A Conceptual Protocol for a Single-Session Solution-Focused Brief Therapy for Medication Adherence Intervention Delivered by General Providers

Introduction

At present, medication adherence in coronary heart disease (CHD) is still disappointing, followed by adverse disease outcomes and high costs, and medication adherence intervention is usually unsatisfactory.^1,2 Most importantly, tailored intervention has become the trend of medication adherence intervention with three elements: (1) clarifying non-adherent patients, (2) identifying barriers to medication adherence, and (3) providing individualized intervention for each barrier, sequentially.^2–4 It increased the relevance and effectiveness of medication adherence intervention by increasing its problem-oriented focus on barriers to medication adherence.^2–4 However, this feature reflected the pathological view of psychology, while running counter to the current trend of positive psychology, especially in psychological interventions.^5–7

Meanwhile, psychological interventions are urgently needed to improve patients’ medication adherence⁴ because psychological factors are essential for medication adherence.^8,9 Psychological interventions have been widely used for cardiovascular disease, while they have been less dedicated to medication adherence interventions.^10,11 Psychological interventions usually require professionals to conduct multiple sessions, which is inconvenient and even difficult for general providers.^5,12,13 Therefore, more alternative psychological interventions with brief and highly structured protocols are urgently needed to provide more choices in clinical practice. Fortunately, in recent decades, psychological interventions have evolved greatly in recent decades, with trends toward integrative, brief, and evidence-based interventions with fewer sessions,^14,15 and even single session,^16,17 such as the solution-focused brief therapy (SFBT).

SFBT is a strengths-based and positive-oriented intervention that focuses on solutions with simple and brief interventions.^18,19 It is considered a “real-world” practice appropriate for a broad population and an evidence-based intervention with fewer sessions than alternative psychotherapies.^20,21 In the medical setting, SFBT is a good practice for patients’ health-related psychosocial, behavioral, and functional health outcomes and medication adherence.²² To our knowledge, there is no research on the use of SFBT for medication adherence interventions, and the SFBT used in the medical setting is usually a classic SFBT delivered by professionals,^23,24 which still sounds complex to general medical providers. The classic SFBT typically involves four to six sessions with three characteristic frameworks and more than ten representative questions with different uses and outcomes.^18,25 However, beginners always find that the SFBT is easy to understand and learn, but difficult to master and apply. In particular, it is not clear how to combine these frameworks and representative questions into a complete counseling session quickly and efficiently. And sometimes the SFBT sounds too straightforward without enough warmth.²⁶ These features increase the difficulty of generalizing it to general providers in clinical practice. Therefore, a highly structured SFBT with more detailed procedures and more understandable logic, especially in a single session, is urgently needed for medication adherence interventions in CHD patients.

In the Chinese community, scholars from Taiwan China, especially Wen Hsiao and Weisu Hsu, are usually the teachers of many mainland China SFBT learners.²⁷ Qitang Lin, who is a scholar from Taiwan China and a disciple of Wen Hsiao, is active and well known in mainland China.²⁸ He provides a conceptualization of single-session SFBT with four steps named in Chinese, specifically, tiejin, xiwang, nengliang and xiuxing, which mean closing, hoping, empowering, and changing and acting, respectively.²⁸ Closing uses techniques of not knowing, normalizing, reframing and positive empathy to capture the client’s emotions with the logic of addressing feelings before shifting perceptions. Hoping helps clients to see the changeable and beautiful views in their lives by setting goals and/or using the miracle question to propose solutions. Empowering searches for the client’s resources and energies to deal with current problems, mainly through exception questions and coping questions for internal resources and compliment and relationship questions for external resources. Finally, the client is encouraged to change behavior and/or take action by giving compliments, building bridges and discussing homework, namely, changing and acting. Compared to classical SFBT, Lin’s conceptualization integrates SFBT techniques into a more logical, understandable, and operational procedure, with the potential to be integrated into medication adherence interventions in clinical practice.

The purpose of this paper is to present a conceptual protocol of a single-session SFBT for medication adherence intervention (SFBT-MAI), based on the tailored medication adherence intervention procedure and Lin’s conceptualization of SFBT, with some modifications to fit clinical needs. We hope that this design of SFBT-MAI will integrate the advantages of tailored intervention and single-session SFBT to be brief, highly structured, understandable, and positive-oriented. Therefore, it will be helpful to improve medication adherence in CHD managed by general providers in clinical practice.

Methods

This is a conceptual protocol of SFBT-MAI developed based on our understanding of tailored medication adherence intervention, SFBT, and the clinical practice of CHD. It was developed using the following methods. (1) The procedure of tailored intervention was considered as the basic procedure of the SFBT-MAI, and its three elements, as we mentioned above, were integrated into two parts based on the relationship between them.⁴ (2) The techniques of SFBT, especially its representative questions²⁵ and Lin’s four steps of single-session SFBT, as we learned from his course,²⁸ were integrated into the two parts of the tailored intervention. (3) Our previous experience of clinical practice of CHD was also taken into account.

Results

The conceptual protocol of the SFBT-MAI was developed as follows.

Basic Setting

The SFBT-MAI was established as a method of health education prior to the discharge of inpatients with CHD from the Department of Cardiology. It focuses on medication adherence intervention, while also mentioning lifestyle to emphasize the importance of integrative health in CHD.²⁹ A one-on-one conversation between the provider and the recipient was considered. The provider may be a physician, nurse, or pharmacist, and the recipient is mainly the patient or his/her relatives.

The basic procedures of the SFBT-MAI are divided into two parts: assessment and intervention. In the first part, the patient’s medication situation, medication adherence, barriers to medication adherence, and lifestyle are assessed in order to select mainly patients with medication non-adherence as intervention participants and to clarify individual barriers to medication adherence as intervention targets. After a brief general health education, the second part is mainly a single-session SFBT based on Lin’s four steps for individualized medication adherence intervention. The four steps are closing, hoping, empowering, and changing and acting. Each step provides specific techniques of SFBT and examples of expressions. The SFBT-AMI focuses on the barriers to medication adherence to reflect the nature of the tailored intervention, while it is conducted with the positive, future, and goal-oriented feature and balanced warmth and brightness to reflect the nature of classical SFBT and Lin’s conceptualization. Figure 1 shows a brief structure of the SFBT-MAI, and Table 1 lists the key techniques and their examples of SFBT used in SFBT-MAI.

Figure 1 The brief structure of the SFBT-MAI.

Table 1 The Main Techniques of SFBT Used in SFBT-MAI

Part One: Assessment

After introducing oneself and obtaining the patient’s consent, it is imperative to review the patient’s medication plan following their discharge to ensure that they are informed and comfortable with their medication regimen. Subsequently, their medication adherence since the diagnosis of CHD should be assessed to clarify any medication non-adherence either through the use of a self-report scale, such as the MMAS-4,³⁰ or the provider’s personal experience by communicating with the patient or reviewing their medical history. Additionally, the scale question of SFBT should be employed.²⁵ Barriers to medication adherence should be evaluated and clarified either by using checklist or by asking the patient directly. Depending on the personal preferences of the general provider, similar methods may be used to assess the patient’s lifestyle. The patient is then given feedback that includes a summary of the assessment results, expressions of gratitude for cooperation, and an invitation for non-adherent patients to participate in the upcoming intervention, expressed as health education. Informed consent is obtained from patients who agree to undergo the above interventions.

Part Two: Intervention

Brief General Health Education

Prior to the tailored medication adherence intervention, a brief general health education is needed to help the patient to understand the general requirements and principles of treating CHD, including medication adherence and maintaining a healthy lifestyle (e.g., quitting smoking, limiting alcohol consumption, maintaining a bland diet, and moderate physical activity). This section was placed before the delivery of individualized interventions, such as a preface, to address the importance of general health education and to provide an overall view of CHD treatment.²⁹

The Four Steps of Single Session SFBT

Step 1: Closing (Focusing on Barriers to Medication Adherence)

It is better to focus on the most important barrier identified by the patient; the following text is an example of dealing with one barrier. (1) Not knowing and clarifying: Patients should be asked sincerely, respectfully, and in a friendly manner about the details of the difficulties in taking medicine. The technique of not knowing actually means the provider’s manner of emptying himself/herself to provide enough space for the patient’s content, while clarifying is to ensure the essential content of the patient’s difficulty. For different barriers, the main point of clarification may be different; for example, to calculate the details of the treatment cost in one year (financial difficulty), to clarify the understanding of being asymptomatic, having symptoms and disease (asymptomatic), or to ensure the exact symptoms of side effects to know whether they are actual experiences or subjective fears (experiencing or concerning side effects). (2) Normalizing and reframing: Patients may develop negative emotions and perceptions when they encounter difficulties. Normalizing means to impress upon the patient that this situation is temporary, changeable, and predictable; anyone else in this particular situation could do the same thing as the patient. Therefore, it is normal or just one step in a normal process. Reframing shifts the patient’s perspective from negative to positive by becoming aware of the positive side of the difficulty, pointing out the deep desire behind the complaint, and guiding the patient to observe his or her efforts, values, and desires. The provider is encouraged to formulate personalized expressions for reframing based on the patient’s actual situation and the provider’s experience in clinical practice.

Step 2: Hoping (Setting Goals)

According to Lin’s view of goal setting, we first set a big and general dream to maintain hope for our lives, and then, we set a small and detailed dream to emphasize step-by-step actions toward the realization of the big dream.²⁸ In order to stimulate patients’ motivation for medication adherence, stabilizing the disease and being healthy in a foreseeable time is set as a big dream; adhering to medication and lifestyle is set as a medium dream; and addressing or overcoming barriers to medication adherence is set as a small dream. (1) Disease goal: In this step, miracle questions or supposed questions can be used to guide patients to recognize the benefits of keeping the body in a stable condition for as long as possible. (2) Adherence goal: The goal of strict adherence to the prescription for a long period of time should be stated, and the patient’s understanding should be asked and listened to, so that the gap between strict medication adherence and the patient’s actual understanding can be clarified without any misunderstanding. (3) Barrier goal: Addressing barriers to medication adherence is essential and immediate. According to SFBT, the goal should be important and valuable to the patient, under the patient’s control, and based on the patient’s realistic environment. Its expression should be positive and operational, with measurable behavior, such as I want something rather than I do not want something. Miracle questions or supposed questions can be used to elicit this goal, followed by several questions to enrich the details to impress the patient’s positive expectations. The provider and the patient are encouraged to discuss the details of the goal.

Step 3: Empowering (Uncovering Energy)

Empowering reveals the patient’s potential and strengths that are limited by frustration in the face of difficulty. This is almost the most powerful step in SFBT with several classic techniques.²⁵ The SFBT-MAI integrates three major questions into three conditions for logical understanding. The first is an exception question to find and expand the moment when the barrier to medication adherence was not present or not working. An exception is the goal of addressing barriers. The second technique involves a coping question to elicit and capture the patient’s efforts, persistence, and strengths. This question is usually powerful in terms of the provider’s admiration and understanding. The third technique is the compliment, which can be expressed as a direct compliment and consultation. The essence of the compliment is sincere, based on the information from the coping question. If there was ever an exception as our main expectation, then more exceptions (such as the last one, the most impressive one, and the first one) would be expected. An exception should be chosen for discussion to expand its details as much as possible, including the time, place, people (relationship), event, feeling, etc., and coping questions and compliments can be used to uncover the patient’s energy. If there is no exception and the situation is always bad, then the patient’s insistence on the treatment can be focused on, its details need to be expanded, and the coping question and compliment should be given. If there is no exception while the situation has improved, then the point of discussion can turn to summarizing this situation as a miracle or surprise; its details are expanded, and then, coping questions and compliments are used.

Step 4: Changing and Acting

According to Lin’s conceptualization, the steps of changing and acting include summarizing compliments, building bridges, and discussing homework. Based on the information from the above communication, a compliment is delivered to briefly summarize the patient’s past efforts. A series of questions is then used to build a bridge between past efforts and future behavior changes. These questions include scaling question, different question, a small step, and relationship question to predict the patient’s future medication adherence, situational differences, first effort, and relationships, respectively. Finally, homework is discussed based on patient responses. According to Lin’s conceptualization and the characteristics of medication adherence intervention, if the patient still has many complaints about taking medication and is not motivated to change and act, observation work may be the first choice. The patient is advised to observe when he/she adheres to a prescription and what he/she has done to cause this result. If the patient has already accepted the responsibility to change and act, then action is recommended. This homework points out the patient’s specific barriers to medication adherence and should be positive, specific, detailed, practical, and operational for implementation.

Ending

If time is available and the provider-patient relationship is good, the four steps of the SFBT can be used again to address the patient’s other barriers to medication adherence and/or lifestyle. If time is limited, the patient’s lifestyle should be discussed or briefly mentioned. A brief summary should then be used to reiterate the patient’s efforts and their value. Finally, the patient should be informed of the end of the interview, follow-up information, positive expectations, and sincere gratitude for his or her cooperation with the provider.

Discussion

In this study, we present a conceptual protocol of SFBT-MAI for medication adherence intervention delivered by general providers to patients with CHD. The tailored intervention procedure was considered as the basic procedure of the SFBT-MAI, and the techniques of SFBT and Lin’s four steps of single-session SFBT were integrated as the main techniques. The SFBT-MAI was established as a method of health education and one-on-one interview between general providers and CHD patients prior to the discharge. It consists of two parts: assessment and intervention. The first part is to select non-adherent patients and identify their barriers to medication adherence. The second part is the main body of SFBT-MAI, which mainly includes Lin’s four steps of single-session SFBT, namely closing, hoping, empowering, changing and acting. The entire protocol is highly structured and positive oriented, with a balance of warmth and brightness. It is hoped to improve the effectiveness of medication adherence interventions for patients with CHD and to promote the use of brief psychological interventions in clinical practice.

To be useful in clinical practice, the SFBT-MAI provides sufficient consideration of the characteristics of medication adherence interventions, SFBT, and the clinical setting. First, it was designed mainly based on the procedure of tailored intervention while also considering general health education to form an integrative medication adherence intervention and reflect the requirements of multifaceted interventions.^2,4,31 This design is similar to the development of a medication self-management program.¹² Second, the present design attempted to address patients’ emotions, cognition, and behavior simultaneously. Classical SFBT emphasized cognition and/or behavior change while overlooking emotion.²⁶ Lin paid more attention to emotion and integrated the spirit of narrative therapy to see the desire and effort behind the client’s difficulty.²⁸ SFBT-MAI agreed with Lin’s emphases and was dedicated to addressing the patient’s emotion, cognition, and behavior as a complete procedure. Third, the present protocol was designed to be friendly to general providers in busy clinical practice. The protocol was highly structured with single session to reduce operational difficulties, and the background of the interview was set in the ward before the patient was discharged with the topic of health education to be integrated into the provider’s routine work. With these efforts, we believe that the SFBT-MAI is also beneficial for improving the provider-patient relationship and can serve as a reference for other diseases.

This paper includes three contributions. First, we designed a highly structured protocol of SFBT-MAI with specific techniques and examples at each step, so that general cardiology providers without a psychological or psychiatric background can quickly learn and apply it in their busy clinical practice. This is helpful for generalizing the use of psychological interventions, which are urgently needed in clinical practice.⁴ Second, we provide a highly structured and positive-oriented psychological intervention tool for medication adherence intervention. Tailored intervention is the growing trend of medication adherence intervention with problem-oriented needed psychological intervention,⁴ classical SFBT is positive-oriented,¹⁸ and Lin’s single-session SFBT is highly structured with balanced warmth and brightness.²⁸ We integrated them into a conceptual protocol and expanded the choice of medication adherence intervention. Third, we used Lin’s single-session SFBT to serve CHD patients, it is helpful to inspire more psychological practice in psycho-cardiology.³² Present psycho-cardiology needs more psychological intervention,³³ and our work provided a possibility of successful intervention.

Our study had several limitations. First, we developed the structure of the SFBT-MAI and its specific techniques in each step, but did not develop specifically tailored expressions for each technique (e.g., clarification, goal setting, reframing) for each possible barrier. The latter is practical work that should be done in future clinical trials. Second, this study is limited by its conceptual protocol without a practical test. Further research is needed to test its feasibility and effectiveness in clinical practice, and to develop a more simplified model for broader generalization in the future. Third, this design mainly focused on patients’ efforts and paid less attention to other factors beyond patients’ control to improve medication adherence. As a preliminary protocol, we would like to address patient factors first because of their importance,^2,34 and then develop a more comprehensive intervention based on the success of the present protocol.

Conclusion

Medication adherence interventions require the integration of psychological techniques and highly structured protocols to serve general providers in busy clinical practice. We developed a conceptual protocol of SFBT-MAI by integrating the tailored intervention procedure, techniques of SFBT, and Lin’s four-step of single-session SFBT. This is a highly structured protocol with logical understanding and specific techniques and examples to reduce operational difficulties delivered by general providers. It attempts to balance the problem-oriented feature of tailored intervention and the positive-oriented feature of SFBT, as well as the tailored intervention and general health education. It is dedicated to addressing patients’ emotion, cognition, and action simultaneously with the four steps of Lin’s conceptualization in single-session. It is hoped that this work will improve the effectiveness of medication adherence interventions for patients with CHD and to promote the use of brief psychological interventions in clinical practice. As a preliminary attempt, this work was limited in conceptual protocol, lacked further details, and was limited in patient effort, all of which require further research to perfect its details and test its feasibility and effectiveness.