“I know me. I won’t do it." Compliance or adherence?
In my nearly 50 years of counseling/coaching individuals and families I have heard the statements “I know me. I won’t do it.” many times. It is usually in response to a recommendation that an individual make a commitment to practice some piece of health care such as exercise, eating better, journaling, meditating/praying, or perhaps attending a support group such as a 12-step meeting.
Most of the time I see individuals or families for counseling because the want something to change. They may be struggling with anxiety, depression, addition or some other “dis ease”. Occasionally I see individuals or families because they are court ordered or they have been given the choice of jail or treatment. Even when there is a sincere commitment to and belief in the possibility of change, I often hear this response to a recommendation I have made, “I know me. I won’t do it.” Frequently, it would seem that this response is based on past history. An example could be that a person may have made a decision to exercise, many times in the past and, yet, they have not been able to consistently give themselves this gift. They might say that the truth is that there is just too much to do. If I take time to exercise, the family is mad that I am not at home. Thinking that the client and I are engaged in a logical discussion I might suggest that we explore a way to combine family time and exercise. Occasionally they might work, but frequently it does not. I might then ask if they could start with 5 minutes of yoga, walking or some other mild exercise a day. They may agree to do this this or they may again say, “I know myself. I won’t do this.”
At this point, they may be saying to me that: “You cannot make me exercise.”, “You do not appreciate how bad I am feeling.” or “I don’t have any hope that exercise is going to make a difference in how I feel. I will just feel more tired and not any better emotionally.” It is my job as a clinician to attempt to hear what they are saying and to find a piece of health care which they are able to do. I know that as long a plan is my plan for them and not their plan it is not going to work. Some of my colleagues have a list of recommendations which the client/patient must follow or else they will not work for/with them. A cardiologist I know refused to continue to see a patient because the patient has been unable to quit smoking. The cardiologist said to the patient, “You obviously do not want to get well. There is no reason for me to work with you if you cannot follow a simple order. You know that smoking is bad for your health.” Of course, this patient knew that smoking was bad for his health. Yet, repeated attempts to quit smoking had not worked more than a brief time for him. This man has lost a lot because of his struggle with mental illness and other medical problem including recent heart surgery. It felt to him as if giving up nicotine was one more loss on top of lots of losses. The rational part of his brain knew it would make sense to quit smoking but emotionally he did not feel able to face another loss. We also know that nicotine addiction is one of the most difficult to let quit.
A person may be saying that they know themselves and they are not able to do x behavior. What they may not be saying directly is that they have no faith that doing x will make a significance difference or they may be saying that they feel as if they have no gas in their emotional or physical gas tanks. Change takes energy. If there is no energy available a person cannot make a change no matter how “sensible” the change might seem to the clinician and even to the client/patient.
So often when a patient or client (including ourselves) is saying that they know themselves and know they will not take action X they are begging “Please do not set me up to fail again.” or “Please pay attention. I cannot do action X.” It is important that we clinicians listen to the patient/client and come up with a treatment plan which works for them. Just because I find it relatively easy to get myself to the gym, fix healthy meals or make other changes does not mean that it is easy or even possible for another person. When a treatment plan is my treatment plan for a client/patient, it is not the patient’s/client’s treatment plan. When a treatment plan is arrived at with a client as a joint venture then the chances of success is much greater. For example, a client last evening said she can walk her dogs. She cannot find or make time to go to the gym or even do 5 minutes of yoga a day. She can and will walk the dogs daily. She will also walk at work. When we began to track her steps on a Fitbit she was walking an average of 8000 steps a day which is quite good. It would be good if she could add some yoga stretching and centering, but that does not feel doable for her right now. We may be able to explore some stretching with the class she is teaching. Or not!
My point is that that I do not want to set up clients/patients to fail my plan or to give the appearance of punishing them when my plan is not their plan.
Several years ago, there was a movement to change the goal from client/patient compliance to adherence. Adherence was operationally defined as being able to follow a plan which was jointly agreed upon by the clinician and the patient/client. If the plan did not work, there was no one to blame. The patient/client and the clinician simply took a step back and explored a potentially more workable plan. Thus, as with all scientific inquiries, the goal was to find what works and what does not work.
A clinician may not know what will be helpful for a particular client/patient. Together the clinician and the patient/client may or may not be able to arrive at a plan which both agree would be helpful or effective. On the other hand, there may be times when the clinician may need to refer to a colleague who might be more helpful. There may also be times when the patient/client just needs validation that they are not now able to envision making the changes they need to make to be healthier. The clinician may then be able to work with them to expand their vision or just accept that the patient/client are making a decision based on what they are convinced they are able to do.
We clinicians need to appreciate and respect that decision without punishing or giving the appearance of punishing the client/patient.
Written September 7, 2017
In my nearly 50 years of counseling/coaching individuals and families I have heard the statements “I know me. I won’t do it.” many times. It is usually in response to a recommendation that an individual make a commitment to practice some piece of health care such as exercise, eating better, journaling, meditating/praying, or perhaps attending a support group such as a 12-step meeting.
Most of the time I see individuals or families for counseling because the want something to change. They may be struggling with anxiety, depression, addition or some other “dis ease”. Occasionally I see individuals or families because they are court ordered or they have been given the choice of jail or treatment. Even when there is a sincere commitment to and belief in the possibility of change, I often hear this response to a recommendation I have made, “I know me. I won’t do it.” Frequently, it would seem that this response is based on past history. An example could be that a person may have made a decision to exercise, many times in the past and, yet, they have not been able to consistently give themselves this gift. They might say that the truth is that there is just too much to do. If I take time to exercise, the family is mad that I am not at home. Thinking that the client and I are engaged in a logical discussion I might suggest that we explore a way to combine family time and exercise. Occasionally they might work, but frequently it does not. I might then ask if they could start with 5 minutes of yoga, walking or some other mild exercise a day. They may agree to do this this or they may again say, “I know myself. I won’t do this.”
At this point, they may be saying to me that: “You cannot make me exercise.”, “You do not appreciate how bad I am feeling.” or “I don’t have any hope that exercise is going to make a difference in how I feel. I will just feel more tired and not any better emotionally.” It is my job as a clinician to attempt to hear what they are saying and to find a piece of health care which they are able to do. I know that as long a plan is my plan for them and not their plan it is not going to work. Some of my colleagues have a list of recommendations which the client/patient must follow or else they will not work for/with them. A cardiologist I know refused to continue to see a patient because the patient has been unable to quit smoking. The cardiologist said to the patient, “You obviously do not want to get well. There is no reason for me to work with you if you cannot follow a simple order. You know that smoking is bad for your health.” Of course, this patient knew that smoking was bad for his health. Yet, repeated attempts to quit smoking had not worked more than a brief time for him. This man has lost a lot because of his struggle with mental illness and other medical problem including recent heart surgery. It felt to him as if giving up nicotine was one more loss on top of lots of losses. The rational part of his brain knew it would make sense to quit smoking but emotionally he did not feel able to face another loss. We also know that nicotine addiction is one of the most difficult to let quit.
A person may be saying that they know themselves and they are not able to do x behavior. What they may not be saying directly is that they have no faith that doing x will make a significance difference or they may be saying that they feel as if they have no gas in their emotional or physical gas tanks. Change takes energy. If there is no energy available a person cannot make a change no matter how “sensible” the change might seem to the clinician and even to the client/patient.
So often when a patient or client (including ourselves) is saying that they know themselves and know they will not take action X they are begging “Please do not set me up to fail again.” or “Please pay attention. I cannot do action X.” It is important that we clinicians listen to the patient/client and come up with a treatment plan which works for them. Just because I find it relatively easy to get myself to the gym, fix healthy meals or make other changes does not mean that it is easy or even possible for another person. When a treatment plan is my treatment plan for a client/patient, it is not the patient’s/client’s treatment plan. When a treatment plan is arrived at with a client as a joint venture then the chances of success is much greater. For example, a client last evening said she can walk her dogs. She cannot find or make time to go to the gym or even do 5 minutes of yoga a day. She can and will walk the dogs daily. She will also walk at work. When we began to track her steps on a Fitbit she was walking an average of 8000 steps a day which is quite good. It would be good if she could add some yoga stretching and centering, but that does not feel doable for her right now. We may be able to explore some stretching with the class she is teaching. Or not!
My point is that that I do not want to set up clients/patients to fail my plan or to give the appearance of punishing them when my plan is not their plan.
Several years ago, there was a movement to change the goal from client/patient compliance to adherence. Adherence was operationally defined as being able to follow a plan which was jointly agreed upon by the clinician and the patient/client. If the plan did not work, there was no one to blame. The patient/client and the clinician simply took a step back and explored a potentially more workable plan. Thus, as with all scientific inquiries, the goal was to find what works and what does not work.
A clinician may not know what will be helpful for a particular client/patient. Together the clinician and the patient/client may or may not be able to arrive at a plan which both agree would be helpful or effective. On the other hand, there may be times when the clinician may need to refer to a colleague who might be more helpful. There may also be times when the patient/client just needs validation that they are not now able to envision making the changes they need to make to be healthier. The clinician may then be able to work with them to expand their vision or just accept that the patient/client are making a decision based on what they are convinced they are able to do.
We clinicians need to appreciate and respect that decision without punishing or giving the appearance of punishing the client/patient.
Written September 7, 2017
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