I once worked in an outpatient addiction treatment setting serving individuals with dual diagnoses of concurrent addiction and mental health issues. Unfortunately, it’s not uncommon to encounter prescribers and therapists with attitudes that convey a sentiment that the caretaker is the ‘expert’ in a sometimes paternalistic manner. Paternalism is particularly common in the addiction treatment setting when patients are sometimes viewed as incapable of making correct decisions for themselves. As a result of this culture, I can recall multiple situations where patients are labeled ‘non-compliant’.
While I agree that patients seek treatment because they need help—and because of their disease of addiction, are unable to make all the right decisions—I don’t think they are entirely incapable of making any decisions on their own. For example, the decision to take medications for underlying mental health conditions should be a joint effort between patient and prescriber.
I can recall one troubling situation in practice where the paternalistic culture overtook the patient-prescriber relationship of decision making and led to unnecessary outcomes. I met this patient for an initial psychiatric evaluation as I do all new patients entering our facility’s sober living home. The patient was in his early twenties with brown hair falling below his eyes and ears and a necklace with some sort of crystal dangling around his neck. His eye contact was minimal, and he was soft-spoken and polite. I could tell he was apprehensive about meeting with a “medical provider” who might try to “diagnose” him and prescribe medications.
This patient had an extensive history of using methamphetamine, hallucinogens, and various other illicit substances. He was in treatment with us because he had had several run-ins with the law because of his drug use and needed sober living and treatment for his addiction. He answered all my standard assessment questions. When asked about trauma history, he answered those questions succinctly and with a detached sense as he reported he had experienced physical, sexual, and emotional abuse throughout his life since childhood.
He admitted to difficulties controlling emotions at times, particularly irritability and anger. When asked about auditory and visual hallucinations unrelated to substance use, he responded that he had experienced some of these symptoms in his past. He spoke at times about having had some sort of interaction with the Manson family, which made me think he may have some sort of delusion regarding the cult. Still, from my overall assessment with him, I did not think he was actively psychotic or require immediate medication intervention. He was at no risk of harming himself or others, and no distress was noted. I did feel he may have some sort of underlying bipolar disorder in addition to trauma and possibly substance-induced psychotic thinking. Still, his long history of substance use obscured his true diagnosis so early in recovery. Time was needed to determine his true diagnosis, especially if he was unwilling to explore medication options at this time.
The patient made it clear he was not interested in medications, nor would he take them if prescribed, but he was willing to meet weekly with me as I did with all my other patients. He was worried about medication side effects and did not want to feel numb or ‘like a zombie’ when taking medications. When I asked about therapy to address trauma, he expressed interest. He reported he felt many of his anger and substance use difficulties might be related to his trauma.
When I discussed this patient’s case with our treatment team of therapists the following week, they were very bothered that he was not prescribed medications. In fact, it was determined that because he was unwilling to take medications, he was quickly labeled ‘non-compliant’ and was at risk of being on a behavioral contract at the sober living house if he did not agree to take medications. While I am only one member of the treatment team, I made it clear that while I thought medications could be helpful, they were not essential at this time, especially if he wanted to attempt to address his issues with therapy rather than medications which I thought was a good place to start.
The following week at our treatment team meeting, I was notified that the patient had broken an object in his room when upset with his peer. This event escalated the treatment team’s insistence on medications. Unfortunately, because he continued to refuse medications, this patient was discharged from the sober living house. I was frustrated by the outcome of this situation because I felt many of his difficulties could have been effectively managed if therapy were initiated instead of delayed. Medication is not always ‘The Answer.’
I believe a combination of medications and therapy is most effective in many situations. I also respect patients’ desires to approach interventions with medications, therapy, both, or neither. While prescribers are considered ‘experts’ in healthcare, patients should be considered experts in their own lives and experiences. It’s very clear that a collaborative approach should be taken to address a patient’s needs to result in successful outcomes.
A cultural shift needs to occur in healthcare, especially in addiction treatment, where patients are not quickly labeled as ‘non-compliant’ but instead listened to carefully and decisions are made collaboratively to make the best treatment outcomes. Until this occurs, patients will continue to feel unheard and dismiss treatment altogether.
