Friday, May 28, 2010

Fostering Adherence to Psychotropic Medications

OK, I'm going to tell what is probably my best story from New Orleans. It's Mark Twain funny, like A Scientologist Lawyer in King APA's Court. (If only I could write that well...)

But first of all, several friends have asked me whether I was an "infiltrator" at the APA's convention. No, no, no ... I haven't spied on anyone for years....

Besides that, it's a misconception of the dynamics involved. There were probably 20,000 paid attendees at this annual meeting of the American Psychiatric Association, from all over the world. Nobody cared who or what I was, as long as my credit card authorized. I registered on line like thousands of other people, with my real name, address and personal info, including the fact that I'm an attorney with the email address: It was a very large enterprise with all kinds of people and no perceivable thought or measure against any "infiltration".

The death march (featuring a real coffin) and CCHR picket outside (Hey, hey, APA, how many kids have you drugged today?), and the elaborate, dramatic, "Psychiatry: An Industry of Death" exhibit, which was set up in the Riverwalk Mall directly adjoining the convention center, were all quite well tolerated, even assimilated, as part of the diverse festivities.

The two classes I took on Sunday were a tiny fraction of the information and viewpoints presented during the week-long event. My presence was basically unremarkable. Although in retrospect, there was at least one Aha! (or better yet, ACHA! - with a German accent) moment.

My afternoon class was Fostering Adherence to Psychotropic Medications: A Practical Resource for Clinicians. I had paid the $170 tuition for this figuring it was directly relevant to my work in Illinois state nuthouses, where everyone is simply told from day one that either they take the meds they're prescribed, or they'll never be let out. "Fostering adherence" sounded like a new slant for sure - maybe I could learn something useful.

Well, sure enough, the first discussion was about why we should use adherence rather than compliance as the correct term. This was just practical as all hell, and it showed how much psychiatry has improved.

It turns out that compliance means the act of complying with recommendations (whatdya know!), and that's not collaborative enough, because meds only work if the patient believes in them, and he's less likely to believe if you can't suck him into the idea gradually enough to make him think it was partly his own.

At least, I'm pretty sure that was the point....

My first question was way too basic for this specialist/professional group, although one other guy was at least polite enough to pipe up and say he agreed with me completely.

What about this definition of compliance? Isn't it always something a little more imperative than a mere recommendation with which people are asked to comply? I mean, if a psychiatrist is just recommending meds, then the patient can follow his helpful suggestion or not - right? There's no issue of compliance to begin with.

Anyway, there was a whole lot of research and statistics which proved adherence was a far better word, so the good doctors running the class didn't spend very long discussing my plebeian semantics. Even though everybody tried to call me "Doctor" while I was in New Orleans, I knew my understanding of real psychiatric issues was totally inhibited by my years of legal advocacy in state nuthouses. (It's a lower kind of psychiatry there, you know, it's paid for with taxes, of all things!)

The most exciting part of the afternoon class was when we broke up into groups of three or four students each, to actually drill building collaboration for adherence to psychotropic medications.

In each group, somebody volunteered to play a mental patient and somebody a doctor. Whoever was left was an observer. (For some reason there were only a dozen students all together, so we had less than a handful of drill groups. More people had been expected; the guys running this class had had to move to a smaller room. I can't imagine why the subject wasn't a huge draw.) I volunteered to be the patient.

The character I created for the drill was a composite, off the top of my head, of several clients I've had at Elgin Mental Health Center. But the guy who played doctor wasn't allowed to just say, "If you don't take Risperdol plus three other meds until you're a totally fried diabetic, you'll never get out of here." He had to implement what was called an "integrated adherence strategy." This was cool, but it didn't work. He couldn't get my character to improve his motivation for adherence above a red light level (i.e., I ain't takin' that shit!), even with the help of several very advanced assessments and instruments provided by the class directors.

I felt bad afterwards, like maybe I should have gone along to give my "doctor" a win. But the character I played was genuinely unconvinced. The only reason he would ever consider taking meds or (much more likely) pretend to do so was because a judge had ordered that he be treated. He was actually worried that his judge would keep sending him back to the hospital if he didn't at least pretend to go along with treatment. But that wasn't good enough. It was too much compliance, too little adherence. In this class, it wasn't allowed. So my "doctor" got nowhere with me.

During a break, I suddenly realized how he could have fostered my adherence. He could have told the patient, "Hey, are you just going to be afraid of being sent back, and have to lie and fear discovery all your life? Why not just try the meds long enough to say you tried, and maybe get even better arguments for why you don't like them and shouldn't have to take them? You might actually be able to talk us out of this treatment, if you try it for a little while and really know about how it affects you from experience..."

That sort of appeal might have gotten my character started at least. And if he'd taken that first step, the next one and the next one would be progressively easier. He might have gotten sucked into the idea gradually enough to think it was partly his own.

The student who had drilled the part of my "doctor" listened to this, and suddenly realized that it probably would have worked! He was impressed that I had learned the four steps (or maybe it was ten, I don't quite remember) which a medication provider uses to foster adherence, so quickly and so well.

I was proud of myself momentarily. Then I decided that, being a lawyer and not a psychiatrist, I really wasn't at the same specialist level of technical competence as the other people in this class.

So I took the rest of the afternoon off to cruise the exhibit hall. I got to see MECTA Corporation's newest Electroshock machine.

And (paraphrasing Twain) I wondered whether psychiatry is full of smart people who are putting us on or imbeciles who really mean it.

1 comment:

  1. Psychiatry is, if nothing else, simply a game of semantics.