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Our lives are spent either in doing nothing at all, or in doing nothing to the purpose, or in doing nothing that we ought to do; we are always complaining our days are few, and acting as though there would be no end of them.Seneca (4 bc to 65 ad)
Imagine your practice with fewer complaining patients. Imagine your patients more focused on their goals than their grievances. Patients begin with complaints, but complaints are just the raw material of goals. Embedded within every complaint is at least one goal. Our patients often need help seeing things that way.
Goalification is the term I use to describe the process by which we transform complaints into goals. You “goalify” complaints by articulating their opposites. Put mathematically:
You’re on an antonym quest. The International Classification of Diseases helps us with diagnosis and Roget’s Thesaurus helps us goalify. Here are some examples:
|COMPLAINT||POSSIBLE ANTONYMS (GOALS)|
|Depression||Happiness, contentment, enthusiasm, satisfaction, joy|
|Anxiety||Calmness, serenity, ease, peace, tranquility|
|Social anxiety||Extroversion, confidence, social comfort, social ease, participation|
The core concern is that complaining leads nowhere. If you allow your patients to complain for 10 years—all the while providing exemplary empathy—they’ll no doubt feel “understood,” but there’s no assurance that they’ll have solved their problems. A decade of dedication to goal-focused behaviour doesn’t guarantee results either, but the odds are immeasurably higher.
There’s a standard script in primary care: patient complains doctor draws empathy into syringe doctor administers bolus of empathy patient feels good and thanks doctor patient returns to life, changing nothing empathy buzz wears off patient books another appointment.
You might have learned that lengthy supportive listening is the sine qua non of caring. But science suggests there’s a U-shaped curve: outcome is optimized with a midrange of empathy. Overemphasis on supportive listening sometimes creates an “empathy addict” with a stagnant life. It’s tough to goalify unless you prioritize being helpful over being thought nice and polite. In the following dialogue I interrupt in the service of redirecting the patient’s energies:
Pt: I’m so depressed [elaborates].
Dr: [Accurate but brief empathy statement, then …] It sounds like your goal is the opposite of that. I wonder what that would be? Maybe happiness?
Pt: [Slight pause, then resumption of complaining] Yeah, sure … but I’m so depressed. I’m so depressed.
Dr: [Accurate but brief empathy statement, then …] Sorry to interrupt, but it sounds like you’re saying you have a goal of making yourself happier—do I have that right?
Pt: [Slightly longer pause, then resumption of bitter complaining] Yeah, but I’m so depressed. I’m so depressed.
Dr: Wow! I hear the passion in your voice! You’re fed up with being depressed, aren’t you? It sounds like you really want the opposite of that—that you really want to increase your happiness! It sounds like you’re ready to truly commit to doing the things required to make yourself happier. Have I got that right?
Pt: Yeah, it would be nice to be happier. But how do I do that?
If there’s patient buy-in at that point, the patient is directed toward a review of the things she or he is willing to do to make progress toward the goal (future articles in this series will elaborate on this). There’s sometimes an opportunity to highlight—in the nicest way possible— that except in the most idealistic New Age philosophy, simply desiring an outcome is no guarantee that it will “manifest.” Put more diplomatically, downstream from the same old behaviour is the same old mood. If the patient wants a new mood, the patient will likely have to behave differently. You have to earn your mood.
Goalification is particularly appropriate for chronic complainers. It assumes the following:
Goalification’s goals include increased assurance that patient and physician energies are directed properly, improved outcomes, and prevention of physician burnout.
I thank the following CBT Whistler 2010 participants for their helpful critique of this paper: Dr Graham Mansell, Dr Desmond Konway, Dr Susan Burgess, Dr Greg Cully, and Dr Raj Rampersaud.