Sunday, 16 January 2005 - 10:15 AM

This presentation is part of: Mental Health Service Utilization

Strategies Used to Encourage Treatment Adherence by Providers in Assertive Community Treatment

Purpose. Despite a large and robust evidence base regarding Assertive Community Treatment (ACT) for treatment of people with serious mental illness, critics question whether such programs are predicated upon coercive methods of increasing treatment participation and adherence to medication. This study used a grounded theory approach to delineate the ways in which ACT providers address issues of conflict with clients related to non-adherence or unwillingness to follow treatment recommendations.

Methods. We conducted direct observations of interactions between 15 ACT providers and 45 of their clients in two assertive community treatment programs (one urban, one rural). After each provider had been observed on three occasions, we completed a semi-structured interview in which we asked providers to describe and explicate their strategies for dealing with situations in which there was disagreement between themselves and their clients. During these interviews, we also asked the providers to elaborate on specific situations noted in the observation phase. Observation field notes and transcripts were analyzed using grounded theory methods to delineate the range of provider strategies used across settings, conditions and contexts under which strategies varied, and perceived consequences for client-provider relationships.

Results. Providers described a hierarchy of strategies they drew upon differentially, depending upon their projected consequences of continued non-adherence and their attributions about why clients failed to adhere to recommended treatments. Whenever possible, they drew upon low-pressure strategies of reminders, cognitive and emotional persuasion, and the provision of external rewards or reinforcements. They also described decisions to employ more paternalistic strategies (such as appeals to the consumer's sense of reciprocity and obligation to the worker, bargaining for a needed resource, leverage, and physical force) as being rooted in calculations of liability or potential harm to the client or the public.

Implications for Social Work Practice. Although some have argued that coercive strategies are embedded within everyday practices in assertive community treatment programs, this study showed that clinicians drew upon strategies of influence and social control only in rare, selective situations. In everyday practice, they were more likely to rely upon the frequent client-provider contact prescribed by the model to encourage medication adherence through upon monitoring, reminding, and verbal persuasion. We recommend that future studies examine the strategies identified in this investigation in a range of case management programs and assess the effects of these strategies on client experiences of quality of care.

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