers and clinicians in Assertive Community Treatment (ACT), a widely recognized evidence-based practice. Although embedded within a broader concern regarding treatment participation, this pilot effort will focus on discourse about medication management for several reasons: medication use is considered a key service area in the ACT model and is the program element most likely to be shared across all consumers; the cost of medication nonadherence is high (Thieda, Beard, Richter, & Kane, 2003); and medication is a reported source of conflict and disagreement between consumers and providers (Krupa et al., 2005).

A sample of 40 consumers (age 18 or older, with a primary Axis I disorder of schizophrenia, bipolar disorder, or major depressive disorder) will be recruited from an established ACT program. A primary case manager and psychiatrist will be identified for each consumer who agrees to participate, and these providers will in turn be invited to participate. Data collection will occur in three stages: three treatment events (one-on-one contact with primary case manager, scheduled appointment with psychiatrist, and team consultation) will be audio recorded for each participating consumer; consumers will be interviewed; and providers will be surveyed with a questionnaire. Two methods for analyzing healthcare communication, conversation analysis (CA) and the Roter Interaction Analysis System (RIAS), will be utilized for examining the audio data. The expected product of the RIAS and CA analysis phases is a set of coded interactional elements grounded from the audio-recorded clinical interactions. In line with previous research, such dimensions might include giving information, asking questions, correcting the provider, or tailoring a medical term to the consumer's personal style of referring to a symptom. Using measures collected from consumers and case managers, the next step of the analysis will be to examine the relationship between the interactional elements and appraisals by consumers and providers of the quality of the consumer-provider relationship, level of empowerment, recovery, and adherence. Because of the small sample size, these analyses will be considered exploratory and will be conducted using basic measures of association (e.g., correlation, analysis of variance). Expected products of these analyses include taxonomies of provider engagement/adherence strategies and of conversational indicators of consumer participation and engagement which will in turn be used to develop a preliminary method for measuring communication about medication and treatment participation.