Take your meds!

by Stars Training Academy   5 Comments

It’s a commonly heard exhortation and plea to young people enrolled in TAY programs around the country. I frequently hear concerns from TAY providers about “non-compliance” to prescribed psychotropic medications and questions about how to best respond and overcome this “treatment resistance”. Many young people may simply pose the challenging question of “why should I take meds?” My response in the past has been to peremptorily say something like; “to correct a chemical imbalance” and then redirect them to their psychiatrist.

I now advocate for a much different response to these young people identified with serious mental health conditions. Like most emerging adults, questioning authority is a time-honored and empowering activity. Informed consent is more than a form to be signed, it is a cornerstone of recovery-oriented programs and requires patience, proactive education and careful listening. In my opinion, the terms “non-compliance” and “treatment resistant” do not belong in the TAY providers’ vocabulary. These young people deserve validation and support for posing these important questions, and require more than pat, dismissive answers or automatic efforts to get them to comply.

“What’s up?”

I currently train TAY providers to utilize a Transition to Independence Process (TIP) tool called “What’s up?” (based on Motivational Interviewing and stages of change theory). The TAY provider’s task becomes one of facilitating the young person’s self-exploration of “what’s working and what’s not” in regard to their use of psychotropic medications. We may then offer in-vivo coaching and role-playing to the young person, as a way to practice self-advocacy with their psychiatrist. (My personal experience in talking with hundreds of young people with emotional and behavioral difficulties is they quite often don’t know why they are supposed to take medications and feel their concerns about the potential down-sides of medications may be minimized.) “Medication collaboration” might be a better term for this kind of partnering approach between young people, their psychiatrists and TAY staff.

I believe TAY programs and TAY providers must pay particular attention to this sensitive issue, in order to successfully engage and empower youth and young adults to make decisions regarding their own health care.

 

How do you respond when young people ask you; why should I take meds?

{ 5 comments… read them below or add one }

Chad Costello July 11, 2012 at 10:41 pm

Spot on sir!

If someone chose to not take their heart medication because of the side effects, most helping professionals would chalk it up to informed patient choice. The second a psych diagnosis is attached to someone, such choices are immediately relegated to the realm of competency.

What other kind of business could get away blaming the customer when the product they’re pushing doesn’t work as advertised at least half of the time?

I’d be willing to bet that the average GP prescribing both heart medications and psych medications to the same patient would treat the patient’s decision to forgo the heart meds as one of choice and a similar decision to forgo the psych meds as one of anosognosia.

“Non-compliance” is provider shorthand for “I give up” – giving up should be removed from our vocabulary.

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Karyn Dresser July 12, 2012 at 9:14 pm

We like to offer tips for TAYYA about the kinds of questions they might ask their doctor about medications, such as:

1. Are there alternatives or social interventions that we might try before using medication, or effectively used in combination with medication, which may help lower the required medication dose?
2. Does research support the use of the medication for someone of my age, size, physical condition and needs? Has the research shown this medication is effective for my diagnoses?
3. Does taking the medication affect how my body handles other medications? (Please be prepared to list other medications by name, dose, and frequency of use.)
4. How does the medication fit within the overall treatment plan and how will we coordinate with other treatment, such as therapy, school/community plans, and more?
5. What should I be looking for in changes in behavior, changes in symptoms, and whom should I contact with questions about these changes and the medication?
6. What are the potential risks and benefits of the medication and other treatment options, and what are the potential side effects?
7. How will we (you as physician and me as the client) monitor progress, behavior changes, symptoms and safety concerns?
8. How will I know when it is time to talk about stopping medication treatment and what steps need to occur before stopping the medication?
9. How can we best develop a clear communication plan between you as physician, me as the client, and the other treatment providers to ensure open lines of communication so we are all on the same page about medications and treatment at all times?
10. What if I have a crisis and/or I am hospitalized? Whom can I contact in your office, especially if someone wants to change medications?

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Mark Ragins MD, Medical director MHA-LA Village July 13, 2012 at 2:56 pm

Creating widespread effective collaborative medication relationships will take far more than teaching TAY some good questions. I’ve been writing about this for over 20 years (check out http://mhavillage.squarespace.com/writings/) but Whittaker has added an enormous amount of energy and urgency to the conversations. Unfortunatley, like many issues in our country, including involuntary treatment, we rapidly move to a highly polarized, simplified discussion – meds good vs. meds bad – and then become vehementally opposed to the other side. If we’re going to help TAY with their daily challenges we’ll have to do much more. Here are four thoughts of mine, where the conversation could go:
1) I believe that the major goal of serving TAY is building adult self responsiblity – for their housing, jobs, money, sex, emotions, behaviours, getting over past traumas, substance use, treating their mental illnesses, having their own children…their whole lives. All our services should be self responsibility building. Taking self responsiblity for your illness treatment is not at all the same as becoming obedient to doctors and complying with their orders, any more than independent living is the same as complying with your landlord or your parents. They need to develop internal controls not increase fear of external controls. Informed consent is a tool of compliance, not of client driven services. Tools for self responsible use of medicaitons include shared decision making, motivational interviewing, shared personal experimentation and learning, building personal understanding and buy-in. We have to use whatever tools meets them where they’re at.
2) A study a few years ago in the New England Journal of Medicine found that between 1995 and 2005 the number of 12-19 year olds diagnosed with Bipolar disorder and treated with mood stabilizers and/or antipsychotics went from 20,000 to 800,000. While some would applaud that increase as the falling of the wall of stigma and young people finally getting the care they need and deserve, others scratch our heads and wonder what else is going on. My main concern is that presently our process of interaction with young people is a diagnostic evaluation and it’s end point is a diagnosis and medication. I think that ending there is actually depriving many young people of further healing interaction. We tend to be satisfied we’ve done our jobs when we make a diagnosis and get them to take their meds and don’t often enough keep moving forwards with them building enough trust to find out that they’re being sexually molested, teased at school, unable to cope with illiteracy or racism or bullying or military basic training or combat or realizing they’re homosexual or getting a hidden abortion, or using drugs, or their parents divorced, or they were raped, or heartbroken after their first love betrayed them, or struggle with a distorted body image, cutting behaviors, panic attacks, etc. etc. It seems to me that too often more diagnosis and medications are correlated with less understanding and therapeutic relationships.
3) There has been a controversy over whether SSRI antidepressants increase adolescent suicidal related behaviors. On the one side were tearful traumatized families talking to congressional hearings and on the other side calm rational professionals explaining that there isn’t any biology or data to support that connection. The outcome was a black box warning on SSRI’s in the insert and a dramatic temporary decrease in their usage with unclear impact. I didn’t hear any discussion about if the increase in suicidal realted behaviors might not be a biological phenomenon but actually a psychological phenomenon caused by adolescents’ reaction to telling someone about some of their emotions and getting diagnosed with a mental illness and medicated for it. How often is the process itself of diagnosis and medication as we currently practice it traumatic and leads to increase hopelessness, isolation, and feelings of suicidality? A successful therapeutic relationship requires trust, a shared story of what’s wrong, and a shared plan of what to do to recover. How often does our present prescribing practice actually include those requirements? Informed consent is not a short cut to get there.
4) With the enormous increase in medicaitons has not come an enormous increase in psychiatrists. Needless to say, we did not train 40 times as many adolescent psychiatrists between 1995 and 2005 We’re coping with this by increasing case loads and decreasing time spent with each person and trying to pass more prescribing to already overwhelmed primary care doctors. Psychiatric care is deteriorating rapidly as a result. I don’t think that the medications are able to prescribe themselves even in an internet infomrmed world. i’d propose that there be a tax on each pill that would go to funding more medical schools to increase responsible prescription.
That’s my 2 cents worth.
Take care,
Mark

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Ellen Frudakis July 19, 2012 at 6:41 pm

This is a great topic, thank you Wayne for opening up the discussion!

I too experience the labeling of young people as “non-compliant” to be a divisive solution to a difficult (and what many times feels like impossible) situation. Being on the leadership team of Impact Young Adults, a TAY consumer-run nonprofit (and being a grown-up TAY myself), means I have seen and experienced the benefits that come when opportunities for independence and self-expression are made available. It is even more empowering when you can feel that you are supported in that process, despite the mistakes and blunders that are common with inexperience.

I have also come to understand the providers frustration in the last few years as I have expanded my advocacy work. There haven’t been a lot of alternatives available on how to support and manage recovery gridlock. I am inspired and encouraged to hear about the TIP model and look forward to learning more!

– Ellen Frudakis
Co-President/Co-Founder, Impact Young Adults
Program Director, Impact MORE
San Diego, CA

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Angela Igrisan, LCSW Riverside County Deparment of Mental Health Administrator August 17, 2012 at 6:24 pm

Thank you for the considerate article and comments. I whole heartedly agree that the terms ‘resistance’, ‘non-compliance’, and ‘non-responsive to treatment’ need to be eradicated from the vocabulary of not only TAY providers, but all human service practitioners. We all remember our not so distant history when lobotomies were the standard of practice and those who tried to opt out of this treatment were ‘non-compliant’.

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