In my previous column (April 2019), I wrote about the various factors that affect clients’ adherence to treatment. In this second and final installment on adherence, I will present ways to improve and foster clients’ adherence to treatment.
Successful adherence and retention in treatment and recovery is a shared responsibility between clients and practitioners. Integrated treatment that focuses on both types of disorders is recommended for clients with co-occurring disorders (CODs). Assertive community treatment (ACT) can help clients with more severe disorders remain engaged in treatment (Manuel, Covell, Jackson, & Essock, 2011). Motivational interviewing (MI) can be used with all types of disorders to enhance motivation to change and resolve ambivalence in clients, which can impact treatment engagement and retention (Miller & Rollnick, 2012). Motivational incentives (MotInc) that reward behaviors such as program attendance can also improve treatment adherence (Stitzer, Petry, & Peirce, 2010). Both MI and MotInc have a substantial literature supporting the positive effects on outcomes, including adherence. I suggest all treatment programs develop philosophies and policies related to treatment adherence that are client centered and make it easier for clients to engage and remain in treatment, and for early dropouts to reengage in services, given the high rates of dropout.
A good therapeutic alliance with practitioners can positively affect clients’ adherence to treatment (Daley & Zuckoff, 1999; Magura, Rosenblum, & Fong, 2012). Other clinical and systems strategies that can improve adherence among clients with CODs include the following (Daley & Zukoff, 1999; Mee-Lee et al., 2013; Daley & Cohen, 2011; Daley, 2017).
According to the American Society on Addiction Medicine, one of the six dimensions of the multidimensional assessment of the client is “Readiness to Change,” in which practitioners explore clients’ readiness and interest in changing their substance use or psychiatric condition (Mee-Lee et al., 2013). Clinicians may assess clients’ readiness to change and readiness to accept help and find that some clients want to change, but prefer doing so on their own. Self-change is more likely for those with less severe forms of disorders.
This is particularly relevant in early recovery, when the rates of treatment dropout are highest. Accept clients’ resistance to change and ambivalence as normal and address these as clinical issues, rather than as reasons not to work with specific clients. Clinicians can also help clients anticipate roadblocks to treatment adherence based on prior behaviors and thoughts that affect early dropout. Thoughts that need modification may include those such as, “I don’t need treatment,” “I can handle my problems/disorders on my own,” “I don’t like going to group sessions,” or “I don’t want to transfer my addiction to a medicine (such as methadone).”
Clients are at risk to not engage in the next level of treatment after they complete a hospital or residential program. Clients with CODs discharged from a psychiatric hospital are significantly less likely to follow up with outpatient care compared to clients who have psychiatric illnesses without co-occurring substance use disorders (SUDs; Daley & Zuckoff, 1999). Even though these clients have more diagnoses, more complex clinical histories, and need follow-up care, they often fail to keep their scheduled outpatient sessions, which leads to early treatment dropout. Similarly, many clients discharged from addiction withdrawal management or residential treatment programs do not continue with treatment at the next level of care.
Lateness, missed appointments, failure to get prescriptions refilled, failure to take medications as prescribed, and other forms of poor adherence should be addressed as soon as you observe them. Clients often ignore these issues, so exploring them in sessions can led to greater insight, willingness to change, and adherence to treatment.
Practitioners may have clients use a daily calendar to keep track of any or all of the following: level of motivation to change; any substance use; severity of substance cravings; severity level of the main symptoms of the primary psychiatric disorder; and level of adherence to the treatment plan. This process can help clients identify and catch potential problems or symptom exacerbations early so they seek help when symptoms worsen, rather than make the decision to stop treatment or stop taking medications. Level of motivation to change, substance cravings, psychiatric symptoms, and adherence to the recovery plan can be rated on a scale of one to ten, with one being the lowest and ten being the highest. For substance use, clients can track the number of drinks of alcohol or whether illicit or nonprescribed drugs were used.
Case management, peer services, and outreach can be especially helpful to clients with multiple disorders who have many social and medical problems in addition to their CODs. These services can provide support for recovery and help link clients to housing and economic, medical, or social services to address needs or other problems that could impede adherence to treatment for their CODs. These services may also make it easier for clients who dropped out of treatment to reengage in care.
Many dental and medical practices offices call or text to remind patients of their scheduled appointments. Practitioners can use automated or live calls or text messages to remind clients of their appointments. The advantage of a live call is that clinicians can intervene if the clients they reach evidence problems in recovery.
Other treatment system interventions include establishing thresholds for acceptance of adherence levels of treatment for clients, offering flexible hours to accommodate working clients and families, including families in sessions when appropriate, and implementing programs in which incentives are used to improve treatment adherence (Daley, 2017).
Strategies to improve medication adherence include some of those previously mentioned (e.g., using financial incentives or discussing adhering problems as soon as they are noticed by practitioners). Other strategies include the following:
Studies show that practitioners rate client adherence to medications much higher than prescription refill records shows (Chapman & Horne, 2013).
A consistent challenge for practitioners who treat clients with CODs is engaging and retaining them in treatment. By implementing systems and counseling strategies to improve adherence, we can all have a positive impact on client outcomes.
Dennis C. Daley, PhD, served many roles at the University of Pittsburgh School of Medicine. He is the author of many articles, treatment manuals, books, and guides for families and children affected by addiction. He helped facilitate B2H programs at two hospitals.