Treatment Adherence
Written by: Dr. S
Director of Clinical Development
Treatment must be acceptable before an individual makes the considerable commitments of time, energy, money, and willingness to endure painful or distressing experiences in the service of making a change and improving life. Previous negative treatment experiences, negative relationship expectancies, external barriers to care, culture, attitudes, and ideological comments may all have an impact on clients’ readiness to accept help for alcohol problems (Zweben & Zuckoff, 2002).
A multitude of potential sources of non-adherence to treatment exist among individuals seeking help for alcohol problems. First, among these is the possibility that the client holds reservations about nature, extent, and severity of their alcohol problems. Associated with this is the possibility of misperceptions concerning treatment needs. For example, an individual may be interested in medication while the practitioner is interested in providing “talk” therapy.
At the very least, an individual must perceive that the proposed treatment would not be harmful before making a tentative commitment to following a particular change strategy. Individuals who do not believe that they have a problem that needs changing, and who are placed in a treatment program that they do not believe will be helpful, are most susceptible to having adherence problems.
In general, individuals who do not believe that they have a problem that needs changing, and who are placed in a treatment program that they do not believe will be helpful, are most susceptible to having adherence problems. The client may be ambivalent about whether the addictive behavior needs changing since the perceived costs of using may not yet outweigh the common benefits. Clients also differ regarding their expectancies and level of self-efficacy for handling treatment demands. Low self-efficacy may translate into low adherence. Clients may experience high barriers to care, including financial problems, cultural differences, family hardships, conflicting demands, and mandate treatment conditions.
Everyday concerns may be overwhelming to the extent that the task demands of a specific treatment plan may become unmanageable. An example might be trying to follow a complex pill-dosing regimen when there is no daily routine around which to anchor the schedule (e.g., no set meal times, irregular sleep preparations). As indicated above, clients may have barriers resulting from previous unsatisfactory or otherwise negative treatment experiences. Or, the current practitioner may have set into outcome operation expectancies with which the client is uncomfortable. For still others, the stigma that might be attached to seeking help for alcohol problems may interfere with entering or continuing in a treatment program. Individuals with adherence problems are often categorized as being “hard to reach,” “treatment resistant,” and “unmotivated.”
These labels result in clients being deterred or deferred from treatment programs. However, new evidence and the resulting insights have shifted the focus from a trait perspective that promotes labeling and client-blaming, toward an interactional perspective. Social workers are developing and implementing practices that facilitate client adherence. Considerable research supports the efficacy of planning and delivering treatment that incorporates the stages of change and motivation/ readiness processes. One promising example is the practice of Motivational Interviewing.
Motivational Interviewing(MI)
Motivational Interviewing is a critical element for facilitating treatment adherence and outcomes. Mounting evidence suggests a strong, positive relationship between treatment adherence and treatment outcome (Zweben & Zuckoff, 2002). In the field of substance abuse treatment, significant relationships have been found between treatment retention and symptom improvement, life functioning and patient well-being (Westerberg, 1998). In short, among substance abusing patients, the chances of success in both pharmacological and psychotherapy interventions are higher for those who adhere to the treatment regimen.
For these reasons, alcohol treatment providers have increasingly given systemic and administrative attention to moderating adherence problems. Motivational interviewing (MI) techniques have been shown to be effective in addressing adherence problems in individuals with alcohol problems. MI addresses both drinking and adherence by employing strategies aimed at producing motivational readiness. More specifically, MI attempts to modify unrealistic treatment expectations, resolve client ambivalence, and enhance client self-efficacy, to ensure and maintain participation in the treatment situation.
MI is a general concept or style of working with a client, not a specific set of techniques. MI has been employed both as an add-on to treatment and as an intermittent co-therapy with pharmacological intervention (Pettinati, Volpicelli, Pierce, & O’Brien, 2000) or conventional alcohol treatments (Brown & Miller, 1993). In these cases, MI has been shown to facilitate treatment retention and participation along with changing drinking behavior. MI has also been used as a stand-alone treatment specifically designed to address alcohol problems (Project MATCH, 1997). STAGES OF CHANGE (DiClemente & Prochaska, 1998)
Precontemplation
Contemplation Preparation Action Maintenance MI employs certain strategies to improve alcohol treatment adherence. These include issues of interview style that are culturally competent and appropriate, such as:
• Asking open-ended questions
• Conducting empathetic assessments
• Discovering the client’s beliefs
• Reflective listening (rather than asking for more information)
MI techniques also include strategies for motivating individuals toward making changes in their alcohol use practices:
• Normalizing client uncertainties
• Amplifying client doubts
• Deploying discrepancy (fostering cognitive dissonance)
• Supporting self-efficacy
• Reviewing past treatment experiences
• Providing relevant feedback (e.g., results of own tests motivates people)
• Summarizing and reviewing potential sources of non-adherence
• Negotiating proximal goals (i.e., opportunity to achieve “quick successes”)
• Discovering potential roadblocks
• Displaying optimism
• Involving supportive significant others
Bio: Sal Raichbach PsyD, LCSW joined Ambrosia Treatment Center in 2009 with the desire to help the company grow into the premier rehab of the Palm Beaches. Since then, the company has expanded to five locations nationwide. Sal has over 25 years of experience as an actively licensed psychologist in Florida, New Jersey, Nevada and New York. He earned both a doctorate in Psychology, as well as a Masters degree in clinical social work.
