Treatment Nonadherance and the Patient With Serious Mental Illness: Unique Individuals, Unique Challenges
By Marianne Emanuel, RN
Regardless of the severity of a client's illness, when you ask him what he wants to accomplish, what he wants out of life, more often than not he will respond with some variation of "a nice place to live, some friends, and something meaningful to do." In ways that extend beyond the traditional doctor-patient relationship, a client-driven treatment plan that involves caseworkers, nurses, family members, and friends provides the necessary support and opportunities for the client to achieve these self-identified goals. The first step toward a client's reintegration and recovery is to establish a relationship between that person and each member of the treatment team. Each team member must believe that the person with SMI can get better and achieve an improved quality of life. They must believe that these goals are not merely visions and hopes, but rather tangible and attainable objectives.
As the central and most important member of the treatment team, the client must also maintain a strong belief in his capability for improvement and achievement of his goals. "I believe clients need to take ownership of their lives-they need to tie what they want for themselves to their treatment recovery goals," states Belinda Bernard, a case manager who has worked at Clinton Residence in New York City for the past 14 years. "No matter what you want for your client, if he doesn't want it for himself, it's not going to happen." Instilling not only a sense of hope and belief in each client, but also the desire and drive to strive for the life he wants, is essential to the treatment plan.
Upon establishing the client's recovery goals and instilling the proper mindset in the client and treatment team members, the team consults with the prescribing psychiatrist to set the medication regimen. A registered nurse then meets with the client and schedules a physical examination with a primary care provider, complete with bloodwork and EKG. An assigned caseworker submits to a psychiatric rehabilitation program an application specific to the client's goals. When selecting program environments, team members should keep in mind that a clubhouse setting compels the process of socialization and hones many skills that will aid the client upon being employed. Mentally Ill Chemically Addicted (MICA) day programs provide support for substance abuse recovery, while residences and Community Mental Health Centers (CMHC) offer psychological education, health and nutrition education, smoking cessation information, and counseling on money management. Clients who want to further their education should be given the option to enroll in classes at all levels.
Once the initial steps to recovery have been initiated, treatment team members will continue to help the client explore all available resources. Even though many opportunities will have been provided to the client at this point, immediate success is not guaranteed. The client and treatment team may face many obstacles and challenges. One of these obstacles may be the client's refusal to adhere to the medication regimen. As frustrating as this may be for team members, they must remember that it is even more so for the client who bears the consequences of nonadherence. Oftentimes, dedication nonadherence results in the relapse of psychotic symptoms that can interfere with the client's personal relationships-or even in the demoralizing experience of psychiatric hospitalization. Family, friends, and loved ones-important members of the treatment team-may become fearful that the client is "out of control" and capable of hurting himself or others; an employer may suggest termination of the job; and teachers may recommend an extended leave of absence. In these trying situations, the client must be engaged in recovery again, even if he or she has temporarily lost ground. When the treatment team accepts the client's denial and resistance to treatment with a non-judgmental attitude, essential lines of communication can be kept open. At this stage of treatment perhaps more than ever, the client needs to be heard, understood, and respected.
Nonadherence to medication regimens is not the only cause of relapse, nor is it the only challenge the client and treatment team may face. Clients often agree to follow a given medication plan, but the very idea of taking daily medication indefinitely can be frustrating and discouraging, setting the stage for nonadherence. Allowing the client to voice his frustrations, validating these feelings, and relating medical adherence to the achievement of personal goals may be the best way for team members to approach this concern. Discussing specifically how medications enhance the client's ability to concentrate, function at a job, or perform in the classroom may relieve some of the client's qualms regarding daily medications.
The client's concerns regarding medications may extend further, to the various side effects that may be associated with any medication regimen. At times, these effects can actually interfere with recovery. For example, if a client who is trying to maintain a personal relationship with a loved one experiences medication side effects that prevent him from achieving an erection and/or orgasm, the result can be devastating, not just to that specific relationship, but also to the social skills the client has been working to develop. Again, the importance of listening to the client's concerns regarding medications and their side effects cannot be stressed enough. Too often, these concerns are dismissed and deemed unimportant to overall recovery.
Traditionally, psychiatric treatment has focused on the reduction or elimination of positive symptoms. While this is certainly an important component of treatment, each client's specific life goals should be considered even after positive symptoms are under control. For example, a client who is no longer experiencing hallucinations may be suffering greatly from negative symptoms such as anhedonia, avolition, or cognitive impairments. At times, negative symptoms can be even more detrimental to socialization goals, and cognitive impairments can interfere with vocational rehabilitation or schooling. As with all chronic illnesses that require medication, the individual being treated for SMI needs to see results that reflect an improved quality of life and the enhancement of personal goals. Medications for chronic mental illness must constantly be monitored and adjusted, as each client is unique and will respond differently to those agents.
Helping clients reach recovery goals is always challenging. Each client is a unique individual with specific needs that must be addressed in order to help him achieve his goals. Antipsychotic medications are not perfect. Obstacles are bound to arise, dosage adjustments will likely be needed, and relapse is always possible. Crises are likely to occur as well, but they should be viewed as opportunities for careful listening and growth rather than failures or regressions from recovery. The indispensable constants are the beliefs that successful recovery and reintegration are possible, that desire and drive are necessary for achieving success, and that mutual trust and respect must exist between the client and the treatment team members.
Marianne Emanuel, RN, is Nurse Coordinator for clinical research trials for the neurobiologic disorders clinic at St. Luke-Roosevelt Hospital in New York City. She became certified as a psychiatric rehabilitation practitioner in 2004 and is a Neuroscience Treatment Team Partner (NTTP) program speaker. She also works as patient care coordinator for the Project Renewal Clinton Residence, a 57-bed residence for formerly homeless people with serious mental illness. Marianne is also involved with the Fountain House program.
Key Takeaway Points
- The support provided by a multidisciplinary, client-driven treatment team is vital to enabling clients to achieve self-identified goals.
- Belief in success is imperative—team members must embrace the ideal and possibility of recovery, and clients must believe they can achieve real and lasting improvement.
- Adherence and, ultimately, recovery depend equally on contributions from each team member: physicians, nurses, caseworkers, and clients.
- A daily medication regimen of indefinite duration can be a source of great client frustration, possibly leading to nonadherence. To prevent this, team members should allow clients to vent their frustrations, and should express that these feelings are normal but that medication adherence is an essential part of achieving personal goals.
- The importance of listening to the client's concerns regarding medication side effects cannot be stressed enough. Dismissing these concerns as unimportant to overall recovery may damage the client's trust and make it harder to promote treatment adherence and open communication.
- Team members should not focus only on positive symptoms. Negative symptoms can often be even more detrimental to the recovery plan and socialization goals, and cognitive impairments can interfere with vocational rehabilitation or schooling.
- Medications for chronic mental illness must be monitored constantly. Symptom improvement must be balanced against side effects to ensure outcomes reflect an improved quality of life and the enhancement of personal goals.
- The path to recovery and reintegration is fraught with obstacles and the potential for setbacks. Crises are likely to occur, but should be viewed as opportunities for careful listening and growth, rather than as failures or regressions from recovery.
- Always remember: each client is a unique individual with specific needs that must be addressed. Not all treatment approaches can be applied in every situation.
Additional Links and Resources
Antipsychotic Medications: Compliance and Attitudes Towards Treatment
This report discusses how "adherence to antipsychotic medications in schizophrenia continues to be a significant and challenging question in terms of its prevalence as well as its significant impact on the rate of relapse and resource utilization."
Treatment Compliance in Patients with Co-Occurring Mental Illness and Substance Abuse
This article discusses, among other issues, how "poor treatment compliance is often associated with blame, and noncompliant individuals with mental illness are sometimes punished with involuntary administrative discharge from treatment."
