Adherence Begins with Acceptance

By July 16, 2008Uncategorized

Everyone FINALLY seems to be talking about the need for more focus (ie. budget) on Adherence. While long overdue, it is good news for patients and families of all sorts.

So, when we look at the landscape of issues and possible solutions, it is so easy to be seduced by all the myraid of offerings that can be used to form a comprehensive adherence solution. There are technologies galore, pharmacy closed-loop programs, database-triggered email programs, pill counters, alarm clocks, and now, the expensive but interesting human touch with Health Coaches. (

But as usual, as an industry we rush to solutions and in doing so, seem to pass by the patient. (“Don’t worry, we’ll get back to you!”) If there was ever a business that needed to “measure twice and cut once” it’s us. The missing and first element we all need to discuss is the patient behavior. All the devices, gadgets, strategies and methods in the world are useless if they revolve around a noncompliant patient.

I was recently reading a piece by a MS nurse talking about the issues of MS patients and adherence. MS is a textbook example for studying adherence, because it’s a long-term, chronic condition, because medications can retard the disease’s progression but not cure it, and because it’s physically disabling, which makes adherence challenging. This nurse made a very astute comment about adherence — yes, it is made up of compliance and persistence. But the most important element, the real first behavioral barrier is acceptence. Does the patient actually accept that they are sick, or need this treatment, or will get better if they take it? This is a huge insight.

. Acceptance isn’t a one-size-fits-all situation. It can range from simply, finally, irreversibly accepting that you have a disease to having a positive attitude about recovery. Regardless of its nature, acceptance is an absolutely necessary element of any form of change, which definitely includes adherence.

Adherence and compliance ultimately require a patient to revise and maintain a different, and somewhat artificial self-image, one that requires more commitment and effort than that of an acute illness. A patient with an acute illness — say, an inflamed appendix — sees himself as fundamentally well, basically the same as he always was, but with a temporary, treatable disorder. This is not a difficult self-image to maintain, because it inherently incorporates a previous self-image, and any variation from that is known to be transient.

A chronically ill patient, by contrast, has to come to see himself as someone who will always have the condition. The condition has to become part of their identity, and a new self-image has to be developed that incorporates both their previous notion of themselves and the reality of their current medical status. This isn’t easy, and for some patients it’s impossible.

This is something every 12-step program knows well. The very first of AA’s steps, for example, is that the alcoholic admits to being powerless over alcohol, and that their lives had become unmanageable. Until that happens — until the alcoholic fully accepts the idea that his disease is not something he can choose to accept or deny — treatment is pointless.

Acceptance is everything. A patient who accepts his condition can, and will, see a rational reason for complying. One who doesn’t, won’t, and must rely on sheer willpower, which is a pretty limited resource. To change what you do, you have to change who you think you are. Simple as that.

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