Intervention Research

•Medication underuse = most common problem

•Nonadherence rate: = 50%

Statistics• By 2010, 95% of patients should receive verbal

counseling on appropriate use and potential risks of meds.

• Most common example of noncompliance: antibiotic therapy.

• In the general patient population in the U.S., 50% of all medications are taken incorrectly.

• Nonadherence is greatest when patients are symptom free.

• 40% of VA patients diagnosed with schizophrenia are “poorly adherent” with their antipsychotics. This puts them at much greater risk of rehospitalization.

Two types of non-adherence

1. INTENTIONAL NONADHERENCE• Stop taking meds• Creatively alter meds• Unendorsed polypharmacy

2. UNINTENTIONAL NONADHERENCE• Medication errors• Forget to take it• “It costs too much!”

There are three current major Tx Strategies for non-compliance

• Educational-info provided in verbal/written format! i.e. info-e-mails, medication groups, client repeats instructions, bibliotherapy, teaching re: dx.

• Behavioral-e-mail reminders, contracting, reminder containers, family involvement re: reinforcing/decision-making, med. monitoring

• Affective-family support, encouraging adherence, engagment, collaborative decision-making.

Purely educational interventions were least successful. Combination approaches were most successful, in terms of adherence and secondary outcomes.

The current strategies for dealing with N-C assumes there are two

types of doctor/patient relationship

• 1. Activity-Passivity (Treatment takes place regardless of patient’s contribution.)

• 2. guidance-cooperation (patient is expected to comply, to obey)

However, there is a third type of doctor/patient relationship.3. Mutual participation

We think that the notions of compliance and adherence are deeply flawed

Possible myths re:compliance?

• People can be persuaded to do something (i.e,. take medication) that threatens their autonomy, if it is in their ‘best interest’

• Messages of health risk will be heard and accepted by those for whom the message is relevant.

• The decision to take medication is based on ‘rational interests’.

• The decision to take medication can be separate from other lifestyle/lifeworld decisions

• Psychiatric illnesses are similar to other types of illness.

• Psychiatric symptoms are worse than psychiatric treatment

• It is better to attempt to coerce or maneuver someone into taking medication rather than allowing them to refuse.

• Clients should understand and respect “the way we see their illness

The notion of Compliance is based on a model of help that is oppressive and suggests that the client does not know what is best for them! Compliance is coercive!

For many, taking a medication evokes images of weakness, loss of responsibility, and submission to medical authorities. Historically, these are attributions that have closely accompanied the sick role in Western culture. These associations can invite an emotional posture of submission that obscures a patient’s awareness of life choices, to the patient’s detriment (Griffith & Griffith, 1994).

Analyze the following Exchange

Cl: “I’ve feeling a little weird latelyTh: Weird? How do you mean?Cl: Yeah! You know. Things just don’t seem right. I’m on edge and I feel like something bad’s gonna happenTh: Like?Cl: I I I don’t know. The people in my building are weird. The way they look at me…Th: Have you been exercising everyday?Cl: Well….. yeah!Th: everyday? Cl: well…I’m not sureTh: not sure?Cl: Well there are times when I forgetTh: mmhmmmCl: And times when I just don’t feel like it!Th: We’ve discussed how its important for you to stay on your routine!Cl. MmmHmmTh:Exercise can really help you, but only if you do it!Cl: mmmHmmm.

Now substitute medication for exercise!!!

The decision to take medication is incredibly complex and involves an individual ‘weighing’ very complex configurations of ‘pros and cons’ which may change over time.

Notice the issues of social humiliation and depleted self-esteem

•We believe that the decision to take or not take medication is a dynamic, ongoing (perhaps continual) process of decision-making on one of the most important decisions in our client’s life.

•Historically, theories about medicine compliance viewed compliance as a static process of decision-making

•We believe that there are Stages to decisions about taking medication

Initialchange

On-Goingchange

Pre-contemplation

Contemplation Preparation Action Maintenance

Plotting the two stages of decision-making together

KNOWING WHERE A CLIENT IS IN THE DECISION TO TAKE MEDICATION*

1. PRE-CONTEMPLATION- THE PERSON DOES NOT THINK that they have a problem. May have vague awareness that something is wrong; but does not think it is them. Defenses of denial, minimization, projection, repression, ominipotence, devaluation. Often people with personality disoprders never leave this stage! Mandated client often here! The key focus is engagement. Don't try to convince. Try to hook! 2.CONTEMPLATION - I know something is wrong but I haven't decided what I will do about it. I am aware that it may be up to me. However, I haven't decided whether to take action! Defense rationalization, minmimization, devaluation, splitting, reaction formation, displacement, magical thinking corresposnds with responsibility awareness. Lots of support here, some challenging. Encourage exploring options 3. PREPARATION- client is aware of problem and has decided to act. Has made a commitment. They are now involved in planning an action or deciding which steps to take. Defenses used; procrastination, intellectualization. Saupport and realistic view in planning is necessary. Help client narrow options. 4.ACTION - here the client has actually begun to change 5. MAINTENANCE – Here the client does things that insure that the change continues and is permanent *Taken from PROCHASKA & DICLEMENTI’S 5 STAGES OF CHANGE READINESS

• Most therapists assume that clients are in the preparation or action phase

• Biggest mistakes in planned change is assuming client to be in a phase that they are not!!!

• Different interventions are used at each stage in order to move the client through action to maintenance

• One can typically move from one phase to the next.

• One cannot usually move a client from pre-contemplation to action

Initialchange

On-Goingchange

Pre-contemplation

Contemplation Preparation Action Maintenance

Plotting the two stages of decision-making together

• Prochaska & Diclementi’s model of change readiness has not been empirically studied with regard to compliance

• It has been studied with regard to substance abuse and recovery

• What P&D found was that people in recovery cycled through the stages of change several times, usually associated with relapse. That is, just as relapse is ‘built into’ the recovery model, so too people may re-cycle back to previous stages although rarely all the way to pre-contemplation

• Thus they suggest a ‘spiral’ model of change readiness in which decisions are often re-made; reversed, re-visited and re-evaluated, then reversed again.

• If we apply their model to medical compliance for the mentally ill, we must think about a ‘recovery’ model of metal illness in which ‘relapse’ is allowed, acceptable and planned for.

• Relapse in this model would often include decisions to ‘go off’ of meds, ‘refusal’ etc.

• If we consider the decision to take medication as a continual, lifelong process of ‘yes/no/maybe, our goal becomes solely to help the client make

her decisions at different stages!

Helping within in a process that is unavoidable is far more useful than attempting to stop the unavoidable process (i.e. attempting to lead a client to a decision they will not keep!)

Principles of decision therapy1. The goal is mutual cooperation! i.e. the “mutual participation relationship”2. be clear about the purpose of decision therapy. It is not to get the client to take

meds. It is to help them make the best decision they can for themselves at the time! It is their decision! They have to live with the consequences; not us!

3. Extend the principle of charity to the client. We too often assume that our clients really don’t know what they are talking about. The principle of charity assumes that the client knows what he or she is talking about, even when we don’t see it. They are the experts on their lives. This means understanding WHY the client is not taking meds – from their perspective

4. Whenever possible, try to determine in what stage of the decision-making the client is.

5. Use decision-facilitating strategies that matches present stage of change. The goal is to move the client from one stage (in the decision-making process) to the next.

•Detaching•Role-taking•Principle of charity (exploration)•Empathic, Non-judgmental understanding•Focus on feelings (ventilation)•Relationship-bldg•Connect c/ peers•Involve family•Role induction

•Alternative exploration•Externalizing•Force field analysis•Role-playing•Hypothesis testing•Reframing•Humor•Education•Journaling•Role induction•Explore ambivalence

•Force field analysis•Role-playing•Hypothesis testing•Behavioral rehearsal•Cognitive re-structuring•Reinforcement•Education•externalizing

•Behavioral reminders•Reinforcement management•Environmental re-structuring•Support•Normalizing failure•Counter-conditioning

•Behavioral reminders•Reinforcement management•Relapse prevention techniques•Challenging faulty beliefs•Supportive helping relationship•Tolerance for ambivalence•Counter-conditioning

•Focus on self-awareness

interpretation

confrontation

probing focusing•education•Dilemma highlighting•Reframing •Normalizing•Collaborative d-m

•Consequence exploration

sx. Worsening

e.r. visits

homelessness

re-admits

assaults

general non-co•Explore ambivalence

•Mobilizing support and witnesses to new behavior•Behavioral contracting•Self-monitoring

•Dramatic relief/ventilation•Journaling•Self-re-evaluation•Expanding witness base•Support groups

InitialDecisionAboutmeds

On-GoingDecisionAbout meds

Pre-contemplation Contemplation Preparation Action Maintenance

Applying the two stages of decision-making together

Helping within in a process that is unavoidable is far more useful than attempting to stop the unavoidable process (i.e. attempting to lead a client to a decision they will not keep!)

Principles of decision therapy – con’t.

6. Whatever the outcome, respect the client’s process as well as their decision. This is a fearsome and extremely difficult decision.