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I need to do something about my weight (desires change) but I’ve tried everything and it never lasts (desires to sustain).
An ambivalent person has a committee meeting going on inside their brain. Some on the committee are arguing for change; others are arguing against it. When the counsellor argues for change, he adds a voice to one side of the committee. But the ambivalent person’s instinctive response is to add a voice to the other side – to come up with the reasons why she shouldn’t change. This might sound like a stalemate, but actually it’s a win for ‘no change’, since people tend to trust themselves more than others. Hence Miller and Rollnick’s unsettling conclusion: by making arguments to someone about why they should change, you make it less likely they will do so.
In the context of addiction treatment, ambivalence is good: an addict who is ambivalent is one step closer towards recovery than one still fully committed to their habit. But ambivalence can be where addicts get stranded unless the therapist is able to help them win their own internal battle – not by lecturing, but by listening. Miller and Rollnick’s book pioneered a method of drawing out the patient’s thoughts, called ‘reflection’: responding to or summarising what the speaker says in a way that forms a guess about what they mean (‘So if I understand you correctly, you’re saying . . .’). The speaker can either accept the interpretation, or correct it; either way, they feel listened to, and empowered, while the therapist gains insight into how they think and feel.
Miller and Rollnick’s book became a bestseller in its field and proved hugely influential among therapists of all stripes, not least because its methods work. Over 200 randomised control trials have found MI to be more effective than traditional methods across a range of areas, including gambling addiction and mental health; William Miller is now one of the world’s most frequently cited scientists. The principles behind MI proved to be applicable to many types of tough conversation.
Emily Alison had been trained in Motivational Interviewing when she worked as a counsellor for Wisconsin’s probation service. Later, while working with Laurence and the British police, she noticed that interrogations failed or succeeded for similar reasons as therapeutic sessions. Interrogators who made an adversary out of their subject left the room empty-handed; those who made them a partner yielded information. This observation became the basis of the Alisons’ model of rapport, for which they went on to find such powerful empirical support. Rapport is a sense of trust or liking, yes, but also a sense that the partners in the conversation see each other as equals, capable of making their own choices and having their own thoughts, with neither trying to control or dominate the other.
It’s important to bear this in mind during any kinds of disagreement, including those we have at home. ‘I tell the police, if you can deal with teenagers you can deal with terrorists,’ said Laurence. He gave me the example of a father who opens the door to his daughter when she comes home late. The father tells her off for breaking their agreement. His daughter, who feels pushed around, pushes back. A power struggle ensues, until one or both stomp off to their room. Of course, teenagers can be impossible, but what’s certain is that a conversation fails when it becomes a struggle for dominance. If the father had emphasised his concern for his daughter’s safety, said Laurence, a more productive conversation might have unfolded. ‘In a tug of war, the harder you pull, the harder they pull. My suggestion is, let go of the rope.’
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Implicit in Miller and Rollnick’s critique of traditional addiction therapy was the uncomfortable suggestion that counsellors should question their own motivation. Their instinct to ‘fix’ the other person – to correct them or put them right – represented a desire to dominate the conversation, and the relationship. Miller and Rollnick coined a name for this instinct: the ‘righting reflex’. As soon as I read about it, I started seeing it everywhere. The righting reflex lies behind so many of our dysfunctional disagreements.
In their classic book on child-rearing, How to Talk so Kids Will Listen & Listen so Kids Will Talk, Adele Faber and Elaine Mazlish outline a typical mother–child exchange:
Child: Mommy, I’m tired.
Me: You couldn’t be tired. You just napped.
Child: [louder] But I’m tired.
Me: You’re not tired. You’re just a little sleepy. Let’s get dressed.
Child: [wailing] No, I’m tired!
Faber and Mazlish observe that when conversations turn into arguments like this it’s often because the parent flat out tells the child that their perceptions are wrong. There is only one right way to perceive the world: the way of the parent. The child’s response, quite naturally, is to insist even more strongly on their own view.
Many adult disagreements are like this too. Confronted with someone we think is in the wrong, we desperately want to correct them. If only we can articulate the right arguments, we tell ourselves, or provide the critical facts, we can break their resistance to the truth, just as counsellors believed they could break the resistance of addicts. We fantasise about (someone else’s) Damascene conversion, fondly imagining our interlocutor will turn to us after we’ve made some clinching argument and say, ‘My God, you’re right. I’ve been completely wrong about this.’ It comes true, now and again, but more often than not the other person simply becomes more entrenched in their position.
We usually engage in righting behaviour with sincere intent. But try and recall a time when you were being told off, or someone was explaining to you, at length, why you are wrong about something. How did you feel? You probably felt annoyed or even humiliated, as if the other person was trying to order you around or squash you. Think about the language we use for this kind of feeling: I was put in my place; I felt small. That’s why we often push back even when we know the other person is right. In fact, the more right they are, the more we push – and the other person in turn reciprocates. The result is a conversation that either escalates into a full-blown row or shuts down.
The righting reflex exists for emotions, not just beliefs. The Polis team’s advice to the Memphis cops, about never telling a distraught person to calm down, reminded me of arguments I have had with my young children. I’ve found myself telling them to stop being upset about something that to me seems trivial – like not getting the correct mug for their morning milk. I have to tell you, it rarely goes well. But then, I don’t respond positively to being told by people on Twitter that I should or shouldn’t be outraged about whatever is in the news. Come to think of it, my wife doesn’t seem to like it when I tell her to calm down (as Mike O’Neill could have told me, it has precisely the opposite effect). Apart from anything else, we’re making a category error when we do this: emotions are not subject to rational intervention; that’s what makes them emotions. So why do we insist on telling people what to feel? For the same reason that we are over-confident in our powers of rational persuasion. We find it hard to accept that other human beings have minds as real and as complex as our own.
Being wary of the righting reflex is not the same as avoiding disagreement; it means not getting to the disagreement too soon, before the two of you have had a chance to understand each other’s position. Neither does it mean giving up on right and wrong. Crucially, it requires you to put aside the belief that you can control the other person’s mind with your words. Not just the belief, but the wish; you have to approach the disagreement, not as a threat to be fended off, but as a collaboration from which both might gain. After all, there is usually something to learn from a person with whom we’re disagreeing, and some truth to what they are saying. It’s also true that the other person is probably less certain than they appear – that there is an element of ambivalence to their beliefs; some tension or contradiction that can be teased out, as long as they are not too busy defending themselves. It’s probably true of you, too.
If your interlocutor does not wish to co-operate in any way at all there may not be much you can do about it, but at least you won’t get pulled into a draining battle of will
s. By resisting the righting reflex, and actively listening, you send the signal that you’re interested in learning, not dominating. That relaxes them, which relaxes you. The two of you may still vigorously disagree, but you’ll be treating each other as equals, which changes everything, even minds – even your own.
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Maybe I’m avoiding the really hard question here. It’s easier to resist the righting reflex when you at least respect the other’s opinion. If I think your view is wrong but reasonable, and that I might even be persuaded to believe it, I’ll be better at listening and less inclined to go into lecture mode. But let’s test the value of this approach under more extreme circumstances. What if the person I’m talking to is staunchly attached to a belief that is obviously, unequivocally, wildly wrong. Isn’t it important I tell them so directly at the first opportunity?
The question has acquired an urgency in recent years. The internet has enabled those who dispute basic tenets of established scientific knowledge to congregate into groups in which false beliefs are shared and disseminated. In some cases, there are serious ramifications. The so-called anti-vax movement, made up of those who oppose vaccinating children against infectious diseases, is making it more likely that diseases, like measles, which have previously been eradicated in developed nations, will re-emerge.
Since we often call such people ‘delusional’, I wondered if there was anything to learn about how to deal with them from experts in the treatment of clinical delusions, which is why I went to see Dr Emmanuelle Peters at her office in King’s College, London. Peters is a clinical psychologist who specialises in therapy for patients with psychotic delusions: false beliefs that make it difficult for them to conduct their lives. To be clear: disbelieving a widely accepted scientific fact or believing in a conspiracy theory about the Moon landings is not the same as being psychotically deluded. But as it turns out, it’s not completely different either.
More often than not, clinically delusional beliefs are paranoiac: the patient might believe that everyone she passes in the street is part of a secret plan to destroy her, or that she is receiving coded messages from outer space about a forthcoming attack. Other patients have more positive, or ‘grandiose’ delusions, which can nevertheless be debilitating, like the man who believes he is a king who will one day inherit a fortune, and has therefore never bothered to make any income and now finds himself on the edge of destitution. Delusional people come to see therapists not to have their delusion cured – they don’t believe it is a delusion – but because their beliefs are making the world a stressful, difficult place. Somebody who is convinced that the government has put a contract out on their life may find it too scary to leave the house to go to work or visit the shops. The therapist’s first job, says Peters, is to understand what that feels like. ‘The right attitude isn’t, “I must get this person out of their misery by showing them that they’re wrong.” It’s “I must understand where this person is coming from.”’ That is, they need to start where they’re at.
Dr Peters listened intently to my questions before answering in fast, fluent sentences. Her demeanour was confident although her turns of phrase were tentative – she uses might, perhaps, and could a lot – and she habitually checks that her interlocutor is coming along with her. She told me that some mental health professionals feel the need to tell delusional patients how things really are: ‘That person in the park who spat on the ground? Of course he wasn’t sending a signal to you – he was just spitting. There is no vast conspiracy. This is all in your head.’ They soon find out that doing that puts them on a hiding to nothing. The patient has endured months or years of people telling them they’re wrong. They’ve been told they’re crazy. They’ve heard it all. They’re not going to change their mind suddenly just because a doctor is telling them the same thing.
‘The moment you try to change the belief they push back,’ Dr Peters told me. ‘If you go in head-on you won’t be able to help them, because they will spend all their time trying to convince you otherwise.’ Instead, the therapist should offer to help the patient deal with the difficulty they find themselves in. She is not colluding in the false belief – the patient is not going to believe it any more than they already do. By putting herself on the patient’s side, however, the therapist makes it more likely they will listen to her suggestions.
Gently, over time, Dr Peters tries to reduce the patient’s certainty in their belief. Wherever there is a glimmer of doubt, she works with it, inviting the patient to consider evidence for and against. ‘I wouldn’t say to the patient, “devil worshippers don’t exist”, but I might say, “In this particular instance, when someone pushed you on the bus, I wonder whether it might have been an accident?”’
Sometimes, the mere act of listening to someone talk about their delusion can weaken their conviction in it. In a 2015 paper, Kyle Arnold and Julia Vakhrusheva, psychiatrists from Coney Island Hospital in New York, relate the case study of a young woman who had been in therapy for several months before it became apparent that she suffered from delusion. In one session, she was complaining about not being able to make friends. When the therapist asked why that might be, she replied, ‘Well, there is something I hadn’t told you about. You’re going to think I’m crazy if I tell you.’ Her therapist invited her to continue. The patient said, ‘It’s all about the Big Kahuna.’
‘The Big Kahuna?’ the therapist inquired. ‘Yes,’ the patient said, ‘It’s a video game I’m trapped in. I am the Big Kahuna, and the title of the game is also “The Big Kahuna”.’ The patient explained she believed the entire world population participated in a video game in which the objective was to transfer credit from her bank account into theirs. ‘How can you tell when people are taking your credit?’ the therapist inquired. ‘Phones!’ the patient exclaimed. ‘Whenever I walk through a group of people, they pull out their phones and use them to transfer my credit to them.’ The therapist asked her to rate how certain she was about these ‘beliefs’ and she said she was 99.9 per cent sure they were true.
Arnold and Vakhrusheva agree with Dr Peters that while it’s not a good idea to challenge a delusion head-on, that doesn’t mean you can’t probe and prod it. A therapist can ask about the evidence for it and prompt the patient to consider that maybe, at some level, it doesn’t add up. The crucial point, they say, echoing Miller and Rollnick, is that it should be the patient who articulates the arguments against their delusion. The therapist’s role is to help the patient think about their own thinking. In some cases, that can mean saying very little at all. When the young woman explained that she was living in a video game, her therapist didn’t raise his eyebrows in disbelief or shake his head. He listened. At the next session, the patient rated her level of conviction at just 80 per cent.
When the therapist asked why it had dropped so steeply, the woman said, ‘I hadn’t really thought about the Big Kahuna as a “belief” before. When you think of something as a “belief” that means it might not be true, so then you have to think about that.’ ‘And what did you think about it?’ asked the therapist. ‘Well,’ said the patient, ‘it just seemed so . . . weird. I mean if somebody told me about the Big Kahuna, I’d think they were totally crazy.’
What applies to delusional patients also applies to people who deny that vaccines work. Call them deluded or crazy and you only make them more determined to assert themselves. Carli Leon, a mother of two, used to be a vociferous anti-vaccination supporter, before changing her mind on the issue. She told Voice of America, ‘When people would ridicule me and call me a bad mother, it only made me dig my heels in more.’ Insults strengthen resistance.
Like other people in positions of authority, doctors are these days exposed to more disagreement than ever. Patients come armed with information they have read online and expect to have a say in any decisions. The spread of anti-vax beliefs presents the medical profession with a particularly tough challenge. In the USA, where the anti-vaccination movement is widespread, public health o
fficials have learnt to distinguish between hard-core refuseniks and the many parents who are merely uncertain – in other words, the ambivalent. With the latter, the best strategy has proved to be taking their concerns seriously, listening properly and winning trust, rather than taking on the belief directly.
Emma Wagner gave birth in a hospital in Savannah, Georgia, in 2011. When the paediatrician on the ward asked if she was interested in the hepatitis B vaccine, Wagner, who was anti-vaccines, expressed doubts. The paediatrician did not tell her she was wrong or attempt to persuade her there and then. Instead, he told her he would support her decision, ‘and in a few years we’ll talk about immunisations for school’. Wagner, impressed by the respect and care he showed for her, began to reflect on whether she had been listening to the wrong people. She has since become a staunch supporter of vaccination.
Resisting the righting reflex requires humility and self-discipline. Even when you know, intellectually, that telling someone they’re wrong can make things worse, the urge to do so can be overwhelming. Therapists who have been trained not to do this still struggle with it. The reason for that, suggest Arnold and Vakhrusheva, is that it’s upsetting to hear someone flagrantly contradict your own model of reality. Just like everyone else, therapists feel the need to push back, even when it gets in the way of helping the patient.
That chimes with an intriguing finding from research into the effectiveness of individual therapists: the ones who experience more self-doubt are better at their job. A 2011 study in the British Journal of Clinical Psychology found that therapists who rated themselves more negatively were typically judged as more competent by independent experts. Inspired by that paper, a German study compared how much therapists thought their patients were progressing with how the patients themselves felt about it. The researchers found that the less success therapists thought they were having, the better the patients felt. Helene Nissen-Lie, an associate professor of clinical psychology at the University of Oslo, who has also studied this question, finds that therapists with greater self-doubt achieve better outcomes because they are better at listening.