How to Change

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Memo to Therapists: “It’s the Motivation, Stupid!”

Counter-intuitive? Most therapy clients are ambivalent about change.

When Bill Clinton, in his 1992 presidential run, took to heart his campaign strategist James Carville’s edgy advice: “It’s the economy, stupid!” his objective was essentially political. In my own psychological adaptation of this provocative phrase, what I’m wanting to stress is that if therapists are to most effectively help a client alter problematic behaviors, it’s crucial that their number one focus be on keeping the client optimally motivated for the task.

Which is to say that quite independent of their client’s stated goals, therapists must regularly zero in on their client’s session-to-session willingness, or “drive,” to actually give up dysfunctional behaviors—or try out new ones. For nothing is more critical than therapists’ doing everything they’re capable of to keep a client’s motivation for change as avid, intense, and committed as possible.

It’s been said that many clients come into therapy not to change, meaning that what they’re really hoping for is to find a professional who (with all the authority vested in them) will support and validate not their changing but someone (anyone!) else. More often than not, the whole notion of change is anxiety-evoking, threatening, even scary. So even when a person’s life may be in desperate need of major alteration, they may yet resist—and with all their psychological might—any number of ideas and suggestions that therapists might offer to facilitate such (presumably desired) change.

It’s also been remarked that, at the very least, clients feel ambivalent about change. Which makes even more sense since symptomatic behavior almost always contains rewards of its own: Say, the immediate, sometimes irresistible, “benefits” or “advantages” of an addiction high. Or the convenient “excuse” of a client’s anxiety or depression justifying their not carrying out something they’d been reluctant to undertake anyway. Or even the possibility that—if nothing else and however negatively—the symptom has enabled the client to forge some sense of personal identity. The only exceptions I can readily think of to such diverse treatment ambivalence is when the client has entered therapy exclusively to get assistance in developing certain psychological/social skills. Or when the behavior in question was originally adaptive but is now clearly recognized as counter-productive (while the client, nevertheless, still finds it difficult to extinguish because of its stubborn tenacity).

But the so-called “secondary gain” of almost all self-defeating client behaviors (which graduate students in the field are routinely instructed to become cognizant of) relates precisely to the admittedly positive, though temporary, advantages of otherwise maladaptive behaviors. And these not yet fully apprehended “consolations” can make it extremely challenging for clients to—single-mindedly—apply themselves to working toward the beneficial changes they purportedly came to therapy to achieve. Regardless of whether their problematic behaviors are detrimental to their longer-term welfare, clients may have all sorts of hidden internal barriers against altering them.

Most therapists are well aware of how patients placed in psychiatric units often seem to get worse, or regress, as their discharge date approaches. In such cases, their inhabiting a protected, cared-for environment has allowed them to feel increasingly comfortable and secure—vs. living in the outside, and generally much more stressful, world. Similarly, many people on physical or psychiatric disability do much less than they might to wean themselves off such disability because it provides them with a financial security that would be at risk if they overcame that disability.

A great variety of behaviors ultimately harmful to an individual’s welfare are advantageous in the short-term—as well as representing the always alluring “line of least resistance” (and see my post on this "resistance phenomenon"). And, frankly, how many of us aren’t tempted to take the easy way out, even though we may be vaguely conscious that this alternative isn’t finally in our best interests.

Consequently, it’s essential that therapists keep in mind the circumstance that the internal forces in an individual aligned with change may not be that much stronger than the negative counter-forces within them. It behooves therapists always to consider that despite a client’s overtly stated intentions and objectives, their actual motivation to alter dysfunctional behavior may—at any time—be compromised or weakened by numerous hesitancies. When we talk about clients’ being self-defeating or “sabotaging” themselves, it mostly pertains to the assorted ways that—consciously or not—they’re acting out their ambivalence toward change. And therapists need to respect this irresolution as part of the way we humans are wired—specifically to protect ourselves from anxiety and, more generally, from any kind of emotional discomfort or pain.

If therapists simply focus on a client’s professed goals—rather than on their client’s likely internal conflict about methodically working toward these goals—such “benign neglect” is itself likely to sabotage therapy. Only rarely can therapists afford to forget, or minimize, the situation that when it comes to real people in the real world, individuals seeking to alter problematic behaviors are typically of “two minds” about making the change.

So, to boil all this down to a single suggestion: Therapists, please! However you choose to do it, get into the habit of routinely doing “ambivalence checks” to make certain your client remains as motivated to change as they were when they first entered therapy. For whether the client is demonstrating a certain evasiveness in the sessions, has failed to complete an assignment or follow a suggestion, has begun to cancel or come late to appointments, or their therapy has begun to feel “stuck” in general, chances are that you need to attend to—and help resolve—the ambivalence that the client (however indirectly) is trying to communicate to you.

Note: If you can think of anyone who might benefit from this post, kindly send them the link.

© 2013 Leon F. Seltzer, Ph.D. All Rights Reserved.

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How to Change