The Power Of No

Why is it that when someone tells us we can’t have something, we just want it more?  Marketers (those masters of neuropsychology) use this to their great advantage.  “Call now!  Offer expires in ten minutes!”  “Only one more available at this price!”  “Limited edition—Act now!”  Talk about incentive salience!!!

This phenomenon is known as the Scarcity Effect—a psychological principle saying that individuals don’t want to be left alone without an item—particularly something they believe they cannot have.  We’ve all experienced this in our personal lives.  Tight budgets often invite wasteful expenditures.  Obsession over “forbidden foods” has ruined many a diet.  Saying “no” to a child is frequently a trigger for constant begs and pleas.

Given the apparent universality of this concept, it’s surprising that we fall victim to it in medicine as often as we do, particularly at times when we want to motivate behavior change.  Saying “no” to a patient usually doesn’t work—it’s human nature.  In fact, if anything, the outcome is usually the opposite.  Reciting the dangers of cigarette smoking or obesity, for example, or admonishing a patient for these behaviors, rarely eliminates them.  The patient instead experiences shame or guilt that, paradoxically, strengthens his resistance to change.

But if we understand the Scarcity Effect, we doctors can outsmart it and use it to our advantage.  This can be important when we prescribe medications which are likely to be misused or abused, like sleep medications or benzodiazepines (Valium, Xanax, and others).  These drugs are remarkably effective for management of insomnia and anxiety, but their overuse has led to great morbidity, mortality, and increased health costs.  Similarly, narcotic pain medications are also effective but may be used excessively, with unfortunate results.  We discourage excessive use of these drugs because of side effects, the development of physical dependence, and something I call “psychological dependence”: the self-defeating belief I see in many patients that taking a pill is absolutely necessary to do what the patient should be able to do by him- or herself.

If I give a patient a prescription and say something like “Here’s a script for 15 pills, but I’m not giving you a refill until next month,” I’m almost inviting failure.  Just as expected by the Scarcity Effect, the patient’s first thought is usually “but what if I need 16?”

(I’ve worked extensively in addiction medicine, and the same principle is at work here, too.  When an alcoholic in early recovery is told that he can never have a drink again, he immediately starts to crave one.  Now I know that most alcoholics in early recovery are not in the position to say “no” to a drink, but this is the ultimate goal.  Their ability and willingness to say “no” is far more effective for long-term sobriety than someone else saying “no” for them.)

So why exactly does inaccessibility lead to craving?  Because even when it’s clear that we cannot have something, our repeated efforts to get it sometimes pay off.  And here’s where another psychological principle—that of intermittent reinforcement—comes in to play.  People who play the lottery are victims of this.  They know (most of them!!) that the odds of their winning are vanishingly low.  Most people never win, and those who play regularly are almost always losers.  However, every once in a while they’ll get lucky and win a $5 scratcher (and see the news stories about the $80 million jackpot winner just like them!) and this is incredibly reinforcing.

Similarly, if a doctor tells a patient that she should use only 10 Ambien tablets in 30 days– and that no refills will be allowed– but she calls the doctor on day #12 and asks for a refill anyway, getting the refill is incredibly reinforcing.  In the drug and alcohol treatment center where I used to work, if someone’s withdrawal symptoms did not require an additional Valium according to a very clear detox protocol, he might beg to a nurse or staff member, and occasionally get one—precisely what we do not want to do to an addict trying to get clean.

The danger is not so much in the reinforcement per se, but in the fact that the patient is led to believe (for very therapeutic reasons) that there will be no reinforcement, and yet he or she receives it anyway.  This, in my view, potentially thwarts the whole therapeutic alliance.  It permits the patient’s unhealthy behaviors to prevail over the strict limits that were originally set, despite great efforts (by patient and doctor alike) to adhere to these limits.  As a result, the unhealthy behaviors override conscious, healthy decisions that the patient is often perfectly capable of making.

One solution is, paradoxically, to give more control back to the patient.  For example, prescribing 30 Ambien per month but encouraging the patient to use only 10.  If she uses 12 or 15, no big deal—but it’s fodder for discussion at the next visit.  Similarly, instead of making a statement that “no narcotic refills will be given,” we can give some rough guidelines in the beginning but let the patient know that requests will be evaluated if and when they occur.  Recovering addicts, too, need to know that relapses and craving are not only common, but expected, and instead of seeing them as failures of treatment (the big “no”), they are a natural part of recovery and worthy of discussion and understanding.

In medicine, as in all sciences dealing with human behavior, ambivalence is common.  Preserving and respecting the patient’s ability to make decisions, even those which might be unhealthy, may seem like giving in to weakness.  I disagree.  Instead, it teaches patients to make more thoughtful choices for themselves (both good and bad)—exactly what we want to encourage for optimal health.

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10 Responses to The Power Of No

  1. moviedoc says:

    Not sure what you’re getting at, Steve. Ambivalence? Did you mean ambiguity? Bill Wilson knew about the alcoholic’s difficulty with “never.” His idea was “one day at a time” not “well maybe you can drink again when you’re not a drunk anymore.” There’s nothing wrong with saying no to zolpidem (Ambien) or narcotics. Period. Addicts need to learn they can rely on other resources to handle their feelings or cravings, and for conditions that require drugs, that they can relay on non-addictive drugs.

    • stevebMD says:

      moviedoc: “There’s nothing wrong with saying no to zolpidem (Ambien) or narcotics.” I know this, but to the patient, hearing “no” simply increases anxiety and the desire to use a product which has now become more scarce. If instead I say “maybe, we’ll see” (figuratively, of course), it puts more control back in the patient’s hands and invites them to weigh the drug against non-addictive or other resources.

      Regarding your comment on alcoholism, recovering alcoholics can indeed comfort themselves with “one day at a time” (sometimes) but not with the inevitable thought of an interminable sequence of such alcohol-free days. (This, incidentally, is where the “Higher Power” concept can be extraordinarily helpful, for people who can truly adopt it.) My approach is, don’t say “never,” don’t say “no,” just make the right decision at any given time. But realize you might make a mistake or two.

  2. moviedoc says:

    You’re advocating the proverbial mixed message, leading the patient on. You’re saying, “I’m not sure you can handle that anxiety.” In fact this approach encourages testing and manipulation. I don’t like it. When you say no, you also say, “I know you have the strength and resources to make a go of it without this.” True intermittent reinforcement would consist of, for example, rolling the dice every time the patient comes to the office, and when they roll a 4 you give them what they want. Our job is to provide what we believe the patient needs, not to make them comfortable.

    • stevebMD says:

      Good points. But what you say works if– and only if– “no” truly means “no.” For most patients in most situations (and for most addicts in recovery unless they’re being monitored 24/7), this is simply not the case. There’s always a way to outsmart the system, go against the doctor’s advice, and sabotage one’s treatment. Often these attempts fail, but even if they succeed only a fraction of the time, it’s enough not just to keep the unwanted behavior alive, but also to make it stronger.

      And whether this approach encourages “manipulation”: manipulation is more likely to occur when someone’s cards aren’t all on the table. I’m encouraging open discussion and dialogue from both sides.

  3. moviedoc says:

    “There’s always a way to outsmart the system, go against the doctor’s advice”

    Yes, but the patient risks losing you if they violate the contract.

    “I’m encouraging open discussion and dialogue from both sides.”

    Discussion of what? The addict just sees you as a source, so she will try to learn what she has to say to get you to prescribe what she wants.

    • stevebMD says:

      “The addict just sees you as a source…”

      I wanted to make the discussion about more than just substance-dependent patients, but since you mention “addict,” the addict may see me as a source (and indeed I am), but the patient sees me as someone who can genuinely provide help. Addicts, in general, are good people who suffer deeply and desperately need the help that a compassionate caregiver can provide. Seeing them solely as addicts, taking a hard stance with them, and discharging them when they go against our “contract” is disrespecting their intrinsic humanness.

      “…to get you to prescribe what she wants.”

      The good addiction provider has more tools in his/her armamentarium than just “what [the addict] wants.”

  4. Jackie says:

    The Power of Yes also factors in to the patient craving prescription drugs.

    Consider the patient who complains of insomnia and is given a prescription for Ambien or doxepin. They’ve now been given the message that the sleep problem is serious enough for a prescription med, so that sets the anxiety in motion: “What if I can’t sleep without this?” and “What’s going to happen when I run out of this, will I miss my deadline?” “Will I sleep through another class?”, etc.

    But when the same patient is told that the insomnia can most likely be treated by taking a Benadryl, on an as-needed basis, as the OTC med works on the exact same neurotransmitter as the prescription drug, then the patient sees the insomnia in a different light. It’s now something that can be handled without the doctor, so it’s down-graded in the patient’s mind. And it’s now something that’s not unique to them, lots of people have the exact same problem, as the remedy can be bought off the shelf. And the patient (as you said) has control over the problem — can keep some Benadryl in the medicine cabinet, or make a run to the drug store, as needed. So they most likely won’t use it as much as they would use Ambien.

    There’s something that plays with your mind when a “prescription” is involved — and the scarcity model fits, in that you want “more” even if you don’t need it.

    • stevebMD says:

      Jackie,

      That’s exactly my point. When a patient perceives that someone “important” (ie, the Doctor) holds the key to some medication, device, or procedure, it gets imbued with– not to sound too melodramatic here– “special powers.” Sort of like the “spirit guides” which are accessible only to the shaman. (It’s also the reason why companies spend millions of dollars coming up with names for drugs– if they sound more “scientific,” they’re more effective.)

      I think we should just demystify the whole process. Not by making every drug available over-the-counter, but by having honest discussions with patients about what “may” or “may not” be helpful, not what they “absolutely need” or “cannot have.”

  5. Carol Levy says:

    I just want to thank you for making a disctinction between addiction and dependence “Similarly, narcotic pain medications are also effective but may be used excessively, with unfortunate results. We discourage excessive use of these drugs because of side effects, the development of physical dependence” I came to your article from another blog conversation about use of narcotics in chronic pain treatment. Sadly, most of the docs there do not make this distinction.
    Thank you
    Carol Jay Levy, B.A., CH.t
    author A PAINED LIFE, a chronic pain journey
    founder, Women In Pain Awareness website,

    http://womeninpainawareness.ning.com/

    http://apainedlife.blogspot.com/

    member, cofounder with Linda Misek-Falkoff, PWPI, Persons With Pain International,
    accredited to the U.N. Convention on the Rights of Persons with Disabilities member U.N. NGO group, Persons With Disabilities

  6. […] want to hear about the side effects or how it’s not indicated for their condition.  (It takes more energy to say “no” than to say “yes.”)  They often appreciate the fact that there’s a “chemical deficiency” or […]

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