Out with the old, in with the new…another year blogging!

I haven’t been very active blogging lately, so in true blogging style, here is a filler-post rounding up my year!

This year I started to get back to writing after a bit of a thesis-writing hiatus. I’ve had a bit more time to think about the sort of direction I wanted to take my writing in. The biggest change I’ve made is deciding to put my own name to my writing on here, linking together my professional/academic work and my personal experiences. I’ve been asked if I found this “exposing” – the reality is it’s made very little difference. Using my own name has facilitated making connections with other people, both other professionals and others who have had similar experiences to my own. I haven’t experienced any negative consequences, and though I can’t rule out that this could still happen in the future, I feel prepared to defend my own openness. This year I began supervising an assistant psychologist who disclosed their own lived experience and asked my advice on managing this disclosure, and I felt well-placed to give them advice on this.

This blog started as a bit of a catch-all for my writing on topics I found interesting. I’ve made it a bit more focused now, so it predominantly covers professional issues in healthcare, mental/physical health, disabilities/rehabilitation and sexuality/gender issues. Cutting away the more “frivolous” topics (less fashion and pages of photos) has led to a decline in my site hits, but I think the content is better quality (though less widely searched!). I’ve been so busy at work that I’ve been online a lot less, so I feel a bit less involved in the community and might now need to work to become a bit more visible.

This year I’ve also written a few pieces for some other sources – the online blog for Things & Ink Magazine, Discursive of Tunbridge Wells Blog and more recently the Guardian Healthcare Network. Writing for other sources encourages me to be more disciplined and also expands the reach of my work. Now that I’ve qualified and given some of the political changes recently I feel even more strongly about public engagement and bringing greater awareness to “hidden” issues.

After a year in my first qualified post I made a change, moving out of neurorehabilitation and expanding into health psychology more generally. I now work with people with HIV, Medically Unexplained Symptoms and long-term neurological conditions, as well as brain injury. I love working in this exciting mental health/physical health borderland, we’re trying to bring mind and body together. I’m learning so much. I’ve also become more involved in my local DCP and hope to continue this. Like many, I often feel frustration and apathy towards my professional body and about my place within the NHS. It’s easy to feel powerless and resentful, and it can be hard to find the time (and sometimes money!) to really be a part of things. But as they say, be the change you hope to see in the world, and all. I am finding my own way to be involved, connect with others and create something.

A few goals for the new year:

• Blog more often! Finish all my half-written posts
• Collaborate! I have so many people I want to get projects together with, time to turn ideas into action
• Pitch more articles to other sources. I’d like to write some pieces for more mainstream places, even if less academic these places get the message out successfully
• Be more active in my professional body and activism, locally and wider afield
• Spruce the blog up a bit, maybe even get one of those paid accounts so I can avoid getting awful diet ads on the thing

A few of the posts I’ve not entirely finished but will emerge soon are:

• Incorporating sex-positivity into healthcare
• Disillusionment with the trend for “mindfulness” (or how I tried and failed to be more mindful)
• Meaningful occupation and why just any old job isn’t necessarily good for well-being
• Narratives about (dis)ability and how this limits rehabilitation potential
• Community psychology/social justice approaches to rehabilitation (beyond the rehab room!)
• Planning a feminist wedding and muscle-related body image (or why I love weight-lifting even though it doesn’t make me look “pretty”). If anyone wants to get involved in any of the above let me know and they may yet see the light of day!

Great thanks to everyone who has supported me over the last year, I hope you’ve all had a lovely Xmas and wish you all the best for the new year.

HIV Transmission: No “Good AIDS/Bad AIDS”, just people

As a newly appointed HIV psychologist, I’ve been taking some time to better inform myself. I’ve been reading NAM’s Living with HIV and this in itself has provided an opportunity to examine societal (and my own) prejudices. I notice my own resistance to reading the book on the bus. Will people assume I have HIV? Will they assume I’m promiscuous or a drug-user? As a young white woman, perhaps I’ll engender pity, probably the victim of an assault or an infected blood transfusion? Why does it matter to me if people make these assumptions?

As we come to the end of HIV testing week and prepare for World AIDS Day (1st December) HIV is very much in the media. An article interviewing Silvia Petretti of Positively UK really stood out to me

“How did you catch HIV?

I find this question very judgmental. Whether I say that I got HIV by selling sex, injecting drugs, from my husband or my mother in the womb, this puts me in a category.  Either I’m an innocent victim or somebody reckless, who got what they deserved – as the coverage around Charlie Sheen seemed to suggest. It’s the reason so many women living with HIV shy away from the media. It doesn’t matter how I got HIV. It matters how I live with it.”

To me, this quote gets to the heart of our attitudes towards HIV. When we find out someone has HIV we want to know WHY. We associate HIV with sex and sex always gets our attention. Perhaps this curiosity is born out a society that devours salacious celebrity gossip and online rumours, but often there seems to be a darker side to it. Underlying the question is a sense of placing blame. Who is at fault? How did they allow themselves to be infected?

But do we really have a right to know someone’s transmission story?

Although certain groups are at greater risk of HIV, sometimes people just get it and it’s hard to pin it down to something they did or didn’t do. Many people have the virus and don’t know their status and with a late diagnosis it becomes increasing difficult to establish how it was transmitted. Many people living with HIV don’t know how they contracted it, and have to live with this uncertainty.

If a gay man contracts HIV is it easier for us to condemn his sexuality and “irresponsibility” rather than try to understand and relate to his experiences? Perhaps it is easier for us to cope with the possibility that any one of us could catch HIV, by thinking that it only happens to “bad” people.

Petretti mentions the media coverage of Charlie Sheen’s disclosure of his HIV status, which falls a bit too close to the BrassEye’s satirical sketch on “Good Aids/Bad Aids”. In the mock-documentary Chris Morris admonishes a gay man for having “bad AIDS”, the kind that’s your fault for getting.

NB – This is a very dark comedy and could potentially be offensive or triggering. 

 

Sheen’s disclosure could be a turning point in attitudes towards HIV – an image of a public figure living well with the virus. For many their image of someone with HIV was born out of 80s campaigns and they view HIV very much as a death-sentence. Many people don’t know that with good treatment adherence, viral load can be undetectable (meaning that you can’t pass the virus on, even if you have unprotected sex) and life expectancy is only a little less than that of the general population. Media has instead focused on his lifestyle, making assumptions about how he contracted the disease. With good treatment, many people’s immune system is supported so they don’t go to develop the infections associated with AIDS. In many ways, people can live ordinary lives, aside from regular medication and review appointments.

Charlie Sheen, the most recent celebrity to speak openly about his HIV positive status

This early newsreel from 1982 is particularly moving, released before HIV was really known about. It describes a form of “cancer” that seems to be affecting gay men. This is before HIV-stigma set in and it was seen as an illness rather than a judgement on someone’s life choices.  As our understanding of the virus has increased, so too have stigmatising attitudes that criticise and exclude.

We have no right to know how people contract HIV, that is their own story to share as they see fit. Condemnation and pity are both unhelpful responses. Attitudes towards HIV limit people from getting tested and disclosing their status, which increases the risk of transmission. Although HIV is often transmitted through sexual contact, in many ways it is comparable to other infectious diseases. It’s a long-term condition and if treated appropriately, it should enable the person to live a “normal” life and not endanger any other person. There is no “good” or “bad” AIDS, no more or less deserving. When we can detach ourselves from our seedy fascination with knowing the hows and the whys, we can allow ourselves to take a step back from our ingrained prejudices. Then we can really see the person.

Monica Bellucci, older women, sexuality and the media

The sexuality of older people is frequently denigrated and neglected. This is particularly true for women. People of all genders are taught a dogma of youth=beauty and marketed a multitude of products to fend off the effects of time. But whilst men become “distinguished” with age, women are touted botox in a bid to keep their partners from trading them in. 54-year-old George Clooney is still considered a sex symbol, Hugh Hefner surrounds himself with bikini-clad bunny girls and it’s not uncommon for women to talk lustily of “salt and pepper hair” and be-suited “silver foxes”. Where is our celebration of older women? Of grey hairs, lines around the eyes, ageing breast tissue and hot flushes? Women are encouraged to continue to remain looking youthful, or risk being deemed “ugly” and discarded. Meanwhile, men are taught to only see attractiveness in the young. Where does this leave us?

Ever see this gender-swapped with an older woman?

Much has been made of the casting of Monica Bellucci in the latest Bond film, Spectre. The choice of the 51-year-old actress as a Bond Girl (or should that be, Bond Woman), a pedestal of sexual attractiveness, has been lauded as “ground-breaking” and a “triumph” for feminism. Should it really shock us that Bond (played by Daniel Craig, aged 47) has finally been cast alongside a woman of his own age? We think little of him being paired with women in their 20s and 30s, as is common for the franchise. Bellucci, who can hardly be described as“old”, holds all of the assets commonly associated with “beauty”. She is famed for looking younger than her years and an ex-model, so perhaps her casting will not give great comfort to other middle-aged women. The film makes a small step for representation, but the furore around the issue reminds us of how few examples we have of older women portrayed as “sexy” in film.

Daniel Craig (47), with “older” Bellucci (51) and Seydoux (30)

Narrow and negative views of women’s sexuality are punishing at any age. Younger women struggle with Madonna/Whore attitudes, which both encourage them to be “sexy” and then shame them for it. As women age, they quickly become stereotyped as “desperate” and predatory “cougars” if they choose to be visibly sexual or become entirely invisible. Although some women may prefer younger men, fantasies of the sexually experienced “older women” (a la The Graduate) aren’t helpful if they’re the only image of sexuality in older women we see. In a depressing excerpt in porn documentary “Hot Girls Wanted” a 25 year old performer describes progressing quickly from being cast as a “teen” to a “MILF”. These fantasies aren’t only damaging to women, who should be given opportunities to explore and express their sexuality as they age as more than a vehicle for a younger man’s naughty adventures. Women who sexually abuse young people are frequently given lesser sentences than their male equivalents and attitudes that boys would be “lucky” to receive such attention abound. Women don’t sexually deactivate at the age of 35, with some women describing feeling more sexual at this age than when they were younger. But all too often this part of women’s lives is silenced and we see little of it represented in the world around us.

Six Feet Under’s Ruth, a great image of a sexually active older woman

Ideas about age and attractiveness are multi-faceted and can’t be entirely blamed on the media. However, greater representation of older women (and not just middle-aged) as attractive and viable sexual partners rather than the butt of jokes or pornographic fantasies can go some way to expand our narrow terms of reference. One particularly good example I’m reminded of is the character Ruth Fisher in HBO’s Six Feet Under. The character is widowed at the start of the series and begins to explore her sexuality, taking a number of lovers. Although there are jokes to her storyline, Ruth’s love life isn’t a humorous sideline and is treated seriously. Ruth’s adult children struggle with her newfound life, but her sexuality is shown in an honest and unedited manner. In one shot, she is shown naked, grey hair falling on her shoulders, lying in bed with her partner, also an older man. How often do we see images like this? Or are we encouraged to see them as somehow “disgusting” or ridiculous?

Recent years have shown an increase in films with older characters, reportedly vying for the “grey-pound”. We need to have accurate representations of people of all ages in the media, not just so that people can identify with characters like themselves, but for the ways in which it challenges and teaches us to think critically about our stereotypes about age. Monica Bellucci is a great addition to the Bond films but let’s not laud her as a game-changer for women in film. We need more representation of older women (not just those with model looks), as beautiful, sexy and sexual. They need not always be centre-stage, but included alongside other plots and characters, for a drip-by-drip education that can encourage us to see activeness in all ages. Images like these could serve to remind women that they don’t have a “best before” date and their sexuality, at any age, is something to celebrate.

Asking about gender – inclusivity and trying to get it “right”

The young person sat in front of me is noticeably androgynous in a loose tunic, with elfin features, the sharp cheekbones of a male-model, and an overgrown pixie-cut. My assessment form demands a tick in the box, are they male or female? I wonder if they fall somewhere outside of this binary, if maybe they define themselves as genderqueer, or somewhere else on the gender spectrum. Maybe they don’t use any label for how they see themselves. I’d like think of myself as reasonably open-minded and something of an ally for LGBT rights and gender diversity, so I want to make an effort, to get it “right”. But I’m also conscious of causing offence – what if they do identify as male, will they be insulted by my asking? Maybe they’ve had a lifetime of being mislabelled as feminine. Will this break down our relationship before it’s even begun?

“What would you like me to put down for gender?”

(pause, confused expression) “Um…male”

“Okay… I only ask because some people identify as genders different from “male” or “female””

“Oh yeah… I know some people like that”

“Okay, what shall I put for your ethnicity?”

And so we move on.

This encounter made me think about how I ask questions about demographics and diversity. In healthcare often the forms we use as restricted – used to generate statistics and leaving little room for greyer areas. But there are many aspects of personhood that aren’t immediately obvious. I have no difficulty asking someone their age, but somehow checking in with someone about issues such as gender and sexual orientation feels more difficult – my concern is that others will think I have made assumptions about them, “What makes you think I’m gay?”.

One way of making diversity questions less personal is to ask them routinely, even when the answer may appear “obvious”. Guesses at ethnicity and sexual orientation are also open to error without checking in (for example: someone who appears caucasian but is actually of mixed heritage). It is time-consuming to run through these kinds of questions but when I have the chance I do find it helpful. Most of the clients I work with have “majority” characteristics but they are rarely offended when I ask anyway. Often the form can be a starting point for these conversations “It’s something we ask everyone” and can reveal difference that isn’t immediately obvious in a relatively safe manner. Giving people assessment forms to complete themselves may also be another route, and including “other” boxes alongside diversity checklists. I also wonder, for those who sit in the majority groups, whether being asked the question provokes some thinking about diversity and brings a degree of normalisation.

NB – I don’t consider myself an expert on these topics, this is merely a reflection on my own experience. I recommend anyone interested in informing themselves about being sensitive and inclusive towards gender diverse individuals do some research – e.g. BPS, genderbread  , Christine Richards. 

Endings, yet again. Thoughts on coming and going.

This week marks a new milestone for me as I leave my first qualified job. It also marks a year since I completed my training (additionally it’s also a full 10 years since I started at university as an undergraduate, where does the time go?). Training, with its 6 month placements, had its share of endings. As I began therapy with clients I explained that I was a student, giving them my leaving date. The ending was out of my hands, it had been already decreed, and it wasn’t personal. The teams gave me cards, cake and flowers and wished me well for my next stage. To date my endings have tended to relate to pre-imposed deadlines or expected career progression. No one begrudged me leaving my graduate post to take up a position on a doctoral course, if anything it reflected well on the team and they wished me luck for the future.

Now, in a permanent post, I have a entirely new experience. I am forced to choose my own ending. My leaving has been met with mixed responses by the team. As a young (ish) newly qualified professional, it doesn’t surprise some that I want to try my hand in other areas. My leaving unfortunately increases burden on other staff, who will inevitably have to should some of my workload. Inevitably I feel some guilt about this. As with many teams, there are some organisational issues and stressors, and my leaving perhaps brings up some mixed feelings in those left behind to hold the fort. I felt disloyal, using my leave to go to interviews, staying quiet in team meetings whilst future plans were discussed. I don’t have the excuse of a deadline or a geographical move to fall back on, I need to own this ending. Responses to my leaving have felt quite muted and I’ve been surprised by how upset this has left me feeling. I don’t know what I expected, some kind of pat on the back, for others to celebrate my departure. Whilst it’s been a very important year for me, other staff have been there far longer and seen many people come and go. It has the flavour of an amicable break-up where we decide to forgo discussion of difficult feelings to keep the peace.

Given I’ve been working with clients with cognitive impairments; there have been some additional complexities to my leaving. It’s felt like a sore topic – many of my clients aren’t free to go and some see me as holder a “jailer” position. I am often working “behind the scenes” so much of caseload don’t have regular therapeutic contact with me. Many are very disoriented and forgetful so it’s been difficult for them to understand when I’ve explained my leaving. It is a strange dynamic, many of clients don’t really understand who I am or what I do, and I doubt they’ll experience much a loss when I’m not there! But at the same time we have informal contact daily and I’ll miss seeing them and hearing their unique perspective on life.

When I left the building for the last time I found myself just sitting in my car just watching the building, a strange heavy feeling in my stomach. I feel the frustration of missed opportunities – projects and initiatives I was never able to complete, ideas that never took hold, plans that never materialised. Sadness too, for the connections I’ve had with staff and service-users, that I’m giving up to step into something completely new and unknown. That night I dreamt of reports still to do, work left undone. But it’s over now.

The experience of leaving reminds me of my ongoing process of separating myself out from my job. Working in healthcare will never be “just a job”, but similarly it’s not the entirety of who I am and a job needs to serve my needs as well as my clients’.

FYI – My new posts are a split between a service for Medically Unexplained Symptoms and an HIV Clinic – I’m sure I’ll have a lot to write about this soon!

Working 9-5: if only! Towards 24/7 healthcare

 http://youtu.be/UbxUSsFXYo4

If you work in healthcare you can’t have missed the recent outrage around government intentions to move the NHS to a ‘7 day service’. Thousands of people have signed a petition calling for a vote of no confidence in health secretary Jeremy Hunt. Mr Hunt hasn’t endeared himself to me, moly sorting from the point where he tried to shut Lewisham Hospital, a recently renovated site that serves a huge population of South Londoners and was noticeably not failing. Following public outrage and months of protest around the legality (not to mention ethics of making hundreds of sick people travel an hour to another busy A&E department when there’s a decent one nearby), the plans were reversed and Lewisham H still stands.

A 7 day health service is a good idea. People don’t just get sick on working hours and we need to accommodate them, not the other way around. But it’s also not a revolutionary idea. I don’t know if you’ve been to a hospital on a weekend. I have and I can assure you it’s still open. Doctors and nurses work long hospital shifts around the clock every day of the year. It is a fallacy to suggest that they don’t or won’t work weekends – they rarely have a choice. Walk in centres are open weekends, and many GPSs offer a Saturday clinic. Mental health crisis teams cover weekends, keeping people in great distress safe and out of hospital. But Friday night is still not a great time to get ill. Whilst NHS staff do work weekends, it’s usually not the full working force that you’d get on a weekday. Additionally, doctors don’t work in isolation. There work depends on other staff, many of whom do not work weekends. Discharges may face a length delay whilst waiting for assessment from a social worker, occupational therapist or physiotherapist. Scans and tests need to be carried out an analysed. If transferring to another team then liaison is needed, and administrative staff for all the records and associated paperwork. A 7 day service is needed from all staff to keep the operation working.

Writing and things (less serious edition)

Lately I’ve been making some more time to write and am finding some new publications and organisations to get involved with. As I’ve moved to having this blog more focused on psychology, sexuality & health I wanted to find some spaces to write about other less serious or just different subjects. Most recently I’ve started contributing to the blog for magazine Things & Ink.

T&I began as a publication celebrating female tattoo culture. They’ve recently increased their remit to all independent tattooing but maintain a feminist slant. To the uninitiated, sexism in the world of tattoos might not seem obvious. Photographing ink naturally requires the display of skin, but all too often women are only featured in magazines as ‘tattooed pin-ups’, in sexualised poses and revealing outfits. Meanwhile male artists and collectors are pictured very differently. There obviously isn’t anything wrong with a tattooed woman enjoying her sexuality and flaunting her body, but it’s problematic if these are the only images of inked women we see. Female tattoos still tend to be culturally linked to promiscuity and a lack of ‘class’ (think of the narrative around ‘tramp stamps’). Visibly tattooed women frequently experience sexual harassment in the street, including uninvited touching of their skin (I could go on but actually I plan on writing something more in depth about this!). I love the magazine as it’s so different and also beautifully out together, with such a range of articles, so it’s great to have the opportunity to be involved. So far I’ve written two pieces, one on white ink tattoos and one on cultural appropriation.

Another little project I have is a beauty blog focused on pale skin and suncare. I can be a bit of a nerd when it comes to suncream and I’d never been able to find much in terms of blogs and reviews for similarly sun-intolerant people. It’s just a bit of fun and in the works. I’m reviewing higher end suncreams and make-up with SPF in, and plan to do more features related to pale skincare.

“Just a phase”? Freedom to be a little sexually flexible

Queer women’s sexuality appears to be having something of a media ‘moment’. The new series of Orange is the New Black has got many heterosexual women claiming they’d “go gay” for genderfluid star Ruby Rose and supermodel face-of-everywhere Cara Delevigne is on the cover of Vogue describing her loving relationship with singer Annie Clarke. A comment from journalist Rob Haskell has drawn particular anger “Her parents seem to think girls are just a phase for Cara, and they may be correct.” Having their same-sex attraction written-off as “experimentation” is an experience many queer people can relate to. Photos of Kirsten Stewart sharing intimate moments with her partner Alicia are often naively captioned as “Kirsten and friend”. Bisexuality is often treated as invisible when the individual is in an opposite-sex relationship, as though their past relationships, attractions, preferences and sexual experiences are no longer a part of their identity. People of non-heterosexual identity are keen to stand up and proclaim that their sexuality is not a “phase”, that it’s who they are and it’s here to stay.

But what’s wrong with having a “phase”? Tastes and preferences vary throughout our lives and experimentation is a way in which we can work out what we like, what we want. The phrase has become imbued with negativity – connotations of inauthenticity. Ideas that sexual experimentation is motivated by ideas of what is “cool”, what is expected at a certain age, being a part of a peer group where such a thing is “expected”. Sexuality is treated as a trend, a fashion. Implicit is the notion that the experience, and any feelings attached to it, is not genuine. In cold hindsight it is rewritten as meaningless.

The more I work in healthcare the more I feel like I’m in someone else’s game of Theme Hospital

If you never played this simulator game back in the 90s then you surely missed out. The basic premise is that you’re running a hospital. You build walls, stick in different rooms and allocate them different functions (diagnostics, treatment etc), hire staff and design the building to include seating (important), toilets (very important) and an array of vending machines to keep everyone happy. It’s best to design the hospital for a quick in’n’out for patients, to save the staff time. 

People are points, the more you get through the door and the more you cure, the more money you make and the closer you are to levelling up. Once you’ve got your reception area set up patients start flooding in. They have bizarre conditions such as Bloaty Headedness (an abnormally large head that requires surgical deflating), Slack Tongue (requiring stretching and cutting) and a range of wonderful psychiatric conditions including the King Complex where sufferers believe they are Elvis. Sometimes you have no idea what to do with them so you can chance an experimental cure or throw them out before they make the hospital look bad.

An advantage the game has over real life is that you can tell people’s mood and how sick they are just by looking at them, which is great as people give you some warning before they complain/die. Waiting lists are easily manipulated by dragging and dropping people in the queue. If something important happens for some reasons people use a fax to tell you.

You’re always trying to turn a profit and compete with the glossy rival hospital. Research improves your treatments but it’s expensive. Inspectors and important people turn up out of the blue, causing everyone to panic. Usually you can fool them by building walls to hide the worst bits of the hospital and making the place look nice with some pot plants. It’s best to chuck patients out if they’re looking likely to die on the premises as that isn’t good for the hospital’s reputation or staff’s morale.

You get applications for staff and get to pick between the more expensive and the more…. professionally dubious. When staff complain you can give them more money or fire them. It’s a good idea to take care of them so they work better, but that takes up time, money and valuable space. Back to work!

If you do well you’re quickly poached by a rival hospital. If you do badly, the corridors are overflowing with sick people, bodily fluids and rats and all the staff are miserable. Maybe you should cut your losses and just start a new hospital.

Sound familiar?

For reasons I cannot understand they never produced an update of this game. You can download the original here, it’s pretty low-tech by current standards. My computer’s actually too new to play it now.

Luckily for me I work in healthcare so the game never really ended. Now where’s my head-deflater….

Won’t get well: Trying to understand medical non-compliance

How many unfinished prescriptions are left in your medicine box?

This post was born out of discussions with my doctor friends, who frequently struggle with “revolving door” patients. The kind of people you discharge knowing you’ll be seeing them in a few weeks, maybe even a few days. Individuals who  grudgingly accept treatment, as though intent on remaining sick. Those who fail to follow medical advice, despite the pain and risks they then live with. Questions arise as to whether we should treat these patients at all, whether the resources are justified when they seem determined not to look after their own health.

“Non-compliance” has a very punitive ring to it. We comply with authorities, with court orders and sanctions. It suggests the existence of an external control and an absence of choice. The somewhat softer “non-adherence” is perhaps something all of us can relate to. Which amongst us have not been entirely adherent to medical advice? Perhaps we failed to complete a course of medicine, drank whilst on antibiotics or missed a few doses. This kind of non-compliance is one of the highest rated frustrations for doctors, but is very common.

Who is more likely to be non-compliant?

In a review of 102 papers, Jin, Sklar, Oh and Li (2008) found that those who do not comply are more likely to be male, younger, single, to have a lower level of education. Those who have a cognitive impairment (e.g. dementia), a mood disorder or use substances were also found to be more likely to be non-compliant. The complexity of treatment regime, level of medical knowledge, quality of relationship with the prescriber, and stigma attached with the treatment were also highlighted. However, it may not always be as clear “why” an individual is non-compliant, and attention needs to be given to the paradoxical nature of the behaviour.

Beliefs impacting on compliance

Research suggests that cognitive factors may lie behind this “everyday” non-compliance: faulty and inaccurate beliefs that guide behaviour. Patients may believe that the treatment will be ineffective or there will be minimal consequences to non-adherence. They may believe that they are not “truly” ill or that the treatment will impact them negatively. They may believe that the disease is uncontrollable or have religious beliefs regarding illness, or that an alternative method that will help them more.

Readiness to change

Thinking of the “stages of change” model, many patients may still be at the ‘pre-contemplation’ stage in relation to changing their behaviour. They will need support, education and counselling to progress to a point where they feel capable of change. When medical emergency forces a patient to receive medical treatment, they may still not be ready to engage in change, despite professionals escalating the situation on their behalf.

A good relationship with a professional will be needed to open up a dialogue in which it may become apparent that patients hold these beliefs. In many cases education may be enough to shift the belief, but this will need to be provided in a respectful manner so it can be well received. Motivational interviewing techniques have been used successfully to help a patient to identify discrepancies between their behaviour and their goals.

But what of people with more “severe” forms of non-compliance? Those who seem to actively avoid treatment and seem to exacerbate their condition?