Adherence vs Compliance

Is adherence better than compliance? I recently saw a doctor tweet a list of words he hates to read in patient charts. One of those words was compliant. He indicated adherent was superior, always. I’ve been thinking about that in light of the difficulty many of us have in complying with medical advice – including specialized diets.

I know, it may seem like semantics. But maybe in this case semantics matter. And I think this doctor makes an important point.

To get the greatest benefit from medical advice, patients need to adhere to plans developed by their medical team and agreed to by them. But I’ve most often heard this described as compliance, not adherence.

Why does this distinction matter?

In the strictest definitional sense, compliance means acquiescing or yielding, especially in a weak or subservient way. I don’t want to feel weak or subservient when it comes to decisions about my health. I’m pretty sure no one does.

I strongly believe in patient-centered care. In such a system, the patient is a valued part of their medical team. I’m not sure you can feel valued as part of the team when are related to by medical professionals as though you are, or should be, weak and subservient.

And let’s be honest, many times there’s pressure from medical professionals for patients and families to behave in a subservient way. If they do not, they may receive dismissive or condescending treatment. When this happens, it seems predictable that patients will tire of such treatment and rebel.

If a doctor talks down to, bristles at questions, fails to explain, or refuses to listen to patients, that physician is not going to be as likely to get a buy-in on a prescribed health plan. If that professional perceives there is pushback and relies on a position of superiority to attempt to enforce compliance, the patient will rebel even more.

And why not?

Our lower brains may perceive this kind of pressure as danger. When that happens, the patient must try to somehow twist their being into compliance while feeling they could be in danger. And the feeling of danger is exacerbated by a constant barrage of advertising pushing medications and health screenings.

Essentially, we’re asking people to do something very difficult to do. Intellect may not intercept the lower brains signals on a conscious level leaving behavior to be guided by survival instinct or reflex. Of course this won’t be true in every case. But it may be true often enough that we could improve adherence just by changing our rhetoric.

Adhering connotes steady devotion, allegiance, and attachment. In other words, if I choose to adhere to something, I embrace it. That sounds like the relationship I want when it comes to my health. I hope to embrace a plan that I perceive as the healthiest for me in any given moment.

Adherence places the patient back in a position of power in charge of their health. It is willingly given and does not require pushing at all.

Why not change our approach to seek adherence? When we treat patients in a manner that encourages them to embrace a plan, there will be no need for pushing, cajoling, shaming, or arm twisting them into compliance.

Could such a subtle shift make a difference?

There’s no way to really know until we try it. But if one physician has recognized the benefit, I’m guessing there are others. And if we as patients push for this change, we may get more palatable healthcare.

I feel like eating plans tailored to the needs of an individual and presented respectfully will make many dietary recommendations less objectionable and easier to embrace. That will take us a long way toward adherence.

Some may determine that adherence vs compliance is a bit potayto, potahto. I disagree. I feel like a shift toward adherence is just the shift we need.

Seeking Safety

How much of our relationship to food is about seeking safety? I’d like to know the answer to this question. I also understand that the answer is variable and individual and therefore impossible to answer in an objective way. 

Since Abraham Maslow proposed the idea of a hierarchy of needs in the 1940s, we have generally had a picture of physiological needs as the basis of a pyramid. That means physiological needs are the priority. After that, comes the need for safety, then the need for love and belonging, etc.

But it’s really not that simple. We aren’t a perfect pyramid built one layer at a time. We need to feel safe or we may throw up any nourishment that’s available. We need love and belonging to feel safe so it’s impossible to meet our physiological or safety needs without incorporating that next layer of love and belonging. If this were not true, it would be the norm for babies to thrive whether or not they recieve love and attention.

Perhaps it would be more helpful to view ourselves as layer cakes. The layers support each other. Each is the same size. Each is equally important. When tasted together, the flavors enhance each other. 

A layer cake is a stable tower when the layers are securely held together. In a cake, we use frosting as the glue that both sweetens the tower and keeps the layers connected. In people, the frosting is attachment. 

Secure attachment looks like frosting applied with a steady hand. It has uniform thickness across the layer. The amount is perfectly matched to the thickness of the layers. Secure attachment feels safe. 

When our attachment style develops as avoidant, dismissive, ambivalent, anxious, or disorganized, we may not always feel safe in our relationships. This can affect any or everything in our lives and may manifest in our relationship to food.

Sometimes, we will need a full pantry to feel safe. Sometimes, the urge to eat or not eat will be about the feeling in our stomach. Sometimes, we need to feel soothed by the act of swallowing.  

Most often, overeating or binging and purging are characterized as attempts to fill a void. Again, that seems like an oversimplification. If a person to whom I felt anxiously attached withheld food from me during my developing years, I may feel a need to protect myself from starvation any time a similar feeling appears. That feeling may be triggered by an event that looks situationally different, but feels the same. 

If I eat during an emotional flashback (heightened sensation moment), I’m not really trying to regain attachment. My lower brain is signaling me to survive. I have to calm the lower brain before I can begin to consider repairing attachment. That means getting past the feeling and/or subconscious belief that I won’t survive. 

Once I am able to recognize what’s happening in the moment, I can explore the food and eating choices I make any time I experience this trigger. Without this recognition, the subconscious will continue to sabotage well-intended eating plans. 

We often feel guilt or shame when we fail to follow an eating plan. Understanding that your body may be seeking safety without your conscious knowledge can help alleviate guilt and give you a beginning point for exploring how this affects your relationship with food.

With insight and exploration, it’s possible to move the subconscious to the conscious. From there, all change is possible.

Trouble With Gratitude

How can anyone possibly have trouble with gratitude? I appreciate knowing when someone is thankful for something I’ve provided. And I want others to have that feeling as well. But last week when I was working on a project centering around gratitude, I found myself writing things like: Gratitude is a hard pill to swallow; and gratitude may be an attitude, but it’s not mine. 

Typing out whatever pops into my head can help me get past a writing obstacle. Once the word flow begins, I quickly delete whatever nonsense I’ve been typing and forget about it. In this context, my seemingly bad attitude toward gratitude is a normal part of the process. What I wrote made me laugh and laughter is a catalyst for moving me forward.

But like all things funny, this makes me laugh because some kernel of truth resonates. I am truly grateful for many things. I’m grateful that I am resilient. I know how to gather myself up after a setback and try again. I know how to work past fear to meet a goal. I know how to temper my desire for immediate gratification. I understand the value of these skills and appreciate how they have helped me succeed.

While all of this is true, gratitude can also feel like a catch-22. Usually, I feel this way on days when something has triggered the sting of early memories. Some of my best skills were honed in (because of) less than ideal circumstances. And some days, for a few moments, the feelings pull me away from gratitude. That’s how I sometimes have a problem with gratitude.

I’m not proud of those moments, but I’m sure I’m not the only one who has them. And that is why practicing gratitude in a deliberate way is important for me. If I’m not intentional, it’s easier to lapse into old feelings rather than look at the good that surrounds me in any given moment.

It would be easy to say that if I did a proper job healing myself, that would not be the case. Anyone who believes that fails to understand the grasp long-term trauma can have on the subconscious. When damage has been done over a long period of years with no relief, the undoing can be nuanced, lengthy, and less than linear. 

There is no such thing as a proper path of healing for any of us. Life will throw unexpected obstacles in our way. Serendipitous meetings will bring unexpected support. The path will shift and we must shift with it. 

The best I can do is live with open eyes, open heart, and intentional action. The rest is beyond my control. Sometimes, I will feel truly grateful. Sometimes, I will know I’m grateful even when what I feel is sad. And that will have to be enough. 

Hopefully, it’s enough for all of us who, at times, have trouble with gratitude.

Food and Mood

How would you describe the connection between food and mood? I attended a webinar last week on using nutrition to facilitate trauma healing. I haven’t had time to review studies on this subject so I won’t give you a specific regimen to check out or links to websites yet. What I will tell you is the message was powerful and visibly resonated with the audience. It’s the only time I’ve ever been in a Zoom call in which numerous participants wiped away tears as they listened.

The crux of the work involves noting sensations or emotions we experience (or are trying to avoid) at a moment when our bodies feel driven to seek stimulating or depressing foods. Are we attempting to pump up adrenaline or calm it down? What is underneath our desire to do this? Can we recognize eating habits we’ve developed to regulate fight, flight, freeze, and fawn responses? What happens emotionally when we change our eating habits?

Why does any of this matter?

We know that a high percentage of people fail in attempts to follow a new diet regimen over a long period of time. This is true whether the diet is designed for weight loss or to avoid gluten. And it’s true in people who may be highly disciplined in every other area. Perhaps exploring what happens emotionally when we change our eating habits can give some insight that will lead to better approaches for lasting change.

What exactly would we explore?

The short answer is how food relates to us and how we relate to food.

We typically do this with a particular diet strategy in mind. We may be more successful over the long haul if we focus on rituals and culture and how food relates to feelings of safety or danger.

How can we discover that?

We can begin with habits – the foods we reach for regularly; times of day we reach for something; whether we tend to withhold food from ourselves, etc. Keeping a journal may be helpful.

What comes next?

Next, we can explore what we are feeling when we reach for the caffeine or chocolate or potato chips or fried chicken that we see regularly appearing in our journals. We can also record how we feel after we consume that food and how long the feeling lasts.

Looking at these patterns allows us to determine our relationship with food. Once we have a grasp of it, we can slowly build tolerance for feelings of uncertainty and danger that may result from changes in diet.

Why on earth would this work?

Food is a mood regulator. You can find plenty of scientific studies about the particular nutritional properties of food and how those relate to mood. In practicality, the specific properties don’t matter until the body is able to feel safe when we change our habits and rituals. This requires deliberately building a framework for safety.

For example, sugar is a stimulant. You can calm the body by limiting or removing it. When you do so, you’ll eliminate empty calories and lose weight. Easy, right?

Yes, but…

The body adapts to threats using the tools it has available for regulation. One of those tools is food. Another is swallowing. It is normal for the body to resort to an adapted response that may no longer be needed.

If a dieter lived with constant stress as a child, a high level of adrenaline may feel normal or “safe.”  That person may consume large amounts of stimulants – chocolate, candy, sweetened coffee drinks, sodas, dried fruit – or skip meals in order to feel normal. When a high level of stimulation feels normal or safe, removing it will cause a feeling of danger.

That means removing sugar from the diet can send the body into fight, flight, freeze, or fawn mode. Because this is an adapted physiological response, it will not magically go away on its own.

But it is possible to develop a framework for healing that shifts our relationship with food over time. It is the change in the relationship that will allow us to use food to improve mood in a healthy, lasting way.

So here’s what I’m taking away from the webinar: If you have struggled with any kind of dietary change, you are not alone. If you’ve ever punished yourself for resorting to old habits, you can stop. Once you recognize your body is trying to protect you from something unbearable, you can stop fighting yourself. Once you stop fighting yourself, there’s more time and energy for realigning the relationship between food and mood.

All of this feels right to me with or without studies to support the specifics. I can’t wait to learn more about my own food and mood!

Here’s to exploration!