Motivational interviewing for antipsychotic adherence

Antipsychotic treatment can reduce psychotic symptoms, but schizophrenia is usually managed over years with support from several services. Taking medication consistently may be difficult because of sedation, weight gain, akathisia, cost, stigma, forgetfulness, or doubts about long-term benefit. Non-adherence can increase relapse and hospital admission risk, yet demanding that someone simply “comply” can damage trust and conceal the barrier that needs attention. In Australia, many antipsychotics are PBS-listed, but concession status, generic or brand preference, repeat supply and PBS authority can still shape what happens at the counter.

Motivational interviewing is a collaborative, goal-directed conversation that draws out a person’s own reasons for change. It is not a technique for making a reluctant patient agree with a prescriber. Its spirit—curiosity, empathy, autonomy and partnership—creates room for ambivalence to be heard. In practice, open-ended questions, reflective listening, affirmations and summaries help a pharmacist understand what matters to the person. Change talk can grow without pressure, while confidence in the plan becomes more realistic. This is useful when medication feels like a demand imposed on someone recovering from psychosis.

The approach should not disguise a mandatory medication review or secure agreement at any cost. People with schizophrenia may have impaired decision-making capacity, limited insight, distressing voices or acute agitation; then a calm, brief conversation may be safer than complex motivational work. The pharmacist should check capacity, respect refusal where appropriate, and involve the treating team when risk is high. Used ethically, motivational interviewing complements clinical assessment, medication reconciliation, consent and coordinated care. It also reflects the Australian expectation that consumers participate in decisions about their treatment.

What motivational interviewing changes

First, it shifts the starting point from a clinician-defined problem—“You are not taking your tablets”—to the person’s priorities. A pharmacist can ask permission: “Would it be useful if we looked together at how the medication fits into your day?” Such wording acknowledges agency and reduces the sense of surveillance. Open questions such as “What is getting in the way?” and “What would you like to happen next?” invite information, while reflections like “It sounds as though the morning dose is the hardest one” check whether the concern has been understood.

During this exchange, distinguish change talk from sustain talk. Wanting less sedation, managing weight, avoiding another admission or having more energy are change talk. Statements that side effects are unavoidable or that stopping will not help are sustain talk. Neither requires correction. Reflecting both accurately tells the person their ambivalence is legitimate and lets the pharmacist work with existing motivation. Affirmations should be specific, such as noticing that the person has already tried several ways to organise treatment.

Readiness is a moving process, not a yes-or-no answer. Asking, “On a scale from zero to ten, how ready are you to make a change?” can reveal what would increase the score. If someone rates readiness at four, ask what would make it a six rather than immediately proposing a plan. Medication adherence is only one part of recovery: sleep, stable housing, substance use, meaningful activity and trusting relationships may shape whether a regimen can be taken consistently.

Published reviews of motivational interviewing in psychosis care report promising but heterogeneous findings, and medication-adherence effects are usually modest. The evidence supports treating the method as an adjunct within a continuing relationship, not a one-off conversation. A single information session may be insufficient when side effects, cost, stigma or disrupted housing remain unresolved. Team supervision and attention to the person’s priorities are therefore as important as technique.

Building trust in the community pharmacy

Community pharmacies are often the most consistently available health service in a person’s life. In Melbourne, Brisbane, Perth or a regional Australian town, a pharmacist may see the same consumer at each repeat even when psychiatric reviews are delayed or mental health appointments are difficult. Familiarity supports brief conversations about timing, side effects and goals, but privacy matters. Offering a private consult room, or moving away from a public counter where sensitive disclosures can be overheard, signals respect.

Trust grows when pharmacists listen before advising and explain in plain English. After asking about the main concern and reflecting it back, the pharmacist can add information about intended effects, common effects and how to raise concerns. A useful summary might be: “You are worried about feeling drowsy and would rather not drive after the evening dose; you also want to keep taking something that supports you at home.” It checks accuracy and gives both concerns a place, without implying a decision has already been made.

Communication must be culturally responsive and trauma-informed. In Aboriginal and Torres Strait Islander communities, decisions about psychotropic medicine may involve family, Elders, community workers or traditional practitioners, but the person’s consent should guide inclusion. A culturally safe approach can involve the local Aboriginal community-controlled health service without assuming family support or shared decision-making. In rural and remote areas, telehealth and locally coordinated pharmacy services shape follow-up. Interpreters, including Auslan interpreters, and accessible written materials should be readily available.

Exploring barriers and medication concerns

A practical method is to pair open questions with Elicit–Provide–Elicit. First ask what the person has noticed or what questions they have. Then provide only the requested information, using “May I share something that might be relevant?” Finally invite a reaction: “How does that sit with you?” This prevents a long lecture and makes room for preferences about taste, tablet size, routines, stigma and privacy. A medicine that is hard to swallow, causes marked sedation or needs a complicated regimen may require prescriber review rather than stronger exhortation.

Side effects should be discussed concretely, because vague reassurance can sound dismissive. Ask about daytime sleepiness, akathisia, tremor, stiffness, appetite, weight, glucose and lipid changes, and sexual or prolactin-related symptoms. Some issues can be managed by changing timing, revisiting the dose or considering a different antipsychotic; these are prescribing decisions made with the psychiatrist or GP. The pharmacist can document concerns and support shared decisions, including whether a long-acting injectable might suit someone who finds daily dosing difficult, while checking preferences and administration arrangements.

Cost and access can also drive missed doses. On the PBS, switching between a generic and brand may change the co-payment or require a new prescription; some longer-acting preparations are subject to PBS authority. A pharmacist can check supply, identify dispensing gaps and ask whether an alternative is clinically suitable. Patient information should be easy to read and accessible to people with low vision or cognitive impairment. Guidance on accessible image design can support better pharmacy resources without adding complexity to the consultation itself.

Turning conversations into shared action

When a person identifies a manageable change, the pharmacist and consumer can shape a specific plan together. “If your morning dose caused drowsiness, would it be worth asking your doctor about taking it at bedtime?” keeps the next step modest and clinically safe. The plan should name the medicine, dose and timing, who will help, what side effect needs monitoring, and when the next review will occur. It can include a calendar prompt, weekly blister pack, arranged repeats or a dose-administration appointment if these match the person’s preferences.

Actions sit within a broader care plan. In Australia, a GP can refer someone for psychological therapy through a Mental Health Treatment Plan, while community mental health services, psychologists, occupational therapists, peer workers and case managers may contribute to recovery. The National Disability Insurance Scheme can fund practical supports for some people, and a Home Medicines Review may be available after hospital discharge or when treatment is complex. For antipsychotic treatment, the psychiatric team may recommend a long-acting injectable and arrange administration through a specialist clinic or community service. The pharmacist should confirm who owns each action.

Good coordination depends on a shared record and clear communication, especially when a consumer moves between services or uses more than one pharmacy. Follow-up can follow the dispensing cycle rather than a generic three-monthly review, with brief telephone or telehealth contact where appropriate. For teams building a learning pathway, further material on patient-centred communication from Johnathan Laird can complement supervised role-play and case discussion. The aim is not fluent scripts, but reliable attention to what the consumer is saying.

Measuring progress and supporting relapse prevention

Evaluation should begin with outcomes that matter to the consumer: fewer distressing side effects, steadier sleep, attendance at work or study, and a greater sense of control over treatment. Standardised tools can support review, but adherence data should not become a punitive score. A medicine possession ratio may show whether medication is collected, yet it cannot explain why someone is not taking it or whether the regimen is tolerable. Brief notes about the person’s goal, concerns and agreed next step often provide more actionable information.

Relapse prevention planning should start before symptoms recur. The pharmacist can help identify early warning signs, including sleep disruption, increasing agitation or withdrawal, unusual beliefs or hearing others speak. A written plan can list warning signs, coping strategies, treating-team contacts and instructions for urgent help if safety is at risk. If a consumer becomes acutely unwell, confused or distressed, the conversation should move to immediate safety assessment and coordination with the appropriate service. A warm handover and continuity of care are more therapeutic than disputing medication.

Implementing motivational interviewing in a busy pharmacy requires more than a poster of four questions. Teams can begin with a brief huddle, practice asking permission, reflecting concerns and making a plan, then review observed consultations. Training should include psychosis, capacity, consent, cultural safety and the limits of motivational work. Measures might include whether consumers feel heard, whether side-effect concerns were identified and whether agreed actions were completed. A practice improvement cycle can compare findings, seek supervision and refine the service rather than blaming an individual clinician.

Start with one agreed topic in your pharmacy, such as morning dosing or sedation. For the next three repeat interactions, ask permission, explore the consumer’s priorities, reflect one concern and agree on one practical next step. Record the discussion, arrange follow-up and review difficult cases with a peer or supervisor. Small, repeatable practice is more likely to change care than a large toolkit left unused.

Pharmacists seeking structured training can combine local supervision with continuing education on communication, medication review and schizophrenia care. Build partnerships with mental health teams, GPs and consumer advocates so referrals and follow-up are clear. Most importantly, keep the person’s goals at the centre. A medication plan that reflects what the consumer values and is feasible turns the consultation into sustained, collaborative treatment engagement.