Attitude Follows Behavior

 When I was in residency, one of my attendings was a pigeon trainer. Not like a guy in a circus, with delicate beaks plucking peanuts from his lips, although he truly was a showman. Like a PhD researcher who learned his philosophy of doctoring by getting birds to press a lever. The story that he liked to tell and that I like to remember is that of a cantankerous patient, someone who, in burning through drugs, had burned all the bridges in his life, and was staring up at the world from the bottom of a pit, with no way to climb out. He would show up at his HIV clinic and throw attitude at everyone; no one liked him. The way my attending told it, he somehow started training him with a system of punishments and rewards. When he came late and was rude or called people names, he was turned away. When he came on time and was nice, he was showered with praise and warmth. The end result, as my teacher told it, was that he began to climb out of the pit and to reestablish relationships with people in the world. In changing his behavior, at first under pressure from my pigeon trainer, and later, voluntarily, in response to others leaning towards him, he gradually changed his approach, his demeanor, his attitude, himself. 

Attitude follows behavior. That’s my line – at least I think it’s original. But also not original. It’s a truth I’ve discovered, or my attending’s lesson put in my own words.  It’s an answer to a question my patients continually ask: can people change? Usually, it’s more of a tired assertion actually: I don’t think he’s going to change. Usually it is a he (I treat women, so, yeah), but sometimes a she, a mother, a sister.

My attending was (and is – though I’ll revert to the man of my memory) in the business of change, really miraculous transformation, more in the vein of a faith healer than a psychiatrist. In one sense, he was a one-off, not really someone whose style you could emulate. He would walk the inpatient wards, trailing an entourage of residents and med students, meet a new patient, and within 5 minutes, be telling them their fortune. You will rise from your wheelchair, find new strength, more than you thought you possessed, and be transformed.  And he was right. He specialized in chronic pain, and changing people’s minds about how they conceived of their pain, and how they let it drive their life. More than one person, let me tell you, did indeed, get up out of a wheelchair, I’m not joking. It helped that he was wicked smart, used the latest medical science to investigate and treat physical pain, did not stint on pharmacotherapy, and was good at getting people on less or no opioids. But still, I think he would admit that inculcating faith was a big component of what he did.

I’m no ringmaster, preferring quiet epiphanies. But I did imbibe his lesson of hope and change. I insist on it, on believing in it at least. Why would you come to me if you were content with the present?

The problem with women changing (yes, I’m generalizing), is that the healthier they get, the more they start looking at the people around them and wanting them to change too. At least that’s one tendency I’ve noticed. Women can be meddlesome, not content to leave others to their fates. I am that meddlesome woman, though as a psychiatrist I deeply respect and teach boundaries. I will be that person brushing the bug I see off your shoulder. But I’ll try to ask permission first, unless it’s a mosquito and you’re in my immediate family.

What I’m trying to say is that my style of psychotherapy is to treat the whole family in absentia, much like a soviet show trial. But with solutions rather than false confessions and gulag time.

Once my patient is healthy enough that she’s no longer distracted every minute by worrying her child is going to be kidnapped or that she’s going to fail in some crucial way at work, once she is sleeping a number of hours (at least 6, preferably 8) that is in the realm of humanity, she’s going to start thinking about her partner, and wonder why she’s doing 90% of the child related chores, or whether his irritability is related to his alcohol use and lack of sleep, or whether she wants to ask him to stop being on his phone so much.

And now we arrive at the tired assertion/question of: what if he won’t change? By this stage, my patient has invested time, energy, and money in her own transformation and appreciates that it is a lot of work. And she’s done it. She is feeling better, she has enough breathing space, to be ready for her partner to feel better too, to help her partner feel better. Only, he’s resistant, scared of therapy, avoidant, not hopeful, not open to, not seeking change. (To those supportive partners out there, who immediately say yes when your woman suggests couples therapy, go forth and spread the gospel to your brethren.)

Now, it’s time for me to get out my line: Attitude follows behavior. You don’t need to ask your partner to change, to Be More Considerate! Be More Present! He wouldn’t know what to do with this request if you did. I wouldn’t know what to do with this request if you asked me to Be More Present! I would need you to break it down for me. Tell me what I just did in our session and how you want me to do it differently, I imagine I would say. And if you told me you wanted me to make eye contact or ask “What’s on your agenda for today?” I think I would say, “I can do that.” Because you’ve made what I call “a concrete ask.”

 So I agree with your skepticism, we don’t have wands or potions that magic you into a tomorrow where you wake up and have a partner who is More Considerate! But if you ask him to start packing the kids lunches, and he does, you might start to feel appreciative and like he is more considerate, and in reality, he might be more considerate, because he is doing a behavior that helps him to realize whoa, she’s been packing these lunches for the last 2 years, and I never realized before exactly what that involved. Or he might get positive feedback from you for contributing in this way and he might start doing other additional things to get more positive feedback.

I am not the first to suggest the behavioralist model of relationships: witness the shamu modern love essay or the Saturday Night Live spoof “Man Park” or something in some ancient Greek play somewhere, probably Lysistrata. Focusing on behavior is smart because it’s doable, and also because it takes you off of the battlefield of Idomorethanyou / noyoudont and just says, “Can you take over the lunches?”- cut and dry like that.  

But there is the fatigue - of carrying energy for someone to be different when their energy is resisting any change. Of carrying enough energy to change ourselves. For us to become different enough to ask them to be different, and to ask again and again rather than be the person who gets by, who accepts less than things could be.

I’ve begun to think of this phenomenon as a kind of energy snowball rolling contest: see if you can develop a snowball of change energy so big that it overcomes your partner’s giant snowball of resistance, so that the energy of his resistance starts feeling like a lower cost for you to pay, and the excitement of your change starts rolling down the hill, gaining speed and enthusiasm and pulling the two of you along with it.

The alternative is stasis and resentment. We have conversations with our family members inside our heads. Why didn’t you notice that I needed help getting the kids ready to go out the door? Or sometimes we don’t even get as far as imagining the conversation. We get frustrated, but we don’t say anything. We sigh and tell ourselves, “They’ll never change.”

And I think what I want to say is: lower the bar. Look for adaptation before change, a new behavior before a new attitude.

We are skilled at adapting, even if we don’t want to. Adaptation is how we survive. Adaptation is sometimes, often probably, unwilling. But it can be where the door gets wedged open for deeper change, because attitude follows behavior. Once we start to change what we do, we may start to want things to be different or be open to things being different.

If my partner asks me to start doing daycare pick up on Thursdays when they’ve been doing it this whole time, I might not want to, I might resent it, or I might feel whiney about it. But if I start doing it anyway, if I’m forced to make room in my schedule, I might start to see the positives, I might appreciate leaving work early and getting to spend time with my kids, the discipline of having to end work at a certain time, of not being able to have things spill over into the evening. After I’ve adapted and made the required adjustments, if my partner now tells me they want to take over doing pick up again on Thursdays, I might not want them to.

The problem of addiction emphasizes this idea. I might not be ready to give up alcohol, but if I put myself in a setting where it’s impossible to drink, and now I’ve had two weeks or a month away from alcohol, I might start identifying differently, as someone who might not want to go back to drinking. We dig in to our current identities, we protect them, we defend them. If I’m drinking too much, it’s hard to admit I have a drinking problem. It becomes easier to view ourselves critically if they are our old selves; it’s typically only after we’ve started to walk away from certain identities that we can admit their limitations and problems. And changing our behavior is the first step.

What is this essay about? There are so many layers. It’s not about why we need to pay attention to resentment and why resentment is bad for relationships. That’s a whole separate essay. I’m trying to make the argument for making a concrete ask, a behavioral ask rather than an attitudinal ask, and the idea that our responsibility is to identify what we need and want and make the ask and be willing to make the ask over and over again and then to be aware that if our partner actually does the thing we are asking, their attitude may change over time. Attitude follows behavior.