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By Jason Briggs, MA
What motivates a client to change and what are the processes therapists can use to help?
If you’re like me, most therapists have a period in their learning curve where they have spent countless hours being ahead of their clients’ abilities to promote effective change because we aren’t seeing what stage of change our clients are in, and aren’t sure what processes could help motivate our clients in therapy. We (therapists) can also be less skillful about being transparent with each other about our own work with clients and how we promote change and challenges to this process we call psycho (mind/soul) therapy (treatment used to treat issues, problems and symptoms one feels conflicted about). This series is an homage to Common factors research (CFR), that points to common factors which underlie all therapy models that work together to promote change in therapy. The three Common factors researchers work I will be summarizing are authored by Douglas H. Spenkle PhD, Sean Davis PhD and (last but not least) Jay L. Lebow, PhD, which can be found in their book Common Factors in Couple and Family Therapy, The Overlooked Foundation for Effective Practice. Sean Davis is in private practice, a supervisor in the Roseville, CA area, and a local Professor at Alliant International University, Sacramento Campus. Dr. Davis was my past academic advisor and admittedly an “at a distance” self-selected role model.
In the age of having many models of therapy to choose from its helpful to know two Common Factors (CF) that help promote effective change in Common factors research (CFR), that being the ‘client factor’ and ‘therapist factor’ both, in connection with each other. What is it specifically about the client that lends itself to change and what is the role of the therapist in supporting this change, that both the therapist and client might have an effective therapy outcome? Many therapists and clients assume it is what the therapist does that is the most important aspect of therapy, but Common Factors Research asserts that it’s not only what the client does in therapy, but what the client does in response to the therapist, or how a client uses and focuses on the information the therapist presents. Ultimately it’s a collaborative venture.
As is often the case, I will invite my clients to share in what is called a “here and now” time, at the end of our sessions to explore our shared experiences in the session. In the “here and now”, I invite my clients to share what they found was helpful, worked or what didn’t work, or just to relate their experience in our session and in particular, with me; their answers never cease to amaze me, often citing something I felt was just a passing comment, experience or interaction or some other very important aspect of their experience. Using this “here and now” time, it is a both/and way of interacting, the focus is on the client but the therapist is wise to find ways to work with clients’ perceptions, being curious about them, and helping them identify what works for them. This should include what they struggle with in sharing their own experiences, cultivating a focus on what a client may feel is “ok” in therapy according to their worldview, and then seek ways that help promote a motivation to expand their worldview and promote change.
The Common Factors researchers do note that an extreme view of Common Factors research may engender a therapist to say “even a poor therapist can do therapy” but in their book they actually say quite the opposite and tend to place great value and importance in their role, but not by placing their own role above the clients’ role. They note, that the therapist who places such extreme value on client factors, to the exclusion of the therapists’ own involvement and development, may run the risk of discouraging themselves to think they have nothing to offer to help the client change and a thus engender a “why try” attitude that could encourage therapist laziness and a lack of a sense of accountability to clients.” The Common Factors research discusses the nature of clients’ and therapists’ factors as being reciprocal (giving and receiving in balance) and further discusses how the therapist can motivate a client to change also asserting that a client motivated to change can then impact the therapist’s motivation and behavior! That’s reciprocity! So, it is clear that their emphasis is on the value and importance of matching our own behaviors as therapists with the client’s motivation to change, and what processes will help them engage in such a change.
It seems all humans pass through Stages of Change (SOC-a common behavioral health model) and have various levels of motivation. Known by therapists as Motivational Interviewing (MI), MI has typically been thought to be helpful to only substance abusers, but it has been used successfully with individuals, couples, and families with other issues as well. Motivation is always present according to the researchers, but that it looks differently depending on each stage, and that each client is motivated by different things. There are 6 stages of change (SOC) and they are Pre-Contemplation, Contemplation, Preparation, Action, Maintenance, and Termination. There are 9 processes of change which are Consciousness Raising, Dramatic Relief, Environmental Re-evaluation, Self-Re-evaluation, Self-Liberation, Contingency Management , Helping Relationships and Counter-Conditioning and finally Stimulus Control.
This will only focus on clients in the SOC called Pre-contemplation, the helpful process and interventions that Common Factors research has shown will help clients at this particular motivation level in their process of change. These clients it would seem are not intending to change anytime in ‘the next 6 months’ and they are either unaware of or uninformed about the severity of their problems. Clients who wish to successfully move from this stage to the next, Contemplation, “need to increase the number of pros (versus cons) they see in a life without the problem.” The Common Factors researchers suggest helping clients focus on increasing insight, suggesting that using the Consciousness Raising processes are ideal during this (SOC). A couple of Consciousness Raising processes offered that I find effective in my practice are, bibliotherapy (book therapy) and psychoeducation (education of the psyche, and how it becomes rigid and flexible in its structures). Another is making a list of what the positive effects of living life without the problem and envisioning a life without the problem. Another I enjoy is helping clients experience guided imagery that focuses on adaptive information they may need to make a shift or change.
Another process of change that may prove helpful during the Pre contemplation SOC is Dramatic Relief, which much like guided imagery, it activates emotions that are felt during the problem. Interventions using this process could be role plays, guided imagery that focuses on a life with the problem in the future, and experiential interventions, such as empty chair/Gestalt, sculpting, inner dialog, etc.
The last process of change Common Factors researchers note that is helpful during this SOC is Environmental Re-evaluation. These interventions include helping the client to accept the perceptions of their family members by carefully exploring each person’s readiness to give and receive feedback, and when ready (can manage emotions), preparing the client to lean into the perceptions of their family, and helping the client experience understanding (not necessarily agreement). Another process is to use any experiential technique that will allow the client to cultivate empathy for those impacted by their behaviors, how it affects the system’s environment, and to see how those behaviors are experienced by others in the system.
Being willing to explore, understand, and apply Common Factors research can help therapists and clients move through change in life in a much more empathic way. There is always motivation to be found and it is the clinician’s role to see what motivates our clients so they can bring about effective change in their lives.
Coming soon, my next writing in this Common Factors blog series is on Contemplation, the next stage of change following Pre-contemplation and helpful processes for the therapist to help clients embrace their own limitless potential for healing and growth.
Douglas H. Sprenkle,Sean D. Davis, Jay L. Lebow. Common Factors in Couple and Family Therapy, Guilford Press, Aug 10, 2009