CFN9885 - SECTION 9: CLIENT MOTIVATION
Why is it that some people are successful, while other people are not successful in meaningfully addressing their problems? The key may be the concept of motivation for change. Consider these two examples:
Example One: Steve is a 56 year old lawyer. He is married for the second time. His wife Cindy is currently a homemaker. They have two children aged 6 and 8. Steve has two children from his previous marriage who are in their mid-20s. Steve was always athletic when he was younger, but beginning in his mid-forties, he began putting on weight. Currently his only form of exercise is playing golf (but he usually rides in an electric cart).
Over the years, he had always been able to more or less address his weight problems by going on a crash diet, but lately he has found that he is putting on more weight and he is not able to lose it as easily. While he is very successful at his job, he is increasingly finding it stressful and less rewarding and the additional stress at home is having an effect on his emotional and physical health. He is finding that raising two young children at his age is more difficult than he imagined and this has contributed to his current problems.
While he has always liked to drink, the last few years he has been drinking more. In the past, he has been able to more or less control his drinking and except for a drink or two in the evening at home or with friends or clients, he usually confined his drinking to the weekends either at home watching sporting events or out with his friends. However, when he thinks about it, he acknowledges that he is drinking more during the week and on weekends.
Steve has always had a problem with controlling his emotions especially his temper, but in the past few years the problem has gotten worse. Additionally, he finds himself feeling increasingly depressed about his current life situation. He has never been good about expressing his feelings. He usually responds in extremes from wanting to be left alone and not wanting to talk about it to outbursts of anger and hostility. Cindy gets very afraid for herself and her young children when he goes into one of his angry outbursts.
Cindy has been increasingly asking Steve to go on a diet, get some exercise, drink less, and get some control over his temper. She would like to go to family counseling with him, but he says he has no interest in going to counseling. He recently went to his doctor for his annual physical and his doctor told him to lose some weight, drink less, and get more exercise because his health is beginning to be seriously compromised.
On the one hand, Steve is being presented with objective evidence that his physical and emotional health, his drinking, and his lifestyle need to change because they are negatively impacting him. Having some awareness of problem behaviors, having the motivation to do something about the problems, and actually doing something about them are very different things. Steve appears to need some additional motivations to get him to seek help for his problems and seriously address them.
Example Two: A man was driving to pick up his children at the city library. On his way to the library it started to rain heavily. As he approached the library entrance he fished in his pocket to find a cigarette, but he found he was out of cigarettes. At the entrance to the library, he caught a glimpse of his children stepping out into the rain, but he continued around the corner certain he could find a parking space, rush into the convenience store, buy the cigarettes, and be back before his children got too wet. At that moment, the view of himself as a father who would actually leave his children in the rain while he ran after cigarettes was the motivation he needed to stop smoking. (Miller & Rollnick, 2002)
Up to this point this man smoked and he valued being a good father. Neither his smoking nor his value of being a good father had changed. What did change was his perception of the meaning of his smoking, in that, it had become more important than his value of being a good father, and at that point it time, it became unacceptable to him.
When a behavior comes into conflict with a deeply held value, a person may be more motivated to change the behavior. Clinicians do not directly change their clients; rather their clients change themselves by choosing to do something different.
The goal in counseling or treatment is to reproduce what happens naturally in life by helping people to see discrepancies between their current behavior and their desired goals and help them to find ways to realize their goals.
Client Motivation and the Impact on Counseling
Most therapy or treatment approaches assume that clinicians are working with more or less voluntarily or at least cooperative clients. People either seek counseling or treatment on their own or they are encouraged to seek assistance by people who are significant in their lives. Because it is assumed that most people who come to counseling or treatment are more or less motivated to work on their problems, the initial stages of the counseling process are rather straightforward. Clinicians are taught to engage the client through active listening and empathy and, once trust is developed, work on the targeted behaviors.
While some clients may exhibit reluctance to discuss and work on some of their problems, we are told that the skilled clinician should be able help most clients meaningfully address their concerns.
The reality for many clinicians and treatment professionals is that people either do not seek treatment voluntarily or respond to encouragement from significant people in their lives. The only reason many people are in counseling is because they are required or highly encouraged by the legal system, employers, the social service system, friends, or family.
If these people come for counseling primarily as a result of these external pressures, they often drop out, do not follow - or are resistant to - the treatment plan, or they cooperate just enough to get through the required number of counseling sessions.
When clients will not cooperate in the counseling process and the counseling is not working, it is common for some clinicians and treatment personnel to blame the client. Clients who refuse, do not comply with, or fail in, treatment are often said to be “in denial” and not motivated enough for the treatment to be effective and until that denial is confronted, counseling or treatment cannot be successful.
This can create a Catch-22 situation for people who are required or highly encouraged by someone else to get counseling or treatment. Involuntary treatment is used because the person is thought to be unmotivated to seek treatment and the person is thought to be unmotivated when involuntary treatment is used.
People may have very good reasons for not wanting to be in counseling or treatment. It is possible that rather than not being motivated, people may not want counseling or drop out of counseling or treatment because, for a variety of reasons, what is being offered is not attractive or working for them at that time.
Early attrition may reflect self-selection, where people find themselves in the wrong treatment setting, wrong therapy group, with the wrong clinician, participating in a treatment program that they feel is not oriented to their particular needs. They may have had bad previous experiences with counseling or treatment, they may fear being negatively labeled or stigmatized, or they may have practical contingencies that impact treatment such as lack of financial resources or other commitments that compete with treatment.
This is confirmed by the fact that most people tend to drop out of treatment or counseling early and most drop-outs usually seek counseling or treatment again somewhere else. It is increasingly becoming clear that retention in counseling and treatment is dependent on a combination of factors including clinician, client, and program characteristics and these variables need to be addressed in any type of counseling or treatment.
Factors that Influence Motivation
Seeking help for one’s problems is influenced by the interactive influence of internal and external barriers and incentives. Historically, motivation for change has been primarily thought of as a personal characteristic, that is, the person comes to counseling or treatment with a certain level of motivation.
Most counseling and treatment personnel emphasize intrinsic or personal motivations for help-seeking under the belief that while extrinsic or external motivators, such as social pressures and legal sanctions, can be useful in getting clients to - and keeping them in - treatment, intrinsic factors are considered more significant in getting the person to become engaged in the treatment process and make meaningful changes.
However, clinician and treatment personnel are increasing realizing that external factors such as encouragement from family, friends, employers, school officials, social welfare personnel, and the legal system can also be important in getting a person into counseling and treatment. (Walters, Rotegers, Saunders, Wilkinson, & Towers, 2001)
According to self-determination theory (SDT), human beings are driven to satisfy three basic psychological needs: 1) autonomy/self-efficacy (the perception that one is in charge of one’s own behavior), 2) competence (the perception that one is a capable, effective human being who can function adequately in a variety of life contexts), and 3) relatedness (a feeling of belonging and participation in social groups). (Walters, Rotegers, Saunders, Wilkinson, & Towers, 2001) SDT says that those individuals who are intrinsically motivated for behavior change, who feel that they have freely chosen their behaviors, and who are immersed in contexts that support feelings of competence, will demonstrate persistently healthy behaviors.
Human motivation lies along a continuum anchored at one end by “amotivation,” where there is a distinct lack of motivation to engage in new behavior, through “extrinsic motivation,” where behavior change may occur in response to specific environmental contingencies (e.g., pressure from family and friends, employers, legal authorities, schools officials, social service agencies, medical personnel), to “autonomous (or intrinsic or internal) motivation,” where behavior change occurs in response to a person’s self-determined reasons for change.
Ideal voluntary clients would be people who recognize they have problems they cannot solve, are willing to seek assistance in addressing these problems, and are willing to make whatever changes are necessary to address the problems. However, ambivalence or resistance about one or more of these factors can be expected in most counseling situations.
Therefore, if clinicians want to be successful they need to address a person’s level of motivation for change. It is how the clinician responds to client resistance that makes the difference. Clinical experience has shown that the more invested clinicians become in their client’s outcomes, the more they see themselves as responsible for the client making changes, the more their own agendas dominate the counseling or treatment process, the less most clients are willing to change. (deJong & Berg, 2002)
The research consistently shows that it does not matter how a person gets into treatment, rather what matters is how the person is approached once they are in counseling or treatment. (Fagan, 2004) Therefore, motivation is best understood not as something that one has, but something one does.
Motivation can be influenced by the client’s life experiences and the therapeutic environment. People do bring various levels of motivation and resistance to counseling and treatment, but the research shows that resistance can also come from the interpersonal interaction and relationship between the clinician and the client.
The research clearly shows that that a change in counseling style can directly affect the level of client resistance. Building a bond between the clinician and the person can increase motivation during and after counseling and treatment. Therefore, what is called for is assessing the person’s level of motivation and developing education, intervention, counseling and treatment strategies which will increase or reinforce their commitment to change. (Walters, Rotegers, Saunders, Wilkinson, & Towers, 2003)
From a counseling or treatment perspective this means that procedures such as personalized feedback and asking people to identify their own concerns are effective because they increase internal motivation. Emphasizing the responsibility of the people and presenting a menu of options promotes a sense of autonomy. Reinforcing a person’s sense of self-efficacy and giving positive feedback can increase the clients’ feelings of competence.
In a similar way, advice or telling a person what they should do should be given sparingly so as not to detract from the person’s sense of ownership of his/her plan for change. Dealing with any practical barriers for change should also be addressed such as finding programs that are located near the person’s home, finding child care so a parent can attend meetings, or finding programs that are affordable.
If the person is unwilling to seek treatment or counseling on their own, clinicians may want to enlist the support of family, friends, employers, schools, and the courts to require or encourage the person to get assistance.