Strategies to promote treatment compliance: a grounded theory study with relatives of people with a serious mental health condition – BMC Psychiatry

Our analysis showed that relatives used various strategies, which included treatment pressures, to promote the treatment compliance of their family member with a serious mental health condition. Relatives commonly employed these strategies when they noticed a change in their family member’s behavior, an intensification of known symptoms or the family member’s discontinuation of medication. Relatives often waited and observed the situation before they interfered, especially at the onset of the mental health condition when relatives were unsure about how to interpret their family member’s behavior.

Relatives emphasized that they tried to initiate treatment or promote compliance out of concern for the family member and, to a lesser extent, other members of the family. Relatives proceeded in steps in their application of the various strategies so as not to lose touch with their family member. Furthermore, regarding initiating the process of hospital admission, relatives often deliberated about how to proceed and which strategies to use because they experienced the process as highly challenging.

When reflecting on situations in which participants initiated involuntary hospital admission or used strategies that they felt involved a lot of pressure, participants often used “one” instead of “I” as the grammatical subject. This may be interpreted as a way of distancing themselves from the action and hence reflects the emotional difficulty and discomfort that relatives experience in these situations.

Based on shared conceptual characteristics, we categorized the strategies we identified in our analysis into three general approaches used by relatives to promote treatment compliance. These approaches are 1) influencing the decision-making of the family member, 2) not leaving the family member with a choice, or 3) changing the social or legal context of the decision-making process. Table 2 gives an overview of the strategies identified within the three approaches. We provide a more detailed description of our analysis below.

Influencing the decision-making of the family member

A) Influencing the epistemic basis of the decision

Persuasion

Our analysis showed that relatives use persuasion most frequently and as their first option. Relatives described how they, often repeatedly, tried to convince their family member to take a certain course of action by presenting them with arguments speaking in favor of acting in the desired way, as recounted by this mother:

And I said this, for example: “Listen, when you took pills, we could talk to you quite reasonably. Uh, we could also help you. But like this, we can’t.” (Participant 8).

Relatives noted, however, that during a crisis, rational argumentation was often unsuccessful.

Unwelcome prediction

Unwelcome predictions involve announcing negative consequences that can reasonably be expected to occur based on the evidence available if the family member does not act in the desired way. Our analysis showed that relatives made unwelcome predictions involving the prospect of formal coercion, such as telling their hospitalized family member that forced medication would soon need to be used if they did not take it voluntarily. As another example, consider the following situation in which the wife of a participant was on a home visit during her hospitalization and refused to return to the hospital:

Of course, I tried to convince my wife and when I was on the phone with the hospital, I explained to her: the hospital says you have to come back and they say, if you don’t go voluntarily, then I should call the police. (Participant 1)

By making unwelcome predictions, relatives merely inform their family member about the expected negative consequences without intentionally bringing these about. For this reason, making unwelcome predictions is a strategy that changes the epistemic basis rather than the actual circumstances of the family member’s decision.

Nudging

Participants also used more subtle and indirect ways of influence because explicit attempts to influence decision-making were often fended off by their family member. Changing the choice environment, for example by selectively making specific information available, was used as a nudge to facilitate the desired choice without making one’s goal explicit. One participant described that when he was trying to motivate his family member to seek professional help for her mental health condition, he would intentionally leave books about mental health conditions on the coffee table or tell stories about other people struggling with mental health conditions.

Selectively withholding information

Relatives sometimes selectively withheld information from their family member because they were worried that having that information would dissuade the family member from taking the desired course of action. For instance, one participant said he was unsure about whether his wife was aware that she had to take her medication for her mental health condition or if she just took it out of routine. Additionally, he suspected that the occasional stomach problems she reported may be caused by her medication. When asked if he discussed that with her, he answered:

No, especially since I am very happy that she takes the tablets relatively voluntarily, or actually voluntarily, except when she forgets, uh, because, as I said, she suffers very much from, uh, stomach problems. And if she were to get the idea that these might be caused by the medication, then perhaps her compliance with taking the pills would become more difficult again and, therefore, I don’t even want to bring up the discussion. (Participant 1)

Deception

In some instances, participants described courses of action that amount to deception. Deception involves intentionally inducing false beliefs in a person to influence her decisions. One participant described that his son constantly locked himself in his room and never came out when anyone was home. One day, a judge needed to see and assess his son for the arrangement of legal guardianship. To make that possible, the family pretended that no one was at home to lead their family member to leave his room. In fact, the father hid in the house and, in this way, once the son had left his room, was able to replace the door handle on his son’s door with one that cannot be locked, thus preventing his son from locking himself in again.

B) Reducing barriers to compliance

Providing support

Participants further reported offering their support to reduce potential barriers to utilizing treatment. They would, for example, offer to go to the hospital together during a crisis or regularly accompany their family member to scheduled appointments. Driving family members to treatment appointments so that they do not have to rely on public transport was another way of providing support, as illustrated by this mother:

I’m not going to say, “You go to some common or garden psychologist because I don’t have time to drive.” […] We sometimes drove twice a week. (Participant 3)

Accommodating the family member’s preferences

Another way of reducing barriers to compliance was trying to accommodate the family member’s preferences to make the family member more comfortable with accepting treatment. One participant recounted that, during one crisis, his wife was hostile towards men. Before going to the hospital, he called to see who was on duty in the emergency room:

I had made sure that it was a woman […] and then we went there […] only then went there together. (Participant 4)

C) Influencing the consequences of the decision

Interpersonal leverage

Our analysis showed that another way for relatives to influence the decision-making of their family member was by exerting interpersonal leverage. The latter builds on the emotional bond between relatives and their family members and amounts to announcing a change in one’s emotional attitude if the family member does not take the desired course of action. Relatives, for example, told their family member how worried they are about the family member’s current situation and implicitly or explicitly tied this to their own wish that the family member consult a psychiatrist or take their medication. This is evident in a mother’s description of the interaction with her daughter after her boyfriend’s father had informed the mother about her daughter’s self-harm intentions:

And we talked to her and just said that we got this call and that we were very worried […] And then she said she was going to the hospital herself. (Participant 5)

Expressing significant worry influences the consequences of the family member’s decision in that it holds the implicit implication that the family member would emotionally burden their relative by refusing treatment. In other cases, relatives explicitly announced a change in their emotional attitude, such as getting angry or desiring to no longer be in contact if their family member were to refuse to take the desired course of action. This is illustrated by this brother’s description of an interaction with his sister:

Then we also became angry and wrote: If you don’t stop [your mental health condition-related behavior] now, we don’t want to have anything more to do with you. Then we break off contact. (Participant 10)

Inducements

Relatives further used inducements by offering their family member something that makes them better off if they act in the desired way. In the following case, a young man currently had no place to sleep during a psychotic episode. His mother recounted:

She [grandma] then called me and said, “Okay, I took him in tonight but told him only for tonight and tomorrow we’ll go to the hospital together and you’ll let yourself be admitted.” (Participant 6)

Relatives also described making agreements with their family member based on a reciprocal commitment. For instance, when asked by their family member to take them home from the hospital or assisted living facility, the relative agreed to do so only under certain conditions, such as the family member taking medication or finding an alternative living arrangement, as illustrated by the following interview excerpt:

Well, I just made an agreement with her […]. Yes, when I bring her home, that we look for a place in an assisted living facility together and that she goes there when we find one. (Participant 7)

Threats

Relatives sometimes used threats by indicating that they will make their family member worse off if the latter does not take the desired course of action. In our analysis, this often involved the prospect of having to move out of the house. One participant, for example, considered telling his wife:

“As long as you act crazy, I will kick you out” (Participant 4).

Not leaving the family member with a choice

Confronting the family member with a decision

Sometimes, relatives simply told their family member what to do or made decisions without their involvement, thus confronting their family member with a decision that had already been made. While this may be frequent in interactions between parents and their children, relatives described this pattern as stretching out to an age where children usually make their own decisions. A mother who registered her reluctant son for an assisted living facility, said:

I just signed him up thinking, “Well, let’s see.” And I informed him of that. (Participant 2)

Limit setting

Participants shared that interacting with their family member during a crisis could be exhausting and that they therefore set limits to make their own needs visible. They described clearly expressing disapproval of specific behaviors, which they attributed to a mental health crisis, to their family member and occasionally reprimanding them for such behaviors. One mother recounted how her son, who had his own apartment and was experiencing a psychotic episode, became very aggressive and insulting towards his sister during a family dinner. She recounted:

We then said: “That’s not how we behave here. You cannot act like this. You have to leave.” (Participant 9)

Relatives typically engaged in limit setting to underline their belief that their family member must take the prescribed psychiatric medication or comply with treatment.

Provocation

One participant shared how she, out of great worry, desperation and under great moral distress, provoked a situation in which her son appeared to be a danger to her to fulfil the legal criteria for involuntary hospital admission after previous attempts to talk him into seeking treatment had failed. When her son came home one evening after wandering around for days, she locked the door of the house, which he noticed when he wanted to buy cigarettes the next morning. She told him she would accompany him and stalled him when he tried to unlock the door, which she expected would make him aggressive. Upon escalation, she called the police.

Changing the social or legal context of the decision-making process

Involving others

Our analysis revealed that relatives frequently involved others in their attempts to promote their family member’s treatment compliance, which we conceptualized as a strategy to change the social context of the decision-making process. Relatives described asking mental healthcare professionals to talk to their family member. Further, participants called the police or the emergency services in crisis situations, often trying to initiate involuntary hospital admission.

And then the delusion gets more and more extreme and at some point, uh, one calls an ambulance. (Participant 11)

Additionally, participants asked friends of their family member, some of whom were service users themselves, to talk to the family member. This way, participants hoped to get in contact with their family member again through a person of trust or with similar experiences.

Arranging legal guardianship

A final strategy that our analysis revealed was relatives initiating an application for legal guardianship of their family member, often to facilitate psychiatric treatment. Legal guardianship changes the legal context and power dynamics of the decision-making process considerably in that involuntary hospital admission and treatment can be arranged more easily. While some participants applied to act as the legal guardian themselves, others preferred an external person to act as the legal guardian because it enabled them to delegate difficult tasks and focus on their role of being a relative. In cases where a third person rather than the relative acts as the legal guardian, this changes not only the legal but also the social context of the decision-making process.

Theoretical integration of our results

As part of our analysis, we theorized the different ways relatives promote their family member’s treatment compliance into more abstract strategies. Doing so allowed us to identify conceptual similarities and differences between the various strategies. Based on these, we categorized the strategies into three general approaches that relatives use to promote their family member’s treatment compliance: 1) influencing the decision-making of the family member, 2) not leaving the family member with a choice, and 3) changing the social or legal context of the decision-making process.

Our categorization of the various strategies into three general approaches highlights that relatives find different leverage points to promote treatment compliance. The first approach aims to obtain the family member’s consent for treatment through a process of negotiation. By contrast, the second approach aims to avoid negotiation with the family member and denies them the opportunity to give consent. Finally, the third approach aims to promote treatment compliance by influencing the background conditions of the decision-making process rather than the decision-making process itself.

The first approach allows for a further conceptual subdivision. Relatives may influence their family member’s decision-making either by influencing the beliefs they hold or by influencing what is the case. By influencing the family member’s beliefs, relatives influence the epistemic basis of the family member’s decision-making without changing any facts about the world. Relatives may do so by adding or stressing specific information, either verbally (e.g., by using persuasion or uttering an unwelcome prediction) or non-verbally (e.g., by means of nudging), or by selectively withholding information. They may also purposely induce false beliefs to promote treatment compliance (i.e., deception).

In contrast to influencing the beliefs based on which the family member makes their decision, relatives may also change the facts that guide the family member’s decision-making. Relatives may do so by altering the consequences of a certain decision to make that decision more or less attractive to their family member (e.g., by means of interpersonal leverage, inducements, or threats). Alternatively, relatives may reduce the barriers to making a certain decision and thus influence the preconditions of that decision (e.g., by providing support or by accommodating preferences).

Overall, our results highlight that the strategies that relatives use to promote their family member’s treatment compliance go beyond the treatment pressures thus far discussed in the literature. The aim of treatment pressures is to influence someone’s decision-making. In our analysis, we found that relatives influence their family member’s decision-making not only by means of persuasion, interpersonal leverage, inducements, or threats, but also by other strategies included in approach one. Furthermore, our development of the three different approaches demonstrates that influencing the family member’s decision-making is not the only leverage point for relatives to promote treatment compliance.