How to Achieve Medication Compliance


By Dr David Laing Dawson

posted with permission from the blog Mind You by Dr David Laing Dawson and Marvin Ross

Anosognosia is an unwieldy word meaning lack of insight, or, literally in translation, `without- disease- knowledge`.  In the case of some brain injuries or stroke the brain may become quite specifically unaware of what is missing. The part of the brain that would perceive this is damaged. With mental illness, schizophrenia, bipolar, the apparent lack of insight  or denial of obvious impairment or implausible grandiosity may be more nuanced and variable. It may be part defensive in nature; it may be more a denial of the consequences imagined; it may be more about the power relationship at hand. Some of it may be merely human, the unwillingness to give up a longstanding belief, whether that be of the second coming,  CIA surveillance and persecution, or of being chosen, special, destined for greatness.  Some of it may be a distorted form of the normally complex parent – adult child relationship.

But almost every family with a severely mentally ill member must deal with, at least once, that time when the ill member claims to be fine when obviously not, and refuses to take medication or go for an appointment to the doctor.

How to approach this. What options do you have. Below is an outline for talks I have given on the subject:

Stage 1

  • Calm and slow
  • Non-threatening (posture, position (e.g. side by side), distance, tone, pace)
  • Aim for a negotiated reality. (not the acceptance of your reality)
  • i.e. He may not be willing to admit he is ill or delusional or needs medication but may be willing to agree that he is in trouble, anxious, not well, in pain, not sleeping, and that in the past the pills have helped with that. He may by his behavior be willing to take pills or come for an appointment as long as he doesn’t have to admit to need or illness.
  • Gently find out what he or she fears.
  • Gently find out what his objections are.
  • Allay these objections and seek a “negotiated reality”.
  • Stay away from labels, declarations, and you defining his reality.
  • Offer pill with glass of water without saying anything.

Stage 2

Family intervention, same tactics as above but with whole family or available members, or a specific family member with influence.

Stage 3

Ultimatums. (You can`t live here unless…..)

But before doing this you should assess the level of risk (provoking violence, and/or leaving and putting self at risk). Discuss in family plus with a professional. Must also assess realistically your tolerance for confrontation, anxiety, worry, guilt. And ultimatums are only effective if truly meant, if you are truly willing to carry through with the ultimatum. If the ultimatum works, do not reiterate it unnecessarily.

Stage 4.

Form 1, J.P., Court order, Police intervention.

Before doing this decide on desired outcome, assess odds of achieving this desired outcome as best as possible (i.e. is there a treatment that works? Will they keep him or her long enough? Does the trauma of this kind of intervention justify the long-term outcome?)

Having decided on desired outcome, use all resources to achieve this. Learn the wording of the Mental Health act to get desired outcome. Use this wording to your advantage. Find family mental health friendly lawyer. Discuss with the health professionals who will be receiving the family member.