Skills of an effective counselor?: Part 10b
Last week we talked about why motivation in therapy was a game of diminishing returns.
Yes, if you understand the Transtheoretical Model of Change you can help clients move from one stage to the next, but the amount of energy you'd put in wouldn't be worth it.
So if that's the case what do you do?
In order for me to answer that question I have to tell you a story about a man named Chris Voss.
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Chris Voss, "Proof of life", and the Solution to Low Motivation
Chis Voss was the FBI's lead international hostage negotiator. After he left the burro, he started a negation consulting firm called The Black Swan. where he and his team teach the FBI negotiation techniques to business negotiators.
(The main skill they teach? Active listening. Yeah, not what you'd think right?)
Anyway, when Voss got into the business world he realized he wasn't as effective in business as he was with terrorist and kidnappers. It kinda surprised him. He'd had a 90% success rate with kidnappings across various countries and cultures, but in business it was hit or miss.
And then he stumbled upon "Proof of Life."
What he discovered was that at least 20% of time in business there was no actual deal to be had. So why do clients call? Well, instead of a deal, they're wanting to compare prices or pump him for information, do "organizational due diligence," or just because they were window shopping.
This is vastly different than international hostage negotiation.
Kidnappers take hostages because they want something badly. And when they call mom or dad and say, "I've got your kid" their is no one else the kidnapper can call. They can't shop around to aunts, uncles, and cousins to see who will give them the highest rate for the hostage. There's only one buyer.
Kidnappers are highly motivated. The same is not true in business.
Voss's solution to this motivation problem was to start asking "Poof of Life questions." See each negotiation has a "favorite," the one the client really wants to work with, and a "fool," the one the client doesn't really want to work with. The first job of a business negotiator is to figure out if they are the favorite or the fool. The savy negotiator does this through asking questions specifically designed to suss out if deal actually has life, or if it's dead on arrival.
So a negotiator might ask, "Wow, I'm excited to do business with you. But I've got to ask, a company like you could choose anyone. Why us?"
If the client says, "well, we're just trying to do due diligence and assess all our options." Then the negotiator knows any further talks are just a waste of time. She's the fool.
However if the client responds, "well you guys are the best. I mean I saw my friend after she worked with you and wow. I knew I had to work with you," then the negotiator knows she's the favorite, and this client is highly motivated to work with her.
The trick is "Proof of Life" questions separate out the low motivated clients from the high motivated clients.
Okay Jordan, you say, but that's business, how does that play out in therapy?
David Burn, TEAM-CBT, and the Motivation Model.
The guy who's really taken the idea to heart in the therapy world is David Burns M.D. He's a former student of Albert Elis and Aaron Beck, and the founder of a modified CBT called TEAM CBT. TEAM stands for Testing, Empathy, Agenda -setting and Methods
As an early student of CBT Burns found that in the hands of a well-trained therapist the techniques worked really well... sometimes. And sometimes, they just fell on their face.
His search to learn why some clients recovered wonderfully, and why some has lack luster results lead him to the idea that clients resist therapy, so any good therapy has to include motivation work which melts away resistance.
Burns' solution was to develop his "magic button question". You ask the client, "if I had a magic button that would take away all of your pain, would you push it?"
The magic button question, like the proof of life question, is an indirect way to see if the client is actually invested in the change process.
And if they aren't motivated, you move on. That's the trick. You don't try and motivate the unmotivated. You just move on.
Obviously, my above that one question is not Burns' full motivation model. I used Burns full motivation model with 11 groups when I was at the psych center, and 4 out of the 11 times patients weren't motivated to change.
So I sent them back to their seats.
Now that's not a representative sample, but it does make you pause. How many of your clients just aren't motivated to change?
Instead of going into Burn's full motivation model (which should definitely do on your own) I want focus on a curious link between Burn's magic button question and Voss' proof of life question.
Why do all these methods of motivation all prefer indirect questions?
If You Address Motivation Head on You May Rupture the Alliance.
Because of the therapeutic alliance.
Turns out if you address the lack of motivation head on, if you push too hard to fast, which is really easy to do, it's very easy to cause a rupture in the Therapeutic Alliance.
Any parents who's ever tried to get their two year old to go to bed knows this.
Just about every night I tell my two year old, "hey man, it's time for bed."
And just about every night he holds up one finger and says "mah mah mum?" Which means "one more minute?"
And every night I say "okay, one more minute. And then what?"
And every night he says "bah buh" which means "bedtime."
And why do we go through this routine every night? Because I know if I push him, he'll have a tantrum and it will take even longer to put him down, but if I play the game, if I don't push too hard, then he'll go down without a fuss. Most of the time.
Since it's so easy to rupture the alliance you have two options. Your first option is to go really slow and easy [1].
Your second option is to address motivation indirectly. Which means asking Proof of Life or Magic Button questions.
My Perspective on Motivation in Therapy.
Whew!
That was a lot! Let's summarize.
1. Motivation has an outsized impact on outcome.
Too often we therapists beat ourselves up when a case doesn't go as planned. But in reality, oftentimes the case didn't go as plan because the client wasn't in the appropriate stage of motivation. However, the flip side is also true. Often therapy gurus will humble brag about how great they are, but the reality is they've chosen highly motivated clients.
2. Approach gently or rupture the alliance.
Because it's sooo easy to rupture the alliance when working with motivation, you have to remember to approach indirectly. Remember, this is one of those situations where you can't always make things better, but you sure can make them worse.
3. It's okay to pick your clients.
You rarely have this option if you're working in an agency, but if you're in private practice, please feel free to niche down and pick your clients. Turn away unmotivated clients. Even hostage negotiators and founders of therapy fields know when its a losing battle.
If you don't feel comfortable picking your clients, then seriously consider matching your intervention to the client's level of motivation. Different types of clients require different interventions.
Hey Agency Therapists and Counselors, I See You.
I think this is hardest for people who work in agencies.
I really feel for you.
If you're in a situation where you can't pick your clients and you're paid to do a model/intervention that is a mismatch for your client's level of motivation I feel for you.
It can be so exhausting to push for change and not see results. And it can feel hopeless not be able to change how to approach therapy.
So you're stuck. And so maybe that's why you feel tired and burnt out.
Know that you are not alone. I see you.
Until next week.
-Fin-
[1] This is basically what they do in Motivational Interviewing. If you watch Motivational Interviewing client and therapist are just having a conversation with a client. The therapist rarely says much of anything. She just reflects. It's actually really boring to watch, but that's what it takes to persevere the alliance.
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