In addition to pharmacological treatments, the other broad category of treatment for severe and persistent mental illnesses is psychosocial treatment. Psychosocial treatments are approaches that attempt to effect change through the manipulation of social or psychological factors. Psychosocial interventions have been found to be very important in the care of persons with these disorders and are discussed throughout this text. Specific models that employ psychosocial strategies include some types of day programs, assertive community treatment, supported employment, and family psy-choeducation. (These approaches are all described in detail in subsequent chapters of this book.) Also the various forms of psychotherapies are psychosocial interventions.
Many experts, such as Craighead and colleagues (1998a, 1998b), Harding and colleagues (1992), and Hogarty (1993), believe the most effective impact on the course of severe and persistent mental illness is achieved through a combination of biological and psychosocial interventions. Based on the available evidence, Hogarty (1993) concluded that the right combination of these two categories of treatments resulted in the lowest possible relapse rates. It is the conventional wisdom that pharmacological interventions are a necessary prerequisite for any psychosocial interventions to be effective. While some experts consider this to be an established fact, others such as Harding and her colleagues consider this to be a myth. They believe that psychosocial interventions can be effective regardless of the use of psychotropic medication (Harding & Zahniser, 1994).
CONTROVERSIAL ISSUE Psychotropic Medications versus Alternative Treatments
Should PsyR practitioners always take a strong pro-medication stance, prioritizing medication compliance because it is the surest route to stabilization and good community adjustment? Are there situations in which a professional should support a consumer's choice to refuse psychotropic medications in favor of alternative treatments?
As discussed earlier, there is strong evidence that medications are the most effective way to treat the symptoms of severe mental illness. PsyR practitioners should share this knowledge with their clients, assist consumers in accessing good psychiatric treatment, and assist consumers in acquiring the skills and resources needed to take medication as prescribed and communicate effectively with their psychiatrist when problems arise. However, these interventions may fail when individuals refuse to take, or stop taking their medications.
How should PsyR practitioners react when an individual is not taking prescribed medication? In some programs, particularly those that adhere in part to the medical model or employ medical personnel, staff may view medication compliance as a primary goal even if the consumer is resistant to the idea of taking medication. In such programs interventions utilized to increase compliance are sometimes coercive in nature (Diamond & Wikler, 1985), for example, withholding privileges or monetary resources if a client has not taken medication. As you will see in Chapter 4, which covers the goals, values, and principles of PsyR, both coercive interventions and identification of treatment goals that are not client chosen are inconsistent with PsyR philosophy.
As addressed earlier, there are many reasons for medication noncompliance, including denial of the illness and discomfort due to side effects. Assisting a consumer in coming to terms with his or her mental illness and eventually accepting psychiatric treatment, or working with the consumer and his or her psychiatrist to develop a strategy to reduce side effects, are appropriate responses to these issues. Psychoeducational approaches can also be effective in terms of increasing adherence to a medication regimen.
Some consumers object to taking medications because of concern about the long-term use of psychotropic medication, or because they are opposed to the ingestion of chemical substances for philosophical or religious reasons. Such individuals may explore alternative treatments. Nutritional supplements and special dietary regimens have been used since the 1950s, but thus far there is no solid scientific support for this approach (Torrey, 2001). Others try homeopathic remedies, or relaxation techniques. Patricia Deegan, a consumer advocate, has written a manual on nonmedical strategies for reducing and coping with symptoms called Coping with Voices: Self Help Strategies for People Who Hear Voices That Are Distressing (1995). For example, when experiencing aversive auditory hallucinations, some consumers may obtain relief by listening to soothing music with headphones. (For more information on Dr. Deegan, see the biography in Chapter 12.) The exploration and use of alternative treatments for a variety of physical illnesses is currently widespread in the United States. Some of these approaches have even begun to attain respectability in medical and scientific circles. It is important for practitioners, including those who may be dubious about alternative medicine, to recognize consumers' rights to explore other approaches to treatment, just as many nonconsumers might when faced with a chronic disease. Unfortunately, because they have a mental illness, consumers' judgments of alternative approaches are often considered to be suspect. Instead, such individuals are more likely considered to be in a state of denial regarding their illness.
The questions that this issue raises are numerous. How far should PsyR practitioners go in supporting a client who chooses to utilize an alternative treatment? Should they help consumers gain access to alternative treatment resources? How should they handle a situation in which it seems obvious that a consumer is not benefiting from an alternative treatment approach? Should practitioners continue to counsel clients to reconsider medications, even when a client has expressed resistance to the idea for a number of years? It is important for PsyR practitioners to be thoughtful, to consider ethical implications, and to have an open dialogue with consumers and other professionals when struggling with such questions.
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