Tag Archives: medication compliance

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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About That Ladder of Scientific Progress – Reminscences of a Psychiatrist

By Dr David Laing Dawson

stone of madnessIn 1971, before my own son was born, a seventeen year old boy left his family home in Ontario, and traveled to the southern United States with his guitar and little else. This young man, Derek, dressed in a robe and sought out an audience for his message of peace and love. He was hospitalized there, his parents contacted, and they drove down to bring him home. Back in Ontario they brought him to the new Community Psychiatry Program at the Medical Center. This was the Thursday before the Easter Holiday weekend. The young man, fully alert and full of energy, was convinced that he had been appointed by God to deliver these messages. But he didn’t want my medication, and he did not want to be admitted to hospital. His parents agreed to take him home and bring him back for a second visit the following week.

This family went to church on Easter Sunday, and to everybody’s dismay, the young man jumped to his feet, interrupted the Priest, and began a loud, rambling sermon of his own. An ambulance was called and he was taken to hospital. His response to medication was good, and when well, he proved to be a bright, engaging, sensitive, smart young man, capable of succeeding in College and life. But he did not like taking the medication. He preferred, quite understandably, the sensation of invulnerability, of energy, of warmth and possibility, of certainty, that accompanies a state of hypomania and delusions of grandeur. He remained my patient for five years, and I struggled with him to find a pharmacology that would keep him sane without taking away his enthusiasm. He often stopped the pills, became ill, and then reluctantly agreed to try again.

After five years I moved to head a different clinic in another part of town, and then out of town, and then five years later, back to town. I had lost track of Derek, and now my own son was that age, seventeen, and I was driving him to something. I think it was October and the leaves were changing on Aberdeen, a wide road of old and stately houses, some of which had been converted to group homes. We slowed at a busy corner, and on that corner a bearded man with unruly hair and disheveled clothing stood, paced, gesticulated and shouted at imagined specters or people in the street, in the clouds, and in the trees. It was unmistakably Derek, now in his mid 30’s.

“Shit.” I said.

“What’s wrong?” asked my son.

“That man,” I explained. “He was my patient years ago, when he was your age.”

He looked at the psychotic man raving at invisible targets. “Dad,” he said, “It’s not your fault.”

Ahh, yes. I remember that moment because of the heart-warming display of empathy and understanding coming from my teenage son.

But really, we did fail Derek, didn’t we?