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A Few Words About Non-Compliance

illness

illness (Photo credit: cambiodefractal)

I recently heard from a mother whose son was diagnosed several years ago with schizophrenia.  Her son has become homeless, and is unwilling to agree to take medication or work with a doctor.  She shared that she is discouraged in trying to work within a “broken” healthcare system, and asked for some feedback.

There is little that can be done to force an adult into treatment unless that person is a danger to self or others, or is “gravely disabled” (roughly, this means demonstrably unable to do what is necessary to stay alive and safe).  It is also true that the healthcare system for psychotic illness can be characterized as “broken.” Each individual situation is so unique that it is not possible to give concrete, blanket advice that will apply to all situations.  

That being said, here are just a few examples of things you might choose to consider.

It is always best to work collaboratively with a person affected by a psychotic illness. I believe the components that serve the patient and the family best are encouragement and praise (when appropriate and sincere), asking questions about the person’s own preferences, and listening. Symptoms are always an effort to defend against unbearable stress, anxiety and pain. It can be so easy to miss the clues provided by symptoms. Yet, they may be the only way to obtain insight into what is driving behavior.

Did I mention listening?  Their reasons for resistance to treatment, for example, often make a lot of sense. Too often, we don’t think about asking and listening because we are so affected by their odd behaviors and are trying so hard to help.  As parents, for example, we have a history of directing our children – a habit, if you will, and one that can be very hard to lose. When we make suggestions as to what they “should” do, bear in mind that their symptoms may render it impossible for them to comply, even if they were willing.  They may be unable to articulate their limitations because the illness affects their thinking and ability to communicate.   They may experience guilt and shame about not being able to please you.  They may be silently grieving the “unlived life” they started out expecting. The end result often leads to increased stress, which becomes expressed as frustrated anger.  Stress heightens the symptoms of psychosis. This loop shows up a lot, even within the scope of the best of intentions.

Let us strive to keep in mind that a person with a mental illness is still a person, more than anything else. In directing our attention and energy to their humanity (in favor of focusing entirely on symptoms and illness), we can help them to do the same. Any opportunity to provide acquiescence, dignity or encouragement is a chance to connect with the healthy part of your loved one – an essence that remains intact, no matter how small it gets in the face of symptoms.

Let’s face it: the medications are not always helpful. Often, they come with a terrible price paid in side effects. Fortunately, therapy can take many forms.  One example: good nutrition can make an enormous difference. If the relationship is intact enough, having your loved one over to dinner without talking about illness at all has been known to be very soothing, and may begin to re-establish and nurture a two-way loving relationship.  If they cannot tolerate a family dinner, you might consider baking some cookies (healthy ones, oatmeal is great) “to go.”  A gift with no strings. Anything that plants the seeds of a supportive, loving relationship without making demands is a good start. Positive relationships for these individuals cannot be overrated.  The task need not always be about symptoms or getting into treatment.

When we begin to work collaboratively with our loved ones within the context of their own felt needs, desires and preferences, we may be able to begin to establish a connection that will help them to trust us and begin to explore options from that place of trust and safety.  The key is patience.  Success is measured over long periods of time, in small increments.  There is always hope.  Always.

Patricia O’Neill, PhD

Los Angeles, California

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Posted in All Articles, For Family, Friends & Others, Psychoeducation, Treatment.


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