Table 1 Motivational interviewing-based adherence therapy for people with schizophrenia

Phase 1 (1 session)

Purposes:

Reviewing antipsychotic medication use and the impacts of psychotic symptoms on medication (and treatment) adherence, the desired and unwanted effects of medication, anti-psychotic side-effects, and attitude and satisfaction with medication taking.

Examining and addressing beliefs and concerns towards adherence, and plan for problem-solving.

Homework assignment: Weekly record of adherent behaviour and reasons for adherence and/or inadequately or fully non-adherence.

(1) To help participants review their past and present states of taking antipsychotics; and

(2) To assess knowledge, attitude and barriers to medication adherence and plan for problem-solving and improving adherence behaviour using a standard assessment form.

Participants identify the present beliefs and concerns, benefits and barriers related to medication and rated the level of distress (i.e., 1–10) attached to each of the main side-effects.

Family members are asked for giving their opinions and attitudes towards medication taking by their relative with schizophrenia.

Participants are asked to do home assignment by recording weekly adherent behaviours and both they themselves and nurse therapist would keep documentation for records and reviews.

The therapist makes an attempt to link medication cessation with relapse. Negative treatment experiences and high levels of distress regarding side-effects are acknowledged and discussed. Denial of need for treatment is met with gentle enquiries into the ensuring social/family/lifestyle disruptions.

Phase 2 (2 sessions)

Purposes:

Revisiting and revising previous goals or add new ones, and their actions.

Recognising factors that may lead to poor adherence, and develop coping strategies to reduce urges for non-adherence

Homework assignment:

Practicing new actions for maintaining or enhancing adherence.

Weekly record of adherent behaviours and reasons for adherence or non-adherence to medication.

(1) To educate about mental illness and its treatment and care required;

(2) To review the goals, actions and adherence records of the last two weeks; and

(3) To identify barriers to medication adherence and develop coping strategies, immediate and longer-term goals/actions.

Participants’ misconceptions about symptoms and side-effects antipsychotic medication will be clarified.

The tendency to stop medication whenever the participants feel well is to be discussed, and their meanings attached to medication are explored, that is, an identity as a ‘sick person’.

Participants are asked to weigh up their benefits and drawbacks of treatment and the nurse therapist ‘home in’ on the benefits, especially when they emerge spontaneously.

Symptoms reported by the participants are fed back as their needs (‘symptoms’) for treatment.

Phase 3 (3 sessions)

Purposes:

Evaluation of the progress of medication adherence with each participant and his/her change in beliefs/insight into illness and treatment during session 5.

Making future plan with participants to continue self-monitoring of adherence and its contractual agreement; and clarifications of means of support from CPNS, family and services.

Homework assignment:

Weekly record of medication behaviours and reasons for adherence or non-adherence.

Risk assessment for relapse prevention and a list of risk factors identified and recorded.

(1) To rationalise participant’s beliefs and concerns and to prevent relapse;

(2) To manage social stigma and enhance social support.

Participants are facilitated to identify the characteristics of prodromal symptoms and the importance of early intervention to prevent a full-blown episode.

In sessions 5 and 6, the nurse therapist use normalising rationale to deal with stigma towards the illness/medication; suggest analogy with physical illness requiring maintenance treatment; and highlight illness prevalence with examples of ex-patients who have been successful in coping with difficulties as theirs.

Participants reframe medication use by participants as a freely chosen strategy to enhance control of quality of life and use metaphors of medication as ‘insurance policy’- staying well.

Future plan and contractual agreement are made to continuously monitor medication adherence and supporting resources from CPNS, family and other mental healthcare services are clarified.