As chiropractors, we routinely encounter all sorts of resistance - to our recommendations, our paradigm and perspective on health, our profession and even to our own sense of purpose.
In my previous column (March 25 issue), I talked about diagnosing and managing internal resistance to change. I addressed internal resistance first because without a clear understanding of our own resistance, it's next to impossible to deal with it in others. When we are aware of our own resistance to change, it becomes obvious that we are not unlike our patients in this very basic, human way. Patients, like all of us, don't see themselves as resisting. More likely, they see their stance as self-protective - as healthy skepticism, a way to stay in control, survive or stay the same (i.e., not change). Or, they may be creating space so they don't feel pressured to make a decision until they are ready. How you handle these reactions on the part of patients depends upon your ability to communicate skillfully relative to the degree of resistance, reluctance or opposition someone else has to your idea, recommendation or even to you personally.
In his book Beyond the Wall of Resistance, management consultant Richard Mauer points out that people manifest three levels of resistance. In this article, let's apply Mauer's work on change management at the organizational level to the doctor-patient encounter, where resistance is often poorly understood. My goal in presenting this material is to help chiropractors better understand and effectively address the three levels of resistance, intellectual, emotional and cultural, in an effort to create better patient outcomes and more successful practices. Let's explore these three levels in depth.
Level 1: Intellectual Resistance - "I Don't Get It"
As trained experts paid to give professional advice and recommendations, we dwell in the world of our own reality, assumptions and paradigms. We are heavily invested in the idea that patients should "of course" choose a natural approach to treat acute and chronic problems. Because we are so committed to our way of thinking about health and hold strong opinions, we tend to deliver our ideas as facts. Then we're shocked, surprised and annoyed when patients don't understand and respond "appropriately."
Level 1 resistance arises in response to lack of information or familiarity with a concept, disagreement with an idea or confusion about what the information being presented means. A great deal of health information is dispensed using logic, facts and statistics - usually from an expert to a layperson. When we communicate using this approach and a patient does not respond positively, we might assume they didn't hear or understand us. We repeat ourselves using slightly different language or a new analogy, but to no avail. And then we keep on talking. At around the fifth explanation, the patient's eyes glaze over. They still haven't changed their mind or accepted our recommendation (or they say "yes" just to get us to stop rambling but then never return for care), and we begin to think either we are terrible at communicating or the patient is unable to see we have their best interest at heart.
With level 1 resistance, a different or better explanation may help the patient see the benefits of what you are offering, but be careful not to push too hard or resistance will only increase. Keep in mind that any new information presented must be 100 percent focused on the patient, who is asking themselves, "What's in this for me?" Before adding one word to what you've already said, ask yourself if what you are about to share is interesting and relevant to the patient or only to you. What information does the patient need at this particular juncture in their care? If it's not obvious, simply ask. Avoid talking too much about process, mechanism or philosophy. Take the conversation back to what the patient wants to know. Stay focused on the patient's goals and needs, not primarily on your own interests and motives.
Level 2: Emotional Resistance - "I Don't Like It"
The second level of resistance is emotional. Patients resist for reasons that are more about how they feel than about what they think. Perhaps the patient doesn't feel heard, has a gut feeling that what you're recommending won't work, or feels vulnerable, manipulated or taken advantage of. This deeper level of resistance is a function of the emotional and physiological brain - the limbic brain that is wired for "fight or flight." A patient who is processing information in this aroused state may perceive your recommendations as a threat to their safety or comfort. This, of course, is not a rational reaction, given that you are dedicated to making people feel better, but at this level of resistance, logic and rationality are not primary. The feeling of being threatened can arise out of pain, confusion or from being given too much information too quickly or too soon. When patients are anxious, uncomfortable or stressed, they simply cannot process information in an effective manner.
You're recommending something that you've done hundreds or thousands of times, but it's all new for the patient. They may be thinking: Will this hurt? Can I afford it? Will the treatment work? Is this doctor as good as my Aunt Linda says? With all of this dialogue going on in a patient's mind, they are out of their comfort zone and not processing information at an analytical level. They feel wary and unsafe. They may even experience a physiological response such as an increase in pulse rate and blood pressure which, according to Dr. John Gottman's research, inhibits one's ability to listen.
Let's say you are giving a patient a report with recommendations for care. They initially appear to be following along and agreeing with you. But then, seemingly out of nowhere, they interrupt to ask how much the treatment will cost. Their limbic brain has kicked in and warned them that they might be in danger and, in this case, agreeing to something they can't afford. You've heard this response before and your own anxiety rears its head. But you continue the conversation as if it were on a rational level (i.e., level 1). The patient begins to withdraw, which just pulls you further into resonance with their hesitancy. Soon you are both in "fight or flight" mode. At this point, neither of you "likes" what is transpiring.
Having already put so much energy into the patient, you work hard to convince them to see things your way. This serves only to create more resistance on their part. (If you don't believe this, recall the last time you said to a telemarketer, "I'm not interested," only to have them keep talking in an attempt to convince you that you really are interested. Click.) Soon the patient is genuinely fearful, your body language says loud and clear that you're irritated, and this relationship is going nowhere fast. You write off the patient as being unmotivated or noncompliant (putting them at fault), step out into the hall to shake it off, and put on a mask of confidence before entering the next treatment room.
How could this scenario have played out more positively? Patient resistance is an indication that you, the doctor, have moved beyond where the patient is in terms of readiness or acceptance of a treatment plan. This is your cue to slow down, see things from the patient's point of view, muster up some empathy and ask thought-provoking questions about what might be important to the patient at this particular juncture. This is the time to back off from giving advice and instead engage in dialogue that will move a patient toward their goals and re-establish mutual purpose. Then gently bring attention to gaps between the patient's stated goals and their decisions. Stay focused on what the patient is always focused on, which is: What's in it for me? Try to engage and inspire the patient to see a more positive future - less pain, better overall health, greater levels of physical function or whatever is most important to them.
In addition to adjusting your own actions in the moment, it's helpful to understand that the only real control you have in a situation like this is control over yourself. The faster you recover and reset your own physiological and emotional response, the better it will be for both you and the patient. It is within your control to help a patient feel safe rather than judged, to not rush them into a premature decision and to support them in making good choices. Doing so sets the stage for a doctor-patient relationship that is based on trust, respect and connectedness. When a patient feels safe, they are more apt to reveal the deeper concerns or questions they have, allowing you to have an authentic conversation about the real issues. Once you are both clear on the most pressing concerns, you can work together to develop a strategy that is workable and effective.
Level 3: Cultural Resistance - "I Don't Like You"
The third and most entrenched level of resistance arises from deeply held cultural beliefs and biases, most of which are largely hidden from view. Here, chiropractors face the greatest resistance to their vision, purpose and alternative perspective on health care. It is stressful to encounter this kind of resistance on a daily basis and try to counter it without recognizing how pervasive and powerful a force it is. Understanding this level exposes the folly of trying to reposition someone's thinking or shift someone's paradigm by trying to "educate" them to think like you do. It is here that trust - or lack of trust - comes into play. It is not until a patient trusts you (which takes time) that they will reveal, and hopefully release, some of their biases and long-held beliefs and begin to accept new ways of thinking about health.
At the cultural level, resistance may not be in reaction only to your ideas or solutions. The patient may, in fact, be resisting you. Perhaps they do not yet trust you or they might sense you do not respect them. The patient may not even know why this is the case, but it is present and powerful. Their resistance at this level may be based on a personal history of mistrust, a disagreement over values or beliefs, cultural or gender differences, or even transference. (e.g., "You remind me of my father and he misused his authority over me and others.") This is all about the lens through which we see the world; the filters through which we observe and assign value to everything and everyone. One of the most challenging aspects of resistance at this level is that even though it is entirely subjective, we assume the lens we are looking through is universal. We assume everyone shares our way of viewing the world. We mistakenly think once we show someone the view through our lens, they will understand our wisdom and adopt our world view related to health.
When you sense you are meeting resistance from a patient who is resonating at this level, be aware that the approaches described above for addressing the first two levels will not work. If you use them you may be viewed as trying to manipulate the patient, which will only create more resistance. Instead, this is the time to pause and realize that although this patient is behaving in a way that is disagreeable or unreasonable to you, it's not personal. The patient is human and only wants to be happy and safe - just as you do. The patient may be trying to self-protect at a level they aren't even aware of. Look for what you have in common with the patient instead of what you see as different or difficult about them. Don't disconnect or check out.
To effectively meet this level of resistance and convey the chiropractic paradigm or model of health requires much more than simply providing information. Guiding a patient to shift their beliefs involves making them an active participant in an ongoing dialogue about those beliefs. Before giving explanations, you must discover what the patient knows, believes, cares about or fears regarding chiropractic and their health. Addressing discrepancies in belief systems requires acknowledging where a person is emotionally, cognitively and experientially. You work from there, building on what the patient knows and connecting new ideas you want to share with what the patient already understands.
Shift Your Biases With Curiosity
Our own biases, blind spots or enthusiasm for our professional approach can lead us to inaccurate conclusions about the level or depth of resistance we encounter from patients. When we do not accurately read and appropriately respond to different kinds of resistance, our effectiveness is diminished and we risk negatively impacting the very people we want to influence toward making more positive health choices. We can meet and manage resistance more effectively (and even learn to circumvent resistance) by staying fully engaged with each patient and exercising curiosity at every turn during the office encounter. Doing so will result in less resistance on the part of patients, a more relaxed approach to practice and greater business success.Click here for previous articles by Shelley Simon, RN, DC, MPH, EdD.