Disagreements In Treatment
One of the biggest struggles in mental health is helping people stay with treatment. Several psychiatric conditions can impact people’s self awareness; these include bipolar disorder, mania, psychosis, addiction and memory disorders. When this happens, people may even lose awareness of the need for treatment (called non-adherence), which often causes conflict in the family. In contrast, people are usually painfully self-aware during depression and anxiety, and motivated to get help.
Non-adherence is a common problem which has many causes. For example, 50% of people with bipolar disorder stop treatment or miss a significant amount of their medication. It is often difficult to bring about change when the problem is due to self-awareness. Conversation and argument usually don’t help, and may even make people less flexible.
If you find yourself in this situation, the most important thing you can do is understand it. From that place, you can develop the “wisdom to know the difference” between what you can – and can’t – change. This is a delicate situation to be in – and trying to change things that you can’t usually makes the problem worse for both you and your relative. Below is a list of important ideas to guide you through this time:
Focus on the long-term
Remember that non-adherence occurs 50% of the time; if we can lower it to 30% that’s a major success. The most reliable way to get there is through collaborative care, which encourages people to take an active role in their treatment decisions. Sometimes they may make mistakes; the hope is they will learn from those. If they view treatment as a voluntary, collaborative process, they are more likely to take responsibility for mistakes that happen and come back to treatment when things go wrong. For this reason, it’s better to have the goal be collaboration rather than 100% adherence.
Sometimes it is tempting to improve adherence by linking it to external rewards, such as housing, use of a car, or financial support. This is a delicate area which is best handled through open discussion with your relative and the treatment team. The downside of this approach is that patients may shift to total non-adherence after the external structures are removed. On the other hand, there may be situations where it is the only reasonable possibility.
See the non-adherence in perspective
Non-adherence is usually not an all or nothing situation. Even the most dedicated patients miss doses of medication. Sometimes people may refuse medication but continue to do other things to improve their mental health, such as visiting their doctor or therapist, taking supplements or vitamins to improve mental health, and doing things to improve sleep and stress management. Try to focus your mind on the ways that your relative is adherent rather than non-adherent – this may seem paradoxical, but it tends to lead to more progress.
Focus on the person, not the illness
When self-awareness causes conflict, therapists recommend that relatives focus on the positive aspects of the person rather than the negative. This tends to reduce conflict, reduce stress, and reward those positive traits in ways that helps them grow. Keep in mind – the thing you shine a light on, or pay attention to – is what tends to grow.
Keep tough conversations short and focused
Tough conversation are those which bring up conflict. The problem with these are that conditions which impact self-awareness can also:
1) Impair verbal abilities, making it difficult to take in and process information
2) Cause reactive emotions, so they may become “hot-headed” or inflexibly stubborn
3) Impair the brain’s ability to read faces, so they may react to you in ways you didn’t intend
4) These conditions may get worse with too much conflict
If you can’t avoid tough conversations, try to keep them brief and focused. Don’t have them when emotions are intense, and if either of you become upset during the conversation it’s best to end it. Ask your relative if they’d rather you write down your concerns (some people find it easier to take in information in that form). Once you have said your peace (hopefully in a planned, calm time), don’t keep repeating it each day. Remember that tough conversations can worsen mood if they occur too frequently. Remember that the problems you are facing are not easy; if they don’t change after a few conversations they may get worse – not better – with repeated attempts.
Don’t try to be their doctor
It’s usually best to stay out of the role of doctor or therapist if you are the relative. That can seriously back-fire for a number of reasons
1) Your relative may automatically discount your advice because you’re not their doctor.
2) If your advice is similar to their doctor’s advice, they may start to see their doctor as taking your side and may discount their doctor’s advice.
3) It goes against the prior message, of seeing the “person, not the illness.”
On the other hand, your observations of the symptoms may be necessary for their doctor to know. Self-awareness often limits patients abilities to describe their symptoms accurately. Keep in mind a few points when sharing information with their doctor:
1) Understand that their doctor is ethically obliged to share what you’ve told them with the patient. There may be exceptions to this, such as emergency, but generally treatment will go best if secrets are not kept.
2) It’s best to come to your relative’s appointment to share the information. That way the doctor can use it to help develop a treatment plan. During the appointment, limit your statements to brief descriptions and keep your tone unemotional. You can also write them down or use the rating scales we have online (www.moodtreatmentcenter.com, click “Forms”) to gather your observations.
3) If your relative doesn’t allow you to come to the appointment, you can still send a written note to the doctor. While this is helpful, it often doesn’t lead to progress though because your relative is likely to disagree with your statement and refuse any treatments that arise out of it.
Much of the advice above is written for situations in which a patient is refusing treatment but is not having an emergency. I call that situation “the gray area” – it’s hard on the family, but little can be done because treatment has to proceed on a voluntary basis. In the following situations, involuntary treatment may be necessary:
1) When the illness causes a serious, imminent threat to safety of self or others.
2) When the illness causes a person to be “gravely disabled” and unable to function on their own (e.g. they would not be able to go out in public or take care of themselves on their own).
Involuntary treatment occurs through hospitalization. This process can be initiated by a relative by going to the clerk of superior court (usually open 24/7 at your local courthouse) and completing a form. That form allows the police to bring your relative for evaluation at an emergency room, and it would then be up to those clinicians to decide if hospitalization is necessary. Alternatively, you can also call the police (911) to intervene immediately (e.g. if there is violence in the home), but this usually does not succeed because the police cannot take people to the hospital unless they continue to be violent when the police arrive (which is rare) or the form has been completed. Involuntary commitment can also be initiated by your relative’s physician if they are able to come to an office visit.
An even better solution is for a mental health team to come to your house to assess the situation. In Forsyth county, the number for this is (888) 581-9988 or (336) 607 - 8523 Ext: 147. Contacts for other services, and local hospitals, are available on our web site at: www.moodtreatmentcenter.com/crisis.htm
We also offer emergency appointments, and crisis-stabilization services, and our office; call (336) 722-7266 to see if these appointments would meet your needs.
Medication options to improve adherence
Some medications (e.g. antipsychotics and a few treatments for addiction) are available in long-acting, injectable forms which can be given every 2-4 weeks. Some patients prefer the injections because they don’t have to think about taking a medicine each day, but injections still require their consent and cooperation. There are also a two medications (the antidepressant prozac and the antipsychotic/mood stabilizer abilify) which last a long time when taken by mouth; these may be prescribed in ways that would allow for missed doses.
Psychotherapy for adherence
There are a few therapies which have been developed to improve people’s self-awareness and adherence. These include motivational interviewing, psychoeducation group for bipolar, interpersonal-social rhythm therapy for bipolar. In these therapies, people learn more about their condition and what they can do to improve it. They also engage in exercises which are designed to improve their own awareness of the problem. These therapies are offered at our center.
If your relative won’t agree to therapy or medication, another option is family therapy. This may be a good place to start, especially if they are convinced that you are the problem. It’s helpful to have a neutral person who is knowledgeable about mental illness hear both sides out and try to reduce conflict. Keep in mind that in these sessions the therapist is unlikely to tell your relative to get into treatment, because that would only backfire unless they were open to hearing it. They will work to reduce conflict, to improve your own management of the situation, and to improve your relative’s self awareness as much as possible.
Lastly, if family therapy is not an option it is best for you to come to therapy alone so you can develop a more effective plan for managing the conflict. It’s best to take on that work with a therapist who is not (or was not) your relative’s therapist. Otherwise your relative may not return to treatment because they associate their therapist with your agenda.
—Updated 4/5/14 by Chris Aiken, MD
Bipolar Care Givers.org a site for family