Prof. Joseph Levine

Senior Psychiatrist




Conversation 35: The effect of the directorate of internalized characters on compliance with drug treatment

By Prof. Levine & Dr. Salganik

Hello everyone, in this short conversation we will discuss the effect of the board of internalized characters on compliance with drug treatment.

First, we will mention that in the model we propose for the "self", one must first differentiate between the primary self, which is actually the basic biological nucleus consisting of several innate structures and which is subject to development during life. and the "social self" [consisting of "secondary selves"], which is a structure that develops during a person's exposure to social influence, and consists of internalizations of figures significant to a person, originating either from external groups or from imaginary groups (related, for example, in the form of a story, from a myth, from a movie, etc.) that were having a considerable effect on the person). We will note here that we assume that at birth there are innate patterns for most parts of the self such as the "social self" and its parts that form nuclei for a possible future development of these structures.

The "secondary selves" included in the "social self" include 1] the variety of representations of the "I" that originate from attitudes and feelings towards the self and its representations in different periods of life 2] the representations of internalized figures that often originate from significant figures that the person is exposed to during his life but as mentioned may also be imaginary characters represented in books, films, etc. that have had a considerable influence on man. 3] My representations of the "subculture" [subculture refers to social influences in the milieu [environment] in which the person lives and are not necessarily related to a specific person].

We call the social self metaphorically the "directory of characters" or more specifically the "directory of internalized characters." We note that, as we mentioned before, in this board there is usually a hierarchy in which there are more influential and dominant figures that we metaphorically called "the dictator self or selves" and these set the tone and even impose censorship on what content, attitudes and behaviors cannot be contained in the board of figures. We note that the person as a whole is not aware of the influence of the directorate of visualizations and recognizes the influence as coming from him, from himself and his own will and attitudes.

How, then, do these internalized significant secondary figures influence medication compliance?

Let's take for example Yair, whose mother died of pancreatic cancer, and the drugs she received caused her extremely severe side effects, which caused her to take distinct positions that consider drug treatment, according to her, "commercial poison." The figure of his mother was internalized in Yair's board of figures as a dominant figure dictating his attitudes and behavior and led him to avoid drug treatment and to try only partial dietary treatment for his diabetes, which led to the worsening of his disease and the appearance of considerable complications.

Or take for example Shula, who lives in a subculture that advocates veganism and staying away from everything industrialized. This subculture shunned drugs and these were considered an artificial product of Western society. These values of the internalized "character" of the subculture were deeply internalized in Shola and influenced her not to take medication for her ulcerative colitis, an inflammatory bowel disease that got worse and worse despite the vegan treatments she took.

We therefore see that the position of the board of internalized characters dictated by the dominant images in it may lead to the positions of the individual that he recognizes as coming from himself and that will harm his response to necessary and sometimes lifesaving drug treatment.

Understanding and managing medication – how to avoid prescription mistakes  and drug errors - First Aid for Life

Of course, the issue of compliance with drug treatment is broad and there are various other reasons for non-compliance such as: economic factors such as the cost of treatment, side effects of drugs experienced by the patient himself, lack of insight into her illness and its treatment, forgetting and not having a treatment routine and even reasons such as a large number of pills, high frequency of treatment, the gender of the patient or a minority population that does not speak the therapist's language, etc.

In general, a patient-centered approach may lead to a better understanding and more effective solutions for non-adherence to medication.

An important component of this approach is building a successful therapeutic alliance between the patient and the clinician. This involves two-way, mutual communication between the patient and the clinician, with an emphasis on empathy, compassion and skilled advice.

Patients often express the need for information about their disease and its treatment, and the delivery of accurate information can also help dispel false beliefs about medications, reduce the feeling of stigma, and foster positive attitudes toward treatment.

In addition, the doctors and therapists must respect the patients' rights to decide on their treatment and engage in joint decision-making with the patients as active and equal partners.

The evidence as a whole indicates that patients place significant emphasis on this interactional component of the therapeutic alliance and that the degree of agreement between doctors and patients on decisions concerning treatment is a high priority for patients.

Along with a series of technical interventions such as concentrating the administration to once a day, beyond forms of providing comfort and more availability to the patient, and those that make use of electronic means and the use of reminders via the mobile phone and other means to monitor the taking of the medication, there are a number of psychosocial interventions that have been proven to improve compliance with treatment.

These include for example:

Psycho-educational approach,

Cognitive-behavioral therapy (CBT),

Family Focused Therapy (FFT),

A psycho-educational approach is a structured intervention that aims to provide patients with information about their disease, its treatment and strategies for managing symptoms and preventing relapse.

Cognitive-behavioral therapy is a type of talk therapy that focuses on identifying and changing negative thought patterns and behaviors that contribute to non-responsiveness to medication.

The family-centered treatment deals with the existing family attitudes and influences and is conducted while inviting the family members, reducing negative emotions and attitudes that oppose the drug treatment and sometimes even the very existence of the disease.

These interventions have been shown to improve compliance with medications, thereby reducing the risk of relapse and improving general functioning in patients.

We suggest that the treatment with RGFT, the "targeted treatment in the reference groups" method, can be used as a great help in cases where figures in the board of directors of the internalized figures influence through their positions, attitudes and behavioral characteristics in a way that dictate a low response or even a lack of response to drug treatment.

This is the case with Yair, who suffered from severe diabetes with complications and whose mother, who died of cancer, developed distinct positions that consider drug treatment, according to her, "commercial poison." Her character was internalized as the most significant in Yair's board of characters as a dominant figure that dictates his attitudes and behavior without him being aware of it.

According to this treatment method, the therapist asked Yair to go to an empty chair where he would sit and speak as his mother’s character while the therapist interviewed this character and while Yair himself experienced the therapist interviewing the character he was playing. This is how the therapist brought up the figure of the mother, her attitudes and attitude to Yair's consciousness – and enabled him to understand her attitudes and their impact upon his behavior. This made it possible to decrease the influence of the internalized mother’s figure on his attitudes and opened a window for him to start formulating his own attitudes separately from her in the context of drug treatment, this time more rational and realistic attitudes, which led to an improvement in his compliance with the drug treatment and a benefit in the state of his illness.

The second case is that of Shola who suffered from severe inflammatory bowel disease and lived in a subculture that advocates veganism and staying away from everything industrialized. A subculture she lived in shunned drugs as a corrosive mash. These values of the internalized secondary self of the subculture were deeply internalized in Shola and influenced her not to take prescription drugs that her doctors offered her. Shula recognized these positions as her own and was not aware of their origin. In the treatment focused on the internalized reference groups, the therapist asked Shula to approach an empty chair where she would sit and speak as one of the characters, in this case someone who represents the subculture she grew up in and lives in while the therapist one interviews such an internalized character, while Shula herself experiences the therapist interviewing the character she is playing.

This is how the therapist raised the figure of the subculture to Shula's consciousness – and made her aware of its attitudes. As soon as she discovered (by herself and not with the help of the therapist's interpretations) the connection between her feelings and the messages of the subculture she called: "my cultural script" that was hidden within her, she was able to say goodbye to it at least partially and develop her own attitudes towards the prescribed medication and take it more regularly, and this is how her situation began to improve. She returned to her work and her friends and managed her illness and medications not according to the "cultural script" but this time according to her own script or plan….

See you in the next conversation,


Dr. Igor Salganik and Prof, Joseph Levine

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