SOCW 6443 WK 11 Discussion 2: Cultural and Contextual Considerations

  

SOCW 6443 WK 11 Discussion 2: Cultural and Contextual Considerations

Mental health professional’s appreciation for culture and context extend beyond general understandings of people grouped by factors like ethnicity and sexual orientation. Mental health professionals invest in understanding the deep, underlying components of all the things that come together to make our clients who they are.

When culture and context are at odds with societal norms and hegemonic expectations, mental health professionals may need to work with clients to help instill and utilize resources to cope with the possibility of negative messages from society. In addition, mental health professionals work together with clients, for clients, and with other professionals to make changes. Consider how collaborating with others promotes positive changes in client well-being. How might collaboration through advocacy result in alternative approaches for addressing cultural or contextual considerations in treatment recommendations?

For this Discussion, view the transcript “Multicultural and Contextual Considerations Case Study Marisol” I have provided in the uploads. Consider new and alternative methods that mental health professionals could use to advocate for Marisol.

The questions in bold then the answers

Post an explanation of how you would advocate for clients like Marisol give a brief description of Marisol and the issues

Explain at least one strategy as a mental health professional you could facilitate culturally and contextually ethical treatment of clients. 

Support your strategy with evidence intext citation and full references in APA 7th addition format 300 to 500 words not including the questions and references

Resources

Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2017). Handbook of clinical psychopharmacology for therapists (8th ed.). Oakland, CA: New Harbinger.

Chapter 22, “Red Flags: When to Reevaluate” (pp. 255-276)

COMMENTARY

The Social Worker, Psychotropic Medication,
and Right to Refuse

Mark L. Ruffalo

“No right is held more sacred, or is more care-
fully guarded by the common law, than the
right of every individual to the possession and
control of his own person, free from all re-
straint or interference of others.”
— Union Pacific Railway Co. v. Botsford (1891)

Social workers employed in psychiatric and mental health settings face a multitude of po-tential ethical dilemmas in daily practice. One
such dilemma is coercive treatment with psychotro-
pic medications. What is the role of the social
worker in such situations wherein a patient is refus-
ing prescribed psychotropic drugs? Does the social
worker have an ethical responsibility to act in such
circumstances? The answer to these questions lies in
an understanding of the social work ethical prin-
ciple of self- determination and, more broadly, the
political and philosophical basis of our democracy.

In a society such as ours, which places such a high
premium on the freedom and autonomy of the indi-
vidual, the legitimacy of medical and psychiatric
treatment does not depend on its efficacy; instead, it
depends on its being administered with the informed
consent of the patient. Whether or not a medication
will help a patient, treat or cure his or her symptoms,
or prevent death, is irrelevant in consideration of the
patient’s right to refuse treatment. The U.S. court
system has repeatedly upheld the right of even invol-
untarily committed psychiatric patients to refuse
psychotropic medications, with few exceptions, such
as if the patient poses imminent and substantial danger
to himself or herself or others in the immediate en-
vironment. The legendary psychiatrist and psycho-
analyst Thomas S. Szasz (1977) noted that “with the
exception of certain life-saving measures on uncon-
scious patients, a medical intervention imposed on a
person without his consent is not treatment but as-
sault and battery” (p. 48). Reamer (2003) noted that
psychiatric patients have a right to refuse treatment,
particularly when coerced treatment violates their

First Amendment rights to freedom of speech and
religion or their Eighth Amendment rights to protec-
tion from cruel and unusual punishment. Readers are
directed to Schaler (2012) and Szasz (2009) for de-
tailed discussions of the legal and ethical aspects of
coercion in psychiatry.

Social workers employed in psychiatric and men-
tal health settings must be ready to support and de-
fend a psychiatric patient’s constitutional right to
refuse medication, even if such a patient is deemed
to be “seriously and persistently mentally ill.” Cer-
tain patients who have been deemed incompetent
can be legally medicated forcibly with psychotropics
under certain circumstances, but the social worker
must also consider these practices an infringement
of the patient’s civil liberty and a gross violation of
the central social work principle of client self-
determination. In a society that values freedom,
there is no morally legitimate justification for coer-
cive medication treatment.

Social workers who find themselves in such situa-
tions must also be prepared for potential backlash from
physicians, nurses, and other professionals involved in
the care of the patient who may adopt a paternalistic
and authoritarian stance on forced treatment. Social
workers are reminded that such professionals may be
misguided by a belief that a patient has an ethical “right
to treatment,” an idea that is in direct contradiction to
the principles of self-ownership and self- determination.
A careful philosophical investigation of such a “right”
reveals that it is baseless and equates to a nonexistent
“right to treat” ( Szasz, 1977). No professional has a
“right to treat” another person unless the person
provides consent, with the obvious exception of the
unconscious person who is assumed to consent to
treatment.

Frequently, health care providers working with
patients who are refusing medication will attempt
to persuade or convince them to accept medication
under threat of consequence or by withholding im-
portant information from them. Such a provider

271doi: 10.1093/sw/sww027 © 2016 National Association of Social Workers

might educate patients about the potential benefits
of treatment without informing them of risks of
such treatment, or similarly prompt them to accept
medication or risk deprivation of other rights, such
as freedom of movement. The social worker must
stand firmly in opposition to such attempts to un-
dermine a patient’s right to refuse treatment and
must view such actions as unethical, immoral, and
illegal. A social worker should educate clients in-
volved in such cases about their legal right to refuse
treatment, and must be prepared to support them in
any decision they choose, even in situations wherein
there is disagreement among professional colleagues.

The National Association of Social Workers’ (2015)
Code of Ethics recognizes client self-determination as
a central ethical responsibility of social workers and
notes that social workers may limit self-determination
only when “client’s actions or potential actions pose
a serious, foreseeable, and imminent risk to them-
selves or others” (p. 7). Because many victims of co-
ercive medication treatment are neither dangerous
nor pose any imminent risk, and because the concept
of “dangerousness” can be broadened to include vir-
tually any person said to be mentally ill, the social
worker must consider all attempts at forced medica-
tion to be in violation of the client’s civil liberties.
The actual right of a person to own his or her own
body and mind supersedes the nonexistent right of
the provider to treat a person without consent.

Defending the psychiatric patient’s right to refuse
treatment falls squarely in the domain of the social
worker who is uniquely qualified to address issues
pertaining to ethicality as they relate to a client’s posi-
tion as a member of the broader society. Protecting
a client’s right to refuse medication requires no spe-
cial training in psychopharmacology but, rather,
knowledge and understanding of the rule of law and
the application of professional ethics. The right of
the individual to own his or her body and self, and
thus refuse medication treatment with psychotro-
pics, is a sacred right in our society, and the social
worker must serve first and foremost as a defender
of freedom and human dignity.

REFERENCES
National Association of Social Workers. (2015). Code of

ethics of the National Association of Social Workers.
Washington, DC: Author.

Reamer, F. G. (2003). Social work malpractice and liability:
Strategies for prevention (2nd ed.). New York:
Columbia University Press.

Schaler, J. S. (2012). Strategies of psychiatric coercion.
Cato Unbound. Retrieved from http://www.cato-

unbound.org/2012/08/06/jeffrey-schaler/strategies-
psychiatric-coercion

Szasz, T. S. (1977). Psychiatric slavery: When confinement and
coercion masquerade as cure. New York: Free Press.

Szasz, T. S. (2009, July/August). The shame of medicine:
The depravity of psychiatry. Freeman, 59, 21–22.

Union Pacific Railway Company v. Botsford, 141 U.S. 250
(1891).

Mark L. Ruffalo, LCSW, is a psychotherapist in private practice,
10335 Cross Creek Boulevard, Suite 15, Tampa, FL 33647;
e-mail: mlruffalo@gmail.com.

Original manuscript received June 3, 2015
Final revision received September 28, 2015
Accepted November 2, 2015
Advance Access Publication April 27, 2016

Social Work Volume 61, Number 3 July 2016272

http://www.cato-unbound.org/2012/08/06/jeffrey-schaler/strategies-psychiatric-coercion

http://www.cato-unbound.org/2012/08/06/jeffrey-schaler/strategies-psychiatric-coercion

http://www.cato-unbound.org/2012/08/06/jeffrey-schaler/strategies-psychiatric-coercion

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Multicultural and Contextual Considerations Case Study: Marisol

Multicultural and Contextual Considerations Case Study: Marisol
Program Transcript

[MUSIC PLAYING]

NARRATOR: Professional counselors consider all facets of a client’s personal
background and history to provide informed ethical care. As such, individuals
belonging to special or minority populations require additional consideration on
the part of the counselor to ensure appropriate care is given. In the case that
you’re about to view, Marisol—the client—presents with special ethnographic
needs.

As the client is introduced, consider possible areas in which the client requires a
treatment approach that incorporates culturally sensitive considerations. Think of
ways to align specific addiction and mental health concerns with cultural
considerations. How should this client be assessed? What alternative
approaches should the counselor employ to address multicultural barriers?

Marisol is a 25-year-old Latina living in a traditional home on the south side of
San Antonio, Texas. Marisol has lived in the United States for most of her life and
has extended family in Mexico and in San Antonio. She is the middle child of six.

Her family and friends are pressuring her to get married. Her grandmother,
mother, and married friends consistently bring up the subject of marriage. Marisol
worries about her ability to be a good wife and mother and sees her siblings
struggle to lead a good life as much as she does.

Marisol is fluent bilingual. However, English is Marisol’s second language.
Although she wanted to succeed in her studies, Marisol struggled as a student
and did not finish high school.

She was always nervous in school. She began working to contribute to the family
income and could never find the time to complete a GED. She worries that she
will never be able to get a good job because of her lack of education.

Marisol is being treated for comorbid cocaine abuse and benzodiazepine
dependence and is having difficulty discussing her mental health issues with her
Caucasian male psychiatrist. Marisol has been seeing her psychiatrist, Dr. Dan,
for treatment of her addictions. Dr. Dan is a Caucasian master’s level counselor
who has received specialized training in addictions counseling.

During the past two counseling sessions, Marisol appeared reluctant to engage
in communicating with her psychiatrist as evidenced by her limited verbalizations.
She responded only to questions that were asked and provided little additional

© 2014 Laureate Education, Inc. 1

Multicultural and Contextual Considerations Case Study: Marisol

information beyond yes and no responses. Her responses have sometimes
appeared to be insincere or evasive.

MARISOL: I met with my doctor two times. Dr. Dan wants me to tell him what is
going on with me. But when I started to tell him a little bit, he seemed impatient.

These are the things that I don’t like to talk about, especially with someone who’s
not a member of my family. If I share too much, he may think I’m a bad woman.
He is a doctor, so what he says goes. He knows what he needs to know from
me, and I don’t want to trouble him.

I like Dr. Dan. He seems nice and all that, but I really don’t feel like he can
understand my problems. First, I don’t think he’s ever had addiction himself. If he
hasn’t had an addiction, how can he possibly understand what I’m going
through?

He’s also a white man. The issues I face as a Latina woman are very different
than those that he experiences. I just don’t understand how he will be able to
help me.

Let me tell you a little bit about myself. I’m 25 years old, and I’ve been using
drugs for the past 10 years. I only really started using drugs to help with my
anxiety. [SPEAKING SPANISH]. Sometimes, when I get nervous, I forget to talk
in English.

Anyway, I’ve been nervous for as long as I can remember. I’ve just—I’ve had
some bad stuff happen, stuff that I don’t want to talk about right now. How am I
supposed to talk to a man about these things?

I know that in order to get better, I have to talk about things. But I can’t bring
myself to talk about them with an educated man like this. I mean, I tried to start
telling him, but he was like in a hurry or something. He started writing a
prescription for me.

You must know what I mean. And—I don’t know, maybe I shouldn’t talk so much,
you know? Where was I? Oh, yes, my anxiety.

I guess I can tell you a little bit about it. Please don’t tell my mother. I had some
bad stuff happen. But even before that, we just really struggled to make it. I was
raised by a single mother, una santa. She’s a saint.

She worked 14 hours a day to make sure that [INAUDIBLE] and the rest of us
had food in our system. We also moved a lot. And sometimes, I was unsure if I
should even unpack, or if we were just going to up and leave. Like I was saying,
my mother worked 14 hours a day. She worked two jobs.

© 2014 Laureate Education, Inc. 2

Multicultural and Contextual Considerations Case Study: Marisol

And she left us kids—there were six of us—with whoever was willing to watch.
Like mi tia, Alejandra. I’m sorry, my aunt. It was hard on all of us. We fought a lot.

All of my siblings have problems, giving my mother grief. My oldest brother, Juan,
has spent most of his life in and out of prison. He joined up with MA, so he’s all
tough and gang banger now. My sisters are in abusive relationships. I don’t think
they know how to keep their men happy.

And my youngest brother, my youngest brother, he’s had the hardest because he
saw too much too early. We used to party sometimes together, you know? But
he’s worked so much. These days, he parties just as hard as he works. I think
he’s stuck on [INAUDIBLE].

Things have been hard for us all. My poor mother—I try to keep it together
because I know that she needs at least one daughter she can be proud of. It’s
too much.

I think that’s why I started using alcohol. I used alcohol first. It was a way to help
me relax and forget about my problems. Plus, I mean, Tia Alejandra said she had
been drinking back at age 12 in Chiapas. No big thing.

I never really liked feeling hung over. Then I started taking Xanax. I really liked
the way that made me feel.

I didn’t feel the anxiety as much. I could get out of the house, go make friends,
and everything. But then I started needing more and more, and that scared me.

I’ve had friends who overdose, and others get sick from that stuff. I thought, I’ll
just cut back. I even had an attack the day I tried to not take it. It—it felt like if my
heart was going to explode. So I called the counseling center, and they had me
see Dr. Dan. They told me to come see you too.

I sometimes use cocaine. I don’t really like the way it makes me feel, though. It
usually just makes me feel more anxious. I know it sounds stupid, but sometimes
I feel like if the cocaine gets me too up, I’ll be too up to even care about being
anxious. Yeah, you know, it’s like I can take it.

Anyway, I can talk to people and not feel so stupid all the time, you know? I just
want to feel better. I want a normal life. I want my mother to be proud of me.

I know that using cocaine and Xanax are very wrong for me. But I just don’t want
to feel anxious every day. I don’t want to feel anxious every day.

I—I haven’t been in a relationship in over three years. And I’m afraid that I can’t
trust anyone. What kind of woman am I if I can’t keep a husband and have a
house and have my husband happy with the way I make things work?

© 2014 Laureate Education, Inc. 3

Multicultural and Contextual Considerations Case Study: Marisol

It’s all too much. So like, I can’t tell Dr. Dan any of this stuff. I’ll be so ashamed. I
mean, he is the doctor, right? He’ll want to lock me up or tell me that it’s my
mother’s fault.

She’s a good woman. She’s worked so much. I wish I could be like that, you
know? What if she found out? It would kill her. I don’t—I just think I won’t go
back.

I can’t stand the judgment. Dr. Dan. He can’t even pronounce my name right.
“Mare-ah-saul”. It’s “Mar-ie-sole.” I just might not come back. I can’t stand the
judgment.

Maybe my anxiety isn’t so bad. Maybe I could just cut back on the Xanax and
maybe only do coke like in the weekends or something. I think I’m wasting his
time.

Multicultural and Contextual Considerations Case Study: Marisol
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© 2014 Laureate Education, Inc. 4

Journal of Human Behavior in the Social Environment, 19:

512

–530, 2009

Copyright © Taylor & Francis Group, LLC

ISSN: 1091-1359 print/1540-3556 onlin

e

DOI: 10.1080/10911350902987987

How Effective are Interventions to Enhance
Adherence to Psychiatric Medications? Practice
Implications for Social Workers Working With
Adults Diagnosed With Severe Mental Illnes

s

LISA TOWNSEND
School of Social Work and Center for Education and Research on Mental Health

Therapeutics, Rutgers University, New Brunswick, New Jersey

This study integrates eight systematic reviews of adherence en-

hancement interventions to develop practice guidelines for social

workers who work with adults who do not adhere to prescribed

psychiatric medications. Findings indicate that existing investi-

gations are disparate in their adherence definitions, methodolo-

gies employed, and sampling strategies, rendering it difficult to

construct overall guidelines for social work practice. However,

themes associated consistently with increased adherence are col-

laboration between clients and providers regarding medication

decisions, consistent follow-up care, and a comprehensive network

of professionals and caregivers who support clients in their use of

medication to facilitate stabilization of mental health symptoms.

KEYWORDS Mixed methods, mental health, medication, adher-

ence

INTRODUCTION

The effectiveness of psychotropic medications in alleviating symptoms of
psychiatric disorders has been documented widely (Kane, 1989; Katon, Korff,
& Lin, 1992; Kennedy, Song, Hunter, Clarke, & Gilbody, 2000; Marder, 1999;
Quraishi & David, 2000; Thornley, Adams, & Awad, 2000; Wahlbeck, Cheine,
& Essali, 2000). However, despite their effectiveness in ameliorating symp-
toms, adherence to psychotropic medications among adult patients is con-

Address correspondence to Lisa Townsend, School of Social Work, Rutgers University,
536 George Street, New Brunswick, NJ 08901. E-mail: LTownsend01@msn.com

512

Adherence Enhancement 513

sistently low (Dolder, Lacro, Leckband, & Jeste, 2003). Fenton, Blyler, and
Heinssen (1997) found adherence rates in adults with schizophrenia ranging
from 11% to 80%. Breen and Thornhill (1998) demonstrated adherence rates
between 20% and 80% in a similar sample. Babiker (1986) and Weiden and
Olfson (1995) conservatively estimate nonadherence rates at 50% in adult
patients with schizophrenia in the first year after hospitalization. Maddox,
Levi, & Thompson (1994) showed that premature discontinuation of antide-
pressant medication was prevalent in their study of depressed adults.

Nonadherence is particularly concerning given its strong association
with symptom relapse. According to Fenton et al. (1997), nonadherent pa-
tients are 3.7 times more likely to relapse than patients who take psychotropic
medications as prescribed. Fortney, Rost, Zhang, & Pyne (2001) found a
strong association between nonadherence and treatment failure resulting
in chronic symptomatology. Weiden & Olfson (1995) demonstrated a link
between reduced medication adherence and rehospitalization in their study
of adult patients with schizophrenia. Weiden & Glazer (1997) later demon-
strated that increased utilization of expensive inpatient services (‘‘the revolv-
ing door phenomenon’’) was related to lack of adherence to psychotropic
prescriptions. Most concerning is the relation between discontinuation of
particular pharmacologic agents and increased risk of completed suicide in
adults (Muller-Oerlinghausen, Muser-Causemann, & Volk, 1992).

Nonadherence to psychiatric medications is a recurrent theme in social
work with adults who have severe mental illness. Floersch (2002, pg. 31)
and Longhofer, Floersch, and Jenkins (2003) identified the ‘‘social grid of
community medication management’’ in adult treatment of mental health
disorders. They articulate the complex ‘‘social grid’’ that interacts to form
interpretations of the effectiveness of psychotropic medications. The grid is
composed of multiple members who perform different functions in helping
individuals manage their mental health care, including psychiatrists, case
managers, friends, relatives, and caregivers. Social workers form an integral
part of this grid, helping clients remember to take medications, delivering
medications, assisting with prescription refills, and counseling clients about
possible consequences of nonadherence. Currently, there are no practice
guidelines to inform social workers how best to help their clients adhere to
psychiatric medications.

The focus of this article is to summarize adherence intervention research
by organizing the results of existing systematic reviews. This follows rec-
ommendations of the Cochrane Group (2005), the Campbell Collaboration
(2005), and Cook, Greengold, Ellrodt, & Weingarten (1997), in which system-
atic reviews are synthesized into practice guidelines so that their conclusions
may be employed effectively by practitioners. Theoretical models of medica-
tion adherence are summarized as a framework for interpreting the empirical
evidence. Subsequently, the methodological rigor of the intervention studies
contained in the reviews is assessed using two criteria: conceptual adequacy

514 L. Townsend

and quality of research methodology. In addition, Proctor and Rosen’s (2000)
rubric for creating practice guidelines is used to evaluate the usefulness of
the results for creating practice guidelines. They recommend that practice
guidelines in social work address the following areas: specification of out-
come targets, presentation of a comprehensive array of intervention options,
criteria for practitioner choice of interventions, and delineation of gaps in
empirical knowledge and limitations of the research. Evidence is presented
that the research methods employed to date have not generated conclusive
data to inform practice guidelines and that refinements in research method-
ology are needed. Interventions that show promise for increasing adherence
are described, and themes consistently represented in successful intervention
outcomes are highlighted for incorporation into social work practice.

ADHERENCE MODELS

Several theoretical models provide a conceptual framework for understand-
ing adherence enhancement interventions. These models of adherence can
provide a foundation for understanding the mechanisms underlying adher-
ence.

Sick Role Theory

Perkins (2002) reviewed existing models that have been applied to nonadher-
ence. Bebbington (1995) adapted Parsons’s (1951) concept of the ‘‘sick role’’
to explain the role that patient passivity plays in contributing to nonadher-
ence. According to sick role concepts, patients are relieved from traditional
involvement in everyday social activities, such as childrearing or work, by
their status as ‘‘ill.’’ It is theorized that the sick role generates passivity on
the part of patients, decreasing their motivation to play an active role in
aspects of care such as medication management. Despite the interesting
possibilities offered by sick role theory, no known studies employing it have
been published to date in the adherence enhancement literature.

Side Effect Models

Side effect models generated a significant body of empirical work after the
emergence of traditional neuroleptics and even greater research interest since
the introduction of atypical antipsychotic medications. Fenton et al. (1997)
and Perkins (2002) review evidence suggesting that high levels of side effects
are linked with nonadherence. Bartko et al. (2002) examined differences
in the tolerability of typical versus atypical antipsychotic medications in
adults with chronic schizophrenia, finding that patients preferred atypical
agents over conventional medications. These studies have motivated efforts

Adherence Enhancement 515

to develop medications with lower side effect profiles. However, adherence
levels remain low in adult psychiatric patients.

Health Belief Models

Health belief models have been employed to explain adherence to a variety
of preventive and treatment regimens, including psychotropic medications.
Originally conceptualized by Rosenstock (1974) and refined by Fishbein and
Ajzen (1975) and Ajzen and Fishbein (1980), the model has been adapted to
explain aspects of psychotropic nonadherence (Perkins, 2002). The health
belief model posits that patients actively evaluate the costs and benefits of
treatment, their susceptibility to symptom relapse, and the extent to which
negative consequences are associated with relapse. This model suggests that
patients are active participants in making treatment decisions, weighing the
advantages and disadvantages of their treatment options.

Models of Subjective Well-Being

Subjective well-being models suggest that patients’ perceived quality of life
is a combination of their subjective experience of medication plus the per-
ceived advantages of symptom relief. This model goes beyond the presence
or absence of side effects per se to account for patients’ subjective experi-
ence and their attitudes toward medication. Instruments such as the Drug
Attitude Inventory (Hogan, Awad, & Eastwood, 1983; Voruganti & Awad,
2002) and the Subjective Well-Being under Neuroleptics Scale (Naber, 1995)
were created to examine subjective well-being factors systematically. These
authors found that measures of subjective well-being correlated significantly
with patient adherence to psychotropic medications.

The following section presents the criteria for selection of the system-
atic reviews and the results of the adherence enhancement interventions
examined. As will be demonstrated, the empirical work on adherence has
not been linked closely with theories about why resistance to psychotropic
medications is so high. The result is a body of loosely connected studies
that provide little direction for practitioners who hope to assist patients
with medication management difficulties. Recommendations for tightening
knowledge gaps are provided in an effort to steer research efforts in a more
cohesive direction.

CRITERIA FOR STUDY SELECTION

The search for systematic reviews cast a wide net, consistent with Cook,
Mulrow, and Haynes’ (1997) emphasis on avoiding sampling bias. Two
major databases were used: PsychInfo (1967 to present) and Medline (no

516 L. Townsend

restrictions). These databases were chosen because of their tendency to
capture studies from a wide range of disciplines. Selection for inclusion in
the review sample was based on the following criteria:

� Articles contained a systematic review or meta-analysis of adherence in-
tervention research.

� The primary goal of the interventions was to increase adherence to psy-
chotropic medication.

� Reviews examined randomized, controlled trials or trials including one or
more comparison groups.

� Interventions were conducted with adults diagnosed with severe mental
illness.

Sampling excluded primary care studies dealing with physical syndromes
and studies of substance abuse treatment. Eight systematic reviews/meta-
analyses were included in the initial sample (Dolder, Lacro et al., 2003; Gray,
Wykes, & Gournay, 2002; Macdonald, Garg, & Haynes, 2002; Nose, Barbui,
Gray, & Tansella, 2003; Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza,
2002; Sajatovic, Davies, & Hrouda, 2004; Vergouwen, Bakker, Katon, Verheij,
& Koerselman, 2003; Zygmunt, Olfson, Boyer, & Mechanic, 2002). Table 1
provides a summary of the systematic reviews and their findings.

RESULTS OF SYSTEMATIC REVIEWS

Numerous interventions have been devised to improve patients’ willingness
to adhere to pharmacological treatment. Interventions found in the literature
subsume a variety of clinical orientations, including psychoeducation, be-
havioral intervention, cognitive-behavioral techniques, family supports, case
management, and motivational interviewing. The following section sum-
marizes the conclusions of eight systematic reviews according to the two
criteria outlined earlier: conceptual adequacy and quality of research design.
Additional consideration is given to the studies’ ability to inform preliminary
practice guidelines according to the criteria outlined by Proctor and Rosen
(2000): relationship of findings to outcome targets, the array of interventions
available for practitioners, criteria for practitioner choice of interventions, and
delineation of gaps in empirical knowledge and limitations of the research.

Conceptual Adequacy

In examining the adequacy of the adherence definitions used in the stud-
ies, four factors were identified that went unaddressed in the interventions
used. These factors were: lack of consistency in definitions of adherence,

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517

518 L. Townsend

patients’ own self-definitions of adherence, environmental impediments to
affording and obtaining medication, and cultural influences on beliefs about
medication.

ADHERENCE DEFINITIONS

Among the 164 primary studies included in the systematic reviews, research
designs differed substantially in their definitions of adherence. Some studies
conceptualized adherence as a binary outcome (‘‘good’’ vs. ‘‘poor’’; Razali &
Yahya, 1995). Other studies relied on bottle-monitoring devices, pill counts,
self-report, clinician report, urine assays, or serum levels. Pampallona et al.
(2002) found that some studies incorporated a variety of measures into a
composite compliance index. Considerable debate remains in the literature
regarding the reliability and validity of adherence measurements. Lack of a
consistent operationalization of adherence renders it difficult to describe ac-
tual levels of adherence and inhibits cross-study comparisons of intervention
outcomes.

Of additional concern is the absence of patient-defined adherence con-
cepts. Not only is it important to establish valid measures of adherence; it
is vital to determine how patients view adherence. It is possible that the
construct of adherence is defined differently by patients than by researchers
and practitioners. No work was uncovered that links patients’ definition of
adherence with interventions designed to enhance it. This is an important
conceptual gap, given that interventions are aimed at enhancing client ad-
herence; their definition of adherence directly impacts intervention success.

TARGET OUTCOMES

Furthermore, findings are not organized separately according to adherence
targets; some studies measured adherence to medication, whereas others
examined clinic appointment or psychotherapy attendance. Although the pri-
mary aim was to include studies examining adherence to medication, many
reviews combined studies assessing clinic appointment or psychotherapy
attendance along with adherence to medication.

ENVIRONMENTAL BARRIERS TO ADHERENCE

Environmental barriers to adherence were not incorporated into the majority
of the adherence enhancement studies: None of the research examined
in this review systematically examined environmental barriers to obtaining
medication. Only one review (Sajatovic et al., 2004) mentioned the impact
of factors such as inadequate housing, lack of funds, or transportation issues
on adherence. These limitations may be formidable obstacles to adherence,

Adherence Enhancement 519

especially in populations of people with severe and persistent mental ill-
ness who are disabled, of lower socioeconomic status, isolated from social
supports, or uninsured.

CULTURAL BARRIERS TO ADHERENCE

The majority of studies reviewed did not include culture, ethnicity, or reli-
gious practice as a factor influencing their interventions. Only one primary
study addressed the impact of culture on adherence. In their sample of Chi-
nese families of patients with schizophrenia, Xiang, Ran, & Li (1994) found
that significant stigma must be overcome before implementing adherence
interventions with patients and family members. The role of culture in this
population plays an important part in the acknowledgement of mental illness
and the corresponding need for treatment. It is likely that other cultures
may hold strong beliefs about the etiology of mental illness, differential
willingness to acknowledge and seek treatment for mental disorders, and
offer differing degrees of support to patients. These features must be taken
into account when designing interventions in this country, as there are many
individuals who come from diverse cultural and ethnic heritages.

Quality of Research Methodology

In reviewing the research designs of the intervention studies summarized
in the systematic reviews, six problems with study design were identified:
(a) lack of a ‘‘gold standard’’ measure of adherence, (b) between-study
differences in adherence outcome targets, (c) heterogeneity of study samples,
(d) lack of consistency in the design of the interventions themselves, (e) lack
of adequate statistical power to detect intervention effects, and (f) lack of
statistical control for the effects of polypharmacy. These issues are discussed
below.

ADHERENCE MEASURES

Much of the foregoing discussion regarding conceptually adequate defini-
tions of adherence is also relevant to evaluating the methodology employed
in the studies reviewed. Not only is adherence defined poorly as a construct;
it has been measured poorly as a target outcome. The intervention studies
reviewed showed little standardization of adherence measures, employing a
variety of assessments with little comparability between them. As discussed
previously, adherence was measured in a variety of ways, including pill
counts, self-report, blood levels, pharmacy refill records, and electronic bottle
monitoring. This presented difficulties for those authors who attempted to
conduct meta-analyses but converted their studies to systematic reviews due
to the inability to standardize adherence results (Pampallona et al., 2002;

520 L. Townsend

Vergouwen et al., 2003). These differences in measurement render it difficult
to integrate the results of studies with markedly different outcome variables.

TARGET ADHERENCE OUTCOMES

A similar difficulty presented itself regarding the issue of desired target
outcomes of adherence. Just as with adherence measurement, the lack of
consistency in desired target outcomes led to a lack of comparability be-
tween intervention studies. In the studies included here, target outcomes
included adherence to medication, clinic appointments, and psychotherapy.
This makes it difficult to generalize results across studies. It is likely that
patients may have different likelihoods of adhering to medication than for
attending psychotherapy appointments, although the two are likely to be
related. Nonadherence to medication may influence patients’ willingness to
visit their doctors, further complicating assessment of these target outcomes.
This necessitates study designs that are capable of separating the overlapping
effects of medication non-adherence from appointment non-adherence.

SAMPLING

Among the studies compared, lack of consistency in patient sampling pre-
vented direct comparability between studies. Across studies, there was signif-
icant variability in the types of patients who participated in the intervention
protocols. Differences existed at the diagnostic level, ranging from studies
including only patients with psychotic spectrum disorders (Nose et al. (2003)
to studies including all Axis I diagnoses (Cramer & Rosenheck, 1998). Patients
also differed in levels of symptomatology, from highly symptomatic (Razali
& Yahla, 1995) to ‘‘clinically stable’’ (Macpherson, Jerrom, & Hughes, 1996).

Of utmost importance to studies’ ability to detect significant adherence
differences, participants also differed in their level of initial adherence be-
havior, from low (Razali & Yahla, 1995) to high adherence at the time of
study enrollment (Atkinson, Coia, Gilmour, & Harper, 1996). Floor effects
may not be significant impediments to research results, allowing room to
detect intervention effects; however, ceiling effects make it difficult to draw
conclusions about the relative effectiveness of interventions when comparing
experimental and control groups that have little room for improvement in
adherence (Shadish, Cook, and Campbell, 2002).

VARIABILITY IN INTERVENTION DESIGNS

Lack of consistency in the type of interventions used to enhance adherence
influenced the ability to compare studies with one another. Intervention
designs differed both across theoretical orientations (as with psychoanalytic
vs. cognitive-behavioral approaches, for example) and within theoretical

Adherence Enhancement 521

orientations (e.g., differing levels of complexity and intensity for cognitive-
behavioral interventions). The interventions reviewed here differed substan-
tially both across and within theoretical orientations. A variety of techniques
were employed, including psychoeducation, case management, cognitive-
behavioral strategies, and motivational interviewing. A single intervention
often incorporated components from a variety of theoretical orientations,
such as combining psychoeducation and cognitive-behavioral techniques
(Peveler, George, Kinmonth, Campbell, & Thompson, 1999).

An example of variability within theoretical orientation is represented
by cognitive-behavioral interventions that varied substantially in their level
of complexity. They ranged from mostly behavioral (Eckman, Liberman, &
Phipps, 1990) to more thought-based cognitive restructuring (Lecompte &
Pelc, 1996). Intervention protocols also differed in terms of the number
and intensity of sessions, length of follow-up, and in type of provider who
administered the intervention. These variations make it difficult to compare
studies between and within theoretical orientations.

LOW STATISTICAL POWER

One of the most serious difficulties with the intervention studies was the
lack of attention to statistical power. The number of participants across
studies ranged from 14 (Altamura & Mauri, 1985) to 4,052 (Melfi et al., 1998).
Although many of the primary studies reviewed enrolled at least 100 partici-
pants, a number of them drew conclusions from significantly fewer patients.
This skews the population of studies from which conclusions can be drawn:
Underpowered studies are unlikely to detect even robust effects, whereas
studies with thousands of subjects are likely to detect results that may be
clinically insignificant. These power differences contribute to the difficulty
in drawing conclusions about the efficacy of adherence interventions.

POLYPHARMACY

A surprising finding of this review was the failure of researchers to address
the issue of polypharmacy, which refers to the simultaneous prescription of
several medications to treat an individual. Over the past several decades,
prescription of two or more concomitant psychotropic medications has be-
come the norm rather than the exception (Ananth, Parameswaran, & Gu-
natilake, 2004; Frye et al., 2000). None of the studies addressed whether
adherence differs for patients who receive different numbers of prescriptions.
In clinical practice, patients may take a mood stabilizer, an antipsychotic,
and an anxiolytic according to symptom-based rather than syndrome-based
prescribing algorithms. Each of these agents has different side effect profiles
and the propensity to generate different patient reactions regarding their
acceptability.

522 L. Townsend

To summarize, adherence intervention studies to date suffer from
methodological flaws that render it difficult for consumers of research to
decide which interventions are most efficacious in helping patients adhere to
treatment. There is no agreed-upon gold standard for measuring adherence,
a variety of adherence targets that may benefit from differing interventions,
and a lack of consistency in the intervention protocols presented in the
literature. Many studies are underpowered and combine a variety of Axis I
disorders without examining whether interventions have differential impact
based on type of mental health disorder.

PROCTOR AND ROSEN’S CRITERIA FOR
PRACTICE GUIDELINES

Proctor and Rosen (2000) devised a rubric for creating practice guidelines
that evaluates the usefulness of data for incorporation into practice. They
recommend that practice guidelines in social work address the following
areas: specification of outcome targets, presentation of a comprehensive
intervention array, criteria for practitioner choice of interventions, and delin-
eation of gaps in empirical knowledge and limitations of research.

Currently, there is little evidence to support development of practice
guidelines for adherence enhancement in adults with severe mental illness,
even at a preliminary level. The intervention protocols examined are too
highly variable to be implemented with fidelity by practitioners, and it re-
mains to be seen whether interventions with a high level of complexity can
be distilled into a smaller number of cost-effective components.

Specification of Outcome Targets

Proctor and Rosen’s first guideline requires that outcome targets be clearly
specified. There is little consistent information provided by the studies re-
viewed that allow results to be synthesized into a format usable by practition-
ers. This first practice guideline criterion cannot be met due to inconsistencies
in existing research designs: Practitioners will be unable to connect clear out-
come targets with specific interventions designed to achieve those outcomes
without studies that link specific interventions to specific outcomes.

Comprehensive Intervention Array and Guidelines for
Practitioner Choice

Proctor and Rosen’s second and third criteria require that practitioners be
able to present a comprehensive intervention array to their clients and that
there are specific standards that guide practitioners as they choose among

Adherence Enhancement 523

the interventions available to them. As it stands now, intervention protocols
are diffuse and non-standardized, making it difficult to organize them in
relation to outcomes desired by clients and practitioners. This also renders
it difficult to construct specific criteria that can be used to guide choices of
one intervention over another.

Research Limitations

Proctor and Rosen’s fourth criterion is that practice guidelines delineate exist-
ing gaps in empirical knowledge and articulate the limitations of the research
that informs these guidelines. For practice guidelines to be usable for practi-
tioners, they must specify recommendations for action while acknowledging
the limitations in knowledge or restrictions on applicability to particular client
populations or circumstances. The underlying assumption is that a substantial
enough body of knowledge exists to inform practice decisions. Regarding
adherence enhancement, the gaps in existing knowledge are wider than what
is known and necessitate a reconceptualization of the types of studies that
will provide the information practitioners need to made educated decisions
about enhancing client adherence.

IMPLICATIONS FOR SOCIAL WORK PRACTICE:
CHARACTERISTICS OF SUCCESSFUL INTERVENTIONS

This section presents findings gathered from the systematic reviews of the
adherence literature that may serve to guide future research efforts; however,
these findings are presented with the caveat that interventions that hold
promise should be subjected to more rigorous examination before solid
conclusions can be drawn about their efficacy.

Overall, psychoeducation without cognitive or behavioral components
was unsupported by the reviews. The majority of studies demonstrated no
significant difference between psychoeducation groups and controls. One
qualification is that studies involving complex approaches, such as combina-
tions of psychoeducation, collaborative treatment, and cognitive techniques,
tended to improve adherence compared to controls (Dolder et al., 2003).

Tentative support across studies was shown for cognitive-behavioral
interventions. Cognitive-behavioral techniques that were supported included
those employing coping strategies such as negative thought replacement
(Robinson et al., 1995) and collaborative treatment with cognitive and mo-
tivational interviewing components (Spooren, Van Heeringen, & Jannes,
1998). Although only evaluated by one group, compliance therapy (Kemp,
Hayward, Applewaithe, Everitt, & David, 1996) received consistent support.
This intervention involves a collaborative alliance between provider and
patient, addressing illness history and symptoms, exploring ambivalence

524 L. Townsend

toward diagnosis and treatment, and motivational interviewing to address
treatment barriers. Of particular significance is the discussion of perceived
stigma and its impact on patients’ perceptions of treatment. These findings
are consistent with the health belief model put forth by Fishbein and Ajzen
(1975) and Ajzen and Fishbein (1980), in which individual attitudes are
shaped in part by subjective norms held by important others in their social
environment. Among the models presented previously, the health belief
model is supported most consistently by empirical evidence and may provide
a useful framework for future research on adherence.

Despite the inconclusive results across studies, a review of the studies
that showed promise revealed several consistent themes that appear to be
associated with increased adherence to medications. These themes may be
of use to social workers in their daily practice with clients who are struggling
with taking their medication as prescribed.

Collaborative Care

One of the consistent commonalities among the cognitive-behavioral tech-
niques employed was the idea of collaboration between the patient and
provider. Each of the successful cognitive-behavioral interventions incorpo-
rated patient perspectives on their illness and symptoms and the impact
of psychotropic medication. Stigma was often addressed, with providers
helping patients to reframe feelings of shame and strive for stability with
the aid of medication. Motivational interviewing, a technique widely used
in substance abuse treatment (Miller & Rollnick, 1991) was employed, ac-
knowledging the importance of patients’ conceptions of their difficulties and
possible resolutions. The concept of collaboration between provider and
patient is consistent with social work’s code of ethics, which requires social
workers to promote self-determination in treatment given that a patient’s
safety is not in jeopardy (Reamer, 2002). This approach also coincides with
the health belief model (Fishbein & Ajzen, 1975; Ajzen & Fishbein, 1980),
which posits that individuals take an active role in weighing the advantages
and disadvantages of treatment recommendations.

Consistent Follow-Up

A second common characteristic of successful interventions was consistent
follow-up on the part of providers to ensure appointment attendance and
early identification of difficulties with treatment. This may represent a vital
element of ongoing care for people with severe mental illness, as their
cognitive abilities may wax and wane depending on symptom severity and
environmental barriers such as difficulties obtaining transportation or main-
taining health insurance benefits may hinder adherence.

Adherence Enhancement 525

Comprehensive Care

A third characteristic of successful interventions was their level of complexity.
More comprehensive interventions that involved patients, caregivers, psychi-
atrists, nurses, and psychotherapists tended to elicit higher levels of adher-
ence to treatment. Given the greater treatment needs of people with severe
mental illness, it is likely that better outcomes will be achieved when patients
are surrounded by a network of caring professionals and significant others
who monitor their progress in a collaborative manner. Floersch’s concept
(2002, pg. 31) of the ‘‘social grid of medication management’’ highlights the
impact of provider networks on patient outcomes, noting that social supports
impact patient well-being and goal achievement.

Psychoeducation

Although interventions employing only psychoeducation were largely un-
successful in eliciting better adherence to treatment, there is little basis to
forgo education altogether. In fact, psychoeducation was incorporated into
many of the cognitive-behavioral interventions that elicited greater adherence
outcomes. Educating clients about the types of treatments that are available
and their relative effectiveness is part of responsible, evidence-based practice
(Gambrill, 1997) and establishes a foundation for treatment. Additionally,
patients are unlikely to benefit from the strategies learned in cognitive-
behavioral treatment if they lack a fundamental understanding of their ill-
nesses, relapse triggers, and the role that medication plays in maintaining
stability.

CONCLUSION

The state of the literature points not to development of practice guidelines
but to suggestions for methodological changes that must be made to generate
guidelines for adherence interventions. Specifically, studies must become
more rigorous in their design and implementation (e.g., conducting power
analyses prior to recruiting study participants and controlling for diagnosis,
symptom severity, and polypharmacy). Increased standardization is needed;
some studies are already manualized (Kluger & Karras, 1983; Hogarty, 2002),
whereas others are non-standardized across intervention sites (Spooren et al.,
1998). Future interventions that employ complex strategies informed by
multiple theoretical orientations should have the statistical power necessary
to partial out main effects, interactions, and multiplicative effects of the
interventions on adherence outcomes. These studies must clarify the specific
intervention components examined and be explicit about how the interven-
tions were conducted. Most important, target outcomes must be linked to

526 L. Townsend

specific interventions. For example, is cognitive-behavioral therapy useful
for both medication adherence and appointment attendance, or are different
interventions needed? Are these effects moderated by client population?

This review highlights a series of important research questions:

� Does intervention effectiveness differ by diagnostic category? (i.e., do
people with schizophrenia derive different benefits from adherence in-
terventions than people with depression or bipolar disorder?)

� Does symptom severity predict the level of benefit patients receive from
an adherence intervention?

� Are there fundamental components of multi-faceted interventions that gen-
erate greater adherence? Can interventions be pared down so that they
maintain effectiveness while consuming fewer practitioner and monetary
resources?

� What is the optimal length of an adherence intervention?
� What client factors predict response to adherence intervention? Are inter-

ventions moderated or mediated by particular client characteristics?
� How do clients themselves define adequate adherence?

Many of these questions are fundamental to our understanding of how
adherence interventions work (and how they fail). Until these questions can
be answered in a scientifically rigorous way, practitioners are left with enor-
mous gaps in their knowledge about which interventions may be effective
for clients. As the number of studies with proper standardization and controls
increases, further systematic reviews can be conducted, organizing interven-
tions according to theoretical orientation, diagnostic population, symptom
severity, or other relevant predictors. Only then can systematic reviews be
used to create practice guidelines that provide definitive information to assist
practitioners in making decisions about which interventions are appropriate
for their clients.

Presently, clinical practice can incorporate the elements of interven-
tions that have shown promise in the empirical studies conducted thus far.
Common elements of successful interventions include cognitive-behavioral
techniques that elicit patients’ own perspectives on medication; a collab-
orative stance between patients and providers that emphasizes patients’
decision-making abilities and freedom of choice; a comprehensive treatment
approach that educates patients about the advantages and disadvantages of
medication and skills to enhance their adherence; and consistent follow-
up so that providers have early awareness of problems their patients may
experience with treatment. These elements common to successful adherence
enhancement and improved patient outcomes are not only starting points for
further research but can be implemented readily by social workers and other
professionals whose work it is to help patients maintain stability and remain
active participants in their treatment.

Adherence Enhancement 527

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