This is one of the most-asked questions of practitioners working with people who have serious mental illnesses. It’s a complex question because the answer(s) depend on the various reasons the person isn’t taking his medication. Is it side effects or a total lack of insight into his illness? The former can probably be managed by adjusting dosage, frequency, etc, but the latter, lack of insight, is harder, because, why on earth would you take medication if you didn’t have an illness?
This lack of insight into illness (anosognosia) often creates incredible conflict and strain within families. In bipolar disorder the issue of insight can vary based on the phase, such as a manic or mixed episode, or it may persist at all times, even when the person is in a stable mood. The struggle for families can be one where they watch the person relapse, get put on medications in the hospital, come out, stop the meds and, around and around we go. This is sometimes called the revolving-door phenomenon.
The best approach to helping someone with anosognosia find his own reasons for taking the medications may be put forward in the book I Am Not Sick I Don’t Need Help by Xavier Amador, PhD, in which he suggests that through using and modifying techniques of motivational interviewing (reflective listening, empathy, avoiding debate, avoiding pushing your own agenda, working as equals), one can diffuse the struggle around medications and treatment. An important point that we see with people who have both anosognosia and take their medications consistently is that they may never believe they have an illness, but they have found their own reasons why taking medication on a regular basis is important and even meaningful: “I can hold a job when I’m on my meds,” “I don’t get hauled off to the hospital,” “I don’t do crazy stuff,” “Without them I couldn’t stay with my wife and kids.”
Other approaches, although more heavy-handed and restrictive, might include the use of mandatory outpatient treatment, sometimes referred to as assisted outpatient treatment, although this is not available in every state.
Finally, for some people with various active legal issues (driving under the influence, breach of peace, probation, etc.), a judge may mandate outpatient treatment as a condition of release, probation, or parole. Having this very real consequence, doing jail time, hanging over someone’s head may motivate her to take medications and to participate in treatment. The trick here is to think beyond the court order, probation, or parole, because once they’re over it’s common for people to drop out of treatment.