Health Professionals
Since the year 2000, we have received countless requests from visitors to our website and readers of “I am Not Sick, I Don’t Need Help!” (Vida Press, 2012) for information on how to attend LEAP trainings. These requests have come from Mental Health Care Providers (HCPs) in addition to others who try and help persons with mental illness. In that time we have trained tens of thousands of HCPs (doctors, psychologists, nurses, social workers, case managers, peer-counselors, etc.).
Relationships between HCPs and persons with serious mental illness are often characterized by mutual distrust (whether stated openly or implicitly), disagreements, and a loss of respect for the other person’s point of view. This stems from many of the symptoms of schizophrenia, bipolar disorder and similar illnesses (including unawareness of illness and paranoia). It stems also from HCPs not having the communication tools needed to bridge the interpersonal chasms these symptoms create.
At the root of the relationship breakdown is the very poor adherence to treatment seen in schizophrenia and similar disorders and our use of outdated communication strategies for dealing with it.
When you start a patient with schizophrenia on oral anti-psychotic medication, research suggests you can expect:
Within 7 to 10 days of medication initiation (Keith & Kane, 2003)
· 25% are non-adherent
· 50% are off medication after 1 year
· 75% after off medication after 2 years (Rummel-Kluge, 2008)
Who is on medication reliably? Only about 33% reliably take medication as prescribed (Oehl, 2000).
Poor adherence is associated with a poorer course of illness, increased involuntary hospitalizations, suicide, poorer subsequent response to treatment, criminal behavior, failure to reach optimal levels of recovery and importantly, estrangement and discord with caregivers and HCPs
Deficits in insight (a.k.a. anosognosia see DSM IV-TR, American Psychiatric Association Press, 2000, page 304) are very common. Not surprisingly, anosognosia predicts poor and partial-adherence. After all, who would want to take medication for an illness they did not believe they had? Research shows that poor insight is among the top predictors of poor adherence, far more predictive than the person’s experience of side effects. Watch this brief interview with Dr. Amador and hear how you can overcome these obstacles to stabilization and recovery and how LEAP Techniques can also help to strengthen the therapeutic alliance between you and the patients you are trying to help.
- Build Trust – Heal Relationships – Become Partners -
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Scope of the Problem
Poor and partial-adherence to treatment presents staggering obstacles to recovery. It is associated with a poorer course of illness, increased involuntary hospitalizations, suicide, poorer subsequent response to treatment, estrangement and discord with caregivers and providers, criminal behavior, and failure to reach optimal levels of recovery. In light of the tremendous advances made in the treatment of schizophrenia and bipolar disorder, the tragedy of both untreated, and inadequately treated, mental illness is compounded. The urgency to implement strategies that optimize adherence and recovery has never been greater.
Non-adherence
Non-adherence rates in schizophrenia and bipolar disorder continue to hover around 50% while partial adherence rates are even higher (75%). Considering that millions of people either flat out refuse to participate in treatment, or if they do, practice only partial-adherence, the “real-world” effectiveness of both the older, and more promising newer treatments, is abysmal.
Deficits in insight
Deficits in insight (a.k.a. “anosognosia” see DSM IV-TR, American Psychiatric Association Press, 2000, page 304) are very common. Not surprisingly, anosognosia predicts poor and partial-adherence. After all, who would want to take medication for an illness they did not believe they had? Research shows that poor insight is among the top predictors of poor adherence, far more predictive than the person’s experience of side effects. Although recent innovations in drugs used to treat these disorders have addressed many of the limitations of traditional antipsychotic medications (e.g., severity of side effects, aspects of cognitive dysfunction), they still do not deal with the problem of poor adherence to treatment.
Improving insight and adherence
Unfortunately, medications do not appear to impact significantly on level of insight, on the other hand, various forms of cognitive therapy and motivational interviewing have been found to improve adherence dramatically. More recently, studies testing the efficacy of such interventions using psychiatric nurses and family members in patents with schizophrenia suggest that extensive professional background is not needed to be effective. Indeed, training caregivers in the LEAP™ approach is especially effective as there are many more opportunities for interaction than is afforded providers. Furthermore, maladaptive communication patterns in the family are usually improved reducing expressed emotion, discord, and estrangement.
Summary
Because of poor insight into the illness and poor adherence to treatment many persons with schizophrenia and bipolar disorder exist at the margins of society and are unable, or oftentimes unwilling, to utilize available drug therapies and services. A set of communication and problem solving skills that can be used by mental health providers, care-givers and other stakeholders can be readily learned by participating in the LEAP™ training program. Below, we describe LEAP™ training in more detail.
