The problem with the word, “noncompliance”

The issue of noncompliance comes up repeatedly in patient care.

Whether in the context of primary care or allied health care, in most situations, patients seem unreasonable and irresponsible when it comes to taking their medication, attending consultations, adjusting lifestyles, or heeding the advice of their providers.

A critical examination presents the term “compliance” as negativistic and synonymous with victimization, powerlessness, and the inability to self-determine. Due to the gravity of some conditions, health care professionals may be less concerned about self-determination and more concerned about the patient’s mortality. Alternatively, the term “adherence,” more positively, considers the patient’s pattern of behavior in following treatment plans and medical instructions. This viewpoint analyses the patient as going through a series of behavioral patterns – initiation, implementation, and discontinuation.

The adherence perspective also considers that the patient has at least tried, but somewhere along the line, “life happened.” Additionally, adherence considers the varying factors beyond the patient’s control that led to the discontinued use of medication or led to a relapse of unhealthy habits. Concordance between patient and provider is, according to Dr. Prashini Naidoo, a concept that describes specific interaction and co-operation between patients and health care professionals. Dr. Naidoo states that non-concordance is the failure of both parties to come to an understanding, rather than a failure of the patient to understand. In other words, the blame game shifts from patient or professional to focus on what is lacking within the patient-practitioner relationship. This is, as part of a multidisciplinary team, I can help.

As a therapist, I encounter the resistance of patients to psychotherapeutic treatment, perhaps more than medical doctors might deal with resistance to pharmacotherapy. After all, I am asking patients to share extremely intimate details about their lives without the incentive of a pill that will make the pain go away or help them numb their minds enough for them to fall asleep at night when the demons come to torment.

Through experience, I have formulated a simple and effective way to increase engagement with my services. Usually, patients already have a psychiatric diagnosis, so they know what is “wrong” with them. They might also have a prescription for medication that they think will be more effective than anything I can offer them. Often, I only have one opportunity to sell therapy.

I use my E.D.U.C.A.T.E. model.

Encourage. I compliment/acknowledge the patient on the effort made so far in seeking treatment. Turning up for a therapy appointment is a great step towards ensuring holistic health. Depending on what I know from the referrer and considering ethical and confidential boundaries, I also point out any positives in the medical history of the patient. We begin the session on a positive note that communicates my respect and willingness to support the patient’s efforts.

Discuss. My encouraging tone often draws out more information from the patient. I direct the conversation towards details on the challenges they have encountered in maintaining a healthy lifestyle. Because I have already expressed some level of empathy by choosing to view their presence and actions as positive, patients often feel comfortable and more open about their lifestyles and habits. I might garner information about recreational drug use, alcohol use, and other factors that the client would hide if they felt judged or chastised.

Understand. From the language the patient is using, I gauge their willingness and readiness to change or to continue following medical advice. Sometimes patients use medical or psychiatric jargon they do not exactly understand. They might be parroting their physician or specialist and do not want to appear ignorant. I take the position of one who does not know. I ask them to clarify and explain things. I also ask where they acquired the information, what they understand by it, and if they concur.

Consult. Prior to the session, I research the patient’s medical history in the EMR from the doctor, dietician, or any other provider with whom the patient is involved. Then I go through this information with the patient.

Assert. It is critical that the patient gets a firm and asserted statement of their health. For example, for a person struggling with addiction, I state clearly that drinking a bottle of wine every night to sleep indicates addiction to alcohol. This single factual statement should be clear and concise. As a pivotal statement, it clarifies for the patient that they must address their problem because their health and wellbeing depend on it.

Teach. Solutions previously offered are revisited, using keywords and language that gives the patient a clear and simple roadmap towards better health. As a teacher, I systematically assess risks factors, protective factors, and so forth. I ask/answer questions, taking the necessary time to draw the full picture with the patient.

Empower. Finally, I ask the question: So, what are you going to do? By asking, I am once more encouraging and communicating confidence in the patient’s ability to take charge. I wait for the patient to answer my question. Unlike other providers, I have more time, so I can wait. When the patient offers a plan of action, I scrutinize it. For example, a client stating they will exercise four days a week for 45 mins must clarify how they plan to make that time, what kind of exercise they will do and what days will work best. Thinking through the practical and mundane details of implementing change is not something they might do alone. We explore options and backup plans, writing everything down. I keep a copy, and the patient has their own. I also encourage them to share their well-structured and thought-out plan with the other health care providers.

My formula has proven useful and efficient, and in most cases, I receive positive feedback from colleagues providing other services. Once they feel they have a firmer grasp on their diagnosis and know what to do, patients are in a better position to focus on their emotional and mental health. Sometimes, having the time and space to work through helplessness and complex treatment plans is the key to concordance.

Tapo Chimbganda is the author of The Classroom as Privileged Space: Psychoanalytic Paradigms for Social Justice in Pedagogy.

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