Noncompliance: What is your role in planning your life?
While I’m on the topic of assessing how mental health workers assess people receiving services (see the post on insight), let’s discuss a neighboring issue. This one is perhaps more blatant, and certainly more widespread. I’m talking about the use of “compliance” or “adherence.”
It is clearly more widespread, because unlike insight, which only clinicians doing mental status exams use, – psychiatrists, psychologists, etc. – physicians and therapists of all sorts use it to check on plans with their clients. I would not presume to discuss its use in medicine, or any area beyond mental healthcare. Just keep in mind that this discussion is potentially relevant in those other interactions, too.
Noncompliance: What is it?
As the name implies, noncompliance means not following instructions. Not doing what you’re told. Tsk tsk. Nonadherence is a softer-sounding word, but really it’s the same thing. This could mean something like, I told you to take this pill with breakfast daily, and you’re taking it when you remember, midday, 5 times a week. Or, you’re supposed to meet with me every other week and you only attend monthly. Or, you’re supposed to practice this exercise every day, and you only practiced twice this week, or not at all. Basically, any plan set out that you didn’t complete 100%.
Clinicians usually reserve the full brunt of “noncompliant” for those doing little-to-none of the plan. Those in between, i.e. the majority of people, are usually called “partially compliant.” Basically, this is a brusque push to shape up. Or else you might end up in the box with the bad kids.
That said, that’s not how I, and many other clinicians, approach planning. We’ll get to that later.
Noncompliance: Why is it?
Why rate how compliant people are with directions? There’s a nice answer, and a not so nice one.
Nice answer:
To get good results, we need to keep track of how things are going! Whether it’s a medication, an exercise, gathering information through homework, or something else, each action plan has a purpose. If you’ve now gathered information – let’s apply it and get steps closer towards your goals! If you’ve tried out a tool for a specific goal, how did it go? Did it work as planned? Do you need more practice, or do we need to refine or alter it? We don’t get to do any of that if you didn’t do it.
Well… not quite. Not doing it is also useful information. I’ll explain why, after we talk about the not so nice answer.
Not so nice answer:
Because I’m the expert and you’re the patient. Don’t you remember that I took all those classes and have all that knowledge about how you function? I carefully led you to exactly what you needed to do and you didn’t do it. There must be something wrong with you. Or, perhaps more insidious, we worked so hard to come to this plan together, I listened so well and you told me everything we needed to know about it and we talked out the rationale and the how and the when and the where. It was a “SMART” goal (Specific, Measurable, Achievable, Relevant, Time-bound), and you still didn’t do it. Really, I did my job. There must be something wrong with you.
The not so nice consequence is that compliance is one of the many wedges that can form in a relationship that is supposed to be helpful. I’ve fallen into this trap myself. With one person in particular, I had gone down one path after another with them, for well over a year, and it felt like nothing had budged. I felt frustrated, and started blaming.
Can’t we be kinder?
Where does this issue come from? Again, there are at least two reasons. The nicer one is that I’ve truly worked very hard to get into this position. It’s natural to have a bit less tolerance for (perceived) push-back on something you’ve worked at so long and so thoroughly. The less nice one is pretension that’s built into the system. I’m well, you’re sick; I’m educated, you’re less so; I’m successful, you’re less so; etc. “Compliance” is one way to identify power differences. Now, power differences will vary across different pairs of clinician-participant. But just look what happens when the participant is higher status than the clinician. I’ll wager “compliance” takes a back seat.
Noncompliance: Current impact
There’s a joke out there among MDs, that doctors make the worst patients. That may or may not be accurate, but if you measure based on “compliance,” we’re all pretty poor.
When I search “compliance with medication” in a research database, I get “about 56,400 results.” There’s been a lot of attention to compliance. Here’s a selection of stats. A sample of people with diabetes mellitus showed 37% “poor compliance.” There was 24.5-40.3% compliance with treatments for asymptomatic carotid artery stenosis. An overall review in 1998 showed people took 58% of prescribed antipsychotics, 65% of antidepressants, and 76% of physically-focused medications. A recent study of people prescribed blood pressure and lipid lowering medicines along with the DASH diet showed only 598 of 4365 (13.7%) people were compliant with the diet at a 5+ out of 9 level. In another recent study, 55% of people prescribed a particular antipsychotic remained on it after 3 years (who knows how regularly the 55% or the 45% were taking it).
Why are we so bad? There are many potential factors. Psychologist Dr. Deegan points out the number of individual steps that have to be accounted for in following a medicine plan. From picking it up, finding it where you’re storing it, remembering the timing, remembering if it is with food or without, to actually taking it, day after day, these steps add up. There will always be additional factors we won’t know about, which is why “compliance” will never reach 100%. But as a psychologist, I recognize that at least a sizeable chunk of it is due to problems with the concept itself. Maybe there’s a better way to understand planning.
A better way to understand planning
I said above that compliance is not how many clinicians think about planning. What might be a better approach? One such approach, which comes out of medicine, is called Shared Decision Making (SDM). Essentially, SDM shapes the conversation into phases of specifying the problem, discussing a full range of options, and then selecting the one that seems like the best place to start. Of course, if the person doesn’t follow through, the clinician could still take it personally; there’s no way around that possibility. However, the SDM process is to then revisit the first two phases. Was the problem specified properly? Perhaps a different option now fits better? When something doesn’t work as expected, it’s a chance for us to fine tune the overall system.
SDM fits perfectly for me, as a behaviorist. As I mentioned above, not following the plan isn’t negative at all: it adds information. Behaviorists create what are called “functional behavioral analyses.” Basically, models of the relevant system the person is working in. If 1 + 2 does not equal 3, then maybe the person didn’t start with 1, or maybe the option selected didn’t add 2; or maybe there’s a -4 hanging out that we totally missed. Or – perhaps 3 isn’t as clear-cut a goal as previously thought.
This approach has its own pitfalls. You most definitely do not want to start looking at a person as a gear in a giant mechanical device. But this does not have to happen: the mechanics apply to the parts, not to the person. A person can set a goal to exercise for an hour 3 times a week, and shoot for that as a typical arrangement. But their experience is so much more. The humanity often shows in being flexible: taking the person in living context. One can set an exercise goal and still understand that sometimes it’s more important to visit a friend, or if they’ve had a rough week, to rest or read a book.
Noncompliance: What can we do now?
Well first off, we can stop monitoring compliance. Compliance demands an expert model, and instead we need a collaborative model, like SDM. You can still keep good track of progress without making it an opposition. Remember: the participant doesn’t need to be there. They aren’t showing up just to waste time and money. If they do not follow through, it’s not for lack of trying or caring. It’s because we haven’t aligned what to try with where they are at in life.
The broader need is more complicated. We need to keep working to recognize the humanity of each of us. Clinician and participant just the same. The best laid plans won’t always go as planned. That may feel frustrating; it may prolong suffering. By remembering that we are each trying our best, we can pick ourselves up and work together to try again.