Treatment Compliance in Mental Health Practice

Transcription

1 Treatment Compliance in Mental Health Practice 1 CE Hour By: Kathryn Brohl, MA, LMFT Scope of practice Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules. Learning objectives Identify causes for low client treatment compliance. Identify methods to increase client treatment compliance. Understand how certain diagnoses can have an effect on client treatment compliance. Introduction Treatment compliance is one of the most important issues in the mental health profession. For example: Up to 90 percent of persons in outpatient care make errors in taking their medications. 33 percent of hospital admissions for heart failure can be traced to treatment protocol noncompliance. Antidepressants have a 65 percent noncompliance rate and anti-psychotics have a 58 percent noncompliance rate for clients not taking their medication as prescribed. 40 percent of all re-hospitalizations for those clients diagnosed with schizophrenia are due to medication noncompliance. After a hospitalization, 65 percent fail to attend scheduled or reschedule initial outpatient mental health appointments. These statistics indicate that treatment compliance is a major barrier to treating mental health clients. Consider these two examples of client noncompliance in mental health treatment: As Jake, a licensed mental health counselor, concludes their psychotherapy session he states, Mr. Bedlam, it appears that you are still experiencing symptoms of euphoria. As you are aware, euphoria is a symptom of your bipolar condition. Mr. Bedlam denies he is euphoric. Instead, he states, he is in a fantastic mood due to his new job promotion and pay raise. After congratulating Mr. Bedlam, Jake continues by saying that, while he (Jake) is not a physician, Mr. Bedlam might possibly benefit from increasing his medication. Mr. Bedlam angrily leaves the session without scheduling any further appointments. Clinical social work supervision is defined in the Education Law and Commissioner s Regulations. Only an LCSW, licensed psychologist or psychiatrist may supervise an LMSW. An LMSW may not employ a supervisor; the supervisor must be the employer of the LMSW or the supervisor and LMSW must be employed by the same agency with the LMSW treating the supervisor s clients under supervision. A LMSW who practices without supervision or an LCSW, licensed psychologist or psychiatrist who fails to provide appropriate supervision may be charged with unprofessional conduct under the Education Law and Regents Rules. Understand the ethical issues associated with client treatment compliance. Betty is approached by Chris, the crisis stabilization unit (CSU) licensed clinical social worker, who says Good morning Betty, we re letting you go today. Here is a bus pass to get back home (a homeless shelter) and your medication prescription. Also, here is a number to call to make your appointment to see the outpatient psychiatrist for your medication management follow-up. Betty passively takes the information and bus pass. Walking out of the CSU she puts the bus pass in her pocket, throws the follow-up information and prescription on the ground, and becomes confused about what bus to take back to the shelter. These two examples help to demonstrate some of the challenges that clients and mental health professionals encounter when considering treatment compliance. In the first scenario, there is a breakdown in communication between the clinician and client. The client is not planning on scheduling another appointment. In the second scenario, the client s basic needs were not taken into account when prescribing follow-up treatment. Case management to provide linkages to community resources and follow-up to facilitate treatment compliance would have helped Betty fill her prescription and follow-up in order to schedule her appointment. The scenarios reflect common treatment compliance issues. How can mental health professionals address treatment compliance with their clients in order to ensure a successful treatment outcome? This question will be explored in this course, in addition to ethical issues related to treatment compliance. SocialWork.EliteCME.com Page 1

2 Definition of treatment compliance Treatment compliance is the extent to which the client s behavior regarding taking medication, following diets or making lifestyle changes adheres to a clinical treatment prescription. Compliance with appropriate, recommended and prescribed mental health treatments simply means that the client is following a doctor s orders. This, of course, includes psychotherapy, support groups and the prescribed medication protocol. Treatment compliance can be measured by successful completion of treatment, attendance at scheduled appointments (support groups, medication management, and individual/family therapy), pharmacological compliance, and treatment participation. In common usage, the term compliance means deference and obedience in elevating the authority of medical expertise. The terms obedience and deference can spark ethical concerns for both the client and mental health professional. Ethical issues Here are some questions to ponder when considering ethical issues concerning client treatment compliance: When do client rights supersede forced treatment compliance when they are not taking their medication? How do mental health professionals deal with client empowerment vs. treatment compliance? How do mental health professionals deal with clients who run out of insurance but are compliant with other aspects of treatment? When do client rights supersede forced treatment compliance when they are not taking their medication? When a client is a danger to him- or herself or others, treatment can be forced in regard to medical interventions and hospitalization, especially when psychotropic medications are necessary for stabilization. Once the client has stabilized and his/her rights are restored, can he/she then refuse treatment? Numerous client advocacy groups feel the answer is a resounding YES. When their rights are restored, clients can and should choose to continue or not continue with treatment. For example, in the state of Florida, Florida Statute (3), (a) indicates that clients have the right to revoke their consent for treatment even during hospitalization for mental health stabilization. How do mental health professionals deal with client empowerment vs. treatment compliance? Mental health professionals must rely on their mental health associations or state licensing boards specific Code of Ethics for guidance in many of the ethical dilemmas. For example, according to the American Mental Health Association s Code of Ethics, the client does have the right to continue or discontinue treatment. Therefore, the choice of treatment compliance rests on the shoulders of the client. Other groups, including the National Alliance on Mental Illness (NAMI), stress empowering the client to take an active role in the course of treatment. The mental health professional, however, plays an active role in the client s decision regarding the issue of treatment compliance by explaining the benefits of compliance to the client and discussing any other issues that may arise regarding barriers in achieving the successful completion of treatment. (Methods used by the mental health professional to increase a client s treatment compliance will be further discussed in this course.) How do mental health professionals deal with clients who run out of insurance but are compliant with other aspects of treatment? The American Mental Health Association s Code of Ethics also states that it is appropriate to discontinue treatment when a client is no longer able to pay for these services. According to its code of ethics, mental health professionals should clearly explain prior to the beginning of treatment all financial arrangements related to the services provided. With guidance from the mental health professional, the client needs to view payment for and investment in treatment services as a very significant aspect of treatment compliance. Client rights, empowerment of clients, and payment for services provided by the mental health professional are but a few ethical issues that can arise and need to be taken into account when viewing treatment compliance. Professional association codes of ethics are very helpful when mental health professionals navigate through the ethics of treatment compliance. Informed consent Informed consent and treatment compliance go hand in hand when obtaining the client s agreement for a recommended treatment protocol. The client should be informed regarding aspects of what to expect in treatment. The following areas should be fully discussed and agreed upon by the client prior to the initiation of therapeutic treatment: Possible risk or discomfort that may arise during treatment. Benefits of treatment. Page 2 Treatment alternatives. Client s refusal to continue treatment can occur at any time. Payment procedures and financial agreements between client and clinician. Possible reasons for discontinuing treatment by the clinician. It is the role of the mental health practitioner to set ground rules for treatment. When the client understands what to SocialWork.EliteCME.com

3 expect during treatment, he or she in general becomes a more willing participant causing increased treatment compliance. The chance of noncompliance increases when the client is not fully informed. The process of obtaining informed consent can help to create rapport between the client and the mental health professional by building trust and understanding expectations on the part of both the client and clinician. Informed consent should not be thought of as a one-time occurrence that needs to be documented only prior to beginning treatment. As the client and mental health professional progress through various treatment protocols, such as hypnotherapy, benefits of treatment, risks or discomfort and treatment alternatives may change. If any of these areas change, the client must be kept informed. Therefore, informed consent is an ongoing process that can change as the client changes in the course of treatment. Keeping the client well informed during all aspects of treatment will also have a positive effect on increasing the client s treatment compliance. Effect on treatment compliance of client diagnosis There is a significant body of research that indicates the more severe the client s diagnosis, the smaller the chance of treatment compliance. Therefore, specific diagnoses can be viewed as risk factors when determining prognosis for treatment compliance. For example, clients who are diagnosed with major depression have a three times greater chance of being noncompliant with medication treatment. Clients diagnosed with schizophrenia, bipolar disorder, major depression, or anti-social personality disorder possibly coupled with co-occurring mental health and substance abuse diagnoses demonstrate decreased treatment compliance. These clients have poor treatment compliance primarily due to the existence of multiple issues surrounding them. The issues can include lack of an adequate support system, lack of adequate income and even lack of food, clothing and housing. Medication and treatment compliance Primary care physicians provide the majority of mental health medication management in the United States. Compliance with taking psychotropic medications prescribed by a psychiatrist or family practitioner is a large area of concern. Medication side effects dominate the reasons given for noncompliance. For instance, psychotropic medications can cause weight gain, sexual dysfunction, fatigue, dry mouth, blurry vision, urinary retention, or muscle rigidity. Other side effects may be less subtle and include the fear of being labeled crazy. Irrational fears about the use of medications can also contribute to the client s unwillingness to comply with prescribed medication treatment. Many of the medications used to treat severe mental illness such as schizophrenia require prescribing other medications to treat the side effects caused by the psychotropic drugs. Other issues that negatively effect treatment compliance There are other factors that may impact client treatment compliance. One of the most significant concerns the therapeutic relationship between the client and mental health professional. If the client does not feel comfortable with the clinician, chances of the client s treatment compliance diminish. Consequently, lack of rapport with one s mental health professional is one of the major reasons given by clients for treatment noncompliance. Additional reasons include the following: Cultural issues that lead to mistrust of the mental health professional by the client. Some cultures frown upon women assuming dominant roles in the mental health profession. And, due to family values or education, the client may feel ashamed of needing mental health intervention or medication management. The client may not believe in psychotherapy and/or medication as a means to feeling better. The type of therapy used by the mental health professional may not reach the client or appropriately address the client s needs. The client may be overwhelmed by all of the suggested areas of change that need to be addressed in therapy with the mental health professional. A lack of an adequate support system can negatively impact a client s treatment compliance. If the client s support system does not approve of the client seeking treatment or is negatively impacted in any way, a client may have difficulty with treatment compliance. This is often the case when addressing co-occurring mental health and substance abuse issues, especially when a member of the person s support system continues to abuse substances. If the client relies on someone or something to provide transportation to and from appointments. Some clients may actually feel that the benefits of their symptoms supersede addressing them through medication and/or psychotherapy. The manic high may be conducive to spurts of creativity and euphoria. To suggest taking those feelings away, especially if rewarded by the client s family or work environment, can be a difficult task for the most seasoned mental health professional. If the client does not have the mental or intellectual capacity to understand the benefits from individual therapy and/ or medication management, treatment compliance can be SocialWork.EliteCME.com Page 3

4 in jeopardy. The client s impaired judgment due to mental illness can again affect treatment compliance. The client may not be able to afford proper medical care or may have several unmet primary needs such as food, clothing, shelter, transportation or financial stability. Legal issues such as court hearings may need to be addressed by the client prior to the beginning of therapy as well. A client s age can affect treatment compliance. For example, young adults have a higher rate of noncompliance with treatment. Gender can have an impact on noncompliance. Men have a higher rate of treatment noncompliance than woman. Unmarried people have a higher rate of noncompliance than married people. The impact of insurance companies has an effect on treatment compliance issues. Clients may need to discontinue treatment due to predetermined treatment caps or may not be able to take certain prescribed medications due to the medication not appearing on the approved drug formularies for a specific insurance company. Red flags of non-compliance Red flags are those indicators that can be used to aid the mental health professional gauge treatment compliance and whether the client will follow through. One of the often-used methods to detect treatment compliance is client self-report. The client s opinion of treatment progress and how he/she feels affects the decision to continue with treatment. If a client does not feel that he/she is gaining anything from treatment or that treatment is a burden, the likelihood of him or her staying with treatment is questionable. A client s family may have a negative effect on the client s treatment compliance by not being supportive, specifically if the family continues to support a lifestyle in direct contrast to the prescribed treatment. A red flag should be raised if, during the initial phase of therapy, the client does not ask any questions or seems disinterested or detached as to what to expect in the course of treatment. If a client continually does not show up for scheduled appointments or is always late for a therapy appointment, it is a blatant red flag. Methods that increase treatment compliance The following are some effective methods to increase treatment compliance: Treating the client with both medication and individual therapy at the same time. Traveling no more then 30 minutes to an appointment. Including the client s support system in therapy. Educating the client regarding treatment outcomes. Educating the client regarding the benefits of therapy. Building a therapeutic alliance. Including the client in the decisions regarding the course of treatment. Using therapy that reflects the client s needs. Having the appropriate understanding about his/her client. Not making a client wait to see a mental health professional. Other factors include: Stability and vulnerability of the client. Cultural competency on the part of the mental health professional. Clients, in general, want to feel comfortable with both their course of treatment and their therapist. Studies indicate that for clients who require medication, treatment compliance increases when paired with individual therapy. To increase their comfort level, clients should be educated regarding the benefits of therapy specifically related to the problem that brought the client into therapy and/or positive treatment outcome, such as the decrease of symptoms. Successful treatment compliance measures Some of the best indicators of successful treatment compliance include: Regular attendance at scheduled appointments. Being on time for scheduled appointments. Taking medications as prescribed. Active participation in treatment. Reduction in hospitalization or re-hospitalization. Reduction in crisis episodes. Client s improved ability to function at work, home and in other social environments. A client s ability to function in his/her environment is one of the most important measures of successful treatment compliance and outcomes of treatment. Reduction in hospitalizations or rehospitalizations, also known as recidivism, is another measure to determine program effectiveness and treatment compliance on the part of the client. Active participation on the part of the client during therapy can be observed and documented by the mental health professional and used to monitor the client s course of treatment. Finally, mental health professionals can measure clients attendance at scheduled appointments as well as whether they are on time for them. Conclusion Treatment compliance is the extent to which a client adheres to a specified treatment prescription. Many factors influence a client s treatment compliance, such as diagnosis, therapeutic relationship between the client and mental health professional, family support, and the client s intellectual capacity. Page 4 SocialWork.EliteCME.com

5 Mental health professionals should rely on their professional associations and/or state licensing code of ethics when dealing with a variety of treatment compliance issues. Methods to increase a client s treatment compliance consist of building rapport and keeping the client informed regarding what to expect during treatment as well as the benefits of treatment. With the client s consent, the client s family may be engaged during the course of treatment to support treatment compliance. A shorter travel time to the service provider and not waiting to get an appointment or not experiencing a long wait between scheduled appointments can improve treatment compliance. In addition, there are different standard methods used to measure a client s treatment compliance, such as a reduction in hospitalizations or re-hospitalizations, showing up for scheduled appointments and taking medications as prescribed. Bibliography American Mental Health Counselors Association. (2004). Retrieved September 23, 2007, from Compliance. (2007). In Encyclopedia of Medical Disorders (pp. 1-5). Advameg Inc. Retrieved June 22, 2007, from Edlund, M. J., Wang, P. S., Berglund, P. A., Katz, S. J., Lin, E., & Kessler, R. C. (2002). Dropping Out of Mental Health Treatment: Patterns and Predictors Among Epidemiological Survey Respondents in the United States and Ontario. American Journal of Psychiatry, 159, Gonzalez, J., Williams Jr, J. W., Noel, P. H., & Lee, S. (2005). Adherence to Mental Health Treatment in a Primary Care Clinic. Journal of Board Family Practice, 18, Retrieved October 10, 2007, from Montoya, I. D. (2006). Treatment Compliance in Patients With Co-Occurring Mental Illness and Substance Abuse. Psychiatric Times, 15, 1-8. Retrieved June 8, 2007, from TREATMENT COMPLIANCE IN MENTAL HEALTH PRACTICE Final Examination Questions Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination. 1. Compliance with appropriate, recommended and prescribed mental health treatments simply means that the client is following: a. A special diet. b. A doctor s orders. c. A specific exercise plan. d. A friend s advice. 2. Informed consent should be documented prior to beginning treatment and is: a. A one-time occurrence for compliance purposes. b. An annual occurrence to document treatment changes for compliance. c. A biennial occurrence to document treatment changes for compliance. d. An ongoing process that can change in the course of treatment and must be documented for compliance. 4. One of the most common used methods to detect treatment compliance is client self-report. a. True. b. False. 5. One of the best indicators of successful treatment compliance is: a. Regular attendance at scheduled appointments. b. Decrease in crisis episodes. c. The client s ability to function at work, home and in other social environments. d. All the above. 3. Which of the following dominates the reasons given for treatment non-compliance? a. The lack of rapport between the client and the mental health professional. b. The side effects of the medications prescribed for the client. c. A lack of adequate family support. d. The client s inability to pay for the service. SWNY01TC15 SocialWork.EliteCME.com Page 5