Introduction
When patients are facing potentially devastating psychiatric disorders such as schizophrenia, bipolar disorder, and major depressive disorder, medications are often life transformative or, in some cases – where suicidal ideation has arisen – even life saving. Unfortunately, it can be a difficult decision to try a medication and to, subsequently, tolerate its side effects while determining an effective fashion for controlling an illness. Nevertheless, no matter how understandable the factors may be that are at play, we are left with the disturbing fact that the number one reason for treatment failure in people coping with major psychiatric illnesses is the fact that their medications are not taken as prescribed or, in some instances, not taken at all. Such is the case with non-psychiatric diseases as well, from diabetes and asthma to hypertension, cancer, and acquired immunodeficiency syndrome (AIDS). As former Surgeon General C. Everett Koop, MD, ScD, so elegantly quipped, “No medications work inside a bottle. Period.”2 It is hard to argue with Dr. Koop on this one.
The amount of human suffering – to our patients and to those who love them – caused by this lack of what is traditionally called “medication adherence” is truly staggering in the field of mental health. At times it even leads to the end of our patient’s life – suicide. Consequently, it is of immense importance to address this issue in any book on clinical interviewing, for I believe the words that we use in talking with our patients about their medications is one of the keys to transforming this complex problem. The Director of the Colorado Health Outcomes Program, John Steiner, provocatively captures this fact by reminding us “that our words are as important a part of the pharmacopoeia as the medications themselves.”3
The Medication Interest Model (MIM) directly addresses the above daunting challenge to healing. The MIM has been evolving for over 20 years. It includes more than 50 behaviorally well-defined interviewing techniques. These interviewing techniques are housed within a conceptual framework – the Choice Triad – which provides a reliable, logical, and simplifying structure for understanding the many complexities of how patients decide to try a medication as well as how they decide to continue or discontinue it. The Choice Triad, which is easily utilized by both experienced clinicians and trainees, provides a platform for clinicians to rapidly and sensitively explore the thought processes and emotional responses patients experience when using medications.
Moreover, transforming medication nonadherence has a lot more to do with our patient’s souls, as our opening epigram hints, than is usually ascribed. By soul, I simply mean “what makes our patients tick” psychologically and spiritually. Moreover, whether we are psychiatric nurses or nurse clinicians, psychiatrists, psychiatric physician assistants, clinical pharmacists, or case managers, we reach our patients’ souls through the power of our relationships with them as forged by our words and nonverbal communications. Thus, the resolution of the problem of nonadherence, to a large extent, ultimately comes down to how we talk with our patients about their medications.
The MIM is a prototypic person-centered model of interviewing. If one were forced to proffer one word that lies at the center of the model it would be the word “choice.” Every single interviewing technique of the MIM is designed to enhance the patient’s ability to consider whether the use of medication is the right choice for himself or herself, and, if so, how to choose a particular medication and how to use it most effectively. From the perspective of the MIM, the practice of “choice” and the issue of “trust” often go hand in hand, leading directly to the heart of the therapeutic alliance. The patient’s trust of any given clinician is frequently partially, and sometimes substantially, based upon the patient’s observations of how the clinician discusses the use of medications.
This state of affairs is particularly accentuated if the clinician is expected to make a medication recommendation by the end of the initial meeting. Obviously, in such instances, the quality of the therapeutic relationship created during the earlier aspects of the initial interview may greatly determine the likelihood that the patient will be interested in following the clinician’s recommendations. But, not so obviously, the reverse may be equally true – the discussion about medications may determine the robustness of the overall therapeutic alliance.
One can argue that, concurrent with the development of the overall “therapeutic alliance,” a prescribing clinician must also develop a “medication alliance.” One can further argue that this “medication alliance” may have a greater impact on the overall “therapeutic alliance” than vice versa. I would go so far as to assert that the fashion in which a clinician handles the transaction over the potential use of medications may even determine whether or not the clinician and the patient will ever set eyes upon each other again.
Let me be more specific. I am suggesting that the microcosm we call the “medication alliance” may have a profound impact on, indeed may represent the primary determinant of, the macrocosm we have traditionally in the field of mental health, and throughout this book, called the “therapeutic alliance.” The discussion of medications in the initial interview marks the first time that the patient and the clinician must truly arrive at a difficult collaborative decision. In this regard, the process of this discussion represents a pivotal database from which the patient will make a formulation of “who is this person sitting across from me?”
From their initial discussion of medications, the patient will determine whether the clinician is genuinely interested in various ways of approaching symptom relief or is merely a “pill pusher.” The patient will gauge the clinician’s degree of actual concern by how carefully and openly the clinician describes the benefits and side effects of the medication. The patient will judge from the look in the clinician’s eyes, and from the tone of his or her voice, whether the clinician is truly registering the patient’s concerns about the potential side effects of the medication. Ultimately, the patient will listen to the clinician’s recommendations in direct proportion to how well the clinician listens to the patient’s recommendations.
If the patient leaves this first interview with a positive assessment of these clinician characteristics, a second session will be more likely to occur. If such a meeting results, one can bet that the process of evaluation of the clinician by the patient will continue. This ongoing evaluation will undoubtedly be greatly based upon the dyad’s exchanges of their opinions about medications.
The patient will determine the clinician’s ability to effectively listen by how carefully the clinician explores the patient’s concerns about his or her side effects that have now morphed from abstract possibilities in the first session to concrete realities in the days preceding the subsequent sessions. It is one thing to hear about potential problems with sleep. It is entirely a different thing to toss restlessly in one’s bed for 2 hours every night before getting to sleep. The patient will decipher the collaborative proclivities of the physician or nurse by whether the clinician is willing to change his or her medication recommendations (stop a medication, lower its dosage, or switch to another medication or, perhaps, an alternative intervention to a medication) based upon the patient’s input. Put succinctly, exactly as Shuman emphasized in our opening epigram, “people want to know that their opinions and concerns are worthy of interest and response.” The MIM is all about this “listening.”
As emphasized repeatedly in this book, each patient–clinician relationship is unique. And each patient–clinician relationship must define its own unique sets of expectations and methods of joint problem solving. This process often begins, and sometimes ends, over the discussion of medications. The remainder of this chapter is an effort to show a variety of concrete techniques that can flexibly be used by clinicians to start this listening and to enhance it with each subsequent meeting.
To accomplish this task we will divide our exploration into five parts. In Part 1, “Nonadherence” – More Than Meets the Eye, we will better familiarize ourselves with the characteristics and consequences of what has traditionally been called “nonadherence.” In Part 2, The MIM: Development and Roots, we will explore the influences that impacted on the creation of the MIM to understand how to use it more effectively. In Part 3, The Spirit of the MIM, we will look at the underlying collaborative principles driving the model. In Part 4, The Choice Triad: The Foundation of the MIM, we will turn our attention to understanding, at a sophisticated level, the fashion in which patients decide whether to try a medication and subsequently stay on it. Finally, in Part 5, Practical Interviewing Tips and Strategies of the MIM, by far our largest section, we will get down to the “nitty-gritty,” examining in detail specific interviewing techniques that can be put to immediate use in the hectic world of everyday practice.
Part 1: “Nonadherence” – More Than Meets the Eye
Extent of the Problem
Whether one is discussing psychiatric illnesses such as schizophrenia and post-traumatic stress disorder (PTSD) or non-psychiatric illnesses such as hypertension and diabetes, hundreds of studies have found that patients with chronic diseases only take their medications as prescribed about 50–60% of the time.4 The actual number depends upon the disease in question, but a large survey cited by the National Council on Patient Information and Education aptly highlights the problem: nearly 31% of the patients had not filled the prescription they were given, almost 24% had taken less than the recommended dose, and 29% had stopped taking the medication before the supply had run out.5 Whether using as recommended or not, about one-third of patients with chronic illnesses have strong reservations about the medications they are on – future examples of discontinuance just waiting to happen.6
We need not look much further than the nearest mirror to see the ubiquitous nature of what is traditionally called noncompliance or nonadherence – I, for one, know that I haven’t always taken meds exactly the way I was supposed to take them. From a struggling mother in a welfare line in Detroit to a wealthy e-business hotshot in a ticket line on Broadway, from a soldier back from Afghanistan to a vacationer on a Cape Cod beach, from a high school dropout to a Rhodes Scholar, all types and shapes of people are guilty of “playing” with their meds. Nonadherence is everywhere, it would seem.
Regarding psychiatric illnesses such as schizophrenia and bipolar disorder, the rate of nonadherence is particularly striking. For instance, Lacro reviewed the literature on prevalence and risk factors for nonadherence in schizophrenia.7 Among the ten reports that met a strict set of study-inclusion criteria, they reported a mean rate of nonadherence of 41%; those patients who met an even stricter set of inclusion criteria reported a 50% rate of nonadherence.
There was some hope that the introduction of “atypical” antipsychotics with fewer neurologic side effects would reduce rates of nonadherence to a clinically meaningful degree, but this has not proven to be the case.8 Unfortunately, these medications have demonstrated a new set of side effects such as weight gain and the triggering of the metabolic syndrome/diabetes, which represent genuinely good reasons for patients who are contemplating taking these medications to be hesitant to do so.
It is important to underscore that relapse is often the result of medication discontinuance. Indeed, Robinson found that with patients who had been successfully treated for their first episode of schizophrenia, discontinuing medication was the single most powerful predictor of relapse.9 Patients who stopped taking their medication were five times more likely to relapse than those who continued on medication.
Each relapse results in enormous personal suffering, family and community burden, and increased health care costs. In addition, there is substantial disruption in psychosocial and vocational functioning and/or interference in achieving personal goals. Psychotic relapse is also associated with an increased risk of violence towards self or others, and involvement in the criminal justice system.
Valenstein10 and Weiden11 have studied the impact of gaps in taking medication based on prescription refill data in large populations of patients. They found that even a gap in medication-taking as short as 10 days resulted in a doubling of the risk of hospitalization. With longer gaps, the risk of re-admission to the hospital continues to rise significantly, with gaps of greater than 30 days increasing the risk fourfold.
Indeed, discontinuation of medications can even result in the loss of our patients’ lives. In a fascinating, yet disturbing, study, Herings and Erkens reported on 603 patients with schizophrenia in the Netherlands using a medication-dispensing and hospital discharge database.12 Adjusting for age and gender, they reported that a 30-day gap in medication treatment increased the relative risk of suicide attempts a stunning 4.2 times. (Thirty-three percent of the patients in their sample had a gap of at least 30 days.)
In contrast, utilizing medications as indicated often results in a significant decrease in both positive and negative symptoms of schizophrenia13 as well as great relief in a myriad of other psychiatric disorders. On a personal note, some of my most rewarding moments in the field have been related to having patients plagued for years, even decades, by the savage mood swings seen in bipolar disorder move into complete remissions through the use of medications such as lithium and other mood stabilizers. Seeing people whose lives had been ruined by bipolar process re-gain their normal personalities, potentials, and dreams is an experience hard to put into words for all involved including patient, family members, and clinician.
Nonadherence: The Nature of the Beast
It is clear from the above that nonadherence is not only common, it is commonly devastating in its impact. The next question is, “Where does it come from?” We will spend much of the remaining pages of this chapter exploring the answers to this question in specific detail. For the immediate purpose of launching our discussion, it is useful to look at the roots of nonadherence from a more general perspective.
Peter Weiden has pointed out that nonadherence tends to fall into one of two broad categories.14,15 In the first category – “intentional nonadherence” – the patient makes an internal active decision that he or she does not want to begin or continue with a medication as prescribed (either lowering the dose or stopping it entirely). In the second category – “unintentional nonadherence” – external obstacles get in the way of a patient, who otherwise wants to take the medication, from doing so. In this sense, Weiden points out that the patient “cannot adhere.”
With regards to unintentional nonadherence, many external factors can block a patient’s ability to utilize a medication. The problems can be as diverse as the cost of the medications, difficulties remembering to take the medications (related to normal aspects of forgetting or to cognitive impairments as seen in dementia and schizophrenia), the complexity of multiple medication regimens, lack of transportation to the pharmacy, language barriers to understanding directions for taking the medications, and interpersonal and cultural pressures to stop medications. Mueser has coined the term “medication follow-through” to describe the patient’s efforts to overcome these external obstacles. He has also reviewed the psychiatric research that addresses methods for helping patients to achieve effective medication follow-through such as mechanical timing prompters, easier-to-use pillboxes, behavioral tailoring, dosage simplification, social skills training, intensive psychoeducation strategies, and outreach programs such as Assertive Community Treatment (ACT) Teams.16
All medication nonadherence can be viewed as stemming from either intentional nonadherence or unintentional nonadherence, or some combination of the two. This delineation allows clinicians to quickly focus upon specific internal or external factors in an effort to transform nonadherence. Moreover, this classification forces clinicians to always evaluate the role of patient choice as being paramount.
From its first inception, the MIM has recognized the importance of both intentional and unintentional nonadherence. In order to avoid the negative connotations of the term nonadherence, as well as emphasizing a positive person-centered perspective, the MIM addresses the intentional aspects of patient choice as “medication interest” and the ability to overcome external obstacles with the term coined by Kim Mueser “medication follow-through.”
Indeed, the situational roadblocks to medication follow-through are not the emphasis of the MIM, for the simple reason that the vast majority of research and innovation has focused upon medication follow-through. In contrast, other than the pioneering inroads made by motivational interviewing regarding medication adherence (nicely documented but modest in results), minimal attention has been given to the topic of patient choice in taking medications. The MIM was designed to right this imbalance. The model emphasizes the importance of viewing adherence as beginning with the one factor with which the patient has direct control – patient choice – focusing upon interviewing techniques and strategies for helping patients to make the very best choice that they can.
Part 2: The MIM – Development and Roots
Development of the MIM
The MIM originated with insights gained from an “in-the-trenches” case management team that was part of a research study sponsored by the Robert Woods Johnson Foundation and led by Robert Drake from the Psychiatry Department of the Dartmouth Medical School in the late 1980s and early 1990s. These teams were developed to help patients with severe and chronic psychiatric disorders (all of the study patients had poorly controlled schizophrenia, schizoaffective disorder, or bipolar disorder) who were also suffering from concurrent alcohol and/or street drug abuse/dependence.17 This case management study pioneered using Continuous Treatment Teams (CTT, often called ACT Teams) to help the most ill of dually diagnosed patients, for all of these patients had histories filled with suicide attempts, violent episodes, and/or multiple hospitalizations – a cohort with traditionally minimal interest in taking medications.
I had the pleasure of developing and directing one of these teams. Our specific team had a high success rate with medication interest and follow-through. By the end of the 4-year study, the team had decreased hospital days on average by 20 days per patient per year,18 a result that seemed to correlate well with higher medication adherence rates. From a concerted effort to tease out the interviewing techniques that seemed to be related to this success (as well as asking our patients why they chose to stay on their medications), the MIM was born and evolved.
A second source for the MIM stemmed from a series of over 200 “medication interest” workshops given by myself over an 8-year span in the late 1990s and early 2000s across the United States and Canada. Participants representing a wide sampling of disciplines including psychiatrists, psychiatric nurse clinicians/nurses, and other mental health professionals as well as primary care physicians, nurses, and case managers attended. These front-line clinicians were asked to share their best practices regarding interviewing techniques that they had found to be useful in enhancing medication adherence. In the subsequent years, and in an ongoing fashion to this day, these workshops continue, with participants providing interviewing tips that enhance the ever-expanding and evolving MIM. The evolution of the MIM also continues through interviewing tips given by readers for inclusion in the “Interviewing Tip of the Month Feature”19 posted on the website of the Training Institute for Suicide Assessment and Clinical Interviewing (TISA).20
Of particular note is the fact that over a hundred of the original workshops were limited to primary care physicians, nurses, physician assistants, and case managers. These primary care clinicians provided a wealth of interviewing techniques – designed to improve adherence when treating illnesses such as hypertension, diabetes, asthma, congestive heart failure, and AIDS – that were immediately appropriate for use with patients coping with psychiatric illnesses. From their feedback it quickly became apparent that the theoretical foundation of the MIM (such as the Choice Triad) as well as its interviewing techniques were equally applicable to psychiatric and non-psychiatric illnesses.
Consequently, the MIM was expanded for use with patients coping with all medical disorders. It is now designed for use not only in psychiatric residency and graduate programs in psychiatric nursing, but also as a core model of prototypic person-centered interviewing in medical, nursing, physician assistant, and clinical pharmacy schools. The MIM is appropriate for use in disease states ranging from diabetes, congestive heart failure, and AIDS to depression and schizophrenia, although in this chapter we will focus upon its use with psychiatric patients. The use of the MIM across all common disease states encountered in primary care led to the publishing of the book, Improving Medication Adherence: How to Talk with Patients About Their Medications.21 This book is designed as a concise, core primer on the interviewing techniques of the MIM for utilization in medical, nursing, physician assistant, and clinical pharmacy schools as well as by residents and nurse clinicians across all disciplines including psychiatry.
Roots of the MIM
Pulling on Clinician Wisdom
Although motivational interviewing has made significant contributions to helping clinicians better understand and improve medication adherence, the MIM, hopefully, adds a new and powerful additional approach. The MIM fully endorses the use of motivational interviewing as a tool for improving medication adherence and is in complete agreement with the spirit of motivational interviewing as described in Chapter 22. Moreover, the MIM agrees with, and utilizes, the general principles of motivational interviewing such as the importance of collaboration, compassion, moving with the patient’s concerns, and allowing the patient to discover his or her own personal reasons for motivation.
On the other hand, the MIM did not derive from motivational interviewing. Nor did the roots of the MIM grow from the same soil (borrowing a treatment approach from substance use counseling and adapting its techniques and strategies to a different arena – medication nonadherence). For the interested reader, the relationship between counseling approaches such as motivational interviewing and solution-focused interviewing with the MIM has been nicely delineated by Cheng.22
The MIM grew from the belief that although many prescribing clinicians and case managers encounter problems with medication adherence (and to some degree lack the necessary interviewing skills to effectively engage patients around the use of medications), many other clinicians are talented at the process. Some clinicians are gifted at it. Consequently, as mentioned above, the MIM was created by tapping the wisdom of these front-line clinicians by talking with – and observing at work – mental health professionals such as psychiatrists, nurses, nurse clinicians, and case managers as well as subsequently doing the same with primary care providers.
As useful interviewing techniques were shared and delineated, an attempt was made to see if a theoretical model of motivation would emerge (the Choice Triad) that could be used to clarify and enhance the use of the many interviewing techniques that were being discovered. Thus, the MIM evolved as a “bottom-up model” derived from the clinicians who are directly prescribing and following medication use with patients on an everyday basis.
Pulling on the Wisdom of Educational Theory and Research on Clinical Interviewing
Time … not enough of it. Clinicians are pushed by the pressures of contemporary practice to move at an ever more feverish pace. In addition, less and less time and financial support seems to be allotted to continuing education by employers and administrators. What little time is left for education must be utilized effectively and be as productive and enjoyable as possible. But there is a limit to the degree with which training times can be decreased while still allowing for the effective acquisition of skills. Several methodologies have added important gains in our abilities to train clinicians to use interviewing skills more effectively to enhance medication interest. But such models of counseling (motivational interviewing) and psychotherapy (solution-focused therapy, cognitive-based therapies) are sophisticated. They cannot be learned quickly and their mastery requires ongoing supervision and coaching.
The MIM is not a style of counseling or a psychotherapy. It is a collection of individual interviewing techniques organized around a simplifying clinical construct, the Choice Triad. Each technique is well defined, brief in nature, and easily taught and learned. No doubt, one can become significantly more adept at employing the numerous interviewing techniques of the MIM through ongoing experiential training and supervision, but learning even a single interviewing technique of the MIM may, in my opinion, significantly improve a clinician’s ability to communicate more collaboratively with patients about medications. To better understand how a single interviewing technique from the MIM can be rapidly learned and subsequently implemented it is useful to review three concepts discussed in our book: interviewing principles, interviewing techniques, and interviewing strategies (see Glossary).
An interviewing principle is a guiding concept for approaching an interviewing task. Interviewing principles help clinicians to recognize when to use specific techniques, how to flexibly handle new situations, and how to be creative and “think on one’s feet” while interviewing. On the other hand, interviewing principles do not show the clinician concretely what words to use. Interviewing principles, because they are abstractions, are by their very nature sometimes unclear to trainees, open to interpretation, frequently difficult to learn, and often notoriously difficult to test with regards to trainee competence.
In contrast, an interviewing technique (which is a specific attempt to apply an interviewing principle) is defined as being a behaviorally defined set of words (often a single statement or a single question) that has been operationalized and tagged with a name. Every interviewing principle in practice can be applied by the use of numerous interviewing techniques flexibly chosen to fit the unique needs of the client and the clinical task at hand.
Consequent to their behaviorally specific nature, interviewing techniques are less likely to be misunderstood by trainees than interviewing principles, are more easily learned, and are quite easy to be objectively tested for competence (if asked to do so, the trainee either does or does not use the interviewing technique required by the instructor with a patient or role-player).
Moreover, two or more easily learned interviewing techniques can be sequenced together to form an interviewing strategy. Earlier, in Chapter 17, we saw a nice example of a sophisticated interviewing strategy, the Chronological Assessment of Suicide Events (CASE Approach) designed to uncover the breadth and depth of suicidal ideation, planning, and intent. The MIM has several short interviewing strategies.
Because the MIM focuses upon interviewing techniques, for the reasons described above, the separate elements of the MIM tend to be easily taught, learned, and tested. Thus the reader can learn as many or as few of the MIM interviewing techniques as is personally desired, choosing to become proficient in those techniques that are most natural to the reader and are most personally appealing. By becoming adept in a variety of techniques, clinicians can learn to creatively choose the techniques that fit the unique needs of any specific patient. The model also allows the clinician to create their own techniques, maximizing creativity to suit the needs of the patient and the clinical context.
For readers interested in training other clinicians, as noted above, educational research has shown that interviewing principles can be difficult to teach. In contrast, a myriad of studies has shown that effective role-playing approaches have been developed that can train clinicians to competency with regard to single interviewing techniques when they are behaviorally operationalized (e.g., Alan Ivey’s “microtraining”).23–25 We have been involved in the development of promising educational approaches that allow trainers to teach complex interviewing strategies when they too are behaviorally operationalized (e.g., Shea’s “macrotraining”).26 In addition, a style of group role-playing in which there is minimal to no acting – scripted group role-playing (SGRP) – has proven to be unusually popular with workshop participants when learning both individual interviewing techniques and complex interviewing strategies.27 Microtraining, macrotraining, and SGRP are directly applicable for experientially teaching the clinical interviewing techniques and strategies of the MIM.
Part 3: The Spirit of the MIM
Collaborative Exploration: The Transformative Engine of the MIM
Choice. The spirit of the MIM arises with the simple acknowledgement that the decision to put a foreign substance into one’s body – sometimes indefinitely – is not an easy choice. Let us be blunt: many people have died from medications; vastly more have been harmed by them. Oliver Wendell Holmes, Sr., a renowned physician from the 1800s acerbically wrote, “I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind – and all the worse for the fishes.”28 Fortunately we have a remarkably more effective and safe stable of medications today than we did in 1860, but, even today, medications must be used with caution and respect, both for their powers of healing and for their potential side effects.
With this idea in mind, the MIM views physicians, nurses, or other prescribing professionals, as well as those who collaboratively follow medication use such as case managers, not as people whose goal is “to get” a patient to take his or her medications; rather, their goal is to serve as knowledgeable and compassionate guides, who provide the information that will allow patients the opportunity to make the best possible choice for themselves. Of the prescribing dyad, only the patient puts the medication into his or her mouth. Prescribers don’t suffer side effects, patients do.
We are reminded of a lesson we learned in Chapter 7 on treatment planning: an ideal treatment plan that the patient will not follow is not ideal; it is foolish. In this regard, treatment algorithms that are solely disease based (as with the patient has this disease so this medication is the correct therapeutic choice) are prone to foolishness. In helping the patient to choose an intervention, one must also consider contextual factors such as: the patient’s personal beliefs, cultural beliefs, spiritual beliefs, and finances. Added to the list are interpersonal factors such as the beliefs of family, friends, other patients, and concurrent healers (for instance, practitioners of alternative medicine).
In fact, from the perspective of the MIM, the collaborative exploration does not begin with the question, “Which medication should the patient choose?” It begins with the question, “Should the first choice be something other than a medication?” Some forms of hypertension and diabetes respond quite well to dietary changes, exercise regimens, meditation, and deep breathing, none of which possess side effects. Many depressions respond well to psychotherapies, changes in family dynamics, and spiritual revitalizations. Various alternative treatments hold promise, from acupuncture in pain to St. John’s wort in mild depressions.
For a patient to trust us, we must always communicate our best-possible treatment recommendation, which, at times, may include the use of a medication. Sometimes patients agree. Sometimes they don’t. Sometimes patients prefer a plan of action not involving medication use. In such instances, if we reflexively disagree with the patient’s choice – try “to right the wrong” as motivational interviewers warned us not to do in Chapter 22 – we may generate an unnecessarily conflictual atmosphere with the resulting loss of the patient’s trust. Alternatively, in many instances, we can genuinely suggest that the patient should try his or her preferred choice. Indeed, we can enthusiastically do our best to help the non-medication intervention to succeed in any fashion that we can. After all, if the patient can achieve healing without a medication, so much the better.
If, for some reason, the alternative choice fails, then the patient will discover for him- or herself that it did not work, and is more likely to seek out the use of a medication. I am convinced that such a process – allowing the patient to arrive at his or her personal decision that the best intervention is a medication – is frequently, almost always, more likely to result in enhanced interest in using and sticking with a medication. People want relief from their pain. If they feel that a medication is the best way to get that relief, they will seek it.
The MIM fully recognizes that a truly collaborative exploration of treatment options necessitates an openness from the clinician that the patient is the expert of what impact a medication is having on his or her disorder as well as upon his or her life. It is important to carefully listen to what the patient is saying, not merely because it strengthens the therapeutic alliance: It is important because the patient is frequently right.
In many instances, the dose is too high, the timing of the dose too rigid to allow for effective use, the medication is not working, the medication’s side effects outweigh its benefits, or a different medication might work better. Perhaps no medication at all is the best course of action. Thus the spirit of the MIM is about collaborative listening. The spirit of the MIM is about learning from the patient. Without question, if we learn from our patients, they are much more likely to learn from us. This listening process, this shared learning, this shared trust is at the heart of the medication alliance. The bottom line is: Few patients will take a medication from a person unless they like that person.
The Truth About So-Called Medication “Nonadherence”
There is a lot about nonadherence that we are not taught in our medical, nursing, and graduate schools and in our psychiatric residencies. The nature of the phenomenon is complex. The term itself is misleading. Indeed, in a very few pages from now, we will abandon the word “nonadherence” altogether, replacing it with a more person-centered term.
Here is the crux of the matter. Throughout our book we have emphasized the reality that interviewing is a dyadic process. From a traditional perspective, medication nonadherence is defined as being that situation in which a clinician recommends a medication and the patient does not do what the clinician is recommending. The patient either refuses the medication, changes how it is taken, or stops it altogether. There is nothing wrong with this definition. On the surface, it is exactly what happens. It is not so much that the definition is wrong. It is that the definition is incomplete.
If one takes the time to actually watch what unfolds when a patient is concerned about using a medication or is down-right refusing to do so, the truth of the matter is that medication adherence requires a more complete definition. This can be stated as, “It is when the patient is not doing what the clinician wants, and the clinician is not doing what the patient wants.” It is a dyadic process. For every clinician thinking, “I wish this patient would ‘get it’ that he needs his lithium to control his bipolar disorder,” there is often a patient thinking, “I wish Dr. Shea would ‘get it’ that there is nothing wrong with me, and I don’t want to keep talking about this stupid drug of his.”
In essence, medication nonadherence is less something that one person does (the patient) than it is an experience that two people share.
It is an experience that is often quite painful to both parties. We feel badly because we know the suffering that is about to occur when our patient with bipolar disorder stops his lithium. Our patient with bipolar disorder is pained by the fact that we do not understand him for who he is, and we view him as having an illness that he feels he does not have. We have a disagreement, a jarring one at that. The next question is, “How do disagreements tend to solidify into rigid stalemates?” How does a disagreement become a wall that separates the patient both from the clinician and from the healing options offered by the clinician?
Let us look, for a moment, at everyday arguments that have nothing to do with medications, for they may shed light on how stalemates occur regarding medications. Truth be told, debates tend to escalate into arguments when one of the two participants tends to increase the push on the other, especially when that push includes a personal attack on the other member as opposed to the other member’s beliefs. Think of politicians during a campaign.
It is one thing to say, “I strongly disagree with you.” It is an entirely different thing to say, “I strongly disagree with you, but that doesn’t surprise me because you’re an idiot.” Think politicians. The fight is on. You can bet the attacked member of the dyad is about to unload their own delightfully wicked cannon shot or tweet. Note that often, not always, it only takes one of the two people to start the oppositional war.
Curiously, it is the same process at work when oppositional dyads settle themselves. It does not necessarily take two to tango. Anyone who has done marital therapy knows that two people screaming at each other do not spontaneously – at an identical moment – pull back saying, “You know we just need to respect each other’s views, for we are both good people.” I don’t think so.
Angry dyads tend to de-escalate when one of the two people pulls back a little. When one of the two people decreases the push of the attack, when one of the pair softens his or her words, sometimes just a bit, the stalemate often begins to crumble. If one of the people in the couple says with a gentler tone, “You know I still disagree very strongly, but I at least see where you’re coming from,” many times, not always, the other member will reciprocate the softening with, “Well, I still feel I’m right, but I get where you’re coming from a little better too.” At such a moment, frequently the originator of the softening will soften even more in their next comment and the partner, too, will reciprocate.
In short, angry dyads often de-escalate in a seesawing fashion. One person softens the attack, the other reciprocates. The first to soften then softens even more, and the partner once again reciprocates until the argument has cooled, and the therapist has a better shot at getting a word in edgewise. The de-escalation often is initiated solely by one person backing off.
Let us now return to the focus of our chapter, transforming medication nonadherence, for it too is a dyadic process. Nonadherence is a roadblock shared by both people, indeed, often partially co-created. Perhaps the best way to motivate patients to take medications lies less upon focusing on how to change the patient’s beliefs and more on focusing how to change the clinician’s beliefs or the pressure with which these beliefs are being communicated.
According to the MIM, in many cases, a change in the beliefs (or communication style) of only one of the two involved parties, in this case the clinician, is all that is needed to kick-start the transformation into medication adherence. I should note that in actuality – with the seriously ill dually diagnosed patients on our CTT – in many instances we did not change our beliefs. I still felt that a given patient needed a mood stabilizer, antipsychotic, or antidepressant. But what I could always change was how I communicated my beliefs. Equally important, I could also change how I asked my patients about their beliefs.
As clinicians, we have direct control over both our beliefs and how we express them. As the above model suggests, on our original CTT we found that how we phrased our questions and made our suggestions often resulted in a complementary change in how our patients viewed the use of medication. Patients, over time, moved from disinterest to interest, from nonadherence to adherence. What is this change in clinician language?
In a sense, it all comes down to the following interviewing principle: Rather than creating the sensation that we are moving “against them,” we want our patients to feel that we are moving “with them” – that we are a team, not opposing armies. It is a principle that reflects the process of collaborative exploration that sits at the very center of the MIM’s spirit.
We can hold opposing views with our patients without being an opponent, depending upon the words with which we choose to ask our questions and with which we share our beliefs. Our words convey not only meaning. They convey relationship.
In Search of a New Word
The terms compliance and adherence should be abandoned because they subtly exaggerate the importance of clinicians, describe behavior inaccurately, and shed little light on motivations.29
Steiner and Earnest, 2000
As we have discovered, the single most pivotal concept of the medication interest model is to create an atmosphere of “going with” patients as allies against their illnesses as opposed to “going against” them as antagonists to their beliefs. This non-oppositional stance is at the very heart of the model, its spirit, and, as we shall soon see, its name.
Unfortunately, as John Steiner and Mark Earnest note in the above epigram, the most commonly used terms – compliance/noncompliance and adherence/nonadherence tend to set the stage for an oppositional field of communication. They also introduce other distorting perspectives.
One of the major problems with the term “noncompliance” is that it implies that clinicians are the ones who make decisions on treatment and that patients are merely supposed to comply with these decisions. But there is more to the problem, for these words also suggest that clinicians have more control over medication use than they really do in actual clinical practice.
For example, the term compliance seems to suggest that clinicians choose medications, but clinicians do not choose medications. Patients do. And, as the sociologist Peter Conrad pointed out, not only do patients choose which medications they want to take, they decide exactly how they are going to take them, a process Conrad aptly calls the patient’s “medication practice.”30 In the end, he explains, the only medication practices that count are those practices that patients choose to do, not the medication practices that physicians, nurses, and case managers tell them to do.
Another problem with the terms noncompliance and nonadherence is that they are too generic, often yielding an inaccurate picture as to why the patient is not taking a medication. These terms, which can exude a subtly pejorative undertone, are often casually applied, not only to that small percentage of patients who may be purposefully oppositional – perhaps as the result of a personality disorder – but also to patients who forget easily or have other external problems hindering medication follow-through. In a similar fashion, patients who miss a dose twice a week are grouped together as being “noncompliant” with patients who almost never take their medication. The terms are also applied to patients who logically decide that one of the beliefs of the Choice Triad, described below, has not been met.
According to sociologist James Trostle, who was one of the earliest pioneers in challenging the use of words such as “compliance” and “adherence” in his ground-breaking article Medical Compliance as an Ideology,31 various alternative terms have been suggested to replace “noncompliance” and “nonadherence,” such as “defaulting,” “self-regulation,” and “self-management,” with some of the newest being “persistency,” and “reconciliation.” Although researchers have wisely attempted to refine these terms such that “primary nonadherence” indicates a prescription not being filled and “persistency” refers solely to long-term problems with use, none of these new terms seems to have caught on with busy front-line clinicians.
Perhaps the best of the lot – “nonadherence” – is generally the most commonly used in the parlance of today, but I believe it has a distinctly oppositional undertone. At one level, terms such as “adherence” and “persistency” are certainly less oppositional sounding than “noncompliance” and “nonadherence,” but for many clinicians they convey a sterile and cold tone towards the patient/clinician alliance that does not reflect its warmth in actual practice. Even the term “reconciliation” suggests that the clinician and the patient are starting at opposite ends of a belief set and somehow resolve their views. In contrast, the MIM suggests that from the beginning the patient and interviewer are collaborators, starting a joint venture.
Our original CCT was vested in finding a term that was positive in nature and that fit a person-centered view of interviewing. We quickly hit upon the positive term “medication interest.” The term aptly captures the person-centered spirit of the entire model and the philosophy behind it, hence the name medication interest model (MIM). The term medication “interest” emphasizes that the goal of the clinician is not to choose the medication for the patient and subsequently make the patient comply or adhere to it; instead, the term metacommunicates that the task is to help the patient arrive at his or her own choice as reflected by their personal interest. As we have already noted, the patient’s choice might even include the decision to not take the medication in the first place.
The concept of “medication interest” also emphasizes a point well acknowledged by veteran clinicians that one of the main skills of a successful clinician is the ability to teach. In the clinical trenches, the success of a clinician depends directly upon the clinician’s ability to collaboratively explore the three steps of the Choice Triad, which we are about to address, while providing accurate information (teaching) for use by the patient in fashioning his or her own decision.
The case management team from which the model initially evolved found that terms such as “noncompliance,” “nonadherence,” and “resistance” could be easily eliminated from daily treatment planning meetings by using questions such as the following:
1. “How interested is Jim in taking his med?” (followed up with a question that provides a concrete idea of the level of interest such as, “What percentage of the doses do you think he is actually taking?”)
2. “If he was here, how would he list the pros and cons that have led to his low interest?”
3. “Is his low interest related to the first, second, or third step of the Choice Triad?”
4. “Does anybody have any ideas how we could increase his interest?”
At last we have arrived at both a theory and a language with which to better understand our patients’ interest in starting and perhaps continuing with their medications. We can now turn our attention to the art of interviewing itself. It is time to move from theory to practice.
Part 4: The Choice Triad – The Foundation of the MIM
Non-adherence is rational behavior – it is driven by patient beliefs about their treatment, disease, and prognosis as well as their objective experiences with their treatment and disease.32
Colleen A. McHorney, PhD
In our original case management work with the seriously ill, dually diagnosed patients (in which high rates of medication interest and follow-through were eventually achieved) the opportunity arose to frequently ask the patients the following question, “How did you decide to take this medication?” The question was designed to better understand the fashion in which patients contemplate the use of medications and, once using them, whether to stay on them. The hope was that such an understanding would lead to practical hints as to how to phrase the conversation around medications in the most collaborative fashion possible so as to create the sensation of “moving with” the patient. Over the years, as the answers came in from our patients, they seemed to fall into three broad categories.
Interestingly, as I subsequently began providing workshops for mental health professionals and primary care providers, both nationally and internationally, I had the rare opportunity to ask the members of my audience the exact same question, for each and every one of the audience members had been, or was currently, a patient. We may be professional providers, but all of us have been on the other side of the stethoscope as well. All of us have taken medications at some time, from antibiotics and cold capsules to antidepressants, antihypertensives, and oral hypoglycemic agents. These workshops offered a rare opportunity to hear from a large number of patients (possessing excellent communication skills) about how people actually decide whether or not to take a medication and subsequently to stay on it. I always told my audience of professionals, “When answering this question forget about your own patients. I want to know how you, personally, decide to take a medication. Please start your answers with the first-person word ‘I’ as in ‘I take a medication because …’”
The results have been, and still are in my current workshops on using the MIM, remarkably consistent. Physicians, nurses, and other health care providers, both nationally and internationally, tell me that they decide to take medications if the following three broad criteria are met – the exact same three criteria the patients with schizophrenia, schizoaffective disorder, and bipolar disorder from our CTT study with dually diagnosed patients had related. People tend to take medications when they personally arrive at the following three beliefs or steps:
Step 1: They feel there is something wrong from which they personally want relief.
Step 2: They feel motivated to use a medication because they believe it has the potential to bring them relief from the perceived problem (or perhaps prevent a serious future problem as with a vaccine).
Step 3: They believe that the pros of taking the medication outweigh the cons.
Nothing startling here. It appears to be common sense. In all of the workshops I’ve given, I have never met a physician, nurse, clinical pharmacist, physician’s assistant, or case manager who would ever take a medication (outside of “meds” such as vitamins or vaccines) unless they thought there was something wrong and felt motivated to get help with the problem via the use of a medication. I have also never met a clinician who would ever take a medication for which he or she thought the cons outweighed the pros. Why would any intelligent person do so? And so it is with our patients.
By way of illustration, a typical 18-year-old male high school student experiencing his first break of schizophrenia seldom believes that there is something wrong with him (he does not accept Step 1 of the Choice Triad). If a clinician suggests taking an antipsychotic for an illness that this 18-year-old does not believe he is experiencing, it would be rather odd for the student to agree, would it not? Added to that, the clinician must also alert the student that this medication might make his tongue dart in-and-out like a lizard’s for the rest of his life, capping it all off with the following truthful statement, “I might be able to reverse this but I might not.” I believe it would be odd indeed to expect the student to reply, “Awesome Dude. Who wouldn’t want to be permanently disfigured by a drug you want me to take for an illness I don’t even have. Sweet, let’s do it Bro.”
I don’t see why one would expect such an answer. This student genuinely does not believe that there is anything wrong with him. Exactly like ourselves, if we did not feel that there is anything wrong, none of us would take a medication, especially an antipsychotic that could cause tardive dyskinesia (TD) – so why should we expect a patient to do so? I, personally, would never take a medication unless I felt there was something wrong with me.
In this instance, refusing medications is not so much evidence of a person being illogical, as it is evidence of a person being smart. Indeed, if he or she thinks that there is nothing wrong, it is quite illogical to take a medication of any kind, let alone a medication that can cause serious side effects like TD or the neuroleptic malignant syndrome. The student is making the exact same choice that I would make if I shared the same belief. It just so happens that in this case, I don’t.
Once this insight is understood by a prescribing clinician, whether a psychiatrist, nurse clinician, physician assistant, or other prescriber, it is a natural next step for the clinician to develop a genuine respect for the patient’s decision-making process, for it is the same as our own. While I may not necessarily agree with the patient’s database or the resulting decision, I certainly agree with the patient’s logic and I respect the patient’s right to his or her own personal beliefs.
A pioneering piece of research by Colleen McHorney, who provided the epigram at the start of this section, retrospectively provided support for key elements of the Choice Triad. In examining the reasons that 1072 patients stayed on medications or stopped them, McHorney found that the three top reasons were as follows: (1) the patient was convinced or not convinced of the importance of the medication (first and second steps of the Choice Triad), (2) the patient worried that the medication would do more harm than good (third step of the Choice Triad), and (3) it cost too much (one of the specific elements of the third step of the Choice Triad).33 As we had discovered in the 1990s through clinical interviewing, McHorney confirmed through research in the 2000s that “nonadherence” is often a logical choice made by a logical consumer.
As we delineated in our section on the spirit of the MIM, our role becomes not one of making a so-called “resistant” patient become compliant, but of helping a patient with poor information become aware of the information he or she needs to make a wise choice. We become teachers. Our goal is to increase our patients’ genuine interest in trying a medication or staying on it once begun. It has been my experience that once patients decide for themselves that there is something wrong that they want help with, that a medication might provide them that help, and that the pros of the medication outweigh the cons, they are often highly interested in taking medications. People don’t like to be in pain. They will gravitate to whatever they feel will effectively end their pain.
I have also found that – as was the case with myself and my fellow team members on the CTT – once psychiatric residents, psychiatrists, nurse clinicians, care managers, medical students, and nursing students, as well as other health care providers and therapists, truly understand this simple fact – that patients refusing medications are often making the same decision we would make if we shared the same belief set – it is rather remarkable how deeply it changes their attitudes towards so-called “resistant” patients. More importantly, it changes how these providers come across to their patients, both verbally and nonverbally, often disrupting a troublesome atmosphere of potential patient/clinician opposition before it can become a problem. Instead, this potentially oppositional dynamic is replaced with an evolving patient/clinician medication alliance based upon the collaborative exploration that drives the spirit of the MIM.
I am, once again, reminded of a great quote by Armond Nicholi, Jr., that we noted earlier in our book but is well worth repeating here:
whether the patient is young or old, neatly groomed or disheveled, outgoing or withdrawn, articulate, highly integrated or totally disintegrated, of high or low socioeconomic status, the skilled clinician realizes that the patient, as a fellow human being, is considerably more like himself than he is different …34
From the perspective of the MIM, and from our understanding of the Choice Triad, concerns that a patient has about medications, the unilateral changing of how a patient is taking their medications, and a patient’s discontinuation of medications is not viewed, with few exceptions, as oppositional behavior. Instead, it is viewed as logical behavior based upon the fact that the patient does not believe one of the three steps of the Choice Triad. We do not take medications unless we believe these three steps. I see no reason why we would expect a patient to do so.
Interestingly, even if the 18-year-old from the above illustration had testily responded to our suggestion with, “I don’t need your medication. I don’t want your medication. I’m not going to take your medication. And I’m about to tell you where you can put your medication [and he is not referring to a medicine cabinet here],” we would still not view it as oppositional behavior from the framework of the MIM. He is simply angrily responding to what he feels is interpersonal pressure to take a medication that is patently inappropriate for him to take, for there is nothing wrong with him, therefore it cannot help him, and it has remarkably dangerous side effects. No wonder he is angry. Moreover, if this is the first meeting of the patient with this prescriber, he will most likely see little reason to trust this person in future meetings, if indeed there ever is a future meeting.
From the perspective of the MIM, the term “oppositional” is used in a specific manner. A person is viewed as being oppositional if they are disagreeing with the clinician on purpose because the patient wants to anger or hurt the clinician. An oppositional patient will refuse to cooperate even if he or she agrees with the clinician’s recommendations, in this case to begin a medication. This is certainly not the case with the student above who genuinely feels that there is nothing wrong with him.
Oppositional refusal of medications sometimes occurs within the context of problematic personality dysfunction such as seen with borderline or passive-aggressive dysfunction, but, in my opinion, such oppositional behavior is a relatively infrequent cause of low medication interest or poor medication follow-through. In contrast, most people who choose against using medications do so because they do not believe one of the steps of the Choice Triad.
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