Alexandra Gayek, ND
One of the common errors we enthusiastic NDs sometimes make is to set up patients for failure by expecting them to make too much change in too short a time. The patient bravely nods as you tell her she will need to stop eating wheat, dairy, and eggs; take this tincture and these 3 kinds of pills 2 and 3 times a day; start an exercise program; and meditate every day. You wonder why she never returns for the follow-up visit.
Here is a way to understand the mental and emotional requirements for change that may improve the success your patients experience.
We will start with a patient I saw recently.
A 62-year-old woman is preparing for a partial replacement of her arthritic knee. Knowing the importance of her attitude in determining the success of her surgery and the speed of her recovery, I ask her the one question that guides my work: “How do you feel about the fact that you have this condition?”
“I feel guilty!” she surprises herself by saying. “Wow. I didn’t know that. Here I’ve been telling myself how optimistic I feel about the surgery, how I expect it to go well because my last knee surgery went so well. I didn’t know I felt guilty.”
What she felt guilty about was that she had been carrying an extra 30 lb for several years. If only she had been able to overcome her habit of instant gratification (alcohol and sweets when feeling anxious), she would have been able to lose the weight and would not be needing surgery.
These are the very thoughts that likely would have come up to haunt and discourage her in the weeks of pain and limitation following the surgery, distracting her from an optimistic and useful focus on getting well. They are the kinds of thoughts that keep our patients awake in the middle of the night and keep the healthy diets, herbs, and nutritional supplements we prescribe from doing their best work to assist in the healing process.
This patient is far from alone with this particular feeling, the knowledge that one should be in a different condition than one is in. It is classic as people (including physicians) begin to encounter signs of physical aging: “How can this be happening to me?”
The feeling generally takes 1 of 2 flavors. The first is shame and guilt in the recognition that one has failed to do what one knew to do. The second is powerlessness because of the belief that one did everything that should have worked (but it did not work) or that one is incapable of doing what was required to prevent the problem.
Like its cousin, denial, this nonacceptance of the condition directly interferes with the person’s responsible and efficient actions to handle the problem.
Like the woman facing knee surgery, the patient is often unaware of the reasons she procrastinated in returning to see you. She is unconscious of why she made excuses instead of following your recommendations. She has not put together her role in the sequence that resulted in so much pain and degeneration that surgery was the best option.
How can you help your patients to avoid heading down this path and get them to willingly follow your brilliant protocols, keep coming to see you, and succeed at getting well?
It is all about managing the stress of change.
It is no secret that stress is counterproductive to healing. Yet, despite the stress of an unwanted condition, most people find that changing the very habits that are perpetuating their condition is stressful. The role of the physician is to make the process of change less stressful for the patient than continuation of the condition.
This means turning the patient’s attention from discouragement, failure, and powerlessness to encouragement, success, and empowerment.
For the patient with a long-term chronic condition, this may seem like a daunting task for the physician. Here is someone who has already tried many methods that did not work. She may be experiencing financial distress from medical expenses or from inability to work. She may have started with shaky self-esteem in the first place. All these are ripe opportunities for discouragement, feelings of failure, and sense of powerless.
The key for both physician and patient is to understand the process of change. To assist your patients in building the courage to do what it takes to heal, it is helpful for both of you to understand and manage the stability of your patient’s “reference points.”
A reference point is something that confirms a person’s identity, feeling of sanity, and sense of stability, safety, and normalcy. For example, your body and everything about its familiar functions, sensations, and appearance form a central reference point to who you are. Because you experience everything else in the tangible seen world through your body, it is your most important physical reference point.
Your mind, if you think of it as separate from your body, is your most important intangible reference point. It is how you interpret the physical world and make sense of it and yourself through your beliefs.
Your computer, phone, car, home, friends, family members, and other familiar people are all reference points, as well as the rhythm of night and day and the weather, roads, buildings, and images you encounter regularly. These reference points confirm where and who you are and that things are “normal.”
Often, you do not think much about your reference points unless something is different.
If the difference is a small element that you have experienced before, understand, and know is only temporary, it is no big deal.
Simple examples of small changes in reference points would be a cut on your otherwise healthy finger, a short detour on the route you normally take to work, an unexpected change in the weather, or something you normally purchase being sold out at the grocery store.
If the difference in a reference point is large, new, or not understood or if you have no reason to expect it to quickly subside without unwanted residue, it is stressful. Examples of large changes in reference points might be a move to a new city, marriage, divorce, a car accident in which you become paralyzed, job loss, the arrival of a new baby into the home, death of a loved one, or destruction of your home.
Even if a change is desired, it can be stressful just because of the requirement of adjusting to new reference points.
Why this is the case has to do with the way the brain functions. Simply put, we humans are programmed to learn. How we learn is by pattern recognition. Your brain sorts through an enormous amount of incoming data to find the bits it has learned that are relevant and important based on previous learning. Reference points are what make up the familiar patterns.
For a person to learn, there has to be enough of a stable structure to which new information is added. Too much change to that stable structure (too many reference points changed all at once) causes a person to experience confusion and to feel overwhelmed. The natural response is a desire to return to something familiar or to go numb.
When you and your patient understand this, you can plan for it. Keep the basic structure familiar. Change only 1 or 2 things at a time. Change less when the person is already handling other large changes to his or her reference points. During times of change, keep the focus and appreciation on stable and familiar reference points.
It can be useful to bear in mind that, when a person has an acute illness, the illness represents a change in the familiar reference point of a well body, making the return to the well body the least stressful direction of change.
On the other hand, when a person has a chronic illness, healing is what represents a change in the familiar reference point of an ill body, making the change to the well body a stressful direction of change, even if it is desired.
Both of these are because of not only the reference point of the body itself but also the familiar lifestyle into which the body fits. A person who is accustomed to being well usually wants to quickly get back to an active life of work and play. A person who is accustomed to being ill faces the larger task of getting used to a new identity that no longer revolves around handling the limitations and suffering (or the support network) that can go along with being ill. Without the excuse of the illness, the person may have to face fears of failure and rejection when participating in the larger world of healthy people.
It is important not to underestimate the magnitude of this task or judge the person who quakes at the prospect of it.
Because both the origin and the results of long-term chronic illness are often associated with low self-esteem, shame, or guilt, the first and most important task of the physician is not necessarily to find the right combination of remedies to treat the illness. Instead, it is to assist the person in building the courage to adopt the identity of a well person. In other words, the primary treatment goal is an empowered person. Physical wellness follows.
Fortunately, you do not need to be a psychotherapist to accomplish this. What is required is to teach the patient about the concept of stable reference points, to work together to identify those that will be prominent in his or her healthy life, and together to choose a protocol of gradually substituting new reference points for old ones.
Step 1: Introducing Change as a Concept
First, the patient must buy into the idea that change is desired. This is easy if he or she came to you for help in changing something!
Then, I find that a useful strategy is to make the person’s brain the focus of cooperation and change rather than the person herself or himself. This way, you have taken pride and shame out of the equation. You and your patient are on the same team, jointly focusing your attention on the brain as the actual patient whose cooperation you must win.
You explain that for change to be successful and lasting, the patient has to work with the brain, which works by pattern recognition, thus reinforcing familiarity and stability. Pattern recognition is how we learn, you explain, and your patient is an excellent learner. The patient has to make sure to maintain enough stability of the reference points so that the brain does not sabotage the change by creating a reaction, causing the patient to be unable to resist reverting back to familiar behaviors that supported the problematic condition.
Here is an example you might use that many people can relate to. It is January 3. Armed with her New Year’s resolutions, Sally bravely gets up 2 hours early and shows up at the gym at 7 am, having dutifully drunk a protein shake instead of eating her usual breakfast. She is in a sleek new outfit for her first independent workout session after meeting with the trainer.
Here she is with strange food, on a new schedule, wearing new clothes, surrounded by strange equipment, in an unfamiliar building, and around people she does not know. She approaches the first machine on her schedule and finds that she cannot quite remember how to use it. How many reference points has she changed all at once? Is it any wonder that Sally rushes to the locker room in tears and then cannot seem to resist a stop at her favorite bakery on the way to work to soothe herself?
To create new habits, they must feel safe and normal. They must fit into the context of who the person wants to be. The more confidence a person has and the more experience he or she has in successfully handling change, the more quickly change can be successfully integrated. The more fragile the person’s identity and the less previous success he or she has had in handling change, the more slowly new change can be successfully integrated.
Step 2: Identifying Stable Reference Points
Once you have had a laugh together about the frightened brain trying to regain its sense of normalcy by prompting those old behaviors, it is time for step 2. Help the patient identify healthy reference points that are already in place and stable. Examples might include the following:
- Breathing
- Drinking water
- Time of waking and rising
- Times of eating
- Time of sleeping
- Home
- Loved ones, including pets
- Friends, neighbors, and other reliable relationships
- Nature
- Accomplishments of which the person is proud
- Past success in handling change
- Aspects of the body that are working
- Foods already being consumed that will be continued
- Healthy habits already in place (eg, toothbrushing, bathing, moving the body, and relaxing)
The patient’s homework is to create a diet and lifestyle diary to identify as many positive reference points as possible.
Step 3: Prioritizing New Reference Points and Creating a Plan
Now is the time to emphasize to the patient the importance of maintaining stability for the brain by changing things in the smallest possible steps. The goal is to do more of what is working and less of what is not working. You might tell the patient that you are aiming for changes in diet, exercise, and bedtime and need to add some supplements, but this is obviously way too much change for the brain to handle all at once without rebelling. So, you engage the patient in identifying the smallest possible steps in this direction. This is the best way to introduce the changes that feel safe and comfortable to the brain and is the best way to create support along the way.
Note that you have taken the patient’s attention off of impatient expectation of results and have focused instead on establishing a rhythm and program of action that the patient is in control of introducing.
You can educate the patient about which changes you think will create the biggest results and which must happen first, and the patient can educate you as to the best way to integrate the changes.
For example, you recognize that for Sally getting her body moving is the most important focus. When you help her recognize the long list of reference points she was trying to change all at once, she can easily see how she set herself up for failure. Looking at the list, she can now choose one thing to change this week. If she likes the idea of aiming toward regular workout at the gym, maybe her first step is to put on her workout clothes at home each morning and practice the stretching routine she will be doing at the gym. When you suggest making the smallest possible changes, the rebellious person can only do more and will still experience success.
Step 4: Monitoring and Living the Plan
When you are working with introducing small changes as a team, frequent check-ins are critical to success. I find that weekly phone appointments are helpful, with office visits at least monthly. The goal is to get the patient into the habit of taking responsibility for her or his own health by regularly making, acknowledging, and celebrating small changes in behavior.
Again, this puts the focus on activities of the patient, on her or his success at implementing action, and on skill and confidence gained in new habits and away from results, which may be slower to manifest.
The additional benefit of focusing on small changes directed by the patient is that she is more likely to remain actively engaged in the process and to talk with you about what she is doing rather than acting like a child whose only options are to follow the rules or to rebel. I have found this is particularly powerful with patients who are healing from childhood sexual abuse and are trying to gain a sense of control over their bodies. The tendency to rebel in potentially dangerous directions, such as self-dosing of pharmaceutical medications, is easier to catch and to guide when the patient is in the habit of communicating and is monitoring her own body.
The most important benefit of empowering patients through the change process lies at the heart of mind-body medicine: lasting wellness requires that a person must experience connection with the vis, the power that heals. The true work of the ND is to facilitate this connection. This technique also improves patient compliance and retention, along with treatment success.
Alexandra Gayek, ND, graduated from National College of Natural Medicine in 1997, completed her residency there in 1998, and now practices on Orcas Island, Washington. She teaches online courses and coaches people worldwide in mind-body healing through her Web site http://www.scienceofbeingwell.net.
