9 Working with people to make choices about their treatment
• To recognise the differences between compliance and concordance approaches to making choices about treatment options
• To discuss the values and skills which aid and support concordance approaches in practice
• To identify the potential benefits of adopting a concordance approach to the management of medication
• To identify the challenges of implementing concordance approaches when applied to a mental health context
Compliance
Compliance in the context of health care is defined as ‘The extent to which a person’s behavior in terms of taking medications, following diets, or executing lifestyle changes, coincides with medical or health advice’ (Haynes et al 1979).
• They may disagree that they have a mental health problem and therefore do not see the need to follow the advice or treatment plans devised by mental health professionals.
• They may experience negative side effects of prescribed treatments which they feel are more disabling than the problem itself.
• They may view the treatment prescribed as unhelpful and not appropriate to address the problem as they perceive it.
• They may want to maintain their current lifestyle or some elements of their mental health problems as it gives them pleasure or is a significant aspect of their identity.
1. Consider an aspect of your lifestyle which you enjoy, for example a hobby, social activity or a way of relaxing.
2. Reflect upon how you would feel if you were asked not to engage in this activity any more because you were told it is potentially damaging to your health or may impact negatively on your social functioning.
3. What would influence your decision whether or not to follow the advice?
A number of service users have expressed their dissatisfaction with this approach to practice. It has been identified as disempowering as it doesn’t acknowledge the person’s perspective or take into consideration their knowledge of themselves (Perkins & Repper 1996). Furthermore, if the person does not agree with the treatment, they are unlikely to follow the plan as prescribed and therefore medication may be thrown away or appointments missed which can be a waste of resources.
In some circumstances a person may have been viewed as unable to contribute to a decision regarding their treatment due to the seriousness of their mental health problem. In these situations it would be appropriate for a Mental Health Act assessment to be undertaken or an assessment of the personal mental capacity. Parts of this legislation allow professionals to administer treatment against the person’s will if it is deemed in their best interests (see Ch. 4). However, it is important to acknowledge that if this is not the case, the person has the right to make an autonomous decision about their treatment even if the mental health professional feels that they could be putting their health at risk. See the scenarios below for examples.
1. John attends a drug and alcohol support service during the day and engages in the various therapeutic interventions which are aimed at reducing his drug use. However, in the evenings with his friends, he continues to smoke cannabis. The quantity and strength of the cannabis he smokes is seriously affecting both his physical and mental health, however it is how he keeps in contact with his friends and so he is reluctant to stop.
2. Sarah has been prescribed an antipsychotic which is known for causing weight gain. Despite the difficulties she is having with her voices, she is very conscious of her weight and feels her appearance is important to her self-esteem and wellbeing. She decides not to take her medication but will not discuss this with her care team because she is sure they will force her to go into hospital.
3. Wesley has been referred by his social worker to a group for young people who have experienced domestic violence. However, he doesn’t want to talk about his feelings to a group of strangers. In order to avoid going to the group he has been missing appointments with his social worker and refusing to talk to his mum about how he is feeling. He is becoming extremely isolated, his mood is getting consistently worse and he is having thoughts of suicide.
Concordance
Weiss and Britten (2003) state that ‘concordance is fundamentally different from either compliance or adherence in two important areas: it focuses on the consultation process rather than on a specific patient behaviour, and it has an underlying ethos of a shared approach to decision making rather than paternalism … it is not possible to have a non-concordant patient’.
1. A willingness to work in partnership with the service user and acknowledge their values, perspective and expertise.
2. An awareness of how the service user may view you as a professional and how this may impact on their willingness to be open with you about their views of their treatment.
3. A purposeful effort to engage with the person and build a therapeutic relationship.
4. The use of communication skills which enable the person to be open with you about their perceptions of the treatment options available.
In relation to medication management, it is beyond the scope of this book to provide you with a detailed explanation of each of the medications used in mental health services and how they work. Box 9.1 contains a brief explanation of the groups of medications commonly used in mental health services.
