My college’s motto was “The Truth Shall Make You Free.” It’s a noble sounding idea but, like a lot of what I learned during those years, many things in life are not quite that simple. Effective management of diabetes certainly requires truthful information. Following the motto, we would then expect this truth to set patients free. Once informed of the effective way to treat their disease, the incidents of heart attacks, stroke, blindness, neuropathy and kidney failure should all return to the levels found in the general population, right? Anyone who has worked with a diabetic population or who struggles with the disease themselves, can tell you that it’s just not that simple.
How come? How come 83% of the people with diabetes do not control their blood pressure? How come, according to the World Health Report of 2001, the average adherence rate for long term medical care was a little over 50%? Further, if you look into the adherence rate for lifestyle change and diet, the adherence rate dips way below the 50% mark. I’ve seen the number 90% thrown around as a conservative estimate of the number of people who regain weight after a period of weight loss. Are these people out of their minds?
The broad answer is no, they are not out of their minds, the problem is that they are not in their minds enough. Too many practitioners and patients work with the assumption (not consciously) that loading in the information is all that is required for change. The assumption is a bit like studying for a test, to stay with the school theme for another moment. Just cram in the information, it will come out when it’s supposed to and you’ll succeed. Both practitioners and patients work with an assumption of automatic compliance. Once we know the “truth,” compliance is supposed to become like our morning routines or highway driving. We are using our minds during those activities but we are not fully present. An article in msJAMA, 10/2000, makes the excellent point that diabetes is a self-managed, chronic disease. Traditional medicine works with a model of physician-managed treatment that fits acute care very well but doesn’t work nearly as well with chronic conditions. With diabetes, the patient has to take care of his/her self. To do that well patients must be psychologically present and in their minds.
I recall a patient with a weight problem who came in quite proud of his newly found insight. He said, “I know what wrong with me. I’m self-destructive!” As pleased as I was to see him engage in the struggle to understand what was happening, I was forced to disabuse him of his conclusion. There is no “self-destruction,” there is “self-obstruction.” We are not “out of our minds” when we behave in ways that harm us, even though we know better. Human beings do that about many things from time to time. When patients stop working with the automatic assumption, when they are present and focussed as they engage in health related behavior, they have the possibility of identifying the conflicting forces that result in excellent adherence at some times and poor adherence at others. This tug-of-war, this balancing act is what adherence is about. We all have the need to stay healthy, to avoid pain, to take care of ourselves. We also have a whole collection of other needs. Some of them pull us towards behaving in ways that are not healthy. It is not the “intent” of the latter needs to harm us. On the contrary, many of them seek to give us pleasure in different forms. That’s not crazy. That’s competition.
So we self-obstruct because there are competing needs and issues. How is that piece of information helpful? One answer is that patients can now start looking for the needs and issues that pull them away from health. When patients operate with the automatic assumption, those needs are free to continue to demand satisfaction with little opposition. Now they can become the targets of change.
I’m sorry to say that the needs and issues that make up this tug of war are as different for each person as their fingerprints. I wish there were one, maybe two key answers that fit all. They would be the “magic” that makes adherence, simple, effortless and consistent. If “magical” answers exist, I don’t know what they are. I’ve heard many, intelligent, earnest individuals present keys they have used or observed as though they were sharing the very secret of life. For them, there was no doubt about the “truth” of their discovery. Their only problem was getting everyone else to appreciate it. At best however, it was their truth they had discovered. What they did or thought or used or felt might be of help to others but to different degrees.
For now, let me invite you to be present i.e. to “do” something here in addition to reading. This will help you as we begin to look at your patients. Take the next few weeks and pay attention to the moments you move away from adherence. Attend to WHAT your experience is in that moment, NOT WHY. Don’t analyze, just observe and record. What thought tells you to adhere, what do you use as a reason? For example: if you don’t check your glucose level you’ll get sick? Is the voice more specific? Does it name illnesses? Is it a picture of you in the hospital? Is it your doctors’ voice?
Now listen for the voice or image that comes afterwards. Does it say that’s too much trouble? What is the “trouble”? Does it say it’s too embarrassing? I don’t want to stop what I’m doing? Why do I have to do this and everybody else doesn’t? I’ll be OK. I’ll make sure I check more often tomorrow?
If you keep listening for these voices, you’ll hear your truth. You’ll probably be amazed to find that the “voices” say pretty much the same thing all the time. If you ask a friend to do this with you (and they don’t immediately suggest a strong psychotropic drug) you’ll find your voice is different from theirs. There may be some similarities but there will be differences. Do this and, despite the fact that you will be listening for voices in your head, you will be on your way to experiencing what I mean by being in your mind, not out of it.
In my next article, I’ll give you some examples of what others have discovered in their experience of the “Urge” or “temptation” or “need” and we’ll talk about how to put these discoveries to good use.
Leonard Lipson, M.A. received his Bachelors degree in Psychology from Adelphi University and his Masters in Psychology from the New School for Social Research. He received four years of post-graduate education from The American Institute for Psychotherapy and Psychoanalysis. He has been in the private practice of psychotherapy for the past 29 years, with offices in Manhattan and Suffern, NY. Mr. Lipson created the Medical Adherence Training program in 1995. The program helps people adhere to what is medically recommended. The program now serves patients throughout the U.S. and is in the process of being put into book form.
Mr. Lipson is a member of the Rockland County Psychological Society, The Society for Behavioral Medicine and The NYS Mental Health Counselors Association.