The Power of Moments

by Chip Heath

  The concept has similar potency in the health care system. Responsiveness is becoming an expected part of patient care. Health systems around the world (such as Sharp from the last chapter) have made more respectful treatment of patients an institutional priority.

  The Institute for Healthcare Improvement (IHI), a nonprofit best known for its lifesaving work reducing errors and infections in hospitals, has in recent years led the charge for patient-centered care. The former CEO of the IHI, Maureen Bisognano, had a personal connection to the topic. Bisognano, the oldest of nine siblings, had a younger brother named Johnny. He was handsome and smart, and as a teenager he loved his side job as a ball boy for the Boston Celtics.

  When he was 17, he was diagnosed with Hodgkin’s disease. The disease progressed quickly, and for several years Johnny was in and out of hospitals. Maureen visited often, and she remembers the parade of doctors through his room. “They’d speak over him, and about him, but almost never to him,” she said.

  When Johnny was 20, his illness was in its final stages. He came to Maureen’s apartment and told her, “I’m not gonna make it.” She didn’t know what to say or do. “He was ready to face death, but I wasn’t,” she said.

  In that era—before hospice care became common—even a dying patient received intrusive care. (Especially a dying patient.) Johnny spent most of his time in hospitals being monitored and probed and treated by caregivers who were well intentioned but unresponsive—they never got around to asking for his perspective.

  Until one day at Peter Bent Brigham Hospital (now Brigham and Women’s Hospital), when a physician came to visit. Maureen was sitting at Johnny’s bedside. The physician turned to her brother and said, “Johnny, what do you want?”

  “I want to go home,” Johnny answered.

  What happened next astounded Maureen. The physician asked for her jacket. He took it from her and draped it around Johnny, then carried him from the hospital bed to her car.

  Johnny returned to his family home, and he spent his final days in the company of the people who loved him most. He died a few days after his 21st birthday.

  Decades later, Maureen Bisognano read an article in the New England Journal of Medicine that reminded her of her brother’s experience. The authors, Michael J. Barry and Susan Edgman-Levitan, had written: “Clinicians, in turn, need to relinquish their role as the single, paternalistic authority and train to become more effective coaches or partners—learning, in other words, how to ask, ‘What matters to you?’ as well as ‘What is the matter?’ ”

  That question “What matters to you?” struck Bisognano like a lightning bolt. It was, at heart, the same question the compassionate physician had asked her brother. It was also a question—she now realized—that captured the essence of patient-centered care. In speeches before hundreds of caregivers, she would appeal to them to ask their patients, “not just ‘What’s the matter?’ but ‘What matters to you?’ ” It was a rallying cry for more responsiveness.

  The question caught on immediately with many doctors and nurses. After hearing Bisognano speak in Paris in 2014, one nurse, Jen Rodgers, from a pediatric unit in Scotland, took the question home with her. She gave construction paper and markers to the children on her ward and encouraged them to draw on a page titled “What Matters to Me.”

  One of those kids was Kendra, seven, who had just checked into the children’s ward for surgery. She had autism and had never spoken a word. Her father was with her to help her communicate with the staff.

  But within 24 hours after Kendra checked in, her father suffered a suspected cardiac arrest. He had to be rushed to another hospital, leaving Kendra alone, terrified, and unable to speak for herself.

  But she had completed her “What Matters to Me” page, and it opened a door into her world. “My name is Kendra,” she wrote. “I have autism. I can’t speak so I won’t be able to if it hurts. I don’t like medicine by my mouth so watch out I will struggle. I love to feel people’s hair, it is my way of saying hello.” (See her drawing on the next page.)

  Her nurses used her drawing as a guidebook for caring for her. Without it, Rodgers said, the nurses could have easily misinterpreted her behavior. Imagine them dealing with a hard-to-understand child who grabs at their hair and fights when given oral medication. She might have been deemed aggressive. She might have been confined to her room, which would have caused her even more stress.

  Her father recovered quickly and rejoined her within a few days. In the meantime, the nurses had looked after Kendra by honoring her requests. They comforted her. (“I love cuddles to reassure me,” she’d written.) They avoided oral medications when possible, knowing she didn’t like it. They high-fived her. They let her feel their hair, and they combed hers. (“My dad is rubbish at doing my hair.”) Their relationship was utterly transformed because of a simple question: “What matters to you?”

  Rodgers said that the experience with Kendra convinced some of her skeptical colleagues that the question was worth asking every time. Today, the “What matters to you?” drawing has become standard practice for every children’s ward in Scotland.

  And because of the advocacy of Maureen Bisognano and the IHI, that responsive question has been embraced by doctors and nurses around the world. As we saw with the Stanton home visits, with the right kind of moment, relationships can change in an instant.

  3.

  Responsiveness matters in the complex, emotional relationships between caregivers and patients, but it also plays a role in more mundane, day-to-day interactions. When you find yourself infuriated by poor service, for instance, chances are it’s because of a lack of responsiveness. You are seated at a restaurant table and no one acknowledges you for 10 minutes. You are asked at the car rental counter whether you want to buy extra insurance, even though you never have. You wait on hold for a long time and, when a representative finally answers, you are challenged to prove your identity.

  Here’s your authors’ pet peeve: We book a lot of flights, and we always sort the results by duration. (We want the shortest.) For almost twenty years, we’ve been sorting by duration. Yet not once has any travel website stored our preference. Meanwhile, Chip accidentally clicked on a Hello Kitty link months ago, and he is still being stalked around the Internet by ads for cute-kitten luggage. Why does the Internet have a photographic memory for ad clicks and amnesia about what we actually care about?

  What links these annoyances, of course, is the lack of understanding, validation, and caring. We hate being treated impersonally: You are not special. You’re a number.

  Analysts at the Corporate Executive Board (CEB) studied customer service calls and the ratings that customers provided afterward. To the researchers’ surprise, only half of the customers’ ratings were attributable to the particular call they had just experienced. The other half reflected the way they had been treated previously. (For instance, if the customer had made six previous calls to get an issue resolved, then it didn’t matter if the seventh was handled brilliantly.)

  The CEB team called the customers’ memory of previous treatment their “baggage.” Most call center reps had the instinct to avoid the customer’s baggage. If they saw in the records that the customer had been passed around a lot, they wouldn’t mention it. Why bring it up? It’s like pouring salt on the wound, they figured. Better just to resolve the issue as quickly as possible.

  So the CEB ran a set of studies on the art of “baggage handling.” At one call center, the researchers assigned reps at random either to ignore customer baggage or to address it. For instance, let’s say that a customer had called repeatedly about battery problems with a new tablet computer. Compare the responses of the reps:

  BAGGAGE-IGNORING REP NO. 1: Thanks for your purchase. I understand that you are having a problem with the battery. Let’s start from the beginning by going to the “Settings” section on your tablet to make sure that you are not using any feature that is draining your battery more quickly than normal.

  B
AGGAGE-HANDLING REP NO. 2: Thanks for your purchase. I understand that you are having a problem with the battery. . . . Hmm, according to our system, it looks like you’ve called several times about this, is that right? Okay, thanks. Can you tell me what you have tried already, and what has or has not worked to help preserve the battery life? Then we can take it from there instead of repeating stuff you’ve already tried.

  Baggage handling is responsive: It demonstrates understanding and validation of a customer’s frustrating past experience. And the effect it had on calls was stunning: Customers rated the quality of their experience with Rep No. 2 almost twice as highly as the other, and their perceptions of the effort they had to invest to resolve the problem plummeted by 84%.

  In his landmark paper on responsiveness, Harry Reis had set out to explain a “central organizing principle” of relationships. His primary focus was on what makes personal bonds stronger. But we’ve seen the broad reach of the principle: It can explain not just what makes partners happier in a marriage, but also what makes employees feel noticed and valued, what makes patients feel respected in their treatment, and even what makes customers satisfied with a support call.

  If we want more moments of connection, we need to be more responsive to others.

  4.

  Responsiveness doesn’t necessarily lead to intimacy. The baggage-handling phone reps were responsive, after all, but there weren’t any tearful goodbyes at the end of the call. When responsiveness is coupled with openness, though, intimacy can develop quickly.

  Here’s how it happens: One person reveals something and waits to see if the other person will share something back. The reciprocity, if it comes, is a sign of understanding, validation, and caring. I’ve heard you, I understand and accept what you’re saying, and I care for you enough to disclose something about myself. An unresponsive partner—like a seatmate on a flight who puts on his headphones shortly after you make a comment—terminates the reciprocity, freezing the relationship.

  This turn-taking can be incredibly simple. In one study conducted at a bus stop, a researcher approached strangers with one of two canned comments. The “low-intimacy” comment was, “Well, my day is over. How about yours?”

  The “high-intimacy” comment shows how easy it can be to initiate the cycle of turn-taking. All the researcher had to say was, “I’m really glad this day is over—I’ve had a really hectic day. How about you?” That’s the high-intimacy comment! On that scale, a handshake would probably be X-rated. Even so, that tiny bit of self-disclosure sparked significantly more intimate comments in return.

  EXPERIMENTER: I’m really glad this day is over—I’ve had a really hectic day. How about you?

  SUBJECT (young woman): No, I had a great day.

  EXPERIMENTER: You had a great day?

  SUBJECT: Oh, a beautiful day. I went out with someone I really liked, so I had a great day.

  In this scenario, the experimenter reveals something personal, the subject reciprocates, and the experimenter responds further, deepening the exchange. It’s intimacy in steps. Surely we all have a relationship with the opposite dynamic, where our responses might as well be programmed: “Working hard, Dave?” “Nah, hardly working.” “I hear that.” “Another day, another dollar.” “Yup.” “Okay, see you.” That’s a relationship on a permanent plateau.

  Intimacy escalates with turn-taking. For a dramatic example of this, consider a study by the social psychologist Art Aron and four colleagues called “The Experimental Generation of Interpersonal Closeness.” (Which, by the way, would have been a great alternate name for The Bachelor.II)

  In the study, some college students taking a psychology class volunteered to be paired up with another student in the class who was a stranger to them. Each pair was given 36 numbered questions on slips of paper in an envelope, to be drawn one at a time and answered by both people.

  The exercise was divided into three rounds of 15 minutes each. As they progressed, the questions became increasingly intimate. Here are three sample questions from each round:

  ROUND 1

  Question 1: Given the choice of anyone in the world, whom would you want as a dinner guest?

  Question 4: What would constitute a “perfect” day for you?

  Question 8: Name three things you and your partner appear to have in common.

  ROUND 2

  Question 13: If a crystal ball could tell you the truth about yourself, your life, the future, or anything else, what would you want to know?

  Question 15: What is the greatest accomplishment of your life?

  Question 21: What roles do love and affection play in your life?

  ROUND 3

  Question 26: Complete this sentence: “I wish I had someone with whom I could share . . .”

  Question 28: Tell your partner what you like about them; be very honest this time, saying things that you might not say to someone you’ve just met.

  Question 33: If you were to die this evening with no opportunity to communicate with anyone, what would you most regret not having told someone? Why haven’t you told them yet?

  At the conclusion, the pair were separated and asked to complete a short survey that included the IOS (Inclusion of Other in the Self) scale, which is a measure of closeness. The mean IOS score of the participants was 3.82; the scale has a maximum of 7.

  How high is 3.82? Consider that researchers asked another group of students on campus to rate their “closest, deepest, most involved, and most intimate relationship”—possibly their girlfriend or boyfriend or mother or best friend—on the same IOS scale. And 30% of those students rated their “most intimate relationship” at less than 3.82.

  Think about that. Two strangers sat down and had 45 minutes of conversation. That’s a quick lunch or a long tech support call. Yet at the end of it, they felt as close to that stranger as 30% of college students feel to the most intimate relationship in their lives!

  That’s interpersonal alchemy.

  Art Aron’s 36 questions have become famous—there’s even an app you can download if you want to try them out with a partner. (It’s called “36 Questions.”) But in some ways, the questions are beside the point. It’s not these specific questions that create intimacy—it’s the turn-taking. Another set of 36 questions could work just as well, so long as they matched the escalating cycle of vulnerability that Aron created.

  The critical realization, however, is that this cycle will not begin naturally. You must start it.

  To explore this further, we challenged a group of readers as follows: “Sometime in the next week, when you’re having a conversation with a friend or family member, push intentionally beyond small talk. Share something real—maybe it’s a challenge/struggle you’re facing at home or work. Make yourself vulnerable and trust that your partner will reciprocate, allowing you to take the conversation to a higher level.”

  People were amazed at the response they got. Here’s one account from a man named Mike Elam:

  I had a conversation with a fellow manager at the office that started as a project update meeting, but I did go deeper than the project with the discussion. Prior to this meeting, we were strictly peers at work and really knew very little about each other beyond our roles at the company. I found that she was actually relocating to the Phoenix area later this year and would be continuing to work on the project remotely. The reason for the relocation was health issues with her spouse. We then talked about those issues because he has multiple sclerosis and was having issues getting around in the winter here and in their multi-story house, so they decided to move. Then we discussed the trials and tribulations with getting their current home ready to sell and the process of packing to move, etc.

  The first question didn’t need to be too deep or personal but it was like “peeling an onion” where we were going just slightly deeper on each exchange and when finished, we had moved quite a bit. The exercise totally changed the dynamics of my work discussions and relationship with this person.

&
nbsp; Relationships don’t deepen naturally. In the absence of action, they will stall. As Elam said above, “we were strictly peers at work and really knew very little about each other beyond our roles at the company.” That’s a frozen relationship. But, as we’ve seen, acting with responsiveness to others can create tighter bonds: bonds between teachers and parents, doctors and patients, call center reps and customers, colleagues at work, and even strangers in a lab experiment. And those bonds can continue to strengthen with astonishing speed.

  A defining moment of connection can be both brief and extraordinary.

  * * *

  I. For another example of nonresponsiveness, look no further than your teenager. You say something and your teen either doesn’t notice or seems not to be able to translate your clear instructions into coherent action (anti-understanding). When you try to clarify what you’re asking for, the teen rolls his eyes (anti-validation). In a situation where a neutral “Okay, got it” would go a long way, you get the summary statement, “Whatever!” (“Whatever” is anti-everything.)

  II. Jokes aside, The Bachelor and similar shows are masterful at whipping up instant love (moments of connection), for reasons that we are about to see. But note how easily the producers conjure moments of elevation: There is beautiful scenery and delicious food (sensory appeal), plus novel experiences (breaking the script) and competitive excitement (raising the stakes). It’s classic peak-building.

  MOMENTS OF CONNECTION

  THE WHIRLWIND REVIEW

  * * *

  1. Moments of connection bond us with others. We feel warmth, unity, empathy, validation.

  2. To spark moments of connection for groups, we must create shared meaning. That can be accomplished by three strategies: (1) creating a synchronized moment; (2) inviting shared struggle; and (3) connecting to meaning.