Consequences

We have a new little kitten and this morning, despite trying to keep her in the house, she scooted outside and then ran into the local feline bully. The poor little creature came in with a nasty scratch on her ear, and perhaps the understanding that the world can sometimes be a scary place. We had tried to advise and guide her, put sadly she had to learn for herself that there can be unpleasant consequences from running outside.

Similary we all want the best for our children and the people around us, but sometimes we can do them harm if we don’t help them understand the consequences of their actions.

We teach children how to cross the road, and later on, how safely to drive a car and deal with dangerous or exploitative people. We can’t live their lives for them, but we can try to help them understand the consequences of their actions.

Sometimes this important gift fails to materialize when a child or other loved one is struggling with a chronic illness.

Let me explain.

During my clinical career I dealt with two groups of clinical problems in which the biggest difficulty was not diagnosis, but helping people to stay on the treatment that they needed. The two problems were diabetes and psychiatric illnesses. By treatment, I certainly don’t just mean taking medicines: I mean being able and willing to follow a course of action.

There are dozens of reasons why people decide against taking the treatment that they need, whether it’s surgery, medication, psychotherapy or homeopathic remedies.

• Some people don’t see the point of treatment: they are happy as they are even if the illness is causing unseen damage
• Others just forget their treatment
• Others don’t like the side effects, or they are frightened that they may get side effects
• People worry about stigma and about being seen as somehow different
• There are even a few who like being ill: not just the experience of, say, having lots of extra energy, but being cared for and looked after. I have known people who have spent 40+ years in bed, sometimes with quite minor problems.
• Some just deny that they are ill: The extent of the denial can be amazing.

I saw an article on the BBC this morning about a young woman who believes that she went blind from the complications of diabetes because she “rebelled” as a teenager and was probably in denial.

It reminded me of a young woman whom I was once treating. Her metabolic control was becoming worse and worse. She was getting blurred vision and she was rapidly gaining weight. Her mother became extremely indignant when I asked – very, very gently – if the young woman might be pregnant. The patient and her mother vehemently denied the possibility. Less than a month later – on Christmas Eve – I had to arrange for the teenager to have emergency laser therapy on her eyes for severe diabetic retinopathy. Four weeks later she gave birth to a healthy, but very large baby girl. Both mother and daughter were in denial until the very end, and mother did not want to help the daughter face the consequences of failing to treat her diabetes or the pregnancy.

I’d like to give you two other examples of failing to face consequences.

In the first, a family saw me on television and asked me to see their son. He had a major neurological illness, did not want to take medicine, and It turned out that he had already seen some of my colleagues in my department. The parents wanted me to force him into taking medicine.

The second involved someone with attention deficit disorder (ADD) who could not remember to take her treatment or to follow through with any of the therapies that we recommended. Her parents wanted us to treat her. After a while it became impossible, because she had no interest in being treated.

But here is the point. The young man with the neurological illness had something progressive. He could not yet be declared legally incompetent, but he could not see that without treatment he would become very sick. The young woman with ADD also had a potentially progressive illness and was on a slippery slope. Not that the ADD was becoming worse, but because the behavioral consequences of the illness were leading her into more and more risky behaviors.

In each case the parents wanted doctors and other therapists to “Do something.” Yet in each case the parents were probably the only people who could help their kids.

What do I mean by that? Some parents enable their children to avoid the consequences of refusing treatment. I asked the young man’s family what they did if he refused his medications? The answer was that they yelled at him. Yelling helps nobody. But they were aghast when I suggested that his treatment should be linked to having “privileges” at home.

If he truly genuinely needs help, and he can’t see it, sometimes the best way forward is for the person to have to face some consequences.

Whether or not he took his treatment, he might get yelled at, but after that he could go to his wing of the house, watch TV, play on his computer and order food. No
consequences. I suggested linking TV watching to participation in
treatment. The family would not countenance it. They wanted to displace
all the responsibility onto other people who should tell him what to
do. Yet they had unwittingly sabotaged every attempt at treatment in several
countries.

Treatment is a matter of discussion and agreement. And yes, of course, mentally competent people have a right to turn down treatment. But if they cannot see the consequences of their folly, then family and friends may be the only people with the leverage to help them.

Every one of us has wants and needs. If someone is stuck, then those wants and needs can help us to help them. This isn’t a matter of being coercive: it is sheer practicality.

The young man with the neurological problem saw no need for treatment because his every wish was being fulfilled: he even had servants waiting upon him. The young woman with ADD was probably not safe to be driving around in a car, yet her parents gave her one and paid for the gas and insurance anyway. They did not link treatment with providing all those things. So she saw no need to be treated.

Nobody wants to mean to a person suffering from an illness, but sometimes we need to mobilize all the resources that we have to help a person. It is entirely a matter of being pragmatic. The person saying, “Force my son to take his medicine,” is obviously speaking out of frustration. No clinician can or should do such a thing. Confrontation will scuttle any chance of setting up a therapeutic alliance with someone.

We do have some techniques for helping people. One very promising approach that we have been using is called motivational interviewing, and there are others. But even those will have little value unless people can see the advantages of treatment and the consequences of not being treated.

The best way of staying motivated to do something like stop smoking or manage your weight is to combine the advantages of taking action with the disadvantages of staying where you are.

If you know someone who has a real problem and is refusing help, ask if there is anything that you can do help motivate them to face the consequences of what they are doing. It can sometimes be the kindest and most loving thing that you can do for someone.