From the Book, Chapter 3, Disappearance
In this chapter we describe in detail the medication management process. Before we start, however, it’s important to note that this is not a linear process. First, there is the assessment or evaluation. Unfortunately, case managers are not consulted often enough during this phase of the process. This is most often the work of psychiatry. It includes the diagnostic interview. Second, there is the prescription and delivery phase. Here, managers are directly involved. Among other things, you may offer transport to and from pharmacies. In this phase you are often involved in what is sometimes called the med drop, and for many in our public mental health systems, med drops dominate the daily work. They may also be among the least rewarding activities. In the third phase, you stand by to monitor for compliance and often observe with your clients how the medication is working. Here, you may find yourself observing for the effects of medication and, when necessary, doing for your clients. This can also be felt as the most intrusive intervention. How would you address this feeling? Imagine a time in your life when you were forced to take medication or when you took medication while a parent stood by to monitor, coax, or even coerce. Finally, there is the reporting phase. Here, you report to your clients, supervisors, physicians, or team members concerns about medication effectiveness, compliance, and symptom reduction. And often it is the manager who is best positioned to see problems in this unfolding phase of the medication management process.
Here is where the real work of medication case management begins: observing for effects. When case managers, psychiatrists, and other providers empower clients to verbalize thoughts and feelings about medication, they give them power over that medication. And it is in this way that they may become active participants in caring for their bodies, brains, minds, and relationships. They use feelings and thoughts
about the drugs to work with providers to find the right combinations in the right dosages. In your working with clients on medication concerns, start with obvious questions: “I was wondering what you think and feel when you take this medication?” If your client does not know, consider a simple and direct question: “Do you have any fears or hopes about it?” Often you will find it necessary to patiently observe with your client the effects of medication over time. Remember, try not to become a detached, impersonal observer but a partner. No one likes to be observed. Think of times in your life when you felt the intrusive gaze of the observer. How did it make you feel? Together, consider keeping a journal to describe the unfolding medication experience. Answers to these questions might offer information crucial to deepening the reflective case management relationship. First, if your client cannot describe her experience with medication, it may well be that it’s having no effect or perhaps a detrimental effect. Or it may be that she’s not observing or letting herself know something important about the effects. Second, if she offers detailed information such as “It makes me sleepy or causes me to eat continuously,” you may need to work with doctors and the service team to address side effects. And remember, side effects are often as severe as the symptoms they are meant to address. They are not just side effects; they are undesired effects.
If she says, “I think my symptoms are much improved, but I feel so fat that I don’t like myself,” you may need to work with physicians and therapists to deal with concerns about self-image or other emotional states produced by changes in self perception. If you don’t address these concerns, compliance may become a problem. And sometimes, lack of compliance or questions about self-image will work against
medication effectiveness. Remember, too, if you feel as if you’re monitoring and enforcing med compliance, you have altogether abandoned reflective management; you no longer have a partnership.
Consider asking your client what she hopes the medication will do for her. Often, what we hope for does not match what is realistic or possible. If our hopes and the reality are too far apart, there will be disappointment. And disappointment breeds its own problems: anger, frustration, noncompliance. You should also know what the physician and other providers hope for the medication; they, too, may be very
unrealistic about what is possible, or they may participate with clients and others in producing unrealistic expectations. And certain disappointment. Medication can do only so much work. The rest is left to us.