Content area
Full Text
The term "noncompliance" is usually invoked to explain why patients act in a way that their physicians believe is medically inappropriate. Poor therapeutic results frequently are attributed to "poor patient compliance.*1"4 Many studies over many years have shown that around one third to one half of patients do not take their medications as ordered, the problem being especially prevalent among patients with chronic diseases such as tuberculosis and chronic glaucoma.1,4,5,17 Much effort has gone into attempting to understand the causes for noncompliance18,23 and into devising methods of circumventing it. Here I discuss the issue of noncompliance from a broad perspective, and will suggest that the words and the concepts underlying it are signs of serious misunderstandings about health and how to achieve it.
There are several reasons why some patients do not act in a way their physician believes is best for them. The first two I discuss are quite different from the last six.
INTENTIONAL NONCOMPLIANCE: PLAYING THE VICTIM
Of the vast number of individuals who seek care, a few will be self-destructive. Because illness somehow rewards them, they seek to become ill and they want to maintain their illness. Consequently, they resist advice that is likely to make them healthier. Almost always, such patients lack insight into the cause of their noncompliance. They will deny vigorously that they have any intention in maintaining their illness and will protest vehemently against the suggestion that they are not seriously interested in controlling or ridding themselves of it.
Such persons fall into two major categories, those with major emotional difficulties, and those who, considering themselves victimized, choose to benefit from that self-perception. The first subgroup comprises emotionally ill people who unconsciously choose to be victims. Maintaining the victim role is essential to their distorted self-image; being ill is one way of conspicuously maintaining that self-image. Such individuals are usually deeply scarred, coming, for example, from families in which thesy were traumatized. For such people, the victim role may be an important survival mechanism.
The second subgroup of those in whom noncompliance is intentional consists of individuals who consider themselves victims, although in a different way. These are people who in their adult life come to believe that major benefits are to be gained from giving...