TAKING Care of Business
More Reasons For Non-Compliance
Q. I have a hard time getting my patients to comply. Am I overlooking something?
Last month we began a discussion on this issue and talked about how pain, drug side effects, decreased cognition and perceptual problems might affect compliance with a treatment program. Now let's move on to one of the biggest de-motivators: depression.
* Depression often interferes with an individual's volition. In fact, I ask the patient if he or she feels depressed and to what degree, because we need to treat the depression if that individual is going to follow a complete rehab program. Impaired function is a personal loss that brings grief, and as such it triggers the same coping pattern as any other loss. Depression is part of that pattern.
Even when someone is on psychotrophic drugs, depression follows onset of disability. Positive functional change through adaptive physical and behavioral techniques alleviate it most.
Having a sense of achievement and feeling worthwhile are the best antidotes to depression in my opinion. To help that feeling along--it increases motivation toward achieving other goals--I often introduce a highly structured craft activity with cheerful colors.
* Anxiety can stand alone or accompany other symptoms. The anxious person is usually afraid of what has happened and what will happen, fearing that if they do anything, the situation will only get worse.
Have these individuals practice deep breathing before they attempt to do anything. They comply pretty quickly because they feel more comfortable.
* Anger can interfere with compliance in treatment. Recently I had a very hostile woman patient post rotator cuff tear surgery. She did not follow her doctor's or my orders, and exercised herself back into the hospital. This woman, a health club enthusiast who "knew her own body best," was angry at being weakened. Good judgment is frequently lacking in the angry patient, with whom you must stress safety.
* Passive, dependent persons don't want to do anything alone. They will ask their home health aides to get them things easily within their own reach. They feel they deserve to be taken care of--entitled to your therapy. The best you can hope for is reduced home health aide hours. But they rarely become independent.
* Patients involved in lawsuits may not comply to the best of their ability in order to protect their perceived financial position. I usually discharge patients like this as soon as possible because too often I have been asked to support positions with which I disagree. I let them know that a statement from me wouldn't help them.
* Cultural attitudes can alter function programs. Working in New York City, I have treated clients of all races and many cultures. In some societies a chronically disabled person is not expected to be independent, and it is the job of extended families to take care of that individual. I remember a Puerto Rican man with a right hemiplegia who was aphasic but well motivated on the ward. He loved his craft project to switch hand dominance so much he was allowed to attend both morning and afternoon clinics. When he was away from family members, he ate with his left hand. But any time family was present during a meal, he was fed. Through a translator, I learned that feeding him was her perceived duty. Since his progress was sufficient for family expectations, I discharged him from OT.
* Patients who are ready to die will stop complying. I have had many older patients tell me firmly that they really don't want to keep living. They have finished their lifework, put everything in order, and they just want to be left alone. Personally, I believe these have been honest requests. I ask a few gentle questions to make sure such an individual is not just severely depressed. I will also inquire to make sure family and significant others are involved in that dying process.
It is important to know an individual's reason for not complying. You can modify either your activity or your psychotherapeutic approach to help that patient achieve maximum success. (Paid supervision can aid newer therapists in learning how to do this.) But often you must discharge, and when you do, tell your referral sources why. Their future screening can enrich your pool of appropriate patients.
* Dr. Jane Sorensen has been in private practice in New York State since 1971. Readers can reach her at her office telephone, (212) 744-5836, online at firstname.lastname@example.org, or by contacting OT ADVANCE through the Internet Mail at email@example.com.