Today’s article is about helping our patients take the first step down a path towards a better life, whether that means less stress, better diet, more sleep, more meaning, better friendships, greater treatment adherence, fewer drugs, greater sense of security and control, or, even one might hope, more happiness.

A universal frustration among clinicians is how “resistant to change” our patients are. It often feels that “nothing I say or do leads to any improvement in their behaviors.” This frustration is understandable: we want to experience the positive effect our interventions make in other people’s lives, otherwise it feels we’re just wasting time. One can see how this “lack of efficacy” can contribute to clinician cynicism and burnout. It becomes easier to succumb to the thought, “If it doesn’t matter what I say, I might as well not say much of anything.”

Consider instead this mindset: “This person before me would rather be happier, more successful, less stressed and less miserable than they are now – how could they not be – even if it’s in ways that I wouldn’t choose for myself. It is true their resources are thin in many ways. After all, this person has a mental illness or addiction; is likely poor; has few supports; and may have little history of success. If what I’ve been doing and saying hasn’t worked to help this person make some changes, then what can **I** change about **my** approach? Despite my best intentions so far, I’m sure I can think of different ways of intervening.”

Here I throw out a few thoughts for your consideration that I hope can spark your own train of ideas.

Ask the Patient

A simple first step in helping a person change, is to find out what it is **they** want. It may seem obvious what they should want, and this seeming obviousness may have led you to assume what it is rather than to ask what it is. Here are some sample questions to identify what the patient wants:

  • “If you had a magic wand and could change one thing in your life, what would it be?”
  • “Can you take a minute to think what specifically you want to see be different. Make it as specific and concrete as you can, otherwise it’s hard to know how to achieve it.”
  • “Paint me a word picture about how a day in your new life would look like.”

The following list is of common changes a person might desire. They are a good start, but often NOT detailed enough to allow development of a change plan. If a person responds in too broadly, guide them to “operationalize” their desired outcome. For example, rather than say, “I want to sleep better,” guide them to say something like, “I want to get to bed an hour earlier. I just don’t give myself enough time to sleep. My mornings are hell.” Other not-yet-operationalized examples are:

  • “I want to lose weight.”
  • “I want to have a happier marriage.”
  • “I want my kids to behave better and not be fighting all the time.”

After you learn specifically what it is the patient wants for themselves ask them these three questions in this order:

  • “What in the outside world is most getting in the way of you getting to where you want to be?”
  • “What about you or because of you is most getting in the way of getting to where you want to be?”
  • “What do you think I can do to help you the most?”

Specify! And Eliminate Change Bloat

Just as you worked to narrow and operationalize the desired goal, narrow and operationalize the steps needed to reach that goal. The goal here is to narrow down the big change, which is really a goal, into small actionable steps.

The change most likely to stick is change that 1) entails one change at a time, 2) is small, 3) is doable without need for special equipment, locations, and circumstances, 4) is perceived as achievable by the person undertaking change, and 5) can be stated as a simple rule. Here are some examples:

  • I always take stairs when needing to go up 4 floors or less.
  • When I watch network TV, I walk in place during all commercial breaks.
  • I take my dog for a walk for 30 minutes each day after work.
  • I now only use one sugar packet for a small coffee (rather than my previous two).
  • I drink club soda or plain water with lunch.
  • When grocery shopping I don’t buy cookies.
  • I never buy snacks at checkout.
  • When I fill my car with gas, I pay at the pump and don’t go inside to buy snacks.
  • I never check my email after 7:59pm.
  • I set my alarm at 9:30pm and give myself one hour of quiet time before turning out my lights.
  • Right before I’m ready for bed, I spend 10 minutes reviewing all I’m thankful for.

Change Success Tips

Once a person has established a new behavior as a habit and never or almost never deviates from it, they can add a second equally doable change. Through this process, they can develop a sense of greater efficacy and control. If a person struggles with a particular change, it is ok to replace it after awhile but not add on a second one because then they will be left with a pile of unsuccessful change efforts.

It is helpful to instruct the patient to track how well they’re adhering to the new change, and then review with them what’s working and what is not. Work with them in adjusting the process to make it more successful. Repeat this tracking and adjusting for as long as it takes or until the patient is about to or has already given up. A common reason for failure is that the change is too large, too demanding. Keep making it smaller until it seems like almost nothing at all.

Sometimes, even when a patient is succeeding at change, they still voice frustration at how slow progress is. I have two responses: 1) success breeds success and the nature and pace of the undertaken changes can increase as the patient increases their skill at implementing it. And 2) I warn patients (and you and me too) that no change is forever: setbacks and “sliding back into bad habits” is common. This is part of the process and not a good enough reason to give up. Even partial changes that are temporary are beneficial in the longer term. Even these incomplete changes add some good stuff and decrease some bad stuff from the person’s life, and they leave the person with a memory trace of at least partial success that may become the basis for more complete change efforts in the future.

Please let me know what you think and your approaches that work and those that haven’t.

Until next time,

Dr. Jack


Today’s Quotes

“To have what you have never had, you have to do what you have never done.”
Roy T. Bennett

“Of two sisters
one is always the watcher,
one the dancer.”

Louise Gluck

“Action springs not from thought, but from a readiness for responsibility.”
Dietrich Bonhoeffer