But there’s one stage model I keep in mind nearly every minute of every session—the stages of change. If therapy is about guiding people from where they are now to where they’d like to be, we must always consider: How do humans actually change?
In the 1980s, a psychologist named James Prochaska developed the transtheoretical model of behavior change (TTM) based on research showing that people generally don’t “just do it,” as Nike (or a new year’s resolution) might have it, but instead tend to move through a series of sequential stages that look like this:
Stage 1: Pre-contemplation
Stage 2: Contemplation
Stage 3: Preparation
Stage 4: Action
Stage 5: Maintenance
So let’s say you want to make a change—exercise more, end a relationship, or even try therapy for the first time. Before you get to that point, you’re in the first stage, pre-contemplation, which is to say, you’re not even thinking about changing. Some therapists might liken this to denial, meaning that you don’t realize you might have a problem. When Charlotte first came to me, she presented herself as a social drinker; I realized that she was in the pre-contemplation stage as she talked about her mother’s tendency to self-medicate with alcohol but failed to see any connection to her own alcohol use. When I challenged her on this, she shut down, got irritated (“People my age go out and drink!”), or engaged in “what-aboutery,” the practice of diverting attention from the difficulty under discussion by raising a different problematic issue. (“Never mind X, what about Y?”)
Of course, therapists aren’t persuaders. We can’t convince an anorexic to eat. We can’t convince an alcoholic not to drink. We can’t convince people not to be self-destructive, because for now, the self-destruction serves them. What we can do is try to help them understand themselves better and show them how to ask themselves the right questions until something happens—either internally or externally—that leads them to do their own persuading.
It was Charlotte’s car accident and DUI that moved her into the next stage, contemplation.
Contemplation is rife with ambivalence. If pre-contemplation is denial, contemplation might be likened to resistance. Here, the person recognizes the problem, is willing to talk about it, and isn’t opposed (in theory) to taking action but just can’t seem to get herself to do it. So while Charlotte was concerned by her DUI and the subsequent mandate to participate in an addiction program—which she grudgingly attended and only after failing to take the course in time and having to hire a lawyer (at great expense) to get her deadline extended—she wasn’t ready to make any changes to her drinking.
People often start therapy during the contemplation stage. A woman in a long-distance relationship says that her boyfriend keeps delaying his planned move to her city, and she acknowledges that he’s probably not coming—but she won’t break up with him. A man knows that his wife has been having an affair, but when we talk about it, he comes up with excuses for where she might be when she’s not answering her texts so that he doesn’t have to confront her. Here people procrastinate or self-sabotage as a way to stave off change—even positive change—because they’re reluctant to give something up without knowing what they’ll get in its place. The hiccup at this stage is that change involves the loss of the old and the anxiety of the new. Although often maddening for friends and partners to witness, this hamster wheel is part of the process; people need to do the same thing over and over a seemingly ridiculous number of times before they’re ready to change.
Charlotte talked about trying to “cut back” on her drinking, about having two glasses of wine each night instead of three or skipping cocktails at brunch if she would be drinking again at dinner (and, of course, after dinner). She could acknowledge the role that alcohol was playing in her life, its anxiety-muting effects, but she couldn’t find an alternative way to manage her feelings, even with medication prescribed by a psychiatrist.
To help with her anxiety, we decided to add a second therapy session each week. During this time, she drank less, and for a while she believed that this would be enough to control her drinking. But coming twice a week created its own problems—Charlotte was once again convinced that she was addicted to me—so she went back to the once-a-week schedule. When, in an opportune moment (say, after she’d mentioned getting drunk on a date), I’d bring up the idea of an outpatient treatment program, she’d shake her head. No way.
“Those programs make you stop completely,” she’d say. “I want to be able to have a drink at dinner. It’s socially awkward not to drink when everyone else is.”
“It’s socially awkward getting drunk too,” I’d say, to which she’d reply, “Yeah, but I’m cutting back.” And by then it was true; she was cutting back. And she was reading up on addiction online, landing her in stage three, preparation. For Charlotte, it was hard to concede the lifelong fight she’d been in with her parents: “I won’t change, Mom and Dad, until you treat me the way I want to be treated.” She’d made a subconscious bargain that she’d change her habits only if her parents changed theirs, a lose-lose pact if there ever was one. In fact, her relationship with her parents couldn’t change until she had something new to bring to it.
Two months later, Charlotte waltzed in, unpacked the contents of her bag onto the arms of her throne, and said, “So, I have a question.” Did I know of any good outpatient alcohol-treatment programs? She had entered stage four, action.
In the action stage, Charlotte dutifully spent three nights per week in an addiction-treatment program, using the group as a substitute for the wine drinking she used to do at that time. She stopped drinking entirely.
The goal, of course, is to get to the final stage, maintenance, which means that the person has maintained the change for a significant period. That’s not to say that people don’t backslide, like in a game of Chutes and Ladders. Stress or certain triggers for the old behavior (a particular restaurant, a call from an old drinking buddy) can result in relapse. This stage is hard because the behaviors people want to modify are embedded in the fabric of their lives; people with addiction issues (whether that addiction is to a substance, drama, negativity, or self-defeating ways of being) tend to hang out with other addicts. But by the time a person is in maintenance, she can usually get back on track with the right support.
Without wine or vodka, Charlotte was able to focus better; her memory improved, and she felt less tired and more motivated. She applied to graduate school. She got involved with a charitable organization for animals that she felt passionate about. She was also able to talk with me about her difficult relationship with her mother for the first time in her life and begin to interact with her in a calmer, less reactive way. She stayed away from “friends” who invited her out to have just one birthday drink—“Because you only turn twenty-seven once, right?” Instead, she spent the night of her birthday with a new group of friends who served her her favorite meal and toasted her with a creative assortment of festive nonalcoholic drinks.
But there was one addiction she couldn’t quite kick: the Dude.
Full disclosure: I disliked the Dude. His swagger, his dishonesty, his dicking Charlotte around—literally and figuratively. One week he was with his girlfriend, the next he wasn’t. One month he was with Charlotte, the next he wasn’t. I’m onto you I wanted my look to say when I opened the waiting-room door and saw him sitting near Charlotte. I felt protective, like the mommy dog in the driver’s seat in the car commercial. But I stayed out of the fray.
Charlotte would often wiggle her thumbs in the air while narrating the latest installment: “And then I said . . .” “And then he’s like . . .” “And then I’m like . . .”
“You had this conversation in text?” I asked, surprised, the first time she did this. When I suggested that discussing the state of their relationship via text might be limiting—you can’t look into somebody’s eyes or take someone’s hand to offer reassurance even though you’re upset—she replied, “Oh, no, w
e use emojis too.”
I thought of the deafening silence and twitching foot that clued me in to Boyfriend’s desire to break up; had we been texting about the movie tickets that night, he might have waited months more to tell me. But with Charlotte, I knew I sounded like an old fogy; her generation wasn’t going to change, so I’d have to change to keep up with the times.
Today Charlotte’s eyes are red. She found out on Instagram that the Dude is back with his supposedly ex-girlfriend.
“He keeps saying he wants to change, but then this happens,” she says, sighing. “Do you think he’ll ever change?”
I think about the stages of change—where Charlotte is, where the Dude might be—and about how Charlotte’s father’s constant disappearing act is being replayed with the Dude. It’s hard for her to accept that while she might change, other people might not.
“He won’t change, will he?” she says.
“He may not want to change,” I say gently. “And your father might not either.”
Charlotte squeezes her lips together, as if considering a possibility that had never occurred to her before. After all of her efforts to try to get these men to love her the way she wants to be loved, she can’t change them because they don’t want to change. This is a familiar scenario in therapy. A patient’s boyfriend doesn’t want to stop smoking pot and watching video games on weekends. A patient’s child doesn’t want to study harder for tests at the expense of doing musical productions. A patient’s spouse doesn’t want to travel less for work. Sometimes the changes you want in another person aren’t on that person’s agenda—even if he tells you they are.
“But—” she says, then stops herself.
I watch her, sensing the shift happening inside her.
“I keep trying to get them to change,” she says, almost to herself.
I nod. He won’t change, so she’ll have to.
Every relationship is a dance. The Dude does his dance steps (approach/retreat), and Charlotte does hers (approach/get hurt)—that’s how they dance. But once Charlotte changes her steps, one of two things will happen—the Dude will be forced to change his steps so that he doesn’t trip and fall down, or he’ll simply walk off the dance floor and find somebody else’s feet to stomp on.
Charlotte’s first drink after four months of sobriety happened on Father’s Day, when her dad was supposed to fly into town to be with her but canceled at the last minute. That was three months ago. She didn’t like that dance, so she changed her steps. She hasn’t had a drink since.
“I need to stop seeing the Dude,” she says now.
I smile as if to say, That sounds familiar.
“No, really—I mean it this time,” she says, but she smiles too. It’s been her mantra for months while in preparation. “Can I change the time of my appointment?” she asks. Today she’s ready for action.
“Of course,” I say, recalling that I’d suggested this before so that Charlotte wouldn’t have to sit with the Dude in the waiting room each week, but Charlotte hadn’t been ready to consider it. I offer her a different day and time and she puts the appointment into her phone.
At the end of our session, Charlotte gathers up her myriad belongings, walks to the door, and, as always, stops, stalling. “Well, see you on Monday,” she whispers, knowing we’ve pulled one over on the Dude, who will likely wonder why Charlotte’s not there at their regular Thursday time. Let him wonder, I think.
As Charlotte heads down the hallway, the Dude comes out of his session, and Mike and I nod hello, poker-faced.
Maybe the Dude told Mike about the girlfriend, and they spent the session talking about his tendency to juggle people, to mislead, to cheat. (“Oh, so that’s his issue,” Charlotte once said after he’d done this to her twice.) Or maybe the Dude didn’t mention it to Mike at all. Maybe he’s not ready to change. Or maybe he’s just not interested in changing.
When I bring this up in my consultation group the next day, Ian says simply, “Lori, three words: not your patient.”
And I realize that, like Charlotte, I need to release the Dude too.
40
Fathers
During a belated New Year’s cleaning, I come across my grad-school coursework on the Austrian psychiatrist Viktor Frankl. Scanning my notes, I begin to remember his story.
Frankl was born in 1905, and as a boy, he became intensely interested in psychology. By high school, he began an active correspondence with Freud. He went on to study medicine and lecture on the intersection of psychology and philosophy, or what he called logotherapy, from the Greek word logos, or “meaning.” Whereas Freud believed that people are driven to seek pleasure and avoid pain (his famous pleasure principle), Frankl maintained that people’s primary drive isn’t toward pleasure but toward finding meaning in their lives.
He was in his thirties when World War II broke out, putting him, a Jew, in jeopardy. Offered immigration to the United States, he turned it down so as not to abandon his parents, and a year later, the Nazis forced Frankl and his wife to have her pregnancy terminated. In a matter of months, he and other family members were deported to concentration camps, and when Frankl was finally freed, three years later, he learned that the Nazis had killed his wife, his brother, and both of his parents.
Freedom under these circumstances might have led to despair. After all, the hope of what awaited Frankl and his fellow prisoners upon their release was now gone—the people they cared about were dead, their families and friends wiped out. But Frankl wrote what became an extraordinary treatise on resilience and spiritual salvation, known in English as Man’s Search for Meaning. In it, he shares his theory of logotherapy as it relates not just to the horrors of concentration camps but also to more mundane struggles.
He wrote, “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances.”
Indeed, Frankl remarried, had a daughter, published prolifically, and spoke around the world until his death at age ninety-two.
Rereading these notes, I thought of my conversations with Wendell. Scribbled in my grad-school spiral were the words Reacting vs. responding = reflexive vs. chosen. We can choose our response, Frankl was saying, even under the specter of death. The same was true of John’s loss of his mother and son, Julie’s illness, Rita’s regrettable past, and Charlotte’s upbringing. I couldn’t think of a single patient to whom Frankl’s ideas didn’t apply, whether it was about extreme trauma or an interaction with a difficult family member. More than sixty years later, Wendell was saying I could choose too—that the jail cell was open on both sides.
I particularly liked this line from Frankl’s book: “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”
I’d never emailed Wendell for anything other than scheduling issues, but I was so stunned by the parallel that I wanted to share it with him. I pulled up his email and typed, This is what we were talking about. The trick, I suppose, is to find that elusive “space.”
A few hours later, he replied.
I’ve always appreciated Frankl. Beautiful quote. See you Wednesday.
It was typical Wendell—warm and genuine but clearly stating that therapy takes place face-to-face. I remembered our first phone call, when he’d said almost nothing, and how surprisingly interactive he was once we met.
Still, I carried around his reply in my head all week. I could have sent that quote to various friends who would have appreciated it too, but it wouldn’t have been the same. Wendell and I existed in a separate universe where he saw me in ways that even those close to me didn’t. Of course, it’s also true that my family and friends saw aspects of me that Wendell would never see, but nobody would quite understand the subtext of my email as precisely as Wendell would.
The following Wednesday, Wendell brings up the email. He tells me that he shared the quote with his wife, who, he says, is going
to use it for a talk she’s giving. He’s never mentioned his wife, though I know everything about her from my long-ago Google binge.
“What does your wife do?” I ask as if I haven’t seen her LinkedIn profile. He tells me about her work at a nonprofit.
“Oh, interesting,” I reply, but the word interesting sounds unnaturally high-pitched.
Wendell watches me. I quickly change the subject.
For a split second, I think about what I might do if I were the therapist here. Sometimes I want to say, I wouldn’t do it that way, but I know that’s like back-seat driving. I need to be the patient, which means I need to relinquish control. It may seem like the patient controls the session, deciding what to say or not, setting the agenda or topic. But therapists pull the strings in our own ways—in what we say or don’t say, what we respond to or hold on to for later, what we give attention to and what we don’t.
Later in the session, I’m talking about my father. I tell Wendell that he’d been in the hospital again due to his heart condition, and though he’s okay now, I’m afraid of losing him. I’m aware in a new way of just how frail he is, and I’m starting to absorb the reality that he won’t be here forever.
“I can’t picture a world without him in it,” I say. “I can’t imagine not being able to call and hear his voice or ask his advice or laugh together about something we both find funny.” I think about how there’s nothing in the world like laughing with my dad. I think about how knowledgeable he is on almost any topic and how fully he loves me and how kind he is—not just to me, but to everyone. The first thing people say about my father isn’t how smart or funny he is, though he is both. The first thing they say is “He’s so sweet.”
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