Tuesday, September 16, 2008

Accountable To Whom?

In psychiatry, we talk a lot about the treatment of mental illness. Sometimes we talk about the treatment of disordered behavior, but often that discussion falls into the realm of other specialists such as psychologists, social workers, or lay support people (is that what I should call them?)-- members of self-help groups, personal coaches, and others.

Just to be clear, I'm talking about addictions and motivated behaviors-- people who can't stop doing what they're doing and seem to be driven by something other than logic. So the alcoholic who keeps drinking despite horrible repercussions, the smoker, the drug addict who keeps using when he's lost so much, the over-eating overweight person who grabs the next chocolate cupcake, the bulimic, the gambler, the internet sex addict, the pedophile, oh, name your "addiction." Illness or choice? The owners of such problems struggle, and often unsuccessfully.

This is what's frustrating about treating disordered behavior: we're not very good at it. It's really hard to get people to "Just say No." Actually, almost no one just says no. Sometimes people seem to have their own epiphanies-- something clicks-- and they change. Sometimes they "hit bottom" and they turn around. Some people just live in their ditches.

So how hard is it to change behavior? I think it depends on the person and on the addiction. Many people stop smoking-- for some it's harder than for others. The stats are that something like 95% of people regain lost weight within 2 years. I don't quite believe that, seems like I know people who've lost weight and kept it off, though not most. In the course of taking many psychiatric histories, I've heard of many people who've gained better control over a variety of behaviors. The most desperate often seek help, sometimes more than once, sometimes in a variety of places.

Here's my caveat:
I'm not very good at getting people to change behaviors they don't want to change. I've made some observations, I've tried to change some of my own behaviors (-have you seen the chocolate?), I've watched lots of people struggle with big things and small things.

Support helps. A lot. And accountability helps--perhaps it's essential. 90 meetings in 90 days, the mantra of starting in a 12-step program. And having a sponsor, or a therapist, or a coach--someone to be accountable to, helps. Are there things about a sponsor or therapist or doctor that increase the success of the person trying to change? I believe at some level, the "coach" (I just need a term here, let's go for this one) has to be someone the patient respects. It helps if the coach is not judgmental, is optimistic, encouraging, and believes in the patient's ability to meet their goal. It helps if the patient wants to please the coach, but isn't so worried about a negative reaction that he (the patient) lies and says he's meeting goals when he isn't. If the coach is a forbidding character, the patient may simply never return. Frequency of accountability helps: whether by checking in or by face-to-face. Having reasonable goals helps.

Oh, I'm rambling. You tell me what helps a patient change...