# 107 January 2009

"Thus we ourselves produce our own spiritual world, our monsters, our chimeras and our angels; we objectify everything that ferments in us. Everything is marvelous for the poet, everything is divine for the saint, everything is great for the hero, everything is paltry, mean, ugly, bad for the base and sordid soul."

Henri Frederic Amiel
from The Private Journal of Henri Frederic Amiel

(continues below)

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# 107 January 2009

"The Scale Metaphor" for Improving Medication Interest

TISA Description of the Problem: In the Medication Interest Model (MIM), which applies to medications for treating all diseases from congestive heart failure and diabetes to depression, interviewing techniques are described that help clinicians from medicine, nursing, and mental health to transform medication nonadherence into medication interest. The MIM is constantly growing from the never-ending interviewing tips suggested by visitors at TISA and by participants at our workshops on transforming medication nonadherence. It is common for clinicians to talk about the "weighing of the pros and cons" of medications. Duane Difranco, M.D. shows that sometimes it is useful to share this exact metaphor with our patients directly.

Tip: I like to make the implicit model of "weighing the pros and cons" explicit. It is an image that my patients and I can return to again and again. And it emphasizes that ultimately, it is the patient who calls the shot on whether to take a medication or not:

"One of the things I can do is make suggestions of what medications and dosages might be useful in helping you. It's almost like I'm pointing out weights that you can place upon a scale. I can help you know what weights you ought to place on the scale, and your job is to decide how much each of those weights weigh. You are the person who decides how much the medication weighs on the pro and the con sides of the scale for you personally. As you share this information, together we can look at these pros and cons, and you can decide what is best for you."

TISA Follow-up: I don't have much to add to this excellent tip. I find the visual image of placing weights on the scale a compelling one. Sometimes I like to draw images, such as a scale, on a sheet of paper or up on a whiteboard for my patients. And as Duane suggests, it is an image that can be referred to for the rest of the care of the patient.

Tip provided by:

Duane J. DiFranco, M.D.
Executive Director
Michigan Center for Diagnosis and Referral
University of Michigan, Dept. of Psychiatry

TISA is a site dedicated to advancing the science and art of preventing suicide and teaching clinical interviewing