In focusing on orientation to forms of formal psychiatric knowledge practices, the position of service users needed to be taken into account. More specifically,
consideration of what is at stake for service users in relation to psychiatric practice. Contextualising effects of psychiatric practices on the non-discursive experiences of service users was important, so as to highlight the issues involved in orienting to some of the factors involved in the formal practice of psychiatry. One of the key areas in which formal practice impacts upon daily life is the area of treatment. Analysing how treatment regimens could operate and how power over changes to regimens existed primarily in the hands of psychiatric staff, become a pivotal strand in accounting for strategies relating to mainstream practice (see Campbell, Cobb, & Darton, 1998, for discussion of the 'problem' of treatment for users, i.e. issues over lack of control). As the data was analysed it began to emerge that users’ own daily activity levels (in terms of their embodied capabilities) could be limited once a change in medication regimen had occurred, which could result in them no longer being in everyday control of their medication. For instance, as will be seen in the data in this chapter, changes from self-administered tablet medication to service provider-administered regimens can produce contestation over control of users’ bodies. This raises the issue of control over decisions regarding medication administration. The question as to whether it would be a possible course of action for service users to refuse proposed changes to their
medication administration raises specific issues of adherence. Adherence has also been referred to in literature as compliance, and both terms are still used, although for the sake of clarity ‘adherence’ will be used throughout in this thesis.
Adherence has long been recognised as an important issue in psychiatric treatment (Cramer & Rosenheck, 1998). Treatments are designed to improve and be beneficial, so obviously having people to whom they are prescribed actually take them, is deemed an important task. In psychiatry, focus on adherence has been strong due to the
perceived high rates of incidences of non-adherence, where people fail to take their medication (Ley, 1997), or, where their regimen is not adhered to exactly, with some deviation, although not a total failure. In psychiatry, non-adherence is a serious issue because of its potential consequences (Gelder, Mayou, & Cowen, 2001). These mainly focus around a re-occurrence of ‘illness’, and more specifically on the actual factors that can be involved in that. For instance, a return to in-patient hospital care and/or re-
commencement of psychotic episodes (which can include perceived potential for violent behaviour).
Generally, the notion of non-adherence is associated with perceived ‘risk’ of the return of psychotic symptoms and the negative life experiences they can bring, if service users stop taking their medication (Buchanan, 1992). Thus, users may be told that risking any return to illness is not something they should do, and that service providers are strongly against such a course of action. If past mental ill health has resulted in admission to a mental hospital ward, then intentional non-adherence may result in a return to hospital, which some service users may resist due to the lack of perceived control over their lives that it brings. The ‘stability’ that medication can bring is deemed to be very important, so anything that can jeopardise it is taken seriously. This is the paradox for users, namely that adherence can bring stability, but can also involve ceding control.
Given these negative connotations, the position of users in respect of whether they can refuse proposed changes to medication regimens is a complex and difficult one. To be visibly non-adherent and remain as part of the service provision practice is not really an option, and given that all users in this study were in contact with service provision, control over their medication administration was not something that was perceived to be theirs. Thus, room for a sense of control over this aspect of their medication administration was severely limited. However, in the interviews it became clear how important for users it was to represent these changes in terms that served to construct themselves as not completely controlled by external provision, and as such the methodological and empirical focus was one of analysing the discursive strategies of users in accounting for the dilemmas of stake (Edwards & Potter, 1992; Potter,
Edwards, & Wetherell, 1993) facing them. More specifically how do they manage their stake as ‘service user’ in the interview interaction, in terms of the issues involved (i.e. perceived lack of control over medication decisions) with being a service user?
Research into adherence has focused on many areas. A dominant strand adopts a preventative approach, in terms of investigating predictive variables that can lead to non-adherence. For instance, Compton, Rudisch, Weiss, West and Kaslow (2005) have analysed socio-demographic, gender and race data. Another strand has concentrated on reasons behind non-adherence with a variety of factors identified, such as side effects;
lack of understanding of illness (Torrey & Zdanowicz, 2001); difficulty in recognising symptoms (Olfson, Mechanic, Hansell, Boyer, Walkup, & Weiden, 2000); and use of alcohol and illicit drugs (Kamali, Kelly, Clarke, Browne, Gervin, Kinsella, Lane, Larkin, & O'Callaghan, 2006). Given its prominent role as part of psychiatric practice, and as a key issue for both service users and psychiatric staff, it forms a central thread through this chapter. The focus is primarily on how users discursively orient to
psychiatric practice in terms of accounts of adherence, through analysing the ways that service users reflexively orient to and manage the problems posed by issues of
adherence in interview context, and the ways this exposes some of the resources they bring to bear in doing this in other settings (e.g. in home environments). The next chapter will approach more closely issues of the operation of non-adherence, and how they operate as non-discursive embodied concerns in daily lives.