If Not For Yourself, Then Do It For Me!: Motivating Behavioral Health Change In The Family
e20d559354 Asks ...
I have an adult family member who has been diagnosed with severe clinical depression and anxiety. She is very cooperative in terms of going to therapy and taking the prescribed medication. But when it comes to actual necessary habit changing, she doesn't budge. For example, her CPAP sleep apnea machine just collects dust because she says she can't sleep with it on, and she smokes CONSTANTLY - every 10 minutes or so. My questions are:
1) When someone is in such a horrible condition - pretty much comatose 24/7- is it an appropriate time to try to get them to stop smoking? She is very sensitive to even the slightest bit of "stress". So would trying to quit just be compounding her troubles?
2) What do you think of using cigarettes somehow as bargaining chips to get her to use her cpap machine?
Dr. Richard Schultz Says ...
Hello and thank you for addressing this important question to me.
As we Baby Boomers continue to age (at least us lucky ones!), challenges and concerns such as this, which revolve around adherence to medical treatment, and the relationship between family members, caregivers and healthcare professionals, will occur exponentially more often. I also believe that the mental health community can and should be called upon to help.
I am quite sorry to hear of your family member’s medical and mental health challenges, and it is easy to understand why this situation is pretty miserable for you both. She is at perhaps the most deteriorated position of her life, and you are very justifiably concerned, thus attempting to motivate her to help herself and heal, and encountering resistance along the way.
Unfortunately, it does not sound as if your relative is at this time exhibiting a very strong will to adhere to the lifestyle and behavioral challenges that would be optimal, given her existing medical conditions and habits. This is a delicate and precarious dynamic indeed, especially when someone so emotionally close to the patient, such as you, is also trying to be the cheerleader, coach or motivator.
In considering the best intervention for helping your relative, I would want to consider many factors. These include: a) the degree to which she is manifesting symptoms of depression that are NOT being successfully treated by current medications and/or therapy, b) the degree to which her behavior is a deliberate choice based on her current existential crisis (for example, she may not wish to prolong her life and may in fact wish to hasten her death by smoking and not using her CPAP, among other related behaviors), c)the level of her accurate and complete understanding of the deleterious and synergistic effects that her untreated sleep apnea and continued smoking are having on her; and d) the degree to which her seemingly rebellious maladaptive behaviors are in some way a reaction to perceived attempts on the part of others to “fix” her (this last point often termed “iatrogenesis,” wherein treatment or help actually makes the problem worse).
It’s a complex picture, to be sure, and one that must be holistically considered prior to initiating any new “solution.” These are the kinds of challenges that psychologists and psychiatrists face every day, and we ideally bring to the table a wide repertoire of possible interventions to address them, taking into account the big picture.
In this case, I would suggest you begin by doing less to solve these problems. That’s right, I did just write that! I suggest you immediately reduce the amount of attention, and emotional and behavioral energy, you devote to this relative’s challenges. Think of it as “cleaning the slate” or “cleansing the palate” in a way, whereby you till the field before making a new planting. Based on what you describe the current dynamic to be, my guess is that doing so will do no harm, and, more importantly, will actually be helpful to you, your relative, and to the relationship you share. Sometimes, believe it or not, simply doing less to fix a problem is, in and of itself, the best fix for the problem.
After a few weeks of tilling have occurred, it is time to plant! You will begin by approaching your relative and inquiring as to whether it might be okay with her if you were to accompany her to at least part of one of her therapy sessions. You will frame this request as stemming from your love and concern for her well-being, your awareness that your "helping" behavior has probably been at times frustrating or annoying or disrespectful to her, and your desire to do more of what helps and less of what doesn't. You need not mention the CPAP or smoking issues during this conversation; keep it general and, if necessary, mention a condition or symptoms cluster that you KNOW she wants to change.
I don’t know if you (or any other readers) have ever done this or asked to do it in regard to a relative’s psychiatric treatment, but such “guest appearances” can be very illuminating and constructive, IF they are handled sensitively and ethically and at the election of the patient. Benefits may be experienced by the patient, by the guest, and by the guest's relationship with the patient. It is possible, I suppose, that the therapist in question (if indeed true psychotherapy is happening, versus simply medication management and a very brief, supportive check-in, the difference between the two being QUITE dramatic as it concerns the influence of the care provider on the patient) is not even aware of the CPAP or smoking issues, is not focusing on these areas because the patient seems not to be troubled by them (or is intentionally avoiding discussing them), or because the patient has expressed a desire NOT to make change in these behaviors.
And if your relative is NOT receiving solid, empirically-informed psychotherapy from a qualified professional, this will ideally be sought out as soon as possible (perhaps yet ANOTHER motivational challenge; you are going to get good at this!). In any case, the point of participating more actively in the patient’s treatment is to still demonstrate your concern, but at the same time to also access the expertise and influence that can be delivered by the care provider (be it as “expert,” “the only one who really listens to me,” “my friend,” “benevolent and respected authority figure,” etc.). Let the therapist and the intervention be "the enforcer" of whatever plan us put in place, given, of course, that the patient responds receptively to this request to go to therapy with her.
Some strong words of advice: Please consider exactly how you will word your request to the patient very carefully before doing so, and run it past a few others whom you trust, as your first chance will be your best, and thus the stakes are high. If any hint of control, punishment, disrespect, insensitivity, or criticism is present in the request (“I want to talk to your doctor so that I can tell them what a 'problem child' you are”), it is likely not only to fail, but to re-exacerbate the dynamic between you and your relative. This is how therapists are trained to deliver treatment, in a very thoughtful, client-centered manner. Thus, such Motivational Interviewing (a specific clinical approach that has been widely researched and practiced) is not only an important aspect of helping someone seek treatment, but also a very powerful component of the treatment itself.
Further, do not attempt to discuss these challenges with the care provider without first consulting the patient and securing their informed consent (assuming that the patient possesses reasonable mental competence; if they do not, conservatorship or power of attorney may be needed). No licensed care provider is legally or ethically empowered to share information regarding the patient with anyone without such consent unless it is in the context of an acutely emergent and life-threatening circumstance. Perhaps even more importantly, any perceived violation of your relative’s reasonable rights would be likely felt by her to be infantilizing and would certainly do more harm than good, for example by only further strengthening her resistance to your suggestions. In fact, even if the patient agrees immediately to let you speak with her physician or therapist when she is not present, I would still recommend that you not do this. The goals here are to help the patient change AND to empower her as the AGENT of such change.
Once in the room with your relative and her therapist (or psychiatrist or other care provider), you can begin, very gently and diplomatically, to express some of the concerns you have about the patient's well-being, speaking ideally about YOUR feelings and concerns versus making allegations or complaints about THE PATIENT’S behavior and adherence issues. The care provider can then assess the situation and guide you and your family member in a clinically valid and hopefully helpful manner.
If this first approach does NOT work, and in fact even if it does, I would suggest you find a therapist on your own, whom you can consult for further intervention and coping strategies. Ultimately, you probably have a miniscule amount of control over what this relative, or any other person, thinks, feels or does, however you may exert great impact by adjusting your own stance. I would recommend that you seek out a therapist who is well-versed in cognitive behavioral therapy, management of geriatric challenges, and someone who also has grounding in family or systemic work (this situation being VERY different from one in which an individual such as your relative seeks out a therapist to address their personal difficulties with the CPAP or smoking issues). This clinical challenge requires of the provider a far more fluid repertoire and understanding of family and interpersonal dynamics, medical illness, and issues faced by elders than might be the case in a simpler clinical situation. This is all the more reason to find the right therapist for the job. And remember, ALL THERAPISTS ARE NOT TRAINED OR CREATED EQUALLY. Please know this. Perhaps the greatest benefit to seeking your own consultation is that you can talk freely with the therapist about the situation without worry of hurting your relative’s feelings, making the situation worse, or dealing with the bias or allegiance of her existing therapist. This would be akin to hiring a coach to teach you how to coach someone you love at, say, pitching a baseball or playing a violin.
Before closing, I will say that your own points regarding the pros and cons of various interventions are well taken. Yes, although smoking is quite harmful to your relative’s general and specific medical health and condition, it may be far down on her own list of priorities, and the activity of smoking itself may be a valued coping technique which might not survive the cut in a strict cost benefit analysis. Finally, the concept of utilizing any type of “bargaining chip” to increase desired behavior is really one best addressed by a qualified mental health professional. There are a multitude of such strategies that might be implemented and, although the right one may help, the wrong attempted “cure” may indeed end up doing more harm than the disease it was designed to treat is actually causing (see “iatrogenesis” above).
I do hope that some of what I have offered has been of assistance to you, and I wish you, your relative, and the entire family, peace and strength moving forward. I also want to say that your relative is lucky indeed to have someone in her sphere with as much concern for her well-being as you clearly do. I only wish there were a zillion times more family members out there than there are who have the caring and judgment to “Choose Help.” Nice plug there, eh? Don’t worry, this is not a paid gig for me, so that isn’t an ethical violation! J
Please do feel free to write again with an update on the situation (I get very few of those, unfortunately), or if you have any further questions or issues.
Richard E. Schultz, Ph.D.