Angela has been spending a fair bit of time with Sam in recent months. She is a 29-year-old single mother with one child. She studies part-time at the local university and has managed to maintain acceptable grades. She has bipolar disorder that has been well managed with medication, in different combinations at different points in her illness. However, over the last month she has intermittently missed doses and is consequently becoming unwell. It is puzzling that she is missing doses because she is very attached to her child and last time she stopped medication her daughter was placed in care. The following information was obtained from her in order to undertake a functional analysis.

Financially, Angela was managing well on her supporting parent benefit and the maintenance paid by the father of her child. However, her former partner was sent to jail 3 months ago and the maintenance money he was sending her dried up. As a consequence, she started falling behind in some bills about 8 weeks ago. She has told you that this worries her. On top of this, her daughter started experiencing stomach aches last week and is cranky most of the time. Angela has said that she thinks that her daughter may be lactose intolerant and believes that her local GP did not take her concerns about her daughter’s distress seriously enough when she took her to see him 10 days ago.

Since becoming involved with Sam, Angela has struggled to keep a routine for her and her daughter and she says she forgets her medication from time to time. Sometimes Angela loses interest in sex and she thinks that her medication might reduce her libido.

Angela has never received much help from her family because they don’t agree with her diagnosis. He father says that she is just an attention getter and that she puts it on. He says that is why she cut herself when she was a teenager. Her father states that if she just stopped ’boozing’ she wouldn’t be so down and need the medication. Angela disagrees, stating that she has been drinking to help her sleep for years and is drinking no more or less now. Nonetheless, Angela has tried to cut down on her alcohol use over the last month and this has interfered with her sleep.

Introduction and key concepts

Severe mental health problems carry an enormous social and economic burden. Untreated, they usually worsen and result in a decline in the long-term prognosis (Burton, 2005). For many severe mental health problems, one of the most efficacious forms of treatment is pharmacotherapy, in particular the new ‘atypical’ antipsychotic medications (Gilmer et al., 2004; Woltmann et al., 2007). Effective management of major mental health disorders such as schizophrenia usually involves continuous long-term treatment in order to reduce the risk of relapse (Herz et al., 1991). However, across all types of antipsychotic medication prescribed, non-adherence rates tend to be greater than 60% (Lieberman et al., 2005).

The factors most consistently associated with non-adherence are poor insight, negative attitudes toward medication, previous non-adherence, substance abuse, shorter illness duration, inadequate discharge planning or aftercare environment, and poorer therapeutic alliance. Type of medication does not appear relevant (Lacro et al., 2002). Idiosyncratic factors such as memory deficits (Elvevag et al., 2003), cognitive difficulties with conceptualisation (Jeste et al., 2003) and cultural factors, such as different illness representations (Opler et al., 2004), need to be considered in order to understand an individual’s non-adherence.

Such findings clearly suggest that non-adherence is determined by multiple factors (Happell et al., 2002). Generally there are four categories which are used to capture the factors associated with treatment adherence:

the treatment (e.g. complexity)
the clinician (e.g. skill)
the client (e.g. insight)
the relationship between clinician and therapist (e.g. trust) (McDonald et al., 2002; Meichenbaum & Turk, 1987; Zygmunt et al., 2002).

Cognitive-behavioural therapies are among the most efficacious and comprehensive interventions to improve adherence. Cognitive-behavioural adherence interventions aim to get clients actively involved in their treatment and work collaboratively with clients to investigate the range of factors that might influence medication-taking behaviour (Gray et al., 2002, 2010; Lecompte & Pelc, 1996). Cognitive and behavioural approaches form the basis of most contemporary adherence programmes such as motivational interviewing (Rollnick et al., 2000; see Chapter 6), compliance therapy (Kemp et al., 1996, 1998), medication management (Gray et al., 2003, 2004), treatment adherence therapy (Staring et al., 2010) and more recently, medication alliance (Byrne & Deane, 2011; Byrne et al., 2004).

Adherence behaviour is rarely an ‘all or nothing’ affair (Sawyer & Aroni, 2003). Even partial non-adherence can have clinically significant effects upon the individual client (Weiden et al., 2004). Any efforts to enhance adherence are likely to benefit the client. In the following sections we will explore some core strategies used to assist clients to effectively engage in treatment. We will emphasise the importance of establishing a strong therapeutic alliance with the client and the core intervention skill used to achieve this – motivational interviewing (see Chapter 6). While the focus will be on medications, these strategies should be considered ‘transferable’ across treatment domains, such as lifestyle issues, social relationships and other areas of psychosocial support provided to people with severe and enduring mental illness. The strategies, which have been drawn from the medication alliance programme, include:

individualised assessment of medication-taking behaviour
linking adherence to the client’s goals
assessing for and responding to the client’s beliefs about treatment, including normalising non-adherence
simplifying treatment and managing client impairments, such as deficits in executive functions, problem-solving skills deficits or dysfunctional beliefs.

We introduced Angela at the beginning of the chapter. Regular use of her mood-stabilising medication is critical to her mental health as well as to the wellbeing of her daughter. Angela is also a stabilising factor in Sam’s life and if she becomes unstable, this will affect his mental health. How can Angela’s rehabilitation practitioner work with her to improve her medication compliance?

Step 1: develop a hypothesis as to why Angela is experiencing difficulties with her medication at this time

The process of individualised assessment involves the identification of all possible causal variables contributing to the behaviour (non-adherence) and the collection of information about the relative contribution of these variables to the final behaviour (Haynes & Williams, 2003). Causal variables are identified by analysis of four core relationships between the proposed causal variable and the adherence behaviour. Haynes and colleagues (1997) state that a causal relationship exists between two variables when:

(a) they co-vary (i.e. when one changes, so does the other), (b) the causal variable reliably precedes the dependent variable (i.e. the problem behaviour), (c) there is a logical connection, (d) alternative explanations for co-variance can be excluded. (p.334)

We can start our individualised assessment by looking at the information we have about events immediately surrounding the client’s change in adherence behaviour. A useful tool in doing this is the ABC chart. The acronym ‘ABC’ stands for Antecedents, Behaviour and Consequences. Antecedents refer to all the events or variables that preceded the client’s changed behaviour; in the case of our example, this means changed medication-taking behaviour. Behaviour reflects the specifics of what the client is doing or has done in terms of their medication-taking behaviour. This means looking at how they are expressing their reduced adherence (form), ranging from mild resistance, expressions of dissatisfaction and being late to appointments through to complete refusal to use medication and discontinuation of treatment. Behaviour also looks at how long this has been happening (duration) and whether there are variations in this behaviour (intensity). Finally, Consequences refer to all the outcomes associated with the changed medication-taking behaviour, both positive and negative. Box 10.1 provides an example of the ABC approach for the ‘Angela’ vignette.

As you can see from Box 10.1, the ‘Angela’ vignette can be distilled into a series of key issues. When using the ABC approach, it is important to start with the behavior that you are interested in – the ‘B’. In adherence interventions, this means we should always look at the medication-taking behaviour (‘B’) first, in order to understand exactly what the client is doing and when it started. The box identifies that the changes in behaviour began about 1 month ago. This is crucial information because it steers us away from more distant variables as causes of her changed behaviour. We also know that Angela has not stopped taking her medication altogether and that her pattern of medication use is variable. From this, we can hypothesise that she has not instigated a new regimen of medication use independently and that her reduced use of medication is probably not indicative of overall dissatisfaction with her treatment, although her reduced libido may either be a perceived side-effect influencing her adherence (an antecedent) or a result of her mood deterioration (a consequence).

Box 10.1 ABC analysis of ‘Angela’ vignette

Antecedents	Behaviour	Consequences
Loss of maintenance money 3 months ago	Misses doses intermittently	Reduced interest in boyfriend
Falling behind with bills 8 weeks ago	Has not discontinued all medication	Reduced libido
Daughter started having stomach aches a week ago	Began about a month ago and is escalating	Reduced mood
Poor alliance with GP (prescriber) 10 days ago		Sleep disturbance
New relationship began 6 weeks ago/change in routine
Poor support from family (long term)
Reduced use of alcohol resulting in reduced sleep for last month
Reduced libido over last 2 weeks