From Adherence to Self-Determination: Evolution of a Treatment Paradigm for People with Serious Mental Illnesses

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Treatment adherence and nonadherence is the current paradigm for understanding why people with serious mental illnesses have low rates of participation in many evidence-based practices. The authors propose the concept of self-determination as an evolution in this explanatory paradigm. A review of the research literature led them to the conclusion that notions of adherence are significantly limited, promoting a value-based perspective suggesting people who do not opt for prescribed treatments are somehow flawed or otherwise symptomatic. Consistent with a trend in public health and health psychology, ideas of decisions and behavior related to health and wellness are promoted. Self-determination frames these decisions as choices and is described herein via the evolution of ideas from resistance and compliance to collaboration and engagement. Developments in recovery and hope-based mental health systems have shepherded interest in self-determination. Two ways to promote self-determination are proffered: aiding the rational actor through approaches such as shared decision making and addressing environmental forces that are barriers to choice. Although significant progress has been made toward self-determination, important hurdles remain. (Psychiatric Services 63:169–173, 2012; doi: 10.1176/

Many people with serious mental illnesses do not seem to adhere to treatments as prescribed. In this Open Forum we propose that the concepts of self-determination and choice make greater sense of this phenomenon than the concept of treatment adherence and nonadherence. In 1990, one of us (PWC) coauthored an article published in this journal titled “From Noncompliance to Collaboration in the Treatment of Schizophrenia” (1). The article noted that many people with serious mental illnesses did not benefit from recommended practices, in part because they did not fully participate in them. The 1990 article sought to expand on outdated notions of resistance and compliance by framing treatment decisions about evidence-based practices as a collaborative partnership. Although the model described in the 1990 article was a substantial improvement over ideas of the time, it was nevertheless limited, and further shifts in conceptualizing this phenomenon were required.

To support such shifts, we formed the Center on Adherence and Self-Determination (, which is funded by the National Institute of Mental Health. The first five authors of this paper are co-principal investigators of the center. Self-determination is the crux of the new model, and choice is at the heart of self-determination. We begin this Open Forum by briefly recapping what research has shown—that many people with serious mental illnesses do not fully benefit from available evidence-based care. To make sense of this shortfall, we then consider the evolution of ideas in psychiatric practice, from resistance through collaboration to self-determination. The evolution paralleled a significant change in the mental health system, with themes of recovery, hope, and empowerment becoming more salient. The evolution also informs strategies for helping people decide which services will benefit them, and this Open Forum ends by describing decision-making processes.

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Psychiatric Services





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This article was published in Psychiatric Services, Volume 63, Issue 2, February 2012, Pages 169-173.

The published version is available at

Copyright © 2012 the American Psychiatric Association

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