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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Illness Management and Recovery Workbook
Chapter 6
Practitioner Guidelines for Handout #5:
Using Medication Effectively
Introduction
This module gives people an opportunity to become more knowledgeable about
medications and how they contribute to the recovery process. It encourages a
discussion of both the benefits and side effects of taking medications, and
helps people make informed decisions based on their personal preferences. For
people who have decided to take medications, but have difficulty doing so on
a consistent basis, strategies are provided for behavioral tailoring and simplifying
the medication regimen, which help people incorporate taking medications into
their daily routine.
Goals
- Provide accurate information about medications for mental
illness, including both their advantages and disadvantages.
- Provide an opportunity for people to talk openly about their
beliefs about medication and their experience with taking various medications.
- Help people weigh the advantages and disadvantages of taking
medications.
- Help people who have decided to take medications to develop
strategies for taking medication regularly. These strategies include behavioral
tailoring and simplifying the medication regimen.
Number and pacing of sessions
“Using Medication Effectively” can usually be covered in two to
four sessions. Within each session, most people find that covering one or two
topics and completing a questionnaire is a comfortable amount.
Structure of Sessions
- Informal socializing and identification of any major problems
- Review the previous session.
- Discuss the homework from the previous session. Praise
all efforts and problem-solve obstacles.
- Follow-up on goals.
- Set the agenda for the current session.
- Teach new material (or review material from the previous
session if necessary).
- Summarize progress made in the current session.
- Agree on new homework assignment.
Strategies to be used in each session
Motivational strategies
In this module, it is important to avoid lecturing or preaching about medications.
It more effective to take a neutral, open-minded approach, helping people come
to their own conclusions about what is best for them.
When talking about medication, encourage people to explore the advantages
and disadvantages of taking medication from their own point-of-view. People
who come to believe that taking medications will improve their lives become
motivated to take medications regularly. If people don’t see how medications
will help them, they are unlikely to take them.
The following suggestions may be helpful:
- Keep in mind that common motivations for taking medication
include decreasing symptoms, relapses and rehospitalizations, increasing independent
living, and improving relationships.
- When teaching about medication, bear in mind the personal
goals identified in the earlier sessions. There may be opportunities to explore
whether taking medication could help someone achieve one of his or her goals.
For example, if someone identified the goal of working, but has previously
had difficulty keeping a job because of rehospitalizations, you could explore
whether taking medications effectively might help prevent rehospitalizations,
and therefore increase the person’s ability to
keep a job.
- For each major topic covered in the handout, explore the
person’s experiences. Most of the sections provide prompts in the form
of questions, which can be used to facilitate discussion.
For example, when reading the section “How do you make informed decisions
about medication?” Practitioners can ask people if they felt they had
enough information in the past to make informed decisions about taking medication
and whether they had an active partnership with their doctors. That is, practitioners
can ask whether people felt they were listened to by their doctor and whether
they felt their concerns were taken into account by their doctor.
In the section “What are your personal beliefs about medications?”
the practitioner can ask people whether they tend to feel positively or negatively
toward medications or whether they have mixed feelings. The practitioner could
also ask whether one of the quotations in this section reflects their own
beliefs. It is also helpful to explore the basis of these beliefs. For example,
a person raised in an Asian culture may have been taught that Western medicines
are harmful. Or a person may have been taught to believe that taking medications
is a sign of weakness.
- The questionnaire “Pro’s and Con’s of
Taking Medications” helps people to list all the advantages and disadvantages
of taking medications. For people who have been ambivalent about taking medications,
this will be an opportunity to look at all the available information and make
an informed decision. For those who have already made their decision, this
will be an opportunity to reevaluate or confirm their decision. The practitioner
should avoid rushing through this questionnaire, using probe questions to
help people come up with as many pros and cons as possible.
For example, practitioners can ask questions such as the following:
- “You mentioned that you don’t like feeling
drowsy with your medication. Would ‘makes me feel drowsy’
belong under the ‘con’ column?”
- “Remember when you told me you had a relapse the
last time you stopped taking medications? Would ‘helps avoid relapse’
belong under the ‘pro’ column?”
- The practitioner should show an appreciation of people’s
experience and knowledge. Thank people for talking about their thoughts and
feelings. Take breaks to summarize people’s comments and to make sure
you have understood them correctly.
For example, if a person talks about unpleasant events that occurred during
a relapse, the practitioner might reflect, “If I understand correctly,
you were homeless and hungry for several weeks. It sounds like you don’t
want to end up in such a dangerous situation again.” Or if a person
describes a negative experience with medications, the practitioner might reflect,
“That sounds extremely unpleasant. From what you say, it made you feel
distrustful of medications.”
Educational strategies
Educational strategies for this module focus on increasing people’s
knowledge about medications, including both the benefits and the side effects.
The primary message about medications is that for most people they are effective
at decreasing symptoms and preventing relapses. The side effects of medications
vary somewhat from one medication to another, but are generally quite safe.
Each person’s response to medications is unique, however, and each person
has a right to make his or her own decision regarding medications.
The following educational strategies were discussed in detail in Module 1:
- Review the contents of the handout by summarizing or taking
turns reading paragraphs.
- Pause at the end of each topic to check for understanding
and to learn more about the person’s point-of-view.
- Allow plenty of time for questions and interaction.
- Pause to allow the person to complete the checklists and
questionnaires.
- Break down the content into manageable “pieces.
- Find a pace that is comfortable to the person.
Cognitive-behavioral strategies
Cognitive-behavioral strategies focus on helping people decide how they might
use information from this module to think differently or behave differently
regarding medication.
One of the most important cognitive-behavioral strategies for helping people
use medication more effectively is behavioral tailoring. This technique involves
practitioners working with people to develop strategies for incorporating medication
into their daily routine (e.g., placing medication next to one’s toothbrush
so it is taken before brushing teeth). Behavioral tailoring may also include
simplifying the medication regimen (e.g., taking medication once or twice a
day instead of more often).
In each session, the practitioner can help the person think of ways that he
or she might use the information learned in that session. The following examples
may be helpful:
- When the topic “How do you make informed decisions
about medications?” is discussed, some may people say that they have
previously felt uncomfortable asking their doctors questions about medications.
In the session, people can review “Questions to Ask Your Doctor”
and role-play how they might ask their doctor some of these questions. Homework
could include setting up an appointment with the person’s doctor in
order to ask questions.
- After the topic “If you decide to take medications,
how can you get the best results?” practitioners can use the principles
of behavioral tailoring, asking people to choose one of the strategies provided
in the educational handout and helping them to tailor it to their own specifications.
They can practice parts of the strategy during t
he session.
- One example of using behavioral tailoring involves helping people fit taking
medication into their daily routine. Some people say they have difficulty
remembering to take their medication, but always remembers to brush their
teeth. Practitioners could suggest that they might try the strategy of attaching
their medicine bottle to their toothbrush, using a rubber band.
- Another example of using behavioral tailoring would be helping people to
select cues that will help them remember to take medication regularly. Practitioners
could help people develop a chart or calendar they could post on their refrigerator.
They could use the chart or calendar in the session to practice writing down
the medication that they took the day of the session and the day before the
session. Using the calendar at home could be part of homework. Or they could
write a note to themselves and tape it on the coffeepot so they will see it
when they make coffee for themselves in the morning.
Still another example of behavioral tailoring would be simplifying the medication
schedule to make it easier to remember and easier to fit into people’s
routine. Practitioners can help people review their current medication schedule
and role-play asking their doctor about the possibility of prescribing a less
complicated regimen.
- After completing the sections on “What are the side
effects of medications?” the practitioner could ask people to identify
which medications they are currently taking and which side effects they have
experienced. If people have not talked to their doctors about these side effects,
they can role-play what they might say to
their doctor.
- For people who have been experiencing side effects, the
practitioner could ask them to choose a relevant coping strategy from Appendix
#5, “Coping with Side Effects.” The practitioner can model how
to use a particular strategy in the session (e.g., muscle stretching exercise
to help cope with muscle stiffness) and role-play with the person how to use
the strategy himself or herself. Homework can involve practicing the strategy
at home.
(Note that it is important to remind people to always report side effects
to their doctor and make sure that specific coping strategies are not contraindicated
for a
medical reason.)
Homework
It is important that the practitioner assigns homework that is consistent
with people’s decisions about taking medication. For example, people who
have decided to use medication as part of their recovery might benefit from
homework that helps them develop a routine for taking their medication at home.
However, this homework would not be appropriate for someone who is firmly against
using medication.
The practitioner should follow up on homework assignments in the next session
by asking how it went. Reinforce completed homework or the effort people have
made to complete homework. If people were not able to complete the homework,
the practitioner can gently ask them what got in the way and help them develop
(and sometimes practice) ways of overcoming obstacles.
The following examples of homework may be helpful:
- Review the list of “pros and cons of medication”
with a family member or other supportive person.
- Implement a strategy for taking medication on a routine
basis that was developed as part of behavioral tailoring. For example, use
a rubber band to attach the medication bottle to one’s toothbrush, post
a note to remind oneself to take medication at the same time each day or refer
to a list of the benefits of taking one’s medications. Involve family
members and other supportive people whenever possible.
- Talk to the doctor about problematic symptoms or side effects.
- Ask the doctor or nurse specific questions about medication.
- Talk to family members or other supportive people about
their views about medications.
- Review the relevant information sheets in the Appendix
and note which medications were taken in the past and the benefits and side
effects of each.
- Implement a strategy for coping with side effects (such
as scheduling naps to counteract drowsiness, chewing gum to reduce dry mouth,
eating more high fiber foods to counteract constipation, and regular exercise
to combat weight gain) with input from the person’s doctor or nurse.
- Involving family members or other supportive people in
a strategy for coping with side effects or getting the best results from medication.
For example, people who are apprehensive about asking their doctor about changing
their medication might appreciate having a family member accompany them to
some of their doctor’s appointments for support and encouragement.
- Consult with the doctor about simplifying the medication
regimen. The goal is to have the fewest amount of different medications taken
the fewest times per day.
Tips for common problems
- People may say that they do not have a mental illness and
do not need medications.
See “Tips for common problems” in Module #3.
- For some people, medications are a very controversial topic.
They may have strong beliefs that medications are not helpful for them or
are harmful to them.
- It is important to avoid directly challenging or arguing with people about
medications. Instead of becoming adversarial, try to understand the person’s
point of view and encourage him or her to keep an open mind for the future.
- Also, although some people are adamant about not needing medication, they
often acknowledge that other people benefit from it, and are willing to talk
about medication in that light.
- Some people have had unpleasant experiences with medications.
- Sometimes people develop misconceptions about medications based on past
experiences, and their beliefs may change when new or corrective information
is provided. For example, if a person had a severe dystonic reaction to a
high dose of antipsychotic medication in the past, he or she might conclude
that all such medications would produce a similar response. However, this
is not the case, especially if low doses are used at first.
The best overall strategies when people have strong negative beliefs about
medications are:
- provide accurate information
- ask clarifying questions
- use reflective listening
- explore ambivalence about the good and bad things about
medication
- explore whether taking medications could help the person
achieve his or her goals
Review Questions
At the end of this module, the practitioner can use either open-ended questions
or multiple-choice questions to assess how well the person understands the main
points.
Open-ended questions
- What are some of the benefits of taking psychiatric medications?
- What are some of the side effects of taking psychiatric
medications?
- What does it mean to make an “informed decision”
about medication?
- How could you fit taking medication into your daily routine?
- For you, what are the pros and cons of taking medication?
Multiple choice and true/false questions
- Which of the following is a benefit of taking medications for mental
disorders?
They reduce pain and swelling
They improve symptoms and prevent relapses
They cure mental disorders
- Which of the following is an example of a side effect of taking
medications?
Drowsiness
Tooth decay
Hearing loss
- It is a bad idea to ask the doctor or nurse questions about medications
and how they will affect you. True or False
- To get the best results from medications it is a good idea to:
Take the medication at the same time every day
Change the dose of medication depending on the day
Take it whenever you feel the need
- Medication affects people in different ways. True or false
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