As it is the start of a new year, I thought a good topic to get this blog restarted would be that of sustaining motivation for change. From the perspective of Integrative CBT, this is a Level 2 issue; a therapeutic relationship (Level 1) is necessary for many people who need to make difficult changes in their lives, but it is rarely sufficient without other therapeutic factors.
Clients want help, want things to change, and this is what leads them to engage in a therapeutic relationship. However, some changes are hard to make, and even harder to maintain, and many clients become less enthusiastic, even drop out of therapy, once they begin to realise the amount of work that is actually necessary in order to achieve lasting change. They discover (as do therapists) that willpower not enough, that direct persuasion is not productive, that readiness to change is not a fixed quality, and that we can influence, but not control, our deeper, more instinctual motivations and appetites. However, these discoveries don’t seem to stick, so this can be a repeating pattern. The mixed feelings displayed here are therefore not something exceptional, but a normal part of the change process. Our attitude to certain kinds of change (the ones we know are good for us, but which we don’t feel like doing), must by its very nature be characterised by ambivalence.
“Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it.”
The best approach to the issue of ambivalent motivation is still Motivational Interviewing (Miller & Rollnick, 2002, Guilford Press), which was originally developed in response to addiction problems, but is now seen as relevant wherever there are difficult changes to be made. A good example of this is in OCD, where clients are similarly both desperate for change and terrified of change.
The main principles of Motivational Interviewing (MI) are straightforward enough, but they are still worth reminding ourselves about regularly:
1) Express Empathy
2) Develop Discrepancy
3) Roll with Resistance
4) Support Self-Efficacy
Especially useful is the classic Stages of Change model which Miller & Rollnick incorporated from Prochaska & Di Clemente:
MI suggests that people normally move back and forward between the stages many time before achieving lasting change, that we can only help someone if we work with them at their current stage right now (not the one which we or they think they should be at), and that we can only move forward one stage at a time. The Determination/Preparation stage is especially crucial, as it emphasises realistic planning and expectations, and is exactly the stage that is given insufficient attention by most people. It is worth emphasising with clients that there may need to be substantial change in their overall lifestyle, and in specific daily routines and rituals, in order to achieve changes in the areas they have targeted. The classic question to explore is “What else do you need to change in order to change X?”
MI is not a new set of skills/techniques as such, but a perspective we take – all our current skills of empathic listening, Socratic questioning etc are as relevant as ever, but are harnessed in the service of exploring and strengthening motivation, which MI reminds us should never be taken for granted.
I would encourage all therapists to have some familiarity with this approach, and I find that it dovetails particularly well with an Integrative CBT style of therapy.
Speaking of changes, this blog will be posted monthly from now on, but I am also starting another monthly blog about the relevance of Naturalism to psychotherapy, under the heading Psychotherapeutic Naturalism - see http://psychotherapeuticnaturalism.blogspot.com/
I will be exploring topics such as the role of science in psychotherapy, the problems of choice and free will, the nature/nurture debate etc. Hope to see you there!