(Photo Credit: Dmytro Zinkevych)
By Jason Briggs, MA
What motivates a client to change and what are the processes therapists can use to help?
In the last writing, in this series on Common Factors research, the discussion was on aspects of two Common Factors used to promote effective outcomes in therapy. They were client factors and therapist factors. These two Common Factors will be addressed in this second writing as well, along with how they interrelate with a third Common Factor called the therapeutic alliance, all within the Stage of Change known as Contemplation. I will also discuss what some of the change processes I use are and how they are also supported by Common Factors researchers. I will begin with what Common Factors researchers find is essential to Motivational Interviewing, since this was not discussed in my last post. Again, as with all my writings on Common Factors, I am reviewing three Common Factors researchers’ work, authored by Douglas H. Spenkle PhD, Sean Davis PhD and Jay L. Lebow, PhD, referencing information found in their book Common Factors in Couple and Family Therapy, The Overlooked Foundation for Effective Practice.
Motivational Interviewing has elements that when brought together in the context of our clients’ lives, can help therapists join with clients, inviting them to engage in and explore change in whatever Stage of Change they might be experiencing. Common Factors researchers contend and I agree with them, that “within the Motivational Interviewing approach there is no such thing as an unmotivated client. There are only therapists that are out of sync with a client’s motivation” (Spenkle, Lebow and Davis, 2009). So, working systemically, it is often the case that each member in an individual, couple or family system, is in varying Stages of Change and thus motivated at different levels with the different issues they might wish to address. Common Factors suggests part of the therapist role is to shift homeostasis within an understanding of each person’s motivation and the there are five principles to consider, to help us form a better connection with our client and help them move through whatever Stage of Change they are in. We can “(1) express empathy, (2) develop discrepancy, (3) avoid argumentation, (4) roll with resistance, and (5) support self-efficacy” (Miller and Rollnick, 2002) (Spenkle, Lebow and Davis, 2009). These five principles are suggested to fall into three broad therapeutic alliances, which therapists can use three interventions within each stage and they are: “(1) building motivation for change, (2) strengthening commitment to change, and (3) the follow-through (Spenkle, Lebow and Davis, 2009). So what exactly do Common Factors researchers know about the value and importance of these five Motivational Interviewing principles?
“Unpacking” what these Motivational Interviewing principles ignite in our clients, is a great way to motivate therapists to learn these concepts both intellectually and experientially with their clients. As noted above, these Motivational Interviewing principles inherently ask each therapist to embody a sort of attitudinal stance in therapy that helps facilitate a client’s movement toward change. They are (1) expressing empathy and is particularly effective with client ambivalence and is promoted by a listening stance and abandoning a superior/inferior stance, typically embodied by telling a client what meaning we give to their story. Common Factors researchers describe the Therapists’ Alliance in this way: (to be) “a supportive companion and knowledge consultant, (rather) than a forceful instigator of change” (Spenkle, Lebow and Davis, 2009). (2) Developing discrepancy, the second Motivational Interviewing principle is reflected in understanding that most, if not all humans’ emotional and psychological pain exists in direct proportion to the disparity/discrepancy between where they are now and where they want to be, “and when they know better, they will do better” ( BJ Davis, 2012). Common Factors researchers point out, “Depending on which Stage of Change the client is in, the therapist focuses on gently amplifying the discrepancy that is already there (for those in contemplation or preparation stages) or developing a discrepancy (for those in the pre-contemplation stage)” (Spenkle, Lebow and Davis, 2009). Here, we see an emphasis on the therapist knowledge about the Stage of Change in general and needing to know where one’s client is in terms of each Stage of Change and on differing issues, exploring the likelihood of a client having varying levels of motivation to change depending on any given issue and the Stage of Change the client is in with each issue. (3) Avoiding argumentation is the third principles used in helping a client experience the motivation to change. Expecting a client to embrace a certain protocol type therapy, a label, etc. is one way an unsuspecting therapist can invite arguments against, instead of for change (with us or within the client and likely both). Helping to understand a client’s point of view regarding their preferences in therapy, how they have experienced labels, even “mental health issues” can be one way we can allow their meaning to be held up to unequivocal predominance and then join with the meaning our clients make about how they identify this meaning, amplifying, and reflecting it to them. Closely related Motivational Interviewing principle (4), rolling with resistance, which is an essential facet of Motivational Interviewing and the idea of accepting and not rejecting a client’s ambivalence to change. Emphasis is placed on joining with the client not on any particular interventions, trusting a solution will, if acceptance is present, naturally emerge within the client in the space created for them to explore their problems. This assumes an intention on behalf of the therapist, which trusts the client has their own answers within them, assuming a stance of psychological and emotional safety around any issues the client is considering facing. If the therapist achieves this stance and creates emotional safety for a client to explore what they need, want, and are willing to do based on the clients view, their therapist is seen as an “enlightened witness” (Alice Miller, 97). Supporting this safe emotional and psychological space means supporting the next principle in Motivational Interviewing, (5) supporting self-efficacy, the belief that a client can change and unless this empowering attitudinal stance is demonstrated by the therapist in relationship with their client, “a discrepancy crisis is likely to resolve into defensive coping (e.g., rationalization, denial) to reduce discomfort, without changing behavior” (Miller, 1995, p.5) (Spenkle, Lebow and Davis, 2009).
The therapeutic alliance, another essential Common Factor, will be given its proper weight in understanding how client and therapist factors unite within the processes of change during the Stage of Change known as Contemplation. The therapeutic alliance is defined by Common Factors as both/and, what it is, and what it is not. “It is collaborative. The alliance can be misunderstood as a quality that the therapist brings to the client. However, the alliance is fully interactional and systemic, an operation between one or more clients and the therapist (Spenkle, Lebow and Davis, 2009).” This is a foundational therapeutic Common Factor. It establishes emotional bonds between a therapist and a client to form a connection and assists with providing effective outcomes in therapy. So, helping a client see choices for healing that the therapist sees the client may identify with and find helpful is only half of the picture, the other half is seeing what our clients are contemplating and helping them negotiate the changes they seek to make within all the Stages of Change and processes of change they are in and viewed as meaningful. Stated in another way, “On more careful examination, (our) successful alliance formation is better viewed as a dance in which everyone participated as the alliance co-evolved between the clients and the therapist” (Spenkle, Lebow and Davis, 2009). I will add that a felt understanding by the therapist of the clients’ worldviews are essential, along with a sense of therapist “okay-ness” about the clients’ interactions within the therapy room. These perceptions and interactions the therapist has in turn, will impact the client in therapy, whether the client is in therapy with their family, in a couple, or individual unit of treatment. When the therapist creates psychological and emotional safety in the relationship to their clients’ ambivalent interactions, and helps the client contemplate what it might be like doing inner work using certain stage specific processes of change, the client will reveal more of their ambivalence and ideas to contemplate that which will promote change.
In the Stage of Change known as Contemplation, clients are intending to act “within the next six months.” (Prochaska, 1999) (Spenkle, Lebow and Davis, 2009). Clients seeking to make a change in this stage are expressing discontent with their problems, want to overcome it, want to see themselves living a life without their problems, but also see why they shouldn’t try to change. Clients in Contemplation “are not very good candidates for behaviorally focused, action-oriented programs. Their motivation is not yet at the level where they will put all of their heart into behavioral change efforts. They are better suited for more passive insight-oriented approaches that help them explore their problem, weigh the pros and cons of changing and so forth” (Spenkle, Lebow and Davis, 2009). Like in the previous Stage of Change the suggestion for this stage is to continue to weigh the pros and cons of changing and decrease the number of cons. The only additional processes of change aside from three mentioned in Pre-Contemplation is self-reevaluation, to assist in transitioning to the next Stage of Change Preparation. So, the therapist is supporting the client in evaluating themselves without the problem. Aside from active imagination, guided imagery, self-acknowledgement of healing and growth, help consolidate steps the therapeutic alliance has made and clarify steps one still might make in the therapeutic alliance to successfully transition to the Preparation Stage of Change. “Values clarification, encouraging congruence between one’s own values and behaviors and the like can be helpful in this stage” (Prochaska, 1999) (Spenkle, Lebow and Davis, 2009).
A therapist being willing to build a foundational relationship with their client depends to a large extent, on a therapist’s ability to listen, explore, and respect the worldview of their clients, not as an intervention, but more as an attitudinal stance toward their shared humanity, a facet of which was addressed above in the therapeutic alliance discussion. Understanding Common Factors research is important and then applying it in our therapeutic practices can help our clients regain a sense of connection often ruptured in their past and current relationships. Common Factors research can help therapists and clients move through change in their own and their clients’ lives in a much more empathetic and meaningful way. Remembering there is always motivation present is essential, and it is the role of the therapist to identify what motivates our clients to bring about effective change, and to “stay with them” as they contemplate ways to move forward while having a timing and pacing that works for them. See the first writing in this series on Common Factors (CF), wherein I discussed what CF researchers suggested as helpful processes of change in the Stage of Change Pre-Contemplation. Doing so will enhance your focus on the processes of change you can use to help clients focus on increasing insight about moving from Contemplation to begin working in the next Stage of Change known as Preparation, our next blog topic.
Douglas H. Sprenkle, Sean D. Davis, Jay L. Lebow. Common Factors in Couple and Family Therapy, Guilford Press, Aug 10, 2009
Alice Miller. Jan. 7, 1997. http://www.alice-miller.com/en/the-essential-role-of-an-enlightened-witness-in-society-2/