Good Reasons for Bad Choices: Why Your Patients Do What They Do and How to Help Them Change
Rick Kirschner, ND
Many of the problems your patients report have a mental or emotional connection driving them that is well worth exploring, understanding, and changing. The difficulty is that understanding requires going past the surface structure of their awareness and into the deep structure of their map (motivations and positions) of reality.
Finding Good Reasons Behind Bad Choices
When my friend and fellow physician Rick Brinkman and I were doing the research that culminated in a best-selling book, we began with the assumption that behind every behavior is a positive intent, which turned out to be an incredibly useful concept. In other words, people do what they do for what they consider to be good reasons. The value of this assumption is that, when you understand where a patient’s behavior is coming from, it can inform you on what kind of intervention is likely to help you lead him or her to a positive health outcome. By ascribing positive intentions to unhealthy habits, it becomes possible to find opportunities to fulfill those intentions with better habits.
Take the example of people who continue smoking, despite the evidence that the habit is linked to all manner of horrible diseases. On closer investigation, before most smokers developed their full-blown addiction, one finds that they started to smoke for a reason. Maybe it made them feel cool or more grown up, or perhaps it helped them fit in. Maybe it gave them a way to rebel against authority by doing something forbidden or discouraged, instead of going along with the crowd.
Whatever the reason was at the outset, over time it gets joined to newer positive intentions (eg, giving the smoker an excuse to take a break from the action or rewarding him or her for an effort). Or, a smoker may perceive that smoking is a way to gain some control over strong emotions or to feel a small sense of accomplishment watching the cigarettes disappear into smoke. The latter is very common, and although it may sound trite or foolish on the face of it, finishing a smoke can be a moment of deep satisfaction in a difficult world when people feel stymied in life.
The driving forces I am describing here are what are often called the secondary gains of smoking. They often must be dealt with first before people can break the deadly habit.
Driving Forces or Secondary Gains
All sorts of problem behaviors with negative health consequences have unconscious positive intent as their driving force or secondary gain. A patient who was struggling with her weight told us about her daily task of running errands for her husband. She did not like running these errands for him, so she rewarded herself on every run by stopping at a mini-mart or doughnut shop and having a “treat.” Such patterns of secondary gain are typical of people with habits that seem to resist change.
An overweight patient who had been abused in her childhood had somehow learned that the best way to protect herself from abuse was to gain weight—to be bigger and less attractive. Until she found other ways to protect herself, she was unable to control her impulse to overeat.
Such unconscious positive intent is also what drives many attitudinal problems that interfere with positive health outcomes. Do you know some really negative patients who do not believe that anything will help? They may have learned from bitter experience to have low expectations if they want to avoid disappointment. Do you know patients for whom nothing seems to work right and everything gets labeled as wrong? They may have learned from painful experience to look and listen for exceptions rather than the rule, for holes instead of doughnuts, as a way of avoiding trouble or getting caught unaware in unintended consequences by a beckoning good.
A history of heartbreak can cause one to become untrusting, as a protective mechanism against heartache. A history of being ridiculed by more powerful and athletic peers can lead to the protective attitude of having a strong aversion to working out or competing.
Such behaviors are unlikely to go away if one is eating as a reward, smoking as a way of taking time out, drinking as a form of relaxation, or avoiding committed relationships to keep from feeling pain. Resolution occurs only when the purpose they originally served is identified and worked out in a more positive manner.
Nature hates a vacuum. You cannot replace something with nothing. It is a fact that many bad habits help people feel better. In many efforts to bring about change, identifying how a habit meets a need and serves a purpose precedes identifying what better and healthier paths lead to those same positive ends. There are plenty of ways to relax without drinking, to reward ourselves other than by eating, to call time out without a smoking break, to feel good when exercising, and to feel safe in sharing oneself with another person who may one day go away. However, these other paths are only better if the underlying need and intention are met.
The Desire for Change Is a Signal of Readiness
Contrary to how it may seem, unconscious positive needs and intents are not out to sabotage your patients by giving them problematic attitudes, symptoms, and behaviors. When the negative person comes to despise his or her negativity, when the overweight person can no longer stand the burden, when the smoker wants desperately to be able to breathe freely again, when brokenhearted people cannot stop yearning for lasting love, these are subconscious signs and signals that the old attitudes and behaviors have outlived their usefulness. Most important, they indicate better resources and better maps of reality are now available that can lead to healthier choices and lives.
When the desire for change surfaces in a person’s awareness, it presents itself as a problem (health or otherwise) needing to be solved. I think you will find it instructive and constructive to interpret your patients’ awareness of their problems as subconscious signals that they are ready for a change and are able to make new distinctions and choices. In your role as a healthcare expert, you are in the best position to convey the idea to your patients that a problem is not bad or wrong but that it is ready for change. Otherwise, they might just think their problems were normal and live with them. Instead of allowing their frustration with the status quo to feed their senses, help them make it right, and use connected listening to get to the purpose behind it. Connected listening requires you to hear what is said, ask questions about the condition to take your patients deeper into their own understanding of it, and then ask them to define a desired change. When the conscious mind sets the direction and the unconscious intentions rise to the surface and are dealt with creatively, then the subconscious is likely to follow along and create better and more satisfying results.
When I was a third-year student physician getting my clinical experience at National College of Natural Medicine, Portland, Oregon, I had the opportunity to work with a patient having a persistent class IV Pap test result (this was the older reporting system in use at the time). She had already undergone freezing and excision of the abnormal cells, yet Pap tests continued to return the same result. She came to the clinic as a last resort after her regular physician had recommended that her next step was a hysterectomy. Fear brought her in the clinic’s door, but fear was not changing her for the better.
I had 4 visits with the patient before I felt ready with enough understanding to try a natural medicine approach to treatment. However, it was too late because she had gotten better (with no abnormal cells on her cervix) over the brief course of our conversations. I had not prescribed a thing. Rather, I educated myself about how she structured her perception of her world. As I learned what made her tick, so did she.
At the first 2 visits, I gathered information about the patient, her medical history, and family history, and I worked at building rapport (a relationship of trust and cooperation—the click!). At the third visit, I told her that many of the health problems people deal with actually serve some positive purpose, that they are an attempt by our mind-body to protect us from some perceived threat. If her abnormal cervix had a protective purpose at its root, what good reason might explain this? Seconds passed, and then she shared with me a profound insight.
It turned out that she was in an unfulfilling and unloving relationship with a man whose only way of showing that he cared for her seemed to be having sex with her. It was painful, and she felt angry and trapped as she went along with it. She had never said a word about it to him because she was afraid of making him angry and being left alone. Had she ever experienced that before? Yes, a few times, and every time she had spoken up about her own needs, the guys had left her. What was her earliest memory of being left? It was when she was a kid, and her father had left her mother after she had been honest with him about her own needs.
Clarification emerged for both of us. The patient had been brought up with a lot of resentment toward men, and all that resentment had taken up residence in her cervix. She said to me incredulously: “It’s where he and I meet, isn’t it? My cervix has become a battleground between my resentment of him and my desire for love.” I was amazed too. I never would have thought of that, but she did because one of us was asking questions that assumed some purpose behind the unwelcome condition.
We scheduled another visit to plan treatment and another Pap test. That fourth visit was the game changer. I asked her what her cervix might be telling her that she needed to do to regain health in that part of her mind-body. Before my eyes, she went from talking like a victim to empowering herself to deal with a difficult situation in her life more honestly: “Actually, I’ve been thinking a lot about this since I was here last.”
It seemed to me that she sounded very different in this conversation as she said: “I deserve a real relationship with someone who treats me with respect and loving kindness, and the only reason I don’t have it is I keep settling for less. I’ve had enough of this old pattern. I can do better. I will do better.” I asked her what specifically she meant by better, and she described it to me in detail. She articulated a plan to be honest with this guy about her own needs, and I helped her formulate it so as to increase the chances of her being heard by him.
We also talked about what else it would mean if he left her, and she now could see that his behavior in that case would be about him, not about her. That is when she realized he would actually be doing her a favor if he left. In fact, she wanted him to leave and was going to tell him so. We talked our way through the different ways this conversation might go. Her motivation was strong. She committed to take action, promised to call if she felt overwhelmed or needed support, and we rescheduled her next appointment for a Pap test and treatment.
I was not surprised when the result of that Pap test came back negative. She seemed now to have a healthy cervix. Although I had not treated her cervix yet, she had already regained her health. That is how it goes sometimes.
How to Incorporate Mind-Body Diagnosis Techniques
Each question you ask is an intervention in the thoughts and feelings of your patients. So, you want to be careful about the road your question puts them on. In the beginning, the best questions are open ended and serve the purpose of going past the surface of what you hear to what it really means. If a patient tells you he or she is in pain, ask what kind of pain? Where is the pain? When is the pain? How does the pain express itself? Once you have established some trust and cooperation in the relationship, you can add information to your questions, so that they become leading questions. That is what I did when I asked: “If your cervix was trying to tell you something, what might it be?” If the answer comes back, “I don’t know,” say “that’s OK, guess!” or give her some time to think about it and bring it up at the next visit. Many physicians are in a hurry to help, but moving at the pace set by your patient will serve you far better than trying to rush toward a result that your patient is not ready to experience.
People gain new insights, redefine their problems as opportunities for change, come up with their own resources, and make their own plans and act on them for their own reasons. As physicians, teachers, healers, and helpers, we get to witness the positive change and even get some credit for it!
Rick Kirschner, ND is a 1981 graduate of National College of Natural Medicine, Portland, Oregon. Dr Kirschner served on the board of the American Association of Naturopathic Physicians for more than a decade and was the association’s first chair of public affairs and webmaster. Dr Kirschner is an author or a coauthor of 8 books, including Dealing With People You Can’t Stand: How to Bring Out the Best in People at Their Worst (with author Rick Brinkman [McGraw-Hill]) and the comprehensive communication training guide Insider’s Guide to the Art of Persuasion (Talk Natural Press). His latest book is titled How to Click With People: The Secret to Better Relationships in Business and in Life (Hyperion Books). Dr Kirschner is a faculty member at the Institute for Management Studies (Reno, Nevada) and is a thought leader with AthenaOnline and CanDoGo Interactive. He has worked with many of the world’s best-known organizations, including NASA, Providence Healthcare, Progressive Insurance, Starbucks, and Texas Instruments. He has delivered his ideas on change and communication in newspapers and magazines (including USA Today, London Times, The Wall Street Journal, and Executive Excellence) and on radio and television programs (including CNBC, FOX, and CBC). More information can be found on his website (http://theartofchange.com).