So you wanna be a better therapists?: Part 10a
I used to work at a psych center.
Twice a day I'd usher in the patients, usually a small group of 5-10 people, and once the door clicked behind me I'd raise an eyebrow and wait.
Then, after the appropriate pregnant pause I'd ask, "who wants to make a change today?"
On one particular occasion a young man raised his hand.
"Great, " I said, and pulled a seat next to mine, in the center of the room, "have a seat. Why don't you tell us your name and what seems to be the problem. Why are you here"
"Well my name is Sam and I'm here because I was suicidal."
"Okay." I said, "And why where you suicidal?"
"I've had a lot of bad things happen to me. And when I think about those things I just get overwhelmed."
"Oh I see. Is it like a slide show of bad memories play over and over? And whenever you see those it kinda hurts?"
"Yeah."
"So then suicide is your way out?"
"Yeah. Exactly."
"So why now Sam? Was there something that happened recently which triggered all of this? Like a final straw kind of thing?"
"Well, my girlfriend cheated on me."
"Oh sorry to hear that. That's got to hurt." I said. Sam began to tear up. "Okay, well let me ask you. Say I had a magic button. And if you pushed this magic button, poof, all of your suicidal thoughts would just disappear, would you push the button?"
Sam got real quiet and thought about it for a minute.
"Well I'm here because of my girlfriend." He said, "If she hadn't of left me, then I wouldn't be here. "
"Hey, it's really hard to be cheated on. The feeling of betrayal can be... excruciating. You're not to blame that she cheated. That was her decision." I paused, making sure he took in my words. "But I do want to ask you. You're the one who's here, and you're the one in pain right now. Is there anything you need for yourself to heal your own pain."
"No." He said resolutely. "She's the one who wronged me."
"Okay, then you can go back to your seat."
Everyone was looking at me like I was crazy. Wasn't I even going to try and change his mind.
I just shrugged.
He wasn't motivated.
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Motivation and Therapeutic Alliance are Two Sides of The Same Coin.
I don't like talking about motivation in therapy. Mostly because I've never been very persuasive. Don't get me wrong, I tried. I mean I used to use "yes sets" on my in home therapy clients [1]. I'm just not good at it.
So because I suck at it, I'm biased.
However, I do think it's an important topic. You can't talk about the therapeutic alliance without also talking about motivation. They are like an optical illusion in therapy, where if you look at it one way the major change factor is the therapeutic alliance, but if you look at it another way the major change factor is client motivation.
Take my client for example. If you look at it from one angle you could say that my client and I had an alliance rupture.
We had different thoughts about the goals and tasks of therapy. But if you look at it from another angle, you could say he wasn't motivated to do the goals and tasks that would help him. Instead he wanted to blame his ex girlfriend.
So the two, motivation and the therapeutic alliance, are really hard to separate out. Which means talking about one naturally leads us to talking about the other. In this post I'm going to go over what we know about motivation, why I think it's a game of diminishing returns, and how you can work with low motivation.
The Transtheoretical Model of Change.
Most people know about the "the stages of change." In the literature it's actually called the "Transtheoretical Model of Change."[2]
(When you say it you've got to say it like you're summoning the god of thunder as your champion in a cage match)
The basic idea is that most treatments fail not because the treatment doesn't work, but because they are mismatched to the patients level of motivation. Ideally, if you match the treatment to the level of motivation, you can dramatically increase your effectiveness.
Or, in layman's terms, the client's level of motivation dictates your intervention. There are five basic levels [3].
Level 1 - Precontemplation
Where the client doesn't think there's a problem.
In medical settings about 40% of clients come to treatment in this stage.
Patients leave his stage once the pros of change outweigh the cons.
Level 2 - Contemplation
Where the client acknowledges there is a problem, but isn't yet ready to change.
Interventions must lower the negatives of changing.
As a rule of thumb 40% of clients come to treatment in this stage.
Level 3 - Preparation
Where clients are getting ready to make a change.
The goal is to lower the cons to change.
As a rule of thumb 20% of clients come to treatment in this stage.
Level 4 - Action
Where clients are actively engaging in changing, and have experienced some change.
The goal is to give them actionable steps to make progress.
Most interventions assume this is where the patient is, hence they fail because they are mismatched to the majority (80%) of patients who are in earlier stages.
Level 5 - Maintenance
Where the client is maintaining the change.
The goal is to help them continue the actions that work for them.
Technically, most clients end therapy in this stage.
It seems pretty straightforward right? Adjust your intervention to that level of motivation, and voila!
Ha.
No.
The problem with the Stages of Change.
Let's say with each level up you move, 20% more people are helped.
So it would look something this:
20% of Precontemplators will turn into Contemplators
40% of Contemplators will turn into Preparers
60% of Preparers will turn into Actioners
80% of Action will turn into Maintainers
Well if you start with 100 Precontemplators here is what you actually end up with:
Out of 100 Precontemplators 20% become contemplators leaving you with 20 clients.
Out of 20 Contemplators 40% become Preparers leaving you with 8 clients.
Out of 8 Preparers 60% become Actioners leaving you with 5(ish) clients.
Out of 5 (ish) Actioners 80% become Maintainers leaving you with 4(ish) clients.
It's a game of diminishing returns. You went from 100 clients down to 4.
At success rates that low most therapists burn out.
So what do you do about it? We'll talk about that next time. ;)
-Fin-
[1] What's a "yes set"? Its a technique from hypnosis that's supposed to make people say yes more easily.
[2] A good introduction to the Transtheoretical Model of Change is Prochaska, James & Velicer, Wayne. (1997). The Transtheoretical Model of Health Behavior Change. American journal of health promotion : AJHP. 12. 38-48. 10.4278/0890-1171-12.1.38.
[3] Technically there is a 6th stage: Termination. However, there's good evidence that this is a ideal and not actually attainable for the majority of clients. See article in [2} for more.
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