What If the Patient Doesn't Want Help? What Can the Family Do?

In another article I talked to you about family members, and this time we’re back on the same subject. I’m doing so because of a particular case I saw recently, in which circumstances forced me to take steps I wouldn’t have taken under normal conditions. I’m talking about when the patient doesn’t want to do anything to help their own recovery, but their situation is devastating not only their life, but also the lives of their family. If someone decides they’re not going to do anything for themselves, they have every right to do so. But if that decision brings suffering and a poor quality of life to the people around them, that’s another story. You can decide not to do what’s recommended for your recovery, but you shouldn’t force your family to put up with the consequences of that decision. Patients’ lives and happiness are no more important than the lives and happiness of their families.

Let me tell you about the case I mentioned so you can picture it – things are always easier to understand with an example. I’ll keep it very brief so I can focus on the topic of this article. Let’s call my patient María and her mother Pepa. María is in her forties and lives with her parents because of a fairly severe obsessive-compulsive disorder that prevents her from leading a functional life. She has had short involuntary hospital admissions that worked well at first, but after a while María would always relapse. She spent some time at a specialist OCD treatment centre, but her stay was brief, because she decided to come home after a very short time, during which she barely had a chance to work on her problem. It was after coming back that she started seeing me. After a couple of sessions I suggested the idea of a co-therapist, supervised by me, who would go to her home several days a week to do exposure work with her. This person started going every morning (at least three hours a day). It lasted a week. María said that neither the co-therapist nor I could help her. I should also add that she doesn’t take the medication she was prescribed, which worked well for her at the time. If she does take it, it’s very irregularly, whenever she “feels like it”. This went on even after I’d explained the dangers of self-medicating and how it went against her goals in therapy. Now, after three or four sessions, and having barely given exposure a chance, she says she wants to go back to that centre. That would be a very good idea if it weren’t for the fact that she’s going there with the same mindset as the first time, intending to “do things her own way”.

The key point in this case is that María’s decisions are suffocating Pepa, her mother. Pepa is an older woman and is María’s main source of support. She has constant panic attacks and takes anti-anxiety medication because she can’t cope with the situation any more. She’s very tense and sad all the time; 90% of her life and activities revolve around María’s OCD. Pepa cries a lot every day… and she’s on the verge of breaking down. I should point out that María involves Pepa in her rituals, which means her mother spends several hours a day, every day, devoted to her daughter’s OCD. And I want to make it very clear that “devoted” has nothing to do with exposure – quite the opposite. But when a parent sees their child suffering, they’ll do anything to spare them that suffering, even if it makes the problem worse. It’s human and completely understandable, but it has to change.

What does a professional do in cases like this? The patient is María, but she doesn’t want to do any of what she needs to do to recover, which leaves the rest of us stuck. At the same time, her mother sits in front of me crying, shaking and desperate. If María doesn’t want to be helped, we’ll have to move in another direction so that the patient’s decisions affect those around her as little as possible. This is complicated, even more so when they live under the same roof. So what then? We focus on helping the family, even if that means “setting María aside”. With what goals?

1. For Pepa to catch her breath before she reaches breaking point. The first and most important.
2. For María to see clearly that if she doesn’t do anything for herself, the people around her won’t encourage that attitude the way they have until now. We can’t force an adult to want to get better, but we can make it clear that we’re not going to go along with it.
3. To try to give María enough of a nudge that she wakes up and gets involved in her own recovery.

And what does this mean in this specific case? The first step we’ve taken is a temporary physical separation. I sent Pepa and her husband away for a couple of weeks to a country house they have outside the city (we made sure María has her meals sorted, since she doesn’t shop or cook for herself).

The second step (the hardest one, which will happen when they’re back from their break) is for Pepa to start no longer taking part in María’s rituals, facilitating them or accommodating them. This is going to be incredibly hard for her but, as she herself rightly says: “What I’m living through now is already incredibly hard.”

These are the goals we’ve set, but I’m aware that it’s very difficult to get a parent to take this path, because the bond and the feelings involved are very powerful. But, as always, we professionals have to learn to accept the limitations that come with a job like ours, where we deal with people and their circumstances.