A STRATEGIC ROLE FOR PEER SUPPORT SPECIALISTS: SUPPORTING PARTICIPATION DURING TREATMENT (PART I)

While common, poor participation in healthcare—whether it is dropping out of treatment before the benefits accrue or participating in a way that undermines the client’s success—results in bad outcomes and increased costs for clients, their families, and the healthcare system. Peer Support Specialists are well positioned to help clients participate in treatment in ways that ensure a positive outcome.

 Poor participation reflects the reality that most people are ambivalent about change and about participating in healthcare. They have mixed feelings about their illness, their provider, and the experience of receiving treatment. For some, the ambivalence is overcome by their desire to get past their illness. For others, the ambivalence leads to poor participation.

PROBLEMS TO ADDRESS

1.      Dropping Out. The term dropout can refer to people who stop treatment before it produces the target result or those who are on a waiting list to begin a treatment and drop out while waiting. We are talking about decisions to leave treatment or waiting lists that are not positive decisions: Leaving a treatment that is not working and is not likely to work is not a concern. Neither is withdrawing from a waiting list that we should not be on.

 Dropout is surprisingly common in many forms of medical care that require sustained participation.

 ·       Treatment dropout rates range from 25 to 70 percent for treatments of substance use disorders (Brorson, Arnevik, Rander-Hendriksen & Duckert, 2013).

·       Dropout rates for common mental health interventions range from 10 to 40 percent (Edwards‐Stewart, et al., 2021; Fernandez, Salem, Swift & Ramtahal, 2015).

·       If we look at medical services that involve treatment over time, like cardiac rehabilitation or surgical procedures that require follow-up, dropout rates range from 20 to 80 percent (Ruano-Ravina et al., 2016; Schröder, de Wispelaere & Staartjes, 2019).

 2.      Noncompliance. The term patient noncompliance in healthcare usually refers to clients’ failure to follow health interventions that they agreed to participate in. “Noncompliance” is an unfortunate term as it implies that clients must comply with providers’ instructions, when in fact it is an issue of complying with a plan that the client and the provider developed together and agreed upon. We know that this is not always the case, but for the purpose of this discussion, we’ll use the community term noncompliance.

 Rates of noncompliance range between 25 and 75 percent (Joe & Lee, 2016; van Dulmen et al., 2007). This is true whether we are talking about medication, medical treatments, or psychiatric treatments. Noncompliance differs as a function of the illnesses, the treatments, and the degree of the client’s social support.

 Noncompliance in general is costly for everyone, being associated with more symptoms, extended need of care, reduced functioning, more use of inappropriate medical care, and greater cost to the person, their family, the healthcare system, and the community (Joe & Lee, 2016).

 3.      Poor Participation. This term refers to participating in treatment in a way that results in reduced chance of positive outcome. Clients are not dropping out and they are not “noncompliant,” but they are so ambivalent about treatment that their efforts reduce the benefits of that treatment.

 I have seen this in my own life. It may take the form of my failing to proactively pursue healthy behaviors that support my recovery. It may take the form of being slow to implement some element of treatment. I suspect some providers may feel that I am not “fully embracing” the treatment or my role as a client.

 This form is less defined and rarely researched, but I think we all recognize the difference between a highly motivated and engaged client and one who is ambivalent and putting forth the minimum effort.

REFERENCES

Brorson, H. H., Arnevik, E. A., Rand-Hendriksen, K. & Duckert, F. (2013). Drop-out from addiction treatment: A systematic review of risk factors. Clinical psychology review, 33(8), 1010-1024.

Edwards‐Stewart, A., Smolenski, D. J., Bush, N. E., Cyr, B. A., Beech, E. H., Skopp, N. A. & Belsher, B. E. (2021). Posttraumatic stress disorder treatment dropout among military and veteran populations: A systematic review and meta‐analysis. Journal of Traumatic Stress, 34(4), 808-818

Fernandez, E., Salem, D., Swift, J. K. & Ramtahal, N. (2015). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of consulting and clinical psychology, 83(6), 1108.

Joe, S. & Lee, J. S. (2016). Association between non-compliance with psychiatric treatment and non-psychiatric service utilization and costs in patients with schizophrenia and related disorders. BMC psychiatry, 16, 1-8.

Ruano-Ravina, A., Pena-Gil, C., Abu-Assi, E., Raposeiras, S., van’t Hof, A., Meindersma, E., ... & González-Juanatey, J. R. (2016). Participation and adherence to cardiac rehabilitation programs. A systematic review. International journal of cardiology, 223, 436-443.

 Schröder, M. L., de Wispelaere, M. P. & Staartjes, V. E. (2019). Predictors of loss of follow-up in a prospective registry: which patients drop out 12 months after lumbar spine surgery? The Spine Journal, 19(10), 1672-1679.

van Dulmen, S., Sluijs, E., Van Dijk, L., de Ridder, D., Heerdink, R. & Bensing, J. (2007). Patient adherence to medical treatment: a review of reviews. BMC health services research, 7, 1-13.