Words are perishable goods. With time they lose color and flavor, either rot away or dry into small hard things. I was thinking about this when contemplating the word encouragement. It once was and again can be so much more than what we often take it to mean. In fact, encouragement can be a core intervention we use as clinicians.

Sometimes ‘to encourage’ is used as a synonym for ‘I recommend’ as in, “As your high school counselor, I would encourage you to take more math classes and to turn in your college applications early.” Sometimes encouragement brings up the image of a pat on the back with a “at a boy” or “at a girl … you can do it.”

But encouragement is more than advice-giving or an isolated statement of “you can do it” said with befitting enthusiasm. The root of the word ‘courage’ is the Latin word for heart ‘cor’ and for millennia the heart has represented spirit, fortitude, inner strength, the ability to do hard or dangerous things despite one’s fear. Such hard or dangerous things are not limited to activities that can lead to physical injury or death, but to psychological or spiritual injury or loss also.

A simple image that captures the power of changing behavior through encouragement is of a parent with their toddler who fears going up the ladder and coming down the slide. How does a parent encourage their hesitant toddler? Perhaps with these words: “Daddy will be right behind you as you climb the steps” or “Mommy will catch you as you reach the bottom.”

What is the parent offering their child? And what can we offer our patients? Here is a list of possibilities:

  • Safety: people willing to take risks are those who are launching from a place of relative safety. Counterintuitively, the more vulnerable a person feels in their current situation, the harder it is for them to jump into something new that may only serve to increase their vulnerability. As clinicians we can strive to make our offices and time spent with patients a place of refuge from the threats they often experience in the rest of their lives. Also, we can strive to help the patient set conditions for increasing their sense of safety outside our offices. For example, we can encourage formation of new healthy relationships or reconciliation with estranged family and friends. Or we can teach them skills to ask for help from others. We can role-play with them so they can learn experientially.
  • Belonging and community: I’ve always been a fan of group therapy. Rather than seeing it as a cheap alternative, it is a place of mutual support, friendship-making, social learning, and encouragement. Of course, groups can go easily go off track and the facilitator needs to actively enforce adherence to the rules and the spirit of the therapy group.
  • Worthiness: a person needs to feel important enough to believe someone else will want to care about them, and care enough to ‘not take their eyes off of them.’ As clinicians we cannot be ever watchful over patients, of course, and it is countertherapeutic to make promises to patients that we cannot keep over the long term. Such unkept promises destroy interpersonal trust with incredible efficiency. But there are ways we can communicate to patients that they are important to us. Here are some simple interventions:
    •  Patient comes in and sits down. I say, “It’s good to see you. I was thinking about you this week …” What I’m doing is telling the patient that they exist for me even when they are not there in front of me. I’m thinking about them even when I’m not being paid to do so. I’m doing it because I care about them and I care about them because they are worthy of care. My care is ongoing, transcending the limited moments of our appointment time together and even the times they are actively on my mind. I care even when sleeping.
      o I advise the patient to try a new behavior, a new adaptive coping strategy, like, for example, telling a socially anxious patient to join a club at school. In addition to planning the details of undertaking this new scary behavior with the patient, I say, “OK. So, after you meet with the group coordinator, I want you to leave me a message or email me right away. I would like to know how it went for you and we can then strategize some more the next time we meet.” I am communicating that I am invested in the outcome and that their experience is emotionally meaningful to me. I’m waiting on the edge of my seat to learn how it went.
    • I apologize to a patient if I’ve said something that hurt them, even if that was not my intention. I am communicating that their opinion of me matters to me, that I will feel hurt if they are angry with me. Of course, there is a place to engage in transference-focused questioning, such as, “I notice that you’re angry with me. Can you tell me where that comes from?” The problem with such a response is that it communicates that the patient’s hurt or anger has nothing to do with my behavior and is rather just part of their craziness. This kind of unwillingness of the clinician to take responsibility for their contribution to the interpersonal problem leads to a distancing from the clinician, perhaps even a feeling of betrayal of sorts.
    •  The patient explains something about their experience to me and I say, “I want to thank you for sharing that with me. I don’t think I ever really understood such experiences before you explained yours to me.” I am communicating that they have something to teach me and that I am grateful to them for enriching my life. Our relationship is not a one-way street, with me the high guru dispensing words of wisdom to them while they eagerly absorb them. We’re mutually learning from each other. Patients are more likely to learn from me when they know I am learning from them.
  • Planning: to have the courage to do new scary things, it helps to have a plan. The plan should anticipate setbacks and failures and address these likely outcomes within the plan. The clinician communicates that changing behaviors not is a staircase of ever-rising steps. Falls and bruises are part of the process of change, a kind of falling forward to learn from them. It is important to minimize the shame of falling short when encouraging new behaviors. After all, the new behaviors are all part of an ongoing experiment. (BTW, I like to watch parkour videos on the internet, especially ones showing the repeated failures of nailing the landing. They show how much physical punishment some people are willing to go through to reach their goals. I find it oddly inspiring.)

Thanks much,

Until next time,

Jack Krasuski, MD


Today’s Quotes

“Everything that happens to you matters to me.”
Cassandra Clare

“The courage to be is the courage to accept oneself, in spite of being unacceptable.”
Paul Tillich

“A dog has one aim in life… to bestow his heart.”
J. R. Ackerley

“The most critical time in any battle is not when I’m fatigued, it’s when I no longer care.”
Craig D. Lounsbrough