SUMMARY. This article reports on two research projects and argues that current medication management research and practice does not represent the complexity of community-based psychotropic treatment. Ethnographic findings are used to demonstrate that a social grid of man- agement exists to negotiate medication ‘effect’ interpretation. Anthropo- logical and semi-structured interview data are used to illustrate patient subjective experience of atypical antipsychotic treatment. It is argued that ‘active’ and ‘passive’ management relationships are produced by the myriad ways individuals manage the gap between the desired and ac- tual effects of medication. It is shown that psychological and cultural ‘side effects’ are as common as physical ‘side effects.’ [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website:
Research for the study of the subjective experience of atypical antipsychotics was
supported by NIMH Grant MH60232 on “Culture, Schizophrenia, and AtypicalAntipsychotics,” Janis H. Jenkins, P.I.
This paper was presented at the First National Internet Conference on Social Work &
Psychopharmacology, February 3-24, 2003, sponsored by the Ittleson Foundation andthe Virginia Commonwealth University School of Social Work in association with PsyBroadcasting Company.
[Haworth co-indexing entry note]: “Medication Effect Interpretation and the Social Grid of Manage-
ment.” Longhofer, Jeffrey, Jerry Floersch, and Janis H. Jenkins. Co-published simultaneously in Social Workin Mental Health (The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc.) Vol. 1, No. 4, 2003, pp. 71-89; and: Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists(ed: Kia J. Bentley) The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc., 2003,pp. 71-89. Single or multiple copies of this article are available for a fee from The Haworth Document Deliv-ery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].
2003 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300J200v01n04_05
Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists 2003 by The Haworth Press, Inc. All rights re-served.]KEYWORDS. Psychotropic treatment, medication management, com- pliance, qualitative methods, severe mental illness INTRODUCTION
For many, psychotropics offer a panacea, the final scientific and
technological solution to the human experience of depression, psycho-sis, or disabling anxiety. Yet the research on medication managementpoints to relationships and compliance problems well beyond the scopeof psychopharmacology. Some medication recipients, for example, arepassive and readily defer to expert opinion and intervention, requiringthe active involvement of practitioners (Ascione, 1994; Wells & Sturm,1996). Not surprising, therefore, research has shown that for both prac-titioners and clients, there exists a continuum from activity to passivity(Chewning & Sleath, 1996; Chewning, 1997; Cohen & Insel, 1996; deVries, Duggan & Tromp, 1999; Demyttenaere, 1997; Lipowski, 1997;Sleath, 1996; Sleath, Svarstad & Roter, 1997). These states, passive andactive, do not refer to chemicals circulating in the blood. They implicatesocial positions, feelings, and interpretations of medication events andtreatment experiences.
Moreover, dissemination of laboratory discoveries is increasingly
recognized as the next step in pharmacotherapy research and practice. The translation of clinical-trial data for community practice raises ques-tions about how practitioners and researchers include or exclude clientbeliefs and values in treatment decision-making (Chewning, 1997;Chewning & Sleath, 1996; Gournay, 1995; Hohmann & Shear, 2002;Morris & Schulz, 1992). As a result, management models have beenproposed that seek active client participation (Cameron, 1996; Gerbert,Love, & Caspers, 1999; Warren & Lutz, 2000; Warren, 1999). Medica-tion management research has shown how all participants differ signifi-cantly in levels of involvement about prescription, compliance, andsymptom monitoring (Chewning & Schommer, 1996; Chewning &Sleath, 1996; Dowell, 1990; Jordan, Hardy & Coleman, 1999; Sowers &Golden, 1999). Consequently, no matter how hopeful we remain re-garding the use of chemicals to relieve mental suffering, we inevitably
return to human relationships. In previous work (Longhofer, Floersch &Jenkins, 2003) we identified the social grid of medication management;here, we go further to argue that the grid exists to mediate the subjectiveexperience of psychotropic treatment.
It is argued in this article, drawing from the management literature
and from our own research, that a perplexing interpretive difficulty,what will be called a drug aporia, produces the ‘activity’ and ‘passivity’characteristic of most medication treatment relationships. The aporia isan interpretive gap produced by the distance between the hoped-for ‘de-sired’ and the perceived ‘actual’ effect of psychotropic treatment. Some-times, practitioners active in the aporia, interpret effects for clients; atother times they are passive. And many factors, including gender and eth-nicity, influence the subjective experience of atypical antipsychotics(Jenkins & Miller, 2002). Much of management research has been lim-ited to compliance and decision-making in physical medicine or tomanagement of iatrogenic problems related to chronic mental illness(Boomsma, Dassen, & Dingemans, 1999; Bennett, Done, & Hunt, 1995;Gournay, 1995; Hamera, Rhodes, & Wegner, 1994; Roter, Hall, &Merisca, 1998; Steiner & Prochazka, 1997). Others focus entirely onthe narrow problem (Atkin & Ogle, 1996; Berg, Dischler, & Wagner,1993) of compliance and pay little attention to the complex divisions oflabor resulting from deinstitutionalization; indeed, this division of la-bor–among psychiatrists, social workers, nurses, clients, and fami-lies–remains virtually unexplored (Jordan et al., 1999; and Longhoferet al., 2003 are exceptions). There is little interest in how complianceand related behaviors emerge from the subjective experience of medi-cation effect interpretation and how the resulting aporia, in general, isnegotiated through the social grid of medication management. Nor isthere consideration of the deliberate and self-conscious nature of pa-tient and practitioner interpretation of medication effects. In short, pa-tient compliance is rarely psychologically or culturally analyzed;reasons, wants, purposes, desires, and intentions, the causes of compli-ance, are ignored, and their unconscious dimensions inevitably elided(Keat & Urry, 1982, p. 94).
Using data from two research projects, it is argued that current
medication management research and practice does not represent thecomplexity of psychotropic treatment. While the broader process ofmanaging medications includes the presenting problem, prescriptionassessment, delivery, monitoring for compliance and effect, and report-ing (see Figure 1), this essay examines the roles of the case manager, the
Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
work of case management in effect interpretation, and client subjectiveexperience of medication. Indeed, effects are realized in the intensityand extensivity of monitoring for effects, and in the knowledge pro-duced in day-to-day practices and interactions among the key figures:the client, case managers, pharmacists, nurses, and psychiatrists.
First, the study of community medication management and its contri-
bution to psychopharmacologic research, the social grid of communitymedication management, is reviewed. Second, a case example from astudy of atypical antipsychotic treatment is used to empirically groundthe concept ‘drug aporia.’ Finally, in the discussion, it is argued thatpractitioners and clients use the grid to mediate interpretive dilemmas. THE SOCIAL GRID OF MEDICATION MANAGEMENT Methods
The social grid research (Longhofer et al., 2003), conducted in a
community support service setting, used ethnographic methods to ex-plore practitioner management of medication events. Narratives, culledfrom field notes and recordings, were used to specifically explore com-munity monitoring for compliance and effect. Thirty-five managerswere observed in weekly team and monthly clinical meetings; these,attended by team leaders, psychiatrists, nurses, and team clinical so-cial workers, included lengthy deliberations of individual cases. Cli-ent medical records (n = 329 cases) were analyzed for the types ofpsychotropic medications prescribed and a synchronic analysis wasconducted; during one week, medical records were examined to deter-mine the frequency of medication type. These were studied to establisha rough measure of the intensity of interpretation in community medica-tion management. At this particular site medications were monitoredunder the rubric of strengths case management, one of the most popularmanagement models in the country (Rapp, 1998). The program offeredservices to approximately 400 clients. Unlike most urban communityprograms, this suburban location was rich in resources, evidenced bythe manager’s annual salary of approximately $35,000 (Floersch,2002). All managers were required to take an in-house examination onpsychotropic medications. Although the majority had bachelor’s de-grees, a few had post-baccalaureate training. Managers had about 5years of experience (median) and the average caseload was fifteen (seeFloersch, 2000, 2002 for a detailed discussion of methods).
FIGURE 1. The Social Grid of Medication Management
family, pharmacist, nurse, psychiatrist,employer)
X = Who in the medication grid does what?
Longhofer, Floersch, and Jenkins’s (2003) analysis of a suburban
community mental health center identified five elements of a medica-tion management event; thus a single medication experience can be rep-resented as a complex social division of labor. In Figure 1, the elementsare represented horizontally and the social relations mediating them arerepresented vertically. Understanding management requires examina-tion of who does what and why. Most research on medication manage-ment segregates one or another element; few examine the totality(Estroff’s 1981 work on this subject is an exception). The grid repre-sents the social relations potentially correlated with each element of aclients’ medication experience and the overlapping roles and multiplesites for management. For whatever reason, those who lack the abilityto self-monitor are confronted with 24 possible sites (a single site is rep-resented as a cell in the grid) for determining who will do what. And theintensity of external (e.g., case managers, family, nurses, and psychia-trists) monitoring is determined, in part, by client capacity to act aloneat each site. Power, consequently, is differentially distributed through-out the grid and depends on social policy (Cohen, McCubbin, &Guilhème, 2001), funding mechanisms, the organization of mentalhealth services, and, of course, the client’s unique life circumstances. Each service delivery setting and associated community (i.e., rural, ur-ban, or suburban) will produce unique management of the elements. Settings dominated by medical practice, for example, will focus atten-tion on psychiatrists and nurses. Realistically, however, case managers
Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
play a pivotal role in monitoring medications for clients (Floersch,2002).
Research by Longhofer et al. (2003) suggests that compliance is not
one-dimensional or empirically transparent; in reality, compliance, likeall events in the grid, is always in complex ways psychically, culturally,and professionally mediated (see also, Cohen, 2002; Conrad, 1985;Trostle, 1988). In the following compliance illustration, a manager re-ports her observation of client behavior to the case management team;she draws conclusions about failed and hoped-for medication effects:
He had put one of his mattresses outside and it got wet from thesnow and rain. It was ruined. I asked him, “why didn’t you tell us?We could have found a home for it [the mattress].” It didn’t crossmy mind what might happen next. After I left, he went to the trashbin, got the wet mattress, and put it back on his bed. It was soakingwet! He is having a difficult time keeping the place clean. I chattedwith him about his personal hygiene because he is getting a littlestinky. In the way he was describing his routine, I do not think he istaking a shower. He told me that he doesn’t want to take a showerbecause of the mirror in the bathroom. He may be getting para-noid. He so high need and so low functioning at times. Well, hisshot is due soon.
It was irrational to place a wet, ruined, and foul-smelling mattress on adry bed; it was read as a sign of disorganized thinking. The manager re-ferred to the client as “high need” and “low functioning” because he re-ceived considerable help to clean, shop, pay bills, do laundry, and getmedications. For team members this client was sometimes unable to un-derstand or “get it.” Floersch (2002) has shown how “get it” and “highneed” are examples of situated or invented language that assisted man-agers in explaining client behavior when medication failed to producedesired effects. In the example above, the manager reasoned that thebathroom mirror was indicative of paranoia, which prevented him fromtaking showers. The medication’s desired effect was captured in a typi-cal manager oral narrative, “his shot is due.” Managers often condensedcomplex compliance observations such as these into a single medica-tion ‘effect’ interpretation. Here it was hoped that with the injection theclient would take showers, clean his apartment, and demonstrate clearthinking. With respect to grid participant expectations of desired ef-fects, Lorna Rhodes has identified the cultural implication behind the
metaphor “clear the mind,” which was in common use among practitio-ners and patients in our study (Rhodes, 1984).
We found that practitioners seek desired effects and, of course,
clients experience myriad actual effects. And all parties to medica-tion treatment, aware or not, assess and monitor effects. Once in thebody, crosschecking the medicine’s desired effects with the actualrequired continued and active monitoring. Managers constantly ob-served changes in behavior or symptoms and reported these to others. For example, “he had an ER [emergency] med[ication] check yester-day. He was really frightened. When he hears voices, they are usuallyviolent and aggressive. I think it was due to a decrease in his Haldol[conventional antipsychotic]. It looks like he will need both medica-tions [Haldol and Lithobid (antimania)]” (Longhofer et al., 2003, p. 28). This example of effect interpretation–“it looks like he will need bothmedications,” –involved reading multiple dimensions of client reality,including polypharmacy. In assessing the hoped-for desired effect, themanager used behavioral (reference to violent), emotional (reference tofrightened), and cognitive (reference to hearing voices) referents todraw the conclusion that a medication change was needed. However,which medication category, antipsychotic or antimania, would producethe desired effect, less aggression and fear? This is of particular signifi-cance because it highlights the complexity of effect interpretation withpolypharmacy (e.g., Floersch found in one study (2002) of 329 clientsthat 40 percent were prescribed three or more drugs). Behavioral,emotional, and cognitive factors combine to challenge practitioners tospeculate about cause and effect across several dimensions of clientexperience. Was it the client’s fear that caused aggression, whichcaused auditory hallucinations? Or, did auditory hallucinations causefear? Moreover, what was the role of medication? The manager thoughtthat increased fear, aggression, and auditory hallucinations were pro-duced by a reduction in antipsychotic medication. Consequently, evenunder the best of consultation circumstances–which might include thepresence of self-monitoring clients, the psychiatrists, managers, andfamily members–the above example highlights multiple dimensions ofa single ‘effect’ interpretation.
Medication management interpretations, not always observable in
the clinical or team meetings, could only be known in the ebb and flowof daily living in the community and in the occasional visits to the men-tal health center. Increased manic behavior, pressured speech, and ex-aggerated displays of anxiety made managers wonder, “are you takingmeds,” [compliance monitoring] or “perhaps there isn’t enough in his
Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
system” [effect monitoring]. Practitioners had no conceptual tools forundertaking interpretations, nor did they see the need to do so. Eventhough they consistently used a situated language (i.e., “his shot is due,”“has the medication kicked in,” and “it clears the mind”) as a substitutefor pharmacological interpretations, their invented language never be-came a conscious part of daily work.
Moreover, in medication case management, we saw that effect inter-
pretation often spilled over into other life domains. In the next example,managers weighed client self-initiative, self-responsibility, and self-un-derstanding alongside medication compliance and monitoring:
Case Manager 1: We need to make a decision. His apartmentlooks awful. Trash is everywhere and he spills coffee everywhere. I don’t know if he gets it. Case Manager 2: We are using $200 a month of our flexiblemoney to subsidize his apartment living. I don’t have a problemwith $100 a month. I would like to write him a letter. Case Manager 3: I wonder if it is time to sit down with him andtalk about this. I think we could tell him we would not subsidize asubstandard apartment. He is never going to pursue working a lit-tle if we do not cut him off. Case Manager 2: What about meds? Did he do his labs?
Case Manager 1: I think he did, but I don’t know for sure. He likesClozaril but if he isn’t going to follow the protocol, then maybe weshould change it. Case Manager 3: Maybe we should have a team meeting at hisapartment. There are so many issues. Meds, money, and house-keeping–there are at least three issues. Let’s talk to him, but sepa-rate the times and the issues.
In the statement, “we need to make a decision,” we see the acknowl-edgement that client housekeeping was below the team’s standard, es-pecially irksome because the team subsidized his rent. A quid pro quowas expected: we finance your apartment and in return we expect it tobe clean enough to avoid eviction. In this instance, no effect interpreta-tion linked medication compliance with wellness. Rather, unpredictable
adherence was evidence of the client’s lack of understanding (“I don’tknow if he gets it”). The client did not “get” that managers wanted himto see a relationship between compliance and “doing fine.” In the query,“did he do his labs,” managers commented on self-reliance. Interven-tion was considered when it was suspected that the client had not fol-lowed instructions, that is, Clozaril required weekly laboratory analysisto rule out serious side effects. Thus, when blood was not drawn for twoweeks, Clozaril should be terminated. But before termination wasconsidered, the team did for him–changed his medications–to preventmedication non-compliance. Here, the team feared that relapse andhospitalization would be the outcome of inadequate medication moni-toring. In the above example, note in particular the complex relation-ship between compliance and effect interpretation: when the latter wasambiguous, the former became problematic. Was it non-compliance,failed effect, or unanticipated effect, or an even more complex dynamicamong neuro-chemistry, intra and inter-psychic and social forces? Thecomplexity was not sorted out but rather summarized in a situated, man-ager lexicon language: “he doesn’t get it.” (See Floersch, 2002).
Where self-monitoring is not possible, as in the example above, others
in the grid share power or exercise it on behalf of clients, not always inhelpful or caring ways. And the use of this power must be aimed at morethan attempting to achieve behavioral outcomes. Throughout the life courseof any specific illness, monitoring will be variably and complexly deter-mined by a multitude of continuously changing conditions: course of illness,gender, ethnicity, social class, ability to work, family, community and cul-tural context, neighborhoods, quality of human relationships, emotions, so-cial networks, type of medication, polypharmacy, and funding streams. Thus, with respect to practitioner and client management roles, we specu-late that activity or passivity is dependent on (1) the level of a client’s abil-ity to self-monitor and (2) the ease of the effect interpretation. And, effectinterpretation is extremely difficult when the gap between the desired andactual effect is ambiguous and open to multiple interpretations. Using cli-ent perceptions of treatment with atypical antipsychotics, we will illustratethe ambiguity present in medication effect interpretation. CLIENT SUBJECTIVE EXPERIENCE OF MEDICATION EFFECTS
A number of ethnographic and qualitative studies have developed
methods for investigating the relationships among an illness, a person,
Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
and the person’s lived experience (Csordas, 1990, 1994; Good, 1994;Karp, 1996; Kleinman, 1995; Strauss, 1994, Jenkins & Barrett, 2003). These studies include a notion of intersubjectivity alongside subjectiv-ity, emphasizing the interactive zone of lived experience in which theself is dynamically and multiply constituted. Extending these insightsinto the world of medication research provides a doorway into how de-sired and actual effects are interpreted by the medication recipient. Inresearch sponsored by the National Institute of Mental Health, “Cul-ture, Schizophrenia, and Atypical Antipsychotics,” Jenkins, Floerschand Longhofer are studying the subjective experience of atypicalantipsychotics by incorporating the perspectives of anthropology, psy-choanalysis, social work, and history. Methods
Ninety adults (see Table 1) currently receiving outpatient treatment
and management for either schizophrenia or schizo-affective illnesses(see Table 2) are included in the study. Standard research diagnostic as-sessments (SCID, BPRS, and SANS) have been completed on all sub-jects. And using the Subjective Experience Medication Interview (SEMI)instrument, patient experience of antipsychotic treatment and illness isexamined. The SEMI tracks the multiple meanings of medication experi-ence, which are often shifting, paradoxical, and sometimes contradictory. One focus has been the use of patient metaphors to describe medicationexperience. The SEMI is an open-ended anthropological interview guidedesigned to obtain illness and medication narratives; it queries partici-pants about perceptions of antipsychotics. Among numerous SEMIquestions and categories, those relevant for this case study are: “Whatdo you think these medications are doing for you?”; “If you tried to ex-plain to someone not taking this [these] medication[s] what the experi-ence is like, what would you tell them?”; “How would you describe theeffects the medication has on you?”; “What do you like about the effectsof the medications?”; and, “What don’t you like about the medica-tions?”
Data analysis is currently focused on four thematic areas: (1) medica-
tion compliance, (2) emotional changes related to medication, (3) stigmalinked to mental illness and medication, and (4) the usage of metaphori-cal language in articulating the experience of antipsychotic medication. Future analysis will investigate additional domains of gender, social rela-tions, family life, work/employment, and experience of recovery from ill-ness. Using a descriptive illustration, we identify the phenomenological
TABLE 1. Socio-demographic Characteristics of Participants (N =90)
or interpretive gap (i.e., the medication aporia) as the paradoxical, con-tradictory, and ambiguous client feelings and perceptions of medicationtreatment. A Case Illustration of Medication Effect Interpretation
New atypical antipsychotics have often been referred to as the “mira-
cle drugs.” Thus, each research participant was asked if their medica-tion experience could be characterized as a miracle. In one case, theclient replied:
I don’t know. I simply don’t know. It’s freed my anxiety level. Thething I don’t know about the [medication] is that my environmenthas changed so many times since I’ve been on it. First I started tak-ing it when I was [back east]. And then, when I came home [here] I
Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
was living with a guy . . . And then with two guys. So as far as theeffects of the medications on me, it must be so complicated be-cause there is an interaction going on between my environmentand when I take the pills. So I don’t know how to judge it.
In a follow up question–“since you started taking it, do you feel differ-ent in yourself in any way?”–the same respondent, with an upbeat tone,noted:
I feel like a different person. I have self-confidence now. I droppedsix pounds last week. And now I know I can do it because I playtennis and golf every Monday and Wednesday. . . . So [I] showerand shave and [get] out of the house at 8 o’clock, that’s cool. . . . And now when . . . I hear words about the computer like uploadand download and megabytes and modem and stuff that all [my]nephews talk about, I used to go to an anxiety state.
Continuing the interview, he was asked: “what do you want medica-tions to do for you?” “I would want it to help with anxiety. And help mefind a beautiful girlfriend.” And, “what would you want a medicationnot to do?”
I don’t want it to make me gain weight. I’ve had enough of that ex-cess salivation. I don’t want it to make me sleep more. I don’t wantto feel lethargic. And I don’t want tardive dyskinesia. I don’t wantany of the side effects to interfere with my life.
“What does the medication do best?” the interviewer asked. “Onething I’ve noticed is I’m losing weight slowly, that’s good.” With atone of disbelief, the interviewer followed: “Because of the medica-tion?” “Yeah, I think so. And I feel [that] my body [is] softer now.” Theinterviewer’s skeptical tone was understandable; minutes later, in thesame interview, the respondent was asked, “out of the side effects thatyou’ve talked about (i.e., weight gain, drowsiness, and drooling) whatbothers you the most?” Without hesitancy, the respondent remarked:“Weight gain. I don’t wear the clothes that I wore during my youngerdays.”
Excerpts from this interview demonstrate ambiguity, contradiction, and
paradox. Ambiguity is evident in the respondent’s indecision about thecausal powers of medication: “so I don’t know how to judge it.” By not
TABLE 2. Clinical Characteristics of Participants (N = 90)
* for length of treatment at current clinical site
separating environmental from medication effects, this left the client’scausal explanation in doubt and open to myriad interpretations. Yet, bypointing to a time without medication, the interviewer found the respon-dent felt like a “different person” since starting the medication. Indeed,there was the sense that he felt good (i.e., “cool”) about waking early to ex-ercise. Does this contradict the earlier statement about an inability tojudge? To answer this question requires exploring the gap betweenhoped-for and actual effects. The client’s hopeful medication effectseemed fantastic in the hoped-for “beautiful girlfriend.” Were the girl-friend to be actualized, we do not know if he would attribute it to medica-tion. What we do know is that he imagines the powerful possibility ofmedication; therefore, he opens up a very large gap between his desiredand actual medication effect. In his actual dating experience, for example,how might he have claimed that medication delivered to him the hoped-forgirlfriend? Even if medication could, how would the recipient know the
Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
girlfriend had been delivered by the medication? A longing feeling, such asa “beautiful girlfriend,” and “happiness,” were common desires when re-spondents were asked, “if a medication could do anything you wanted,what would you want it to do?” Most stated very clearly, however, thatmedication would not make them happy. And most were fully aware thatthe absence of happiness was attributable to their illness; its lack produceda desire that something, perhaps a medication, could produce a miracle forthem. In at least one case, the association between medication and happi-ness was so strong the client reported pasting smiley faces on each day ofher medication box; she reported her compliance behavior improved bylooking at the happy faces.
In the case example, was medication causing weight gain or loss? In-
terview responses suggested both. Because pharmaceutical companieshave identified weight gain as a side effect, the respondent’s reportedweight gain and reduction, empirically real and experienced by him,had several interpretable causes. He reported exercising, which couldproduce weight loss, and he reported complying with a regimen knownto produce weight gain. Consequently, the weight reduction remarksdid not produce a contradiction; they were statements contrary to re-ceived opinion or belief, and contrary to what was held to be establishedtruth–the prescribed atypical antipsychotic had not been shown to re-duce weight; instead, the opposite had been established. Thus, it was nota contradiction but a paradoxical feeling the client was attempting tosort out. On the one hand, he wanted weight reduction and had experi-enced it. Yet, on the other, following medication compliance, he had ex-perienced weight gain.
Although preliminary, this case example of paradox, ambiguity, and
contradiction is likely to be experienced by many. This is so because ofthe interpretive gap between hoped-for and actual medication effects. The actual size of the gap is dependent on numerous variables not yetfully understood. Nevertheless, the presence of the drug aporia is evidentwhen research methods acknowledge the paradoxical, contradictory, andambiguous feelings that recipients (and practitioners) often experience. DISCUSSION
A medication effect interpretation will always occur alongside at
least one of the five elements of a management event; they are mostprominent when compliance and effect monitoring and reporting are
unfolding. It is in this way that the ‘activity’ or ‘passivity’ of actors,clients or practitioners must be calibrated to careful interpretations ofthe reasons, wants, purposes, desires, and intentions of actors, some-times including unconscious ones. Thus, a patient or client-centeredapproach cannot be predetermined and applied mechanically to anyparticular setting or person; this choice should be the outcome of care-ful, collaborative, and highly skilled medication management, notpreconditions for it. Medication, rather than producing independentbehavior, the intended outcome of most pharmacotherapy models,generates instead inseparable bonds between clients and managers(Floersch, 2002). Medication often becomes the crucial link and thecentral most important basis for establishing and maintaining a relation-ship. In short, in making effect interpretations practitioners evaluate theclient’s capacity to live in the community.
Monitoring and reporting for clients occurs not because practitioners
do not hope for independent compliance behavior. Rather, the drugaporia requires that management participants (inter)dependently and(inter)subjectively resolve the ever-present ‘effect’ interpretations. Inthe earlier case example of a client’s subjective experience of atypicalantipsychotic treatment, there was no one interpretation that could fi-nally settle his cause/effect dilemma: Is it environment or medicationthat produced change? Moreover, why not wish for a medication-pro-duced girlfriend? The hoped-for or desired effect of medication has nu-merous permutations depending on the client’s unique circumstancesand social relations. Indeed, the social relations that constitute the cli-ent’s grid (Longhofer, Floersch, & Jenkins, 2003) offer evidence for theimportance of relationships in any pharmacotherapy intervention; thegrid relations support the participant by managing the five elements(see Figure 1) of medication management. And as long as the gap be-tween the desired and actual effect lingers–always present–the need for‘effect’ interpretations will never disappear (see Floersch  for ex-amples of case manager ongoing ‘effect’ interpretations).
An example of physical medicine is instructive. When one takes as-
pirin and hopes that the headache will subside, and it does, the gap be-tween the desired and actual effect is minimal; although rarely is itcompletely dissolved, perhaps, because simultaneously the person mayhave learned to associate relaxing with taking aspirin. Thus, we specu-late that the extent to which the gap can be reduced to a minimum, forpractitioner or client, doubt will fade as to the medication’s lack of ef-fectiveness. However, as long as a perplexing difficulty or aporia overassigning meaning to our subjective experience of medication exists,the resulting ambiguity and paradox will be negotiated by relationshipsin the grid and associated interpretations. Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
For community social workers and practitioners our findings sug-
gest that clinical interventions need to help participants (1) understandhow medications become meaningful; (2) acknowledge the existenceand function of the grid; and (3) place medication interpretations at thecenter of therapeutic work. To bracket–set at the periphery–medica-tion effects, as if they occur independent of interpretation, requiresadopting a strictly technocratic and rationalistic practice. It is as if weimagine chemicals produce subjective experience without interpreta-tion. Perhaps it is our anxiety over not knowing–and with preci-sion–how to ‘fix’ mental suffering that we imagine that psychotropiceffects are transparent. The drug aporia produced by psychotropictreatment is real, multi-dimensional, and must be researched and under-stood. To do otherwise is to retreat into a rigid mind/body dualism. Ourempirical research on medication management and the subjective expe-rience of clients puts into question dualistic thinking.
Finally, we are left with important questions about the cultural and psy-
chological ‘side’ effects of psychotropic treatment. Are they not as signifi-cant as physical ones? If not, on what empirical grounds could this beargued? Indeed, pharmaceutical companies are required to list physicalside effects and psychiatrists and doctors are instructed to inform their pa-tients about them. Why would we not also consider the cultural and psy-chological effects in our warnings? For example, in hoping for an effectthat medication cannot deliver, does this not constitute a negative psycho-logical side effect? In not respecting cultural difference in how peoplemake sense of medications, is this not a negative cultural side effect? Ifthese are ‘side’ effects, then why are we not including psychological andcultural warnings in our routine informed consents? We may need dualistapproaches in science for research purposes, but in the lives of the medi-cated our findings show that separating cultural, psychological, and bodilyexperiences will not adequately represent the medication experience. Consequently, practitioners and researchers need to take the drug aporiaas seriously as they do symptom reduction and physical side effects.
Ascione, F. (1994). Medication compliance in the elderly. Generations, 18(2), 28-33. Atkin, P. A., & Ogle, S. J. (1996). Issues of medication compliance and the elderly. Ad-verse Drug Reaction Toxicological Reviews, 15(2), 109-18.
Bennett, J., Done, J., & Hunt, B. (1995). Assessing the side-effects of antipsychotic
drugs: A survey of community psychiatric nurse practice. Journal of Psychiatricand Mental Health Nursing, 2(3), 177-82.
Berg, J. S., Dischler, J., Wagner, D. J., Raia, J. J., & Palmer Shevlin, N. (1993). Medi-
cation compliance: A healthcare problem. The Annals of Pharmacotherapy, 27(9Suppl), 1-24.
Boomsma, J., Dassen, T., Dingemans, C., & van den Heuvel, W. (1999). Nursing inter-
ventions in crisis-oriented and long-term psychiatric home care. ScandinavianJournal of Caring Sciences, 13(1), 41-8.
Cameron, C. (1996). Patient compliance: Recognition of factors involved and sugges-
tions for promoting compliance with therapeutic regimens. Journal of AdvancedNursing, 24, 244-250.
Chewning, B. (1997). Patient involvement in pharmaceutical care: A conceptual
framework. American Journal of Pharmaceutical Education, 61(4), 394-401.
Chewning, B., & Schommer, J. C. (1996). Increasing clients’ knowledge of commu-
nity pharmacists’ roles. Pharmaceutical Research, 13(9), 1299-1304.
Chewning, B., & Sleath, B. (1996). Medication decision-making and management: A
client-centered model. Social Science & Medicine, 42(3), 389-398.
Cohen, D. (2002). Research on the drug treatment of schizophrenia: A critical ap-
praisal and implications for social work education. Journal of Social Work Educa-tion 38(2): 217-239.
Cohen, D., McCubbin, M., Collin, J., & Pérodeau, G. (2001). Medications as social
phenomena. Health, 5(4), 441-469.
Cohen, J. S., & Insel, P. A. (1996). The physicians’ desk reference–Problems and pos-
sible improvements. Archives of Internal Medicine, 156(13), 1375-1380.
Conrad, P. (1985). The meaning of medications: Another look at compliance. SocialScience and Medicine, 20(1), 29-37.
Csordas, T. J. (1990). Embodiment as a paradigm for anthropology. Ethos, 18, 5-47. Csordas, T. J. (1994). Embodiment and experience: The existential ground of cultureand self. London: Cambridge University Press.
de Vries, C. S., Duggan, C. A., Tromp, T. F. J., & Lolkje, T. W. (1999). Changing pre-
scribing in the light of tolerability concerns: How is this best achieved? DrugSafety, 21(3), 153-160.
Demyttenaere, K. (1997). Compliance during treatment with antidepressants. Journalof Affective Disorders, 43, 27-39.
Dowell, M. S. (1990). People’s expectations of their medications: An ethnographicstudy. Ph.D. dissertation, The University of Texas at Austin.
Estroff, S. (1981). Making it crazy: An ethnography of psychiatric clients in an Ameri-can community. Berkeley: University of California Press.
Floersch, J. (2002). Meds, money, and manners: The case management of severe men-
tal illness. New York: Coumbia University Press.
Floersch, J. (2000). Reading the case record: The oral and written narratives of social
workers. Social Service Review, 74(2), 169-192.
Gerbert, B., Love, C., Caspers, N., Linkins, K., & Burack, J. H. (1999). “Making all
the difference in the world”: How physicians can help HIV-seropositive patientsbecome more involved in their healthcare. AIDS Patient Care and STDs, 13(1),29-39.
Good, B. J. (1994). Medicine, rationality, and experience: An anthropological per-spective. Cambridge and New York: Cambridge University Press. Psychiatric Medication Issues for Social Workers, Counselors, and Psychologists
Gournay, K. (1995). Mental health nurses working purposefully with people with seri-
ous and enduring mental illness–An international perspective. International Jour-nal of Nursing Studies, 32(Aug), 341-52.
Hamera, E. K., Rhodes, R. M., & Wegner, M. M. (1994). Monitoring of prodromal
symptoms: A method for medication management of schizophrenia. CNS Drugs,2(6), 440-452.
Hohmann, A. A., & Shear, M. K. (2002). Community-based intervention research:
Coping with the “noise” of real life in study design. American Journal of Psychia-try, 159(2): 201-207.
Jenkins, J. H., & Barrett, R. J. (2003). The edge of experience: Schizophrenia, culture,and subjectivity. Medical Anthropology Series Cambridge, UK: Cambridge Uni-versity Press.
Jenkins, J. H., & Miller, D. (2002). A new kind of evidence for mental health services
and interventions: Subjective experience of atypical antipsychotic medications. Pa-per presented at National Institute of Mental Health conference, “Evidenced-BasedPractice,” Bethesda, MD. (March).
Jordan, S., Hardy, B., & Coleman, M. (1999). Medication management: An explor-
atory study into the role of community mental health nurses. Journal of AdvancedNursing, 29(5): 1068-81.
Karp, D. (1996). Speaking of sadness: Depression, disconnection, and the meanings ofillness. Oxford: Oxford University Press.
Keat, R., & Urry, J. (1982). Social theory as science (2nd ed.) London: Routledge &
Kleinman, A. (1995). Writing at the margin: Discourse between anthropology andmedicine. Berkeley: University of California Press.
Lipowski, E. (1997). Introducing theories of patient-focused care in pharmaceutical
education. American Journal of Pharmaceutical Education, 61, 410-414.
Longhofer, J. L., Floersch, J. E., & Jenkins, J. H. (2003 ). The social grid of community
medication management. American Journal of Orthopsychiatry, 73(1): 24-34.
Morris, L. S., & Schulz, R. M. (1992). Patient compliance–An overview. Journal ofClinical Pharmacy and Therapeutics, 17, 283-295.
Rapp, C. (1998). The strengths model: Case management with people suffering fromsevere and persistent mental illness. New York: Oxford University Press.
Rhodes, L. (1984). This will clear your mind: The use of metaphors for medication in
psychiatric settings. Culture, Medicine, & Psychiatry, 8:49-70.
Roter, D. L., Hall, J. A., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998).
Effectiveness of interventions to improve patient compliance–A meta-analysis. Medical Care, 36(8), 1138-1161.
Sleath, B. (1996). Pharmacist-patient relationships: Authoritarian, participatory, or de-
fault? Patient Education and Counseling, 28, 253-263.
Sleath, B., Svarstad, B., & Roter, D. (1997). Physician vs patient initiation of psycho-
tropic prescribing in primary care settings: A content analysis of audiotapes. SocialScience and Medicine, 44(4), 541-548.
Sowers, W., & Golden, S. (1999). Psychotropic medication management in persons
with co-occurring psychiatric and substance use disorders. Journal of Psychoac-tive-Drugs, Jan-Mar; 31(1): 59-70.
Strauss, J. S. (1994). The person with schizophrenia as a person: Approaches to the
subjective and complex. British Journal of Psychiatry, 164(suppl. 23), 103-107.
Steiner, J. F., & Prochazka, A. V. (1997). The assessment of refill compliance using
pharmacy records: Methods, validity, and applications. Journal of Clinical Epide-miology, 50(1), 105-116.
Trostle, J. A. (1988). Medical compliance as an ideology. Social Science & Medicine,
Warren, B. J., & Lutz, W. J. (2000). A client-oriented practice model for psychiatric
mental health nursing. Archives of Psychiatric Nursing, 14(3), 117-126.
Warren, B. J. (1999). Cultural competence in psychiatric nursing: An interlocking par-
adigm approach. In N. L. Keltner, L. H. Schwecke, & C. E. Bostrom (Eds.), Psychi-atric Nursing (pp. 199-218). Chicago: Mosby.
Wells, K. B., & Sturm, R. (1996). Informing the policy process: From efficacy to effec-
tiveness data on pharmacotherapy. Journal of Consulting and Clinical Psychology,64(4), 638-645.
Statistics Concentration)M. S. (Applied Statistics)University of the Philippines at Diliman, 1985Department of BiostatisticsUniversity of Alabama at Birmingham, Oct 2008 – presentCenter for Cardiovascular BiologyUniversity of Alabama at Birmingham, November 2010 – presentCenter for AIDS ResearchUniversity of Alabama at Birmingham, May 2008 – presentDepartment of BiostatisticsUniversity
Door Peter Wonink, Jan Wessels en Erik van der Garde* “het zijn de kleine dingen die het doen…,” zongen Saskia en Serge al in 1971, maar ruim 40 jaar later is het nog steeds actueel. ook bij keuzes voor het beheer en onderhoud van riolerings- systemen, stellen ingenieur Peter Wonink (Roelofs advies en ontwerp), adviseur Jan Wessels (Kijlstra Riolering) en adviseur erik van de