By F. Asam. University of California, San Diego.
Whilst most researchers define insight as awareness of having an illness 0.625 mg premarin fast delivery, others suggest that it is a multidimensional construct which also encapsulates awareness of the consequences of the illness and the need for treatment (Amador et al purchase premarin 0.625mg visa. These findings order 0.625 mg premarin visa, thus, highlight how insight that 277 operates at, and influences, the different stages of the illness experience, including pre-diagnosis, diagnosis, during and after relapses and during the maintenance treatment phase. Another important consumer-related factor which emerged strongly in interview data related to reflection on past experiences. That is, interviewees frequently reported that reflecting on their past experiences of adherence or non-adherence, and the associated consequences, influenced their decisions to take or discontinue taking their medication. Interviewees could frequently be seen to indicate that reflecting on their experiences also facilitated gains in insight; however, it could also be argued that insight is required in order to be able to reflect on past experiences. Furthermore, the reflection on experiences factor could be similar to the concept of retrospective insight, as raised by Amador et al. The reflection on experiences factor is novel as it has not yet been established in the literature. In actuality, the notion that negative past experiences of non-adherence can influence consumers to be adherent in future, as part of a learning process, contradicts the results of prospective studies which suggest that the strongest predictor of future non-adherence is recent past non-adherence (i. It could also be seen to challenge the prevailing view in the healthcare system that significant attempts should be made to avoid relapse amongst consumers. Whilst the findings do not dispute the potentially devastating consequences of symptom relapse for consumers, relapse associated with medication non-adherence may actually represent an experience that consumers can draw on to reinforce to them the benefits of taking medication. For example, McGlashan, Levy and Carpenter (1975) proposed a continuum of recovery styles amongst people with schizophrenia, ranging from “integration” to “sealing over”. An interview study was conducted, whereby consumers were interviewed 12 months following an acute episode. Sealing over was indicated when consumers demonstrated a preference not to think about, and discuss, their psychotic experience during recovery. Those consumers whose accounts were categorised as integration, on the other hand, manifested an interest in psychotic experiences during recovery and were willing to discuss these experiences in an effort to learn more about themselves. Responses from both groups were evaluated and researchers concluded that integrators displayed an awareness of the continuity of their personality before, during and after acute episodes, took responsibility for their symptoms, and were flexible in their thoughts about them. Those who were classified as sealing over tended to resist thinking about their experiences of psychotic episodes and, when confronted by others, were unaware of aspects of it. They additionally viewed psychosis as alien and caused by some force outside themselves. The differences in awareness/insight described by McGlashan, Levy, & Carpenter (1975) relate to past events (retrospective awareness/insight) and have been interpreted as reflecting coping strategies applicable to other stressful life events besides having schizophrenia (Amador et al. It could, therefore, be argued that the sealing over and integration coping strategies could also be applied to consumers’ experiences with medication (which also relate to illness experiences). Integration 279 appears similar to the reflection on experiences code, as in the relevant extracts, interviewees took ownership of, and demonstrated and a willingness to discuss, their illness and medication experiences. Furthermore, they directly stated that reflecting on these experiences facilitated learning. Wciorka (1988) proposed that consumers’ willingness to be reflective about their illness represented a dimension of their attitudes towards their illnesses in addition to identification of the illness with themselves and evaluation of their illness. These results were based on data collected from an interview study in which participants were encouraged to talk about their subjective definitions of their illnesses. The three dimensions were interpreted as reflecting the cognitive, evaluative and reactive components of attitude toward illness (willingness to be reflective representing the reactive component). Even if this is the case, whilst the relationship between insight and adherence has been thoroughly tested, limited attention appears to have been given to the specific relationship between reflecting on past experiences and adherence. Another possible explanation for the surprising absence of reflection on experiences in previous adherence research could be because previous studies have primarily tended to focus on factors associated with non- adherence rather than adherence. Additionally, previous studies may have failed to ask participants about, or overlooked, the cognitive processes underlying their adherence decisions. For example, rather than considering the process of reflecting on experiences as an influence in itself, researchers 280 may have focused on the content of those experiences, such as hospitalisation, and associated the content of specific past experiences with adherence or non-adherence. Another possible explanation for this difference could relate to the nature of the present study sample. Specifically, to reiterate, the sample was comprised of outpatients with schizophrenia, who were predominantly adherent to their present medications. This group of consumers may have had enhanced reflective capacities when compared to first episode consumers, for example, as their symptoms were largely stabilised, most demonstrated insight in relation to their illnesses and the mechanism of medication and, importantly, they had experiences to draw on. Future research could explore whether the reflection on experiences code is replicated by consumers at different stages of their illnesses. Following on from the insight and reflection on experiences code was the self-medication code. Self-medication in the present context refers to consumers deciding to start, adjust or stop taking prescribed medication according to their perceived health needs (Mitchell, 2007). Interviewees occasionally reported that they self-medicated with their prescribed medication to address symptom fluctuations or kept a store of medication to prolong periods between depot administrations. In relevant extracts, interviewees demonstrated insight in relation to their symptoms and triggers for relapse.
Anne buy premarin 0.625mg line, a graduate student in social work buy generic premarin 0.625mg on line, has to meet each week with her advisor for supervision of her casework premarin 0.625 mg without a prescription. Anne does plenty for her clients; she does anything that she thinks they may need help with — spending hours of her own time, even running errands for them if they ask. Her supervisor tries to tell her to pull back from giving excessive help to her clients; he says that her bending over backwards to assist clients doesn’t help her or her clients. However, Anne’s worst fears surround the required presentations in front of graduate school classmates. Before giving talks to her classmates, she spends an abundance of time in the bathroom feeling ill. During lively dis- cussions in her class, Anne remains quiet and almost never takes sides. Well, a cost/benefit analysis of Anne’s approval schema reveals that people walk all over her. It also shows that fellow students fail to appreciate how bright she is, because she rarely speaks up in class. Anne neglects her own needs and at times feels resentful when she does so much for others and they do so little to return the favor. Sure, she rarely receives criticism, but because she takes so few risks, she never gets the approval and praise that she really wants. Reviewing vulnerability The anxious schema of vulnerability plagues people with worries about their safety, livelihood, and security. People with this schema often receive a diagnosis of Generalized Anxiety Disorder (see Chapter 2). Peter, a college graduate with a business degree, receives a promotion that requires him to move to California, but he turns it down because Chapter 7: Busting Up Your Agitating Assumptions 113 he fears big cities and earthquakes. Peter watches the weather chan- nel and listens to the news before he ventures any distance from home and avoids driving if the radio reports any chance of inclement weather. He also worries about his health and often visits his doctor, complaining of vague symptoms, such as nausea, head- aches, and fatigue. Peter’s doctor suggests that his worry may be causing many of his physical problems. He tells Peter to fill out a cost/benefit analysis of his vulnerability schema, which you can see in Table 7-4. Table 7-4 Cost/Benefit Analysis of Peter’s Vulnerability Schema Benefits Costs I keep myself safe. I’m so concerned about getting hurt that I’ve never enjoyed things that other people do, such as skiing or taking trips abroad. I am more careful than most people about I worry so much about tomorrow saving for retirement. My doctor tells me that my worry probably harms my health more than anything else. Someone as entrenched as Peter in his vulnerability schema certainly isn’t going to give it up just because of his cost/benefit analysis. However, this analysis starts the ball rolling by showing him that his assumption is costing him big-time. Counting up control People who have an anxious control schema only feel comfortable when they hold the reins. They fear that others won’t do what’s necessary to keep the world steady and safe. Jeff takes pride in the fact that, although he asks for plenty, he demands more of himself than he does of his employees. Although known for productivity, his division is viewed as lacking in creativity and leads all others in requests for trans- fers. The real cost of Jeff’s control assumption comes crashing down upon him when, at 46 years of age, he suffers his first heart attack. Jeff has spent many years feeling stressed and anxious, but he never looks closely at the issue. Debating dependency People with a dependency schema turn to others whenever the going gets tough. Unfortunately, people with the anxious depen- dency schema often lose the people they depend on the most. At the beginning of their relationship, Dorothy was fond of Daniel’s constant attention. Today, he still calls her at work three or four times every day, asking for advice about trivia and sometimes seeking reassurance that she still loves him.
Peer workers were frequently positioned as more relatable and credible than other health professionals cheap premarin online, who lacked direct experience of having a mental illness and taking antipsychotic medication order premarin master card. The role of peer workers in promoting medication adherence has not previously been explored extensively (if at all) and discount 0.625mg premarin amex, thus, may represent an avenue for future research. Additionally, peer workers involved in the present study reported that their experiences in this role were positive and empowering, consistent with recovery literature, which suggests that participation in consumer-run programs may be instrumental in motivating a person to sustain treatment and rehabilitation (Liberman & Kopelowicz, 2005). Evaluations of case managers, by contrast, were mixed, with some interviewees indicating that they were helpful whereas others considered this service relatively hands-off and ineffectual. Summarising the service-related code reveals several limitations to the current services available for consumers in metropolitan Adelaide (and potentially beyond). Despite the therapeutic alliance having been established consistently as a strong predictor of adherence, there remain rotating systems of psychiatrist in medication clinics. Additionally, whilst there has been an ideological shift in conceptualisations of the relationship between health professionals and consumers towards greater equality and enhanced agency and control of the consumer, this does not appear to reflect practice, in the treatment of schizophrenia, at least. Too frequently, interviewees reported power imbalances in favour of the prescriber in therapeutic alliances. Tailoring to consumers’ unique circumstances often does not take place and there appears to be a concerning lack of interest in the consumer perspective, reflected through a lack of knowledge of consumers’ histories and repetitive, 288 concrete questioning. These results challenge how “therapeutic” the relationship between the prescriber and the consumer actually is, especially in the context of non-adherence to express resistance, whereby interviewees reported taking extreme measures such as over-dosing or becoming non- adherent to induce a psychotic episode in order to elicit responses from prescribers or the healthcare system. Experiences with case managers were mixed and, notably, few interviewees actually had case managers. One interviewee positioned her case manager as similar to a consumer advocate, who facilitated communication between herself and her prescriber, highlighting how case managers could have pivotal roles in assisting with adherence and improving relationships between prescribers and consumers. Positively, there was support for the increased role of peer workers in services to assist with adherence, who were consistently positioned as credible and relatable, highlighting a potential clinical implication of the present research. As can be seen, there is significant overlap and interaction between the categories outlined. Whilst they have been divided up for presentation purposes, they should be considered collectively, particularly when interventions and clinical implications are being considered. A possible reason for the ineffectiveness of previous interventions could be that they have focused on only one or a few factors or categories and, thus, failed to address other important aspects of medication taking experiences. Several interventions have been proposed to address adherence, 289 however, a review of the literature indicates that they have had limited effectiveness, with only approximately one third of interventions leading to significant improvements in adherence (Zygmunt, Olfson, Boyer & Mechanic, 2002). Interventions that have most commonly been studied include family therapy, psychoeducation, behavioural and cognitive therapies. Neither family therapy nor psychoeducation have consistently been associated with improvements in adherence, unless combined with other therapies/intervention modalities (Eckman & Liberman, 1990; Fenton et al. When psychoeducation has been shown to moderately improve adherence, the effect has tended to be modest and not sustained over time (Lowe, Raynor, Courtney, Purvis & Teale, 1995). Behavioural interventions have been shown to be comparatively more effective at improving adherence than other modalities (Boczkowski, Zeichner & DeSanto 1985; Falloon, 1984; Zygmunt et al. Cognitive and motivational interviewing interventions have also been studied, to a lesser extent than other interventions, with mixed results (Gray et al. In the present study, interview data overwhelmingly contraindicated the utility of a generalised, “one size fits all”, pre-determined intervention to address adherence amongst consumers. This finding could explain why previous intervention studies have reported only limited success in terms of improving adherence. Interviewees in the present study justified their 290 opposition to such interventions through constructions of adherence as a personal issue, influenced largely by consumers’ unique experiences. This is consistent with the findings of other qualitative research (Carrick et al. Adherence was frequently described as a process which involves experiential learning, and is thus, mediated by a variety of factors at different stages of the illness, which differ for individual consumers. Adherence could, thus, be seen to encompass a complex interaction of influences, which may change over time. Furthermore, adherence decisions were frequently framed as rational choices based on the information and resources available to consumers. Interviewees acknowledged that in some instances, non-adherence not only represents a logical choice, but it may be the best option for consumers, contrary to assumptions in the literature (and arguably the healthcare setting) that adherence is always positive and should be strived for. Additionally, adherence and non-adherence experiences, including associated consequences, were often constructed as learning opportunities. Many interviewees reported that non-adherence experiences, in particular, reinforced the benefits of taking medication. Furthermore, they posited that resistance (or non-adherence) may allow consumers to actively question and participate in their treatment plans, in line with the present findings. Results of the present study, therefore, highlight the limited effectiveness of prescribers and other health workers imposing or encouraging adherence amongst consumers who do not themselves perceive 291 adherence as desirable or appropriate. For example, interviewees indicated that when medications failed to treat symptoms or produced intolerable side effects, adherence is neither an attractive nor a beneficial option.