Spark the change

“Remember, Mr. N—people, places, and things. You need to be mindful of those triggers.” My preceptor repeated the advice a third time to help the patient commit it to memory. Mr. N was on his way out after another short stay in the addiction medicine unit. In response, he simply shook his head with a weary smile. “I hear you, Dr. M. You say this every time I’m here. You have to understand—I was raised by people who used and grew up with friends who still  use.  And now it breaks my heart to see my kids running away in fear every time I’m drunk and get angry. But I also don’t know where to begin.”

His words described a recurring conundrum I’d observed during my time in the unit. Where, indeed, to begin? How do we motivate patients to change when their locus of control is so restricted?”

I found an unexpected answer while sitting in on a voice therapy session that afternoon. The patient, Mr. B, was recovering from unilateral vocal cord paralysis, which had affected his work as a pastor at the local church. He was now learning to modulate his pitch as a way around it. “Now let’s try the ‘m’ words, Mr. B. Hope you’ve done your homework,” the therapist said cheerfully. Mr. B nodded, repeating the words, eager to try more difficult ones. After carefully watching his therapist enunciate them, he mirrored the pitch, shakily at first and then more confidently on his third try. It was an impressive back-and-forth as they practiced new sounds together.

“This is what I call the zone of proximal development. It’s what the patient can do on their own with the tiniest bit of help from me. It’s where magic happens,” the therapist said. I watched, in awe, as Mr. B successfully upgraded to the next level by the end of the session.

“What’s your secret, Mr. B?” I asked.

“There’s no secret,” he said. “Everyone can be taught. I was just lucky enough to find people to help me.”

Here’s what I learned: 

1. Zone of context

Helping patients acknowledge the context in which they operate is a great first step. Breaking down that context into triggers —people, places, and things—encourages self-advocacy.

2. Zone of nonjudgment

Shame and guilt can be a big barrier to change. Creating a safe space for patients to voice their concerns, hopes, and fears helps them stay on track to lasting change.

3. Zone of proximal development

Establishing long-term patient relationships through empathy and trust is the key to recognizing this zone. Working on goals within this zone builds the patient’s self-efficacy and capacity for change.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.