Schizophrenia

Preventing Relapse Through Therapeutic Partnership


Prelapse Magazine, No 3., April 1996

Respectfully submitted by: Jane Hamilton Wilson, RN, BAAN, MHSc. Heather Hobbs RN, CBS.dip., Shelley Osborne RN, Dr. Suzanne Archie MD on behalf of all the partners of: The Psychotic Disorders Team, Chedake McMaster Hospitals, Canada

The Psychotic Disorders Team at McMaster University Medical Center, Hamilton Ontario, has developed a model of "Therapeutic Partnership" which has several unique aspects. There are many things that clinicians, working in partnership with clients and their families, can do to enhance medication treatment and thus reduce the risk of psychotic relapse. Clinicians must set a stage for treatment success in general. Success which includes, but is not limited to, medication compliance. Clinicians must try to understand the meaning of the illness to the client and the meaning of having to take medications. Frequently, clients associate having to take medication with acute illness symptoms. Most often, they expect to reach a point of wellness where medications can be discontinued. However, the goal of relapse prevention is best accomplished by the continuation of medications beyond the resolution of the acute episode. Prophylactic use of medications must be actively supported as a health promotion behaviour aimed at maintaining levels of functioning and preventing disability. For the purpose of this brief paper, descriptions of techniques which appear to enhance replication success will be divided into three phases: (1) Preparing for Medication Treatment, (2) Commencing Treatment, and (3) Maintaining Treatment.

Preparing for Medication Treatment
In order to comply with treatment, individuals must first understand and support the expectations. Treatment goals must be negotiated explicitly with particular emphasis upon opportunities for rehabilitation. Most clients are very interested in activities and efforts which increase the likelihood of returning to a previous level of functioning. With this goal in mind, medication treatment can most certainly be seen as a powerful tool which has the potential to foster rehabilitation success.

* Extensive education for clients and families should be provided before commencing treatment. Long- and short-term goals should be negotiated and recorded. Mutual expectations and responsibilities of partners can be clarified. Honestly discussing the limitations of medication treatments can help to distinguish illness symptoms from side-effects. Target dates for the evaluation of treatment response should be decided upon prior to the first dose.

* Partners must help to determine what medication might be most helpful given the presenting symptoms. Does this client require a sedating medication? Would a less sedating medication enable this client to continue with his studies? Specifically outline the medication choices available. It is also helpful to understand who will pay for the medication. Does this individual and or family have access to a drug benefit plan? Financial considerations can often be a key factor in choosing a medication regime and enhancing long-term compliance.

* Partners must also help to determine the setting for commencing treatment. Does this client require hospitalization? Can the symptoms be treated on an outpatient basis? Often clients and their families prefer to avoid an inpatient admission.

* Knowing that a large percentage of patients are tempted to give up on the medications when they experience side-effects illustrates the need for proactive clinical practice. Clinicians should openly discuss the common side-effects and devise the action plans to address these prior to initiating treatment. A clear commitment from the clinical team to contain side-effects and to act quickly to resolve these problems can most certainly enhance success.

Commencing Treatment
Perhaps the most potent determinant of successful treatment is the extent to which all partners invest in the approach and hold themselves responsible and accountable for successful outcomes. Clients most certainly hold the right to accept or reject treatment suggestions. However, once a treatment agreement has been confirmed there are numerous clinical techniques which are likely to enhance treatment outcomes.

* Always start with a low dose of medication. Increases should be made in small increments in order to reduce the likelihood of overwhelming side-effects. Clients and families may need extra support as the dose is slowly increased. Psychotic symptoms will not "disappear overnight". Treatment personnel will need to be available to reassure clients and families that patience is required at this stage.

* All partners must engage in open dialogue about medication concerns and side-effects. Clinicians must invite discussion about side-effects and ask the questions that will determine their presence. Uncomfortable side-effects are often at the root of treatment failure. Working to resolve and minimize these experiences is likely to enhance long-term compliance.

Maintaining Treatment.
Maintenance treatment is extremely important in resolving psychosis and preventing relapse. Adjunctive rehabilitation can also be helpful. Optimal wellness depends upon holistic strategies which reinforce successful adaptation to chronic illness while minimizing the potential for disability.

* Partners must engage in a process of ongoing negotiation during all phases of the illness. Medication doses for acute treatment are often higher than those required for maintenance/prophylactic treatment. Clients who are symptom-free need opportunities to discuss the rationale for prophylactic treatment. In the absence of this information these clients may be at risk of discontinuing drug therapy. Attempting to prevent relapse and the potential for disability takes a concerted effort on the part of all partners.

*Providing periodic consultation to clients and families who are on maintenance therapy can help to alleviate concerns about the possible development of long-term side-effects. The Psychotic Disorders Team routinely invites former clients to meet with team members. The team actively supports a stance of preventing problems before they create concern.

* A client's choice to discontinue medications is likely to result in relapse. Clinicians are wise to avoid coercive power struggles or paternalistic rescuing activities. Feeling the uncomfortable symptoms of relapse is, for most clients, a valuable learning experience. Clinical teams must allow clients the dignity of learning from their own choices and decisions.

Conclusion
Successful treatment approaches which enhance wellness and reduce disability are best facilitated within the context of Therapeutic Partnership. Ultimately, preventing relapse is dependent upon shared goals, shared agreements and a dynamic and responsive treatment contract. Members of the Psychotic Disorders Team have had the privilege of working with many clients and families over a period of many years, and a considerable number of former clients have made a commitment to prophylactic medication use. These clients continue to share the larger goal of relapse prevention.


Reprinted with permission.

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