Understanding Noncompliant Behavior: Definitions and Causes (2024)

Failure of Communication and Lack of Comprehension

As I have stated, early in my career I thought most NCB was caused by my failure to communicate and thus by a patient’s inability to comprehend my advice. Patients differ greatly in levels of education, intelligence, and language skills. An explanation of a disease process delivered in English may be perfectly clear to a native English speaker who graduated college but may be totally unintelligible to someone who did not graduate from high school or who speaks English as a second language. One of our duties as physicians is to give patients our explanation of their health problems and our recommended solutions using terms that are clear and meaningful to each patient. However, very little of our physician training is designed to facilitate this vital communication. We also lack tools and time to monitor how successfully we are communicating with our patients. Many patients are too polite—or too embarrassed—to speak out when their physician unintentionally confuses or mystifies them. These patients suffer in silent bewilderment.

Physicians are highly educated, typically have above-average intelligence, and belong to a culture that values education and intelligence; we often do not understand how intimidating we can be to others. Although some of our patients may have below-average intelligence, our duty to effectively communicate with them remains. Many years ago, I was a medical consultant for an organization that supported independent living for developmentally disabled young adults; many of their clients were my patients. They were, almost without fail, wonderful patients. They looked forward to their visits with me; they worked hard to understand what I said and recommended; and they appreciated my attention. People who have limited intelligence can be excellent and compliant patients.

Patients may be unable to comprehend our explanations and advice for other reasons. For example, progressive dementia can have an insidious onset in older patients, who may remain well-adapted socially and whose behavior may seem appropriate. Sometimes NCB in a patient who previously had been compliant is the first clue to what may be a significant degree of dementia. I now use the Mini-Mental State Examination for a newly noncompliant elderly patient and am often surprised by poor scores.

Cultural Issues

We filter our understanding of life’s important experiences through the values and concepts of the culture in which we grew up. This filtering process certainly applies to our understanding of good health, causes of medical problems, and effective medical care. The greater the discordance between the cultures of the practitioner and of the patient, the greater the opportunity for miscommunication and misunderstanding. Even when ostensibly from the same cultural roots, the physician and patient can be divided by differences in class or education.

Clinicians who see patients with markedly different cultural backgrounds must be aware of the many ways cultural differences can impede successful communication, mutual comprehension, and cooperation. Language barriers may complicate communication even when the patient speaks English, because words used in the English language can have slightly different definitions in different cultures.

When faced with a patient’s apparent NCB as well as with cultural difference between patient and physician, the physician’s responsibility is to explore possible cultural factors that may obstruct effective health care. Some cultures value a direct and explicit communication style; others favor a more indirect and subtle style. In some cultures, to challenge or disagree with a physician is considered improper; therefore, a patient’s lack of agreement or understanding may lead to silence during the office visit or passive noncompliance afterward. Culturally sensitive health communication is an enormous issue worthy of much research and training.

“Psychological” Issues

I put “psychological” in quotes to emphasize that my understanding of this term includes biological, environmental, cultural, and patient-specific factors. Psychological issues that commonly result in NCB include denial and depression and, less commonly, severe psychiatric illness such as psychosis.

In this context, denial is the process by which painful or upsetting thoughts and issues recede from consciousness—a very common response to bad news. Denial in mild forms is of considerable value—otherwise, we would all be preoccupied with our problems and unable to function within our daily life. Denial in more severe form can be crippling and maladaptive. In my experience, denial is especially common in long-term diabetic patients whose diabetes was either of juvenile or of midlife onset. Good blood glucose control demands enormous effort compared with control of signs or symptoms of other common chronic illnesses, such as hypertension. The diabetic patient must pay close attention to diet and exercise; monitor blood glucose levels at home, a process requiring finger sticks; schedule frequent blood tests; and take pills, insulin injections, or both. Contemplating these complex requirements along with the long-term risk of blindness, kidney failure, and cardiovascular complications may stimulate denial in many patients.

In evaluating depression as a cause of NCB, I do not only include patients with a clear diagnosis as defined by the Diagnostic and Statistical Manual of Mental Disorders but also patients whose depressed mood and defeatist attitude sabotage their ability to deal with their medical condition. Patients who have more severe depression may engage in NCB that appears suicidal and that may lead to an abrupt and early death, for example, a patient with insulin-dependent diabetes who will not self-monitor blood glucose levels and who is frequently hypoglycemic.

Patients with bipolar disorders are often unpredictable, and their degree of compliance varies, depending on their mood state.

Patients who are clinically psychotic or who have thought disorders with psychotic features present one of the greatest challenges to addressing NCB. For example, a patient who is delusional and paranoid may refuse psychiatric care and live independently. This patient could refuse treatment for a serious disease, such as early-stage breast cancer. Despite enormous effort, a physician may be unable to convince the patient of the seriousness of the disease; in fact, the patient may stop coming to office visits and may stop answering letters or phone calls from the physician.

Secondary Gain

Some patients feel rewarded for remaining sick. In my experience, the most common reward is being classified as medically disabled: the patient is considered unable to work or requires long-term modification of duties. In this way, NCB (and a worsening or stationary health status) is financially rewarded, and the patient is removed from a stressful or onerous work situation. I believe that often this is not a conscious process, such as deliberate malingering or premeditated self-sabotage, but instead that subconscious positive reinforcement occurs when NCB results in the patient continuing to be classified as medically disabled.

Patients who receive and enjoy special attention from family members while in poor health may engage in NCB.

Psychosocial Stress

An overwhelmed patient is often ineffective at self-care. Many of our patients face complex and stressful living situations. Realities such as poverty, long hours working in multiple jobs, difficult parenting problems, or troubled relationships can leave people exhausted, feeling besieged, and simply unable to cope with the added time and energy required to fully manage a chronic illness. Feeling trapped and hopeless destroys that sense of optimism for the future that usually helps motivate good self-care for chronic illness.

For many chronic illnesses, such as hypertension, noncompliant patients may feel perfectly healthy until complications such as congestive heart failure or stroke occur. These patients must truly believe the diagnosis and the physician’s advice, have a clear understanding of the consequences of NCB, and develop the ability to prioritize their own needs to take daily medication and keep regular medical appointments even while they feel healthy—in the hope of a healthier future.

Drug and Alcohol Dependence

People who are addicted to alcohol or drugs often fail to take care of business in many of life’s arenas and are often erratic or noncompliant with regard to their health care. These patients often suffer from medical complications of their addictions, such as hepatitis C or cirrhosis; because of poor self-care, they are also prone to many other chronic illnesses. Treating the addiction is often prerequisite to treating comorbidities, but the denial that these patients usually have impedes effective medical care. Stress and disorganization in the lives of many addicted patients—as well as health problems—create a formula for massive NCB and poor health outcome.

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Fred Kleinsinger, MD, Primary care physician in the Department of Medicine at the Kaiser Oakland Medical Center. He has an active outpatient panel practice, is physician team leader for a group of 11 medicine physicians, and manages the Mentoring Program for the Medicine Department. E-mail: gro.pk@regnisnielk.derf.