What are your New Year's Resolutions? Post any you want to share in this thread.
--I've found that I can often seize the day and feel better if I get to bed at 10 pm and begin the next day with a good early start. This has been easier said than done for me, so in 2021, I'm going to try to get to bed most every night at 10 pm.
I've posted these essay blogs before from the psychiatrist who taught our boards review prep. I thought this one is useful food for thought related to the topic of New Year's resolutions and making positive change. Dr. Jack Krasuski in this one gives advice for psychiatrists to help motivate patients to make changes. But it's good advice for anybody trying to make them I think.
Motivational Enhancement by Dr. Jack Krasuski -
Today, I will not lay out the richness of motivational enhancement and save a detailed treatment of it for a future post. Instead, I’ll share my simple-minded way of thinking about it and presenting it to patients. It’s the “Point A - Point B” conceptualization, which has three main parts: Point A is the here and now, all the ways the patient is in pain, symptomatic, dysfunctional, facing a myriad of overwhelming problems, and feeling stuck. Point B is the desired outcome, a vision for what life would be like if the patient were able to move beyond their pain, symptoms, dysfunction, overwhelming problems, and stuckness. The third part consists of the barriers that impede moving from Point A to Point B.
To move through this approach, I say something like the following to the patient: “It sounds like you’re feeling frustrated and stuck. Our next step is to find the ways – practical and doable ones – to get you unstuck. The way I think about this is as the ‘Point A – Point B’ problem. You are now stuck at Point A, which you’ve described to me already. Point B is what you want in life and out of this treatment. So, let’s now focus on Point B, that is, describe to me in as much detail as possible what you want your life to be like if you could get unstuck”. Here I encourage the patient’s open-ended exploration of what their day-to-day activities would be like once they reach their desired state. In this exploration, I might throw in the ‘miracle question’ which is, “If you woke up tomorrow morning and all the problems you described to me were gone, like a miracle, what would your life be like? What would you be doing?”. It is important to force the patient to be specific by asking follow-up questions, such as, “What time would you get up each morning? What would you eat for breakfast? What would you do to improve your finances? What would your relationship with your kids be like? What would you do for fun? How would you handle new problems as they arise because, we can be sure, new problems will arise?”. The goal is to have the patient visualize and feel their future life, to have a rich imaginal experience of it. During this exercise, some patients realize they never really thought about what their alternative better life would/could be like. They had always focused on their pain, symptoms, dysfunction, forgetting that the amelioration of the bad stuff does not directly translate into a life worth living. A compelling positive vision of what life can be like is often a necessary ingredient in moving forward.
The last step of this model is exploring and fixing the barriers to moving from Point A to Point B. Note that barriers include both bad things that exist in the person’s life and good things that are absent. A violent domestic partner may be a bad thing that is in place, while childcare support may be a good thing that is absent. As with the previous parts of the model, the barriers – what needs to be removed or overcome and what needs to be added – need to be explored in detail. The rubber needs to hit the road. The patient must be guided to consider, choose, and carry out practical and doable solutions. There are likely many problems that need resolving and likely many changes to be made. The patient should be guided to prioritizing and choosing the first step. My approach is to say, “It’s not uncommon to get a little overwhelmed when thinking about all these changes that need making. The best way to succeed is to choose one thing to change and start there. And then, over time, add other things to change. So, in your judgment, what is the single thing you believe would make the biggest difference in your life right now?”.
If all this sounds like a lot of work that will take a lot of time, it usually is exactly that. The alternative is like what much of psychotherapy is actually like, an endless focus on the problems, frustration, stuckness, etc., without adequate focus on moving through solutions into a desired life. For example, many people in treatment for an addiction would like to stay clean and sober. But staying clean and sober requires many concrete choices and actions carried out over extended periods of time. Often the motivation for change is low and not robust in the face of setbacks, not because the current life of active addiction is great, but rather because the life of sober living seems unattainable and perhaps not even that compelling. Exploring in detail Point B as well as the barriers that need addressing can help increase motivation, hope, and a feeling of growing agency.
To end, the reason I riffed on motivational enhancement is that it is my way of responding to fears of manipulating the patient. Do I manipulate the patient by increasing their motivation, trying to get them to think about things they haven’t thought about, and to take actions they otherwise might not undertake? Of course I do. The better I can do this, the more effective I become.
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--“To be a person is to be constantly engaged in making yourself into that person” ― Christine M. Korsgaard
--“This I choose to do. If there is a price, this I choose to pay. If it is my death, then I choose to die. Where this takes me, there I choose to go. I choose. This I choose to do.” ― Terry Pratchett