Akratics and Making Them Change Their Behavior

I am troubled by a particular, close friend who is drinking too much, which has prompted me to ruminate on what to do to motivate him to change.

Some Habits Are Hard to Change

As a doctor, a lot of my time and energy goes in to trying to get people to change from their unhealthy habits. Trying to get them to adopt healthy ones. 

And some of my patients have!

The common sort of scenario is my saying to the patient, “you know Mr. Bloggs, you really should be doing some exercise, even if it’s just walking”

“Yes doctor”

“And I’m sure you could loose some weight if you cut back on the refined carbohydrates”

“Yes doctor”

“And I’m sure I don’t have to tell you again how bad cigarettes are for you.”

“Yes doctor.”

And Mr. Bloggs nods enthusiastically, thanks me profusely and goes home to continue all his bad habits just like before.

And those cynics who I see eyeing the rather too tight buttons on my white coat I have to remind of the doctor’s maxim of “do as I say not as I do.”

But as we’re about a month out from New Year’s resolutions, I thought this a good time to address the whole business of people changing their health habits. 

The Science of Change

Making changes and adopting good habits is a whole science – discussed at great length by psychologists who describe five stages:

  • Pre-contemplation; 
  • Contemplation; 
  • Preparation; 
  • Action
  • Maintenance.

The stages before action can go on for years – and frustrate any caregiver. But the joy of being a doctor is you have to blunder on, undeterred by your patient’s recalcitrance. The experts tell us “bring up quitting smoking at every encounter with your smoking patients” and one day the message will get through and they’ll quit (and I can take the credit?).

The eggheads also talk about “suppressed anxiety” and “learned helplessness” as the kind of psychological quirks our patients suffer from that stop them from being able to make the changes they should. 

There’s even a term a term for it – “akrasia” from the Greek word meaning “lack of command or competence.” Akratics don’t do the things they know they should - and there’s a lot of akratics out there.

Of the different ways to get people to make changes, the “least effective strategies were those that aroused fear” notes a studyperformed by the British Economic and Social Research Council.

It is common for parents to want to change the behavior of their children.  And using fear seems to me a very common method – the “wait till your father gets home” technique.  (incidentally I am a firm believer that there are a lot of parallels between parenting and being a doctor). 

Nor is using what David B. Agus, MD, author of The End of Illness, and head of University of Southern California’s Westside Cancer Center calls an “umbrella statistic.”

“Hearing another umbrella statistic such as ‘heart disease is the leading killer in our country’ has little impact” he notes. But he is in favor of personalized warnings to help – he is in favor of genome analysis to determine your need for change. “If you knew your personal risk for having a heart attack was 90 percent, you’d probably do everything you could to treat your heart well” he notes.

Helping You Change

So what does motivate change? 

First step is to establish your motivation to change, and then set out clear goals. And according to psychologist Arlene Matthews Uhl, author of "The Complete Idiot's Guide to the Psychology of Happiness,"it takes 21 to 30 days to change a bad habit into one that improves your health.

According to marriage and family therapist, Amanda Deverich, writing in the Huffington Post ‘Life’ blog, catalysts that help you change are relationships, hope, and keeping doing what works. But specifically:

  • Celebrate and validate any changes you do make – and there are many ways to reward yourself.
  • Hang out with people who are doing what you are trying to achieve – be it how they eat, or that they exercise, abstain from the drugs you are trying to give up, or alcohol (Alcoholics Anonymous or Narcotics Anonymous is of course a prime example of this – though it’s a bit more than just hanging out with “birds of a feather”).
  • Find a “guru” to guide you. Someone charismatic and knowledgeable about what you are trying to achieve. And who cares, and picks you up when you fall. Or who helps you celebrate when you succeed. A personal trainer need not only be for people at the gym. 

Engaging the Alcoholic

Specifically on the subject of persuading people to stop drinking, the problem is getting them engaged. So often they don’t see it causing any problem. The sort of “if it bothers you, that’s yourproblem” attitude. But that’s all part of the minimization and denial. 

And they get angry and defensive when you do confront them (anger is one of the features of the CAGE alcohol screening questionnaire which asks; have you ever felt the need to Cut down?”; have people Annoyed you by criticizing your drinking?; have you ever felt Guilty about your drinking; have you ever felt the need of an Eye opener? – though some say this last question should be replaced with have you noticed your tolerance changed so you need to drink more?).  

A manifestation of the irritability of alcoholics is the tendency to be “prickly.” There have been several occasions when I have seen a new patient and they’ve seemed particularly reluctant to tell me much. Seem well defended. Then as I get to know them, there is the flash of “of course. They’re a drinker.”

The relationship/marriage is usually the first thing to suffer. Is the canary in the coalmine. 

You usually can’t get a strait answer asking the person “do you think you’re drinking too much?” as the drinker usually doesn’t see a problem in themselves (the minimization and denial again). But I find a good question is to ask, “what would your wife (husband) say about your drinking?” 

Even in denial they are often acutely aware that – for some reason – their spouse is all bent out of shape.

I'm Sure She's Not an Akratic

Those defenses can be real hard to overcome and make it very difficult to talk to both patients and friends about their drinking.

Even having studied/ruminated on how to get people to change, I’m still hesitant about confronting my friend who’s drinking too much.

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