Treatment Compliance and the Therapeutic Alliance

Treatment Compliance and the Therapeutic Alliance

Barry Blackwell, editor

The Netherlands: Harwood Academic Publishers; 1997. 325 pp. with index

ISBN 90-5702-546-9 (cloth)

Many clinicians take the “compliance” of their patients for granted. They assume that medications are taken as ordered and rarely check pill boxes or take any action other than questioning the patient to ensure that instructions are being followed. Yet we know from well-designed studies that as many as 50% of patients do not take their medications as prescribed. Contrary to expectation, psychiatric patients are not notably less compliant than nonpsychiatric “medical” patients. Compliance also is impaired in older patients when medication requirements are complex, and in socially isolated people, and it is adversely affected by a poor doctor-patient relationship.

The philosophy of compliance is also changing, to keep up with changes taking place in the role of the physician in our society. The older paternalistic medical model of “the good doctor knows best” no longer holds. Patients are far better informed about their health problems and their treatment options and are encouraged, and rightly so, to take charge of their medical treatment. With some exceptions, the medical profession has come to terms with these changes, and most physicians have accepted their new role as health educators and advisers rather than treatment directors.

This book deals with many of these issues, in particular the doctor-patient relationship. Yet it is curiously uneven in content, philosophy and quality. It is divided into 3 sections: “Compliance research, theory and social context,” “Participants in the alliance” and “People with special needs.” The first section provides a useful and practical overview of the field. The chapters entitled “Models of the compliance process, “Medication noncompliance in schizophrenia,” “Insight and compliance” and “Compliance and decision making capacity” were of particular interest and value. The second section includes chapters on community mental health programs, the role of families, and the role of the physician in the therapeutic alliance. The final section has chapters on schizophrenia, manic depression, developmental disabilities, alcoholism and the elderly.

The quality of the book starts at a high level but rapidly deteriorates in the middle and later chapters. Many of the later chapters are written by “consumers” or health care professionals with antiestablishment axes to grind. Their tone tends to be adversarial, and they write as if nothing has changed since the days of the paternalistic medical model. There is much discussion of the individual’s right to refuse treatment but little or no discussion of a patient’s right to have effective treatment when such is available. The topical issue of community treatment orders is barely mentioned. Although the editor (who authored 2 of the chapters) commendably attempts to integrate compliance into the therapeutic alliance, the book nevertheless lacks philosophical coherence and consistency. One has the impression that no decision was reached on whom the book is addressed to, and too wide an audience has been targetted.

Despite the importance of the subject, this book is likely to be of value only to those with a special interest in compliance.