SOC8385 - SECTION 2: MOTIVATION FOR CHANGE
Client’s Level of Motivation
Most therapy approaches assume that counselors 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, what is often taught is to, first, engage the client through active listening and empathy and, once trust is developed, work on the targeted behaviors. While clients may exhibit some reluctance to discuss and work on their problems, the skilled counselor should be able help most clients meaningfully address their concerns.
The reality for many counselors 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 treatment is because they are required or highly encouraged by the legal system, employers, the social service system, or family to be in treatment.
If they come for counseling or treatment, they often drop out, or do not follow - or are resistant to - the treatment plan. It is also common for counselors and treatment personnel to blame the client when the intervention is not working. People 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, but 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 being unmotivated, people may 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 counselor, or 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 counselor, client, and program characteristics and these variables need to be addressed in any type of counseling or treatment.
There is evidence that many so-called voluntary or “self-referred,” clients feel they are being encouraged or coerced into counseling or treatment by people around them. However, at the same time, many people who are required to get counseling or treatment report they do not resent being forced to get some assistance for their problem.
Whether a client is voluntary or involuntary may also vary according to whether the client views the counseling or treatment as desirable or undesirable. It is probably best to look at how a client comes to treatment on a continuum from the completely voluntary client, to the client who feels varying degrees of informal pressure, to the person who is required to get counseling or treatment.
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:
Case Examples: Motivation for Change
Case Example One: Dave, 32 years of age, works in sales for a manufacturing company. He grew up in a family where consuming alcohol was a regular part of family life. From his father he learned the tradition of an after-work-drink at a local bar or at home. His family often served alcohol at family functions, at celebrations, and at meals at home or eating out. His mother drank very little, but his father frequently drank too much. Sometimes on weekends his father would drink too much, especially if he was out with his friends. Dave learned to use alcohol when he was happy, when he wanted to relax, and when he was having problems. As a result, alcohol use was an integral part of his life. In fact, Dave could not imagine life without drinking.
Dave had a few drinking related problems, including a lot of heavy drinking when he was in college and a DUI in his mid -20s. He was under performing at his current job primarily because it did not challenge him, and he would have to admit that his drinking after work and on weekends may also be playing a role. But despite these problems, Dave felt he was more or less in control of his drinking. However, soon after his wife left him and subsequently divorced him, his drinking problems escalated. Dave’s wife left him, in part, because she quit drinking and Dave refused to do so.
He has been missing more days of work or showing up for work hung over, and it is beginning to have a serious impact on his job performance. Sometimes after a round of heavy drinking, he would wake up in the middle of the night anxious and depressed, unable to go back to sleep. He woke up one morning after a night of drinking, not knowing how he got home. He has been gaining weight and he has experienced some shortness of breath, but he was afraid to go to the doctor.
Dave is becoming increasingly aware of the problems his drinking is causing him, but he also knows that drinking is an integral part of his life and he enjoys its many benefits. Dave is being presented with some concrete evidence that his drinking is becoming a problem for him, but despite these facts, he is not sure if he wants to make some significant changes in his life at this time. Something has to change in his life or he has to gain a new perspective on his life, for him to consider making changes in his drinking and associated behavior.
Case Example Two: Mike is a 53 year old stock broker. He is married for the second time. His wife is currently a homemaker. She is 15 years younger than him. They have two children aged 6 and 8. Mike has two children from his previous marriage who are now 26 and 23 years old. Mike 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 at his country club (but he usually rides in an electric cart) and occasionally walking with his wife.
Mike is a big man and he has always enjoyed food and drink. Over the years, he had always been able to more or less address his weight problems by going on a crash diet and getting a little more exercise, 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. Additionally, he is finding that raising two young children at his age is more difficult than he imagined.
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. His wife has been increasingly asking him to go on a diet, get some exercise, and drink less. He recently went to his doctor for his annual physical and his doctor basically ordered him to lose the weight, drink less, and get more exercise because his health is beginning to be seriously compromised.
On the one hand, Mike is being presented with objective evidence that his weight, his drinking, and his lifestyle need to change immediately. On the other hand, Mike likes his food and drink. These things have always been an integral part of his life, in the good times and in the bad times. He knows he needs to lose some weight and drink less, but lately it has become more difficult for him to make a plan and stick with it. Besides, he is still one of the top stock brokers at his company. He can still beat most of his friends at golf and it is not like he is an alcoholic.
To an outsider both of these men have some problem behaviors that have negative impacts on them and the people around them. Both of these men have received some objective evidence that they have substance use problems. Both men have some awareness that their behaviors are causing them problems.
However, awareness of problem behaviors, having the motivation to do something about them, and actually doing something about them are very different things. No manner how client comes to therapy, most of them have experienced some medical, social, legal, and/or occupational consequences as a result of their AOD use and the potential for more problems will continue if they continue to use substances in an uncontrolled manner.
Nevertheless, even with these negative consequences, many people will continue to deny that they have a substance use problem. Most people will tend to overvalue the positive role of AOD use in their lives, underestimate the seriousness of the consequences of their AOD use, and/or overestimate the negative aspects of abstinence or controlled use.
Factors Influencing Motivation to Change
Interest in the topic of motivation often begins with wondering why some people apparently do not want to change. It is a common frustration for health, social service, and legal professionals; counselors and treatment personnel; teachers; employers; family and friends. To outsiders it seems apparent that what a person is doing is not working or is even self-destructive, yet the person persists in the same behavior.
People find themselves saying such things as: “You would think having a heart attack would be enough to persuade him to quit smoking, change his diet, exercise more, and take his medication.” “You would think that getting arrested for drunk driving, her husband separating from her because of her drinking, and getting demoted at her job would be enough to convince her to stop drinking.” “You would think his wife leaving him because of his temper, his drinking, and almost getting fired from his job because he got in a fight with his boss would convince him that he has problems.” “You would think that most teenagers would realize that getting a good education, staying away from drugs and out of trouble are important for their future.”
So why do some people refuse or are unable to change problem behaviors?
An alternative question is why some people do change. People who work in the helping professions often believe that what causes change is the service provided, be it counseling, treatment, advice, or education. However, the research shows that most people with problems ultimately address them without any type of formal treatment.
The research also shows that people that get formal treatment make several attempts to address their problems. The stages and processes by which people change seem to be the same with or without some type of formal intervention or treatment. The key to understanding how people change is to understand this natural process of change, and then try to incorporate it into education, intervention, and treatment strategies.
Consider this example:
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 need 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. 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. Counselors do not directly change people, rather people 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 desired goals.
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 counselors want to be successful they need to address a person’s level of motivation for change.
What We Know About 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.
However, counselor 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 important in getting a person into counseling and treatment (Walters, Rotegers, Saunders, Wilkinson, & Towers, 2001).
Most counseling and treatment personnel emphasize intrinsic motivations for help-seeking under the belief that while extrinsic 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.
Miller and Rollnick (1995) summarize what we know about change and the motivation for change in the following way:
- Change occurs naturally.
- What happens during and after formal interventions mirrors natural change, rather than being a unique form of change.
- The likelihood that change will occur is strongly influenced by interpersonal interactions including interactions with counselors, treatment personnel, educators, and others.
- When behavior change occurs within a course of education, counseling, or treatment, much of it occurs within the first few sessions, and, on average, the total amount of treatment does not make all that much difference.
- Who one sees in treatment or counseling is a significant determinant of treatment dropout , retention, adherence, and outcome.
- People who believe that they are likely to change do so, people who are told that they are likely to change do so, and people who are told that they are not expected to improve indeed do not.
- What people say about change is important, in that, statements that reflect motivation for, and commitment to, change do predict subsequent behavior change, whereas, arguments against change produce less change.
These factors have lead to an important shift in thinking about people’s motivation for change. Motivation is better understood not as something that one has, but something one does. People do bring various levels of motivation and resistance to treatment, but the research shows that resistance arises from the interpersonal interaction and relationship between the counselor and the client. The research clearly shows that that a change in counseling style can directly affect the level of client resistance.
It is how the counselor responds to client resistance that makes the difference. Clinical experience has shown that the more invested counselors 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 motivational models suggest that individuals initiate change when the perceived costs of the substance use behavior outweigh the perceived benefits of such use, and when they can anticipate some benefits from behavior change. Motivation is best viewed as a state that can be influence by the client’s life experiences and relationships and what happens in counseling or treatment.
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, 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.
When clients are unwilling or unable to realistically evaluate the role of AOD use in their lives, the counselor’s initial responsibility is: 1) to help the client make a more realistic appraisal of the positive and negative consequences of their AOD use and 2) offer them a realistic option to have better control over their AOD use and thereby improve the quality of their life.
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 client and presenting a menu or 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. Building a bond between the counselor and the person can increase motivation during and after counseling and treatment (Walters, Rotgers, Saunders, Wilkinson, & Towers, 2003).
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, counselors may want to enlist the support of family, friends, employers, schools, and the courts to require or encourage the person to get assistance.