Endings, yet again. Thoughts on coming and going.

leaving cat

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!

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

How many unfinished prescriptions are left in your medicine box?

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

stages-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?

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