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I was watching a colleague who was trying to convince an elderly woman to take her dose of an antidepressant. The nurse was patiently explaining the purpose of the medication and the necessity for getting enough of a starting dose to assess the effect. The client politely listened and replied, "But, I don't need medicine for depression, I need something for my bowels . . . you see, they have died and turned to stone inside me." Without losing a beat, my colleague responded metaphorically. "Ah, but this medicine will bring your bowels back to life." The client beamed, took the pill, and thanked the nurse.
After she left, 1 trotted up to my friend and asked, "Weren't you worried about reinforcing her delusional thinking?" My colleague replied, "Well, I guess on some level I was. However, I saw myself as her interpreter, interpreting the medication's ultimate effect on her depression in terms of the symptom that most affected her quality of life. In other words, I found a shared space between us and used that to help her take her medicine."
The wisdom here lay in the illustration of the sensitive alliance between nurse and client that is so critical to successful drug therapy. Building the alliance is a negotiation built on empathy and an understanding of the client's present reality. In the example, my colleague responded to this client's refusal of the medication as an invitation to collaborate, and chose to interpret benefits of the medication that were personally meaningful to the client.
Rather than creating a problem, refusal to collaborate in pharmacotherapy offers a window into the central dynamics of the client, such as conflicts with dependency or a terror of being rendered helpless. Refusal may illustrate the interpersonal skills with which the client navigates the world of decisions. Furthermore, refusal may also lead the nurse toward an understanding of the client's past experience with medication. This last area...