How to Achieve Medication Compliance

By Dr David Laing Dawson

Anosognosia is an unwieldy word meaning lack of insight, or, literally in translation, `without- disease- knowledge`.  In the case of some brain injuries or stroke the brain may become quite specifically unaware of what is missing. The part of the brain that would perceive this is damaged. With mental illness, schizophrenia, bipolar, the apparent lack of insight  or denial of obvious impairment or implausible grandiosity may be more nuanced and variable. It may be part defensive in nature; it may be more a denial of the consequences imagined; it may be more about the power relationship at hand. Some of it may be merely human, the unwillingness to give up a longstanding belief, whether that be of the second coming,  CIA surveillance and persecution, or of being chosen, special, destined for greatness.  Some of it may be a distorted form of the normally complex parent – adult child relationship.

But almost every family with a severely mentally ill member must deal with, at least once, that time when the ill member claims to be fine when obviously not, and refuses to take medication or go for an appointment to the doctor.

How to approach this. What options do you have. Below is an outline for talks I have given on the subject:

Stage 1

  • Calm and slow
  • Non-threatening (posture, position (e.g. side by side), distance, tone, pace)
  • Aim for a negotiated reality. (not the acceptance of your reality)
  • i.e. He may not be willing to admit he is ill or delusional or needs medication but may be willing to agree that he is in trouble, anxious, not well, in pain, not sleeping, and that in the past the pills have helped with that. He may by his behavior be willing to take pills or come for an appointment as long as he doesn’t have to admit to need or illness.
  • Gently find out what he or she fears.
  • Gently find out what his objections are.
  • Allay these objections and seek a “negotiated reality”.
  • Stay away from labels, declarations, and you defining his reality.
  • Offer pill with glass of water without saying anything.

Stage 2

Family intervention, same tactics as above but with whole family or available members, or a specific family member with influence.

Stage 3

Ultimatums. (You can`t live here unless…..)

But before doing this you should assess the level of risk (provoking violence, and/or leaving and putting self at risk). Discuss in family plus with a professional. Must also assess realistically your tolerance for confrontation, anxiety, worry, guilt. And ultimatums are only effective if truly meant, if you are truly willing to carry through with the ultimatum. If the ultimatum works, do not reiterate it unnecessarily.

Stage 4.

Form 1, J.P., Court order, Police intervention.

Before doing this decide on desired outcome, assess odds of achieving this desired outcome as best as possible (i.e. is there a treatment that works? Will they keep him or her long enough? Does the trauma of this kind of intervention justify the long-term outcome?)

Having decided on desired outcome, use all resources to achieve this. Learn the wording of the Mental Health act to get desired outcome. Use this wording to your advantage. Find family mental health friendly lawyer. Discuss with the health professionals who will be receiving the family member.

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8 thoughts on “How to Achieve Medication Compliance

  1. Everything here is very good advice . Perhaps the most difficult thing to accomplish is a safe and effective landing when using the applicable sections of the Mental Health . Often the family is so disturbed during such times that they even appear to be the ill ones, while the patient has the upper hand and can cover up a thought disorder and appear calm. family and patient have a lot at stake !

    Having helped to attain a justice of the Peace order many times to enable families to access necessary care and treatment. The job is hard, and can fail sometimes However, timing in my view is everything and remaining as calm as possible is a must . It requires the patience of Job. One of the things that I have found useful was giving the police notice that an order was likely to happen within a certain time frame and also letting the Emergency Department and appropriate staff on board that this was likely coming up. The police are often busy and they can appreciate forewarning. Sometimes families are not appreciating that the order does not have to be executed straight away and timing again is crucial.

    The success of accessing appropriate help often depends on the skill of the staff on duty and their willingness to take in some details about the predicament of the patient. Families should remember that they can give input though the system even though the system cannot give them information unless the patient/ill person permits the family to know. However some skills around this will enable staff to read the situation correctly. After all that should know that a patient can often fool the system when the staff is ill informed about psychotic illnesses. I have seen the emergency ward send a patient brought in by the police on a JP order sent packing immediately without a psychiatric examination. But the system was challenged for inappropriate response to the order. It should be as it would be with a diabetic patient in a crisis.

    Persuasion is a good first tactic, but with a very frightened or paranoid individual it is alas not always successful. P.s i have known some individuals challenge many times before a review board to avoid essential treatment. One did so 9 times but was in the end successfully treated. never give up !

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    1. Thank you Jane. I have always admired the courage that so many families show when they have to do this immensely hard thing. I have also admired many psychotic persons trapped in their illness. But I have also seen many of those people later show thanks about the help they eventually received. They suffer so much when they are tortured by symptoms. I learned so much from patients who related how awful it was to be trapped.

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  2. Excellent article and excellent commentary! My loved one was adamant that he did not need or want a doctor. We called 911 and he challenged the police, as he had studied law. It was only when the police, under our advice, told him that he could not return to our house that day, that he went to hospital in the ambulance. Even then, he casually started to walk out the front door of Emergency, and if we hadn’t been sitting in the waiting room he would have vanished! No one was watching him. He was made involuntary and received a 30day certificate followed by two more hospitalization in short order, but that marked the beginning of a wonderful 7 year period of stability and recovery. It was the hardest thing I have ever done, telling him he could not come back to our house. I still feel guilt sometimes, but at the same time, I know that if we had not confronted him and drawn a line in the sand, he might never have received treatment. Unfortunately since then he has relapsed and I dont think he is adhering to the medications prescribed for him. I am gathering my strength for another confrontation.🙁

    I am glad that BC seem willing to keep seriously ill people in hospital. Ontario does not. They almost seem incented to get rid of as many patients as they can, and the mentally ill are an easy target.

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    1. I was in Toronto for a three days last week. There were people all over the place sleeping on frigidly cold sidewalks in high end districts. the tell tale plastic bags in carts and odd bits of bedding barely covering muttering people. Last Thursday was particularly noticeable in this regard. This Sunday morning I Witnessed someone who was so psychotic yelling at the tops of building as he reacted to his hallucinations ….voices and likely visions. He did this for several blocks People looked around the, to wonder if they were safe. Some including me wanted to flee. WHAT IS GOING ON WITH THE SO CALLED SYSTEM? Alas, Ontario is a disgrace and and will not easily be righted. All this while the Mental Health Commission talks niceties. families need an Act that helped them get help for their loved ones her in affluent Ontario. Where is kindness. I spent three decades of my life pleading for an improved mental health care system. It has become fancier but not in the least bit better

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  3. Vancouver is no better than Toronto – probably worse. The Mental Health Commission with it’s focus on mental wellness, mental wealth, mental well-being, etc., has neglected and abandoned citizens suffering from serious mental illness. People with chronic psychotic disorders are not included in their “recovery model” – which is why the BC Schizophrenia Society has refused to endorse it,

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  4. I am troubled by the pernicious spread of the Trauma Informed Care (TIC) movement in the U.S. Oh, that has a lot of folks duped. I just exchanged ‘pleasantries’ with a follow advocate on the topic and he takes the expression at face value…with all of his sterling credentials (Phd). I find it to be a mask for something more pernicious, a umpteenth iteration of a type of Freudian beliefs, that being psychosis caused by external forces/the abusive jerks in one’s family. So, not in the mood to hear any suggestion that Anosognosia is a psychological phenom.

    I do not believe that Anosognosia is denial or a psychological defense…not at all. I have see it up close and there is a flattened, unidimensional state of consciousness going on. Anosognosia in serious mental illness translates to not being aware that thoughts and behaviors are disordered…I like to spell it out that way instead of stating the definition.

    I just learned about Power Threat Meaning Framework (PTMF) launched across the pond. We’ve got our TIC and They’ve got their PTMF – The war on the biological basis rages on.

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