Adherence Management: More Questions and Answers

Dr. Bob Wright

An Interview with Dr. Bob Wright (continued)

The following is an interview with Dr. Robert E. Wright, founder of Behavioral Education and Research Services, Inc. (BEARS). In it, he describes the behavior-based health services clinician-driven process known as Adherence Management (AdM) Coaching®.

We are back with Dr. Bob Wright in our Q and A sessions about Adherence Management.  We’ll start where we ended last time with a question about the differences between outcomes and consequences.

Q: You had mentioned in a previous conversation that there are four pairs or elements of consequences common to every behavior.  And, each type has two extremes.  Can you talk a little more about these elements?

Sure. We already discussed the first pair of elements in our previous session, positive vs. negative. This element is called the “Type” of consequence. This determines whether the behavior is strengthened and will occur again because the patient experienced something positive. Or, the behavior is weakened and will likely not occur again because the experience was negative. 

The other elements of all consequences are “Timing,” (the consequence is immediate or future); “Probability,” (the consequence is certain or uncertain to occur); and “Perception,” (the patient is aware or not aware that the consequence is happening.)

Q: Can you give me an example so our readers can quickly see what you are talking about? 

Let’s look at a 38-year-old, diabetic, male who was just discharged from the hospital for congestive heart failure, pulmonary hypertension and COPD.  His medication list may include albuterol as needed, baclofen 3 times a day, Lovenox injections twice a day, Lasix twice a day, Singulair and Coumadin at bedtime. 

From the physician’s perspective, this plan of care is positive and will lead to immediate and sustained improvement of the patient’s health and well-being. The physician is very aware of how effective this plan will be.  So, from the physician’s point of view, this plan is an all-around PICA consequence (positive, immediate, certain and aware.)

However, from the patient’s perspective, the medication schedule is very intrusive (NICA), the possibility of side-effects is very high (NFUA), and the cost of the medications could be several hundred dollars a month (NICA).  In addition, many of the medications work quietly in the background to prevent future symptoms, but the patient is not aware that they are working (PFUN).  These are mostly negative consequences in terms of convenience, cost and side effects; and, the only positive consequence is something that the patient is not aware of and is uncertain to happen sometime in the future. 

The Consequence Analysis© affords the patient and the AdM Coach the opportunity to evaluate these potential issues and determine ways to either avoid them (by modifying the plan of care) or pushing through these obstacles (with positive reinforcement.)

Q: Can you give me your thoughts on “Perceptions?”  Aware and not aware don’t sound like behaviors to me.

Thank you for pointing that out.  Our perception of a consequence lets us know that something happened or did not happen.  For example, when a patient uses a rescue inhaler, he or she experiences a positive, immediate, and certain outcome or consequence – they can breathe again.  That outcome is referred to as a “PIC.”  The fourth element, “Perception,” deals with whether the user is aware of the consequence or not.  In this case, immediate relief and the ability to breathe normally is very real to the patient.  This outcome is known as a “PICA.” 

Another example is burning your hand on a hot stove. It is negative, immediate, and certain, and you are aware of the pain (NICA). 

Sunburns, on the other hand, are negative, future, uncertain, and people are not aware that the burn is occurring at the time they are enjoying a day at the beach.  This consequence is known as “NFUN.” The sunburn may have negative effects (such as pain or skin cancer), but those effects are in sometime in the future; they may or may not happen; and, the person is not aware that the sunburn is happening, at the time of the behavior.

Many medications, particularly medications for chronic diseases, have consequences that are positive, future, certain but patients are not immediately aware of the benefit (PFCN.)   Consequences that are positive, immediate, certain, and perceived (PICA), will almost always lead to behavior habit development. However, when consequences are NICA or the patient is not aware of the consequence, behaviors will be put on extinction.

Q: So, what you are saying is many medications, taken for chronic illness, may be beneficial, but because, from the patient’s perspective, they are not aware of anything happening and what is happening may actually be causing negative consequences, they stop taking the medications

That’s correct.  All behaviors follow a set of well documented laws.  Any behavior that is not reinforced will eventually stop.  The negative consequences of chronic diseases are often many years into the future.  Also, the clinical positive outcomes of taking chronic medications may also be years away. Future and uncertain consequences are very hard to overcome without some sort of positive reinforcement.

Many times, the day-to-day aspects of pill-taking can often be punishing. And, that punishment happens immediately upon taking the pills.  Another law of behavior is that a punishing consequence will stop behavior.  Any time a consequence is negative, immediate, certain and aware (NICA), you can guarantee it will overwhelm a consequence that is positive, future, uncertain and not aware (PFUN).   

Thank you, Dr. Wright.  That’s all the time we have for today.  Join us next time for Q and A with Dr. Bob Wright.

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