Friday, March 9, 2012

Cold Feet

Last month, I wrote about the stages of change, and how they influence who comes to treatment - and who drops out. It seems to hinge on the degree of ambivalence. When the advantages of changing, and the disadvantages of not changing outweigh the disadvantages of changing and the advantages of not changing, people are motivated to enter/continue treatment. When the opposite is true, people are less likely to begin, and more likely to drop out of treatment.

I initially thought people in the action and maintenance stages were unlikely to drop out of treatment, and more likely to have planned terminations when they felt able to maintain changes on their own. However, I overlooked another possibility: ambivalence may resurface during the preparation, action, or even maintenance stages if there is a shift in the balance of advantages and disadvantages. This kind of shift seems not only possible, but very likely, and therefore important to consider as we help clients through the change process.

Why would the balance of advantages and disadvantages shift? Well, when people initially wrestle with ambivalence during the contemplation stage, and reach sufficient resolution in favor of change to move them into the preparation and action stages, the process and impact of change are hypothetical. People tend to imagine the ideal end result of the change process, but may not consider (1) the possibility that change may have other, less-ideal effects, or (2) what the process of change might be like before they reach the desired end state.

When the problem has been going on for any length of time, it can be very hard to imagine anything different. The experience of change is even harder to conceptualize without having been through it. As a result, clients often experience difficulties they didn't expect. After all, change is an uncomfortable, and sometimes messy business. The difficulty of the change process may cause clients to reevaluate the pros and cons of change...with some new additions to the cons column. And, since the desired outcomes tend to be more long-term than short-term, people may discount some of the pros because they're not experiencing those benefits right now. At the same time, making changes can paradoxically highlight the ways a problem may have felt helpful or necessary, further decreasing motivation for change. The result is an attack of "cold feet" that can sometimes lead clients to drop out of treatment.

It seems logical that, if people aren't experiencing the benefits they hoped for, but are experiencing more discomfort than expected, and are reminded of the ways a problem may have served them, they may decide they don't want to change after all. A key clinical intervention is to help clients ride out this shift in the balance of pros and cons in a way that keeps them motivated for change. We can do that by helping clients remember the negative aspects of the problem that prompted their desire for change, assuring them that the discomfort of the change process is time-limited, and helping clients recognize incremental progress toward their end goals. (However, we also have to be careful to avoid arguing too strongly in favor of change, lest the client respond by arguing against change all-the-more strongly - see this post on resistance. The trick is to get the client to state the argument for change). If we consistently monitor motivational issues that might arise, and intervene in this way, hopefully we can warm up any "cold feet" and maintain our clients' momentum toward their ultimate goals.


  1. Great post. Actually, I recently did a post that seems related to your topic. It talked about how sometimes a client starts to feel a little bit better after a few therapy sessions. Because his suffering has decreased, he decides he doesn't need treatment anymore. I talked about it in terms of how negative emotions can serve as motivation for treatment. But the stages of change are relevant as well. Like you say, the cons start to outweigh the pros and the motivation for change shifts.

  2. Good point. I think this happens pretty frequently, that the intensity of a negative emotion (or other consequence of the presenting problem) motivates someone to begin therapy, but as soon as things begin to improve, the balance of positives and negatives shifts, and motivation for change decreases. I try to get people to remind "me" (themselves) why change felt important to begin with, as a way to keep some momentum.