How To Have An Effective Conversation About Change

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Is there someone in your life whose behaviors are making you miserable?

Have you tried any of these approaches?

1. Tell them that their behavior makes you miserable.
2. Give them advice on how to change.
3. Talk to other people about how bad things are.

Research on the treatment of alcohol and/or drug addiction suggests that any of the approaches listed above are likely to prolong, rather than relieve your misery. People react strongly when they feel their freedom is threatened. Human beings crave freedom from judgment,especially judgment from people they expect to love and accept them. People are more likely to make long-term change when they feel that they are understood and felt by the people who are most important to them.

This observation has led to the development of an approach to facilitating change in others without tripping or offending their sense of dignity. The approach focuses on building motivation, or desire to change-and letting the individual change themselves. Here are some of the ingredients needed for a motivational approach.

1. There is no moral judgment of the behavior.
Labels, diagnoses, inferences of "badness" make change conversations "threatening" and are best left out of a motivational setting for change.

2. Expect and roll with the resistance you will surely get.
Whenever other people perceive they are being judged, they will resist. You can tell you are being "resisted" when your conversation partner ignores, interrupts, argues, or denies in response to your advice. After all, human beings want to be heard and taken seriously.

3. The person who is responsible to change the behavior is the person who has the behavior.
This means that unless you are the person who needs to change, you should not be prescribing how to change. Rather, that is the job of the person making the change.

4. Acknowledging the other person's feelings, identifying mixed or ambivalent feeling and encouraging exploration of the other's thoughts about change are effective door openers to change talk.

Finding a Role that Works in Change Conversations

Ron wanted his wife, Katy to stop using more pain pills than the doctor prescribed. She had injured her lower back and neck in a motor vehicle accident a few years back. For a long time, Katy's primary care physician would prescribe opiate pain medication such as Oxycontin or Percoset. However, Katy would run out after the first week. She started ordering the pain medications from a internet pharmacy that did not ask for a prescription. Ron and Katy had a family friend, Pam, who had unexpectedly died recently, and the autopsy had found Pam had lungs had stopped working (this is how opiates kill people); and she had high levels of opiate medication in her blood. Ron lived in terror that the same outcome could happen to Katy.

An Attempt that Did Not Work
Shortly after Pam's death, Ron decided to confront Katy about his fears.

Ron (using moral judgment): "Katy, I just looked at the bank statement and saw that you had made another order from Ping Ping Pharmacy. It makes me so mad that you take chances on your life by taking pain medication without a physician's supervision. And besides, you don't know what is in that stuff. You need to be more responsible."

Katy (resisting by arguing): "So who are you, Mr. Perfect? Why should I be interested in even having a life, if I have to live every minute in unbearable pain? I need the medication so I can handle the children and household."
Ron (using moral judgment): "If you keep taking that medication, you won't have to worry about the children or household. You will leave them motherless."

Katy (resisting by arguing): "Look, I'm not going to talk about this with you. Just leave me alone. I'm already in enough pain without having to have this conversation."
Katy left the room (resisting by ignoring). As Ron sat there trying to figure out what happened, he heard her start the dryer. He realized he had this conversation a hundred times with her, and it also had the same outcome. It was like it was "scripted"-different day, same argument. He heard her rummaging around the cupboards for a cup. He went into the kitchen and sat down at the bar.

An Attempt that Opened a Door

Ron (acknowledging he had judged her): "You know, Katy-I think I just put myself above you. I came on to you as if it was my job to be your father. But I'm not your father-I'm your companion and your lover. Please forgive me."

Katy: "I'm impressed. You should know that I don't like having to take the medication-I'm scared, too. But I just feel so miserable physically and emotionally when I don't have the medication. And when I feel miserable, I can't pay attention to what the kids need. Then I feel like an awful mother."

Ron (acknowledging her pain): "it sounds like you take the medication to relieve your physical and emotional distress, and then you are able to take care of the kids' needs. But taking the medication creates more distress-you start to worry if the same thing will happen to you that happened to Pam (the deceased friend)."

Katy: "Well, yes. Every day-that's all I think about. First, what will happen if I don't take the medication-and that what will happen if I do take the medication."

Ron (identifying her mixed feelings): "Oh, Katy, that must really be terrifying. So which one of those two conditions is most distressing-the physical and emotional pain from not taking the medication, or the worry about unexpected death?"

Katy: "Well, the physical and emotional pain from not taking the medication is a sure thing-I know I will have it if I don't take the medication. But the worry about dying from using the medication is about something that I don't think will ever happen. But then it did happen to Pam. But maybe it won't happen to me. So I'd have to say-I can tolerate the worry better than I can tolerate the physical and emotional pain."

Ron (encouraging exploration of change): "Have you ever let yourself wonder if there are ways that you could still take the medication and do what you need to do to relieve the fear of the pain in a way that will feel safer and not cause so much worry?"

Katy: "Oh yes, I think about that all the time. . ."
Ron's second attempt to talk about the opiate medication was much different than his first attempt. He was able to establish a collaborative, problem solving atmosphere. He acknowledged Katy's worry and emotional and physical pain. He even acknowledged her concerns that she was being judged. His new approach transformed his role in the opiate problem He now became a resource, rather than another source of pain for Katy. She started coming to him for support when she felt physical and emotional pain, and even started to cut back a little on the medication.

She got some outside help from a pain management doctor, who was able to give her a shot of cortisone at the pain sites. She started physical therapy, and an exercise regimen to help strengthen the core muscles in her back and neck. In a couple of months, she stopped ordering from Ping Ping Pharmacy and let her pain medication doctor supervise her efforts at pain relief.


Katrina Holgate Miller, PhD, MFT is a freelance medical journalist specializing in mental health.

Her professional experience has encompassed many facets of mental health care, including mental health assessment and treatment, substance abuse, domestic violence, sexual abuse (victims and perpetrators), couples counseling, and adolescent group counseling. For the past five years, Katrina has worked with patients across the country to help them resolve their barriers to adequate and effective mental healthcare and chemical dependency/addiction treatment.

Her writing tells the stories of the patients who used their moxie to overcome their distress.


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