Addressing Treatment Noncompliance
Instructor: Dr. Dawn-Elise Snipes

CEUs for this presentation can be found at https://www.allceus.com/member/cart/index/search?q=noncompliance

Objectives
~ Examine some of the reasons for treatment noncompliance including
~ Learning vs. Performance
~ Low motivation
~ Not feeling heard / White-Coat Syndrome
~ Roll with Resistance
~ Tipping the Scales
Questions
~ In what ways are your clients noncompliant?
~ What things are your clients often resistant about?
Noncompliance
~ Is NOT a respect issue
~ Can result from
~ Lack of knowledge
~ Lack of ability
~ Lack of effective skills for that person
~ Lack of motivation
~ No buy-in to new skill or behavior
~ New skill or behavior less effective than old skill or behavior

Types of Resistance
~ Issue resistance
~ Related to a specific issue such as smoking cessation, changing a dietary pattern, physical activity, etc.
~ Relational resistance
~ Has to do with the relationship between you and the client.
~ There is discord in the interactions.
~ Comments may include
~ You don’t understand
~ You can’t help me

Learning vs. Performance
~ Client is motivated but not following through
~ Do they know it?
~ Can they do it?
~ Do they have confidence that they can do it?
~ How do you teach adult learners: ABCD
~ Acquisition: Auditory, Visual, Kinesthetic
~ Buy In (Why do I care?)
~ Connected to current/prior situations
~ Divided into manageable parts

Learning vs. Performance
~ How do you teach performance?
~ Role play
~ Hypothesizing
~ Systematic exposure/experience
~ Example: Distress Tolerance for Anxiety
~ Have client develop distress tolerance plan
~ Remember a time last week when you were distressed and explain how you could have applied the plan
~ Role play a situation that often causes you distress and use the new skills
~ Envision yourself successfully navigating a stressful situation using new skills
Learning vs. Performance
~ Systematic exposure/experience
~ Example: Distress Tolerance for Anxiety
~ IRL: Practice using the skill at least once a day on things that cause you anxiety.
~ Identify how successful it was
~ Identify what parts worked
~ Identify what you could do differently next time

Tipping The Scales of Motivation
~ Stages of Readiness for Change
~ Precontemplation
~ Contemplation
~ Preparation
~ Action
~ Pain  Withdrawal  Romanticize/minimize drawbacks to old behavior
~ Motivation
~ Stages are NOT linear
Motivation
~ Why is the new behavior less motivating?
~ Benefits of old behavior (Drinking, Eating, Cutting, Screaming, Sleeping)
~ How can you meet those needs now
~ Drawbacks to new behavior (Less immediately effective, less enjoyable, hard to remember to use them)
~ How can you minimize those
~ Benefits of the new behavior
~ How can you maximize those
~ Drawbacks to the old behavior
~ How can you magnify/remember these
Motivation
~ What about the new behavior is less motivating
~ No buy in
~ Too hard/complicated/theoretical
~ Assumes skills not available (i.e. need to pause before DT; Need self awareness before communicating needs)
~ Not individualized
~ Meditation/PTSD/ADHD
~ Writing and reading for Extroverts
~ Support group and social gatherings for Introverts, cultures that prefer privacy
~ Tried and failed

 

Motivation Maintenance
~ Regularly review and add to the
~ Benefits of change
~ Drawbacks to staying the same or returning to old behaviors
~ Frequently explore
~ New or lingering drawbacks to change (still not happy or convinced)
~ New or lingering needs resulting from giving up old behavior
Rolling with Resistance
~ Avoid a direct head-on argument and the “righting reflex”
~ Arguments often result from fear or anger.
~ Identify the threat
~ Express Empathy (defuses defensiveness)
~ Try asking/listening instead of telling/talking
~ Empower the client to come up with possible solutions or alternative behaviors themselves rather than forcing suggestions on them.
~ Develop discrepancy to highlight the difference between what they say they want and their current behaviors

Rolling with Resistance
~ Double sided reflection
~ Use knowledge client has already given which conflicts with current statement.
~ Client: I know you want me to only work 40 hours a week so I have more time with my family and I am less stressed, but I can’t do that!
~ Clinician: You can see that your work is creating some real problems in your marriage, but you’re not able think about reducing your work schedule.
~ Reframing
~ Identify a different perspective when a situation or other person is aggravating
~ Client: My husband is always telling me I worry too much. It really bugs me.
~ Clinician: It sounds like he really cares about you and is concerned, although he expresses it in a way that makes you angry. Maybe we can help him learn how to tell help you deal with your anxiety in a more helpful and supportive way
Rolling cont.
~ Reflect the resistant statement
~ You don’t like the idea of coming here/journaling/support groups
~ Reflect the tone of what you are hearing
~ You seem to feel hopeless
~ You are not happy that…
~ Reflect ambivalence
~ On one hand you want to start feeling better/fix your marriage, but on the other hand the time commitment seems overwhelming/you don’t see anything working
~ Acknowledge the resistance
~ We seem to be arguing
~ I hear you feel like [this] won’t work
~ Support choice/self-control
~ You are in charge
~ I am more concerned with what you are going to do than what you are not going to do
~ What do you think might help/work?

Summary
~ Noncompliance often results from fear/hopelessness/disempowerment
~ Continuing to press the issue is like getting a 3 year old to eat Brussel sprouts
~ Increasing motivation and rolling with resistance are ways of helping clients
~ Identify why they are noncompliant
~ Explore ways to deal with that (change the intervention or their attitude)