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Why do we not believe, and if we believe why do we not listen? The medical field has adopted the phrase "noncompliant" to describe patients who do not follow the advice of their physicians while society has labeled them troublemakers. Whom am I talking about? It could be the smoker, the drinker, the drug taker and all the people with medical illnesses that could benefit from treatment. In this column I will focus on the individual with known medical problems that has received good advice but for many reasons does not follow it.
Let me say at the outset that at this stage of my career it disappoints me but doesn't make me angry if one of my patients does not follow my advice. This position was not the case earlier on and only was reached by countless encounters with my patients.
When I was in medical school, I was on my surgery rotation at a large Veterans Administration hospital. My job was to evaluate new patients for surgery and then report to my resident. With my naiveté intact I did my best medical student history and physical. It seemed that my patient had severe stomach pain and would require surgery to remove his gallbladder. Halfway though the physical, he told me that he was leaving. I was taken aback and spoke with the confidence of all my training, "What?" Again, he said he was leaving so, as any good medical student, I ran through the possible options to convince him to stay. My list of reasons fell on deaf ears so I figure we will have to restrain him.
I went to my resident for instructions. Well my resident laughed saying I should just talk him into it. When I returned, the patient was gone. I, again used my quick medical student instinct, went to the hospital lobby and through the window I saw him getting on a bus. How could this person - when confronted with all that medicine had to offer to remedy his pain - just say no?
Not going into surgery, I do not treat stomach pain but I do treat emotional pain that is just as serious and real. How is it that some of my depressed, anxious, obsessive and manic patient's just say no when I offer medical treatment? On one level the answers are straightforward but lurking just beneath are complicated interactions of logic and emotions. One consistent theme in all the reasons I hear is the fear of loss. The loss can be material, physical or emotional, real or imagined.
Not long ago I moved and one of the drivers and I were talking about psychiatry. He asked if it was normal to still be sad and cry a year after his father had died? In some situations this may or may not be normal and I suggested he see a psychiatrist about medication. He did not seem troubled with the idea of taking medication except that he did not want to take anything that would interfere with his driving.
Let me move from this fear of loss of a very real and important life situation to one of my favorites, the following modern hysteria. Very little is more amusing that the comment " I will not put anything into my body that is not natural". This seemingly logical and harmless statement is effectively impossible to argue with because if someone believes it they have stopped using reason and are relying on dogma to guide their life. Since all substances are made of molecules, how can they not be natural? I think that what this modern hysteria indicates is that these persons confuse "natural" with "man-made" and are suspicious of man-made substances. This hysteria stems from our innate struggle to make sense of a seemingly insane world. For example, in the 1950's medical practitioners thought it was a good idea to treat pregnancy-related nausea with a drug called thalidomide - only to find out that it caused horrific birth defects.
Another set of fears is the loss of person and physical abilities. Zombie fear is worrying that if you take medication you will not be you, and will become a "zombie". Part of this is the fear of loss of self. For example, consider that a person has been so ill for so long that his identity has incorporated the illness into his perception of "self". Therefore, treatment is might be interpreted as "the loss of self".
As another example, sex fear is found mostly in men and involves the loss of sexual performance. A common side effect of antidepressants is reduced sexual drive and delayed ejaculation. Since sex is an important part of one's life and sexual performance is linked to one's self-esteem, then for some persons reduced sexual drive is not acceptable.
Finally, the greatest fear is that of being ill. For the majority of people that suffer from long term mental or physical illnesses, denial is a primary defense mechanism. Now do not get me wrong - denial under the right conditions is appropriate. Just think about when we were 18 years old; how could you now do what you had done then? Moreover, how could a solider go into battle knowing he probably will die? However, denial under the wrong conditions only increases suffering, as in the diabetic who does not take her insulin or the depressive who does not want treatment.
Patients who do not want treatment will not come to see a psychiatrist and if forced will not accept treatment. For these individuals in most part I agree not to treat them (there are exceptions). If someone with depression or other mental illness would like treatment, I will do my best to provide it knowing that there are risks, some of which I know and some of which I do not. However, there are also risks of not being treated. As I suggested with the thalidomide story, some of the risks are very large and in this case only came to light after many women had taken the medication. Given that there are these known and unknown risks, why would anyone go see a physician and ask for treatment? The answer is that the risk of not receiving treatment is generally larger than the risk of treatment. Just ask the bipolar ex-bank president who while in a manic episode destroyed the bank and his life. Or consider the depressive police officer that lost his family, job and eventually his life because he was so depressed that he killed himself.
In our society physicians cannot force a competent individual to take treatment and I stand by this. If we are forced to force people who we think are ill into treatment, then we are no longer physicians but rather become like police charged with enforcing society's rules. It is sad that some people do not want treatment. It is also sad for their families to endure the pain. However this pain is the price we pay for our progressive society. Luckily for us, we are not machines to be orderly serviced and repaired. We are individuals connected in the web of life.
© 2000 Peter Melgaard Thompson
Last Modified: February 22, 2000
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