Friday, May 10, 2013

DBT's Motivational Approach

When we think about ambivalence and motivation, the first approach most of us think of is probably motivational interviewing. However, DBT also includes interventions designed to enhance motivation, and while there are some clear similarities to MI, there are also some differences.

In particular, DBT addresses motivation by targeting a related but distinct concept: commitment. In fact making a commitment or agreement to do something is a strong predictor of actual future behavior. Therefore, DBT sees eliciting and maintaining commitment as a key therapeutic task. Therapists elicit commitment from clients to participate in therapy, to target particular problems, and implement particular solutions. And it is often not enough to make a commitment once. With longer term choices (e.g., staying in therapy, making ongoing changes), commitments may need to be made and remade many times.

According to Linehan, "the therapist is often functioning like a good salfesperson. The product being sold is DBT, new behavior, a renewed effort to change, or sometimes life itself" (p. 286). As a result of this perspective, DBT borrows from social psychology's insights on compliance - the same insights used in sales. Most notably in this category is the "foot-in-the-door/door-in-the-face" technique. These terms refer to door-to-door sales or charity drives. The foot-in-the-door approach begins by making an initial easy request, followed by a more difficult request, based on findings that those who agree to one thing are more likely to agree to subsequent things. The door-in-the-face approach begins by asking for something much larger than what the asker really hopes to get, and then "settling for" something lesser (what the asker was hoping for to begin with). The idea is that people who say no to one thing feel more social obligation to say yes to the next request if it is reasonable.

While these techniques may seem "manipulative," they are based on a cultural reality, which is that most of us expect to do some negotiating in our social interactions. When we try to go directly for the commitment we are hoping for, the end result is often NOT an agreement from the client (it might be a flat-out refusal, agreement without follow-through, or negotiation to a lesser commitment). Linehan suggests that the "door" techniques can be used instead, to more effectively elicit agreement.

These techniques can be used separately, or combined. When combining them, either can be used first. In other words, a therapist might start with a very difficult request, followed by a fairly easy request, and finally progress to a moderately challenging request. Alternatively, the therapist might begin with an easy request, move to a very difficult request, and settle somewhere in the middle. An example of a combined approach would be first asking a client not to engage in a problem behavior at all in the coming week, then eliciting a commitment instead to not use the behavior on at least one day that week, and finally asking the client to use the behavior on no more than 4 of the 7 days.

A variation of the foot-in-the-door approach is to connect new commitments with prior commitments. This approach is particularly useful when the client seems to be losing commitment, or when current behavior is inconsistent with past commitments. Of course, in doing this, it's important to assess whether the client still feels committted to the prior agreement; clarifying, renegotiating, and renewing commitment may be needed.

Social psychology has also demonstrated that people are more likely to make commitments when they believe they have freedom of choice, and/or when they believe there are no other options consistent with their goals. These two conditions can also be combined, so that the therapist is simultaneously highlighting the client's freedom to choose, and the lack of viable alternatives. How is that possible? There may not be an alternative that would allow the client to reach the goals s/he has, but s/he is free to choose different goals if unwilling to do what is needed. However, the client's choice of goals has natural consequences, which the therapist also highlights.

Of course, DBT also uses other strategies to elicit commitment. Like MI, DBT therapists help clients evaluate the pros and cons of a particular commitment or change, particularly highlighting the advantages of the commitment, while developing counterarguments for any identified reservations about it. Also like MI, DBT therapists may "play the devil's advocate," arguing against the commitment in order to move the client to the opposite side of the ambivalence (the side in favor of change).

Have you ever used these, or similar, techniques to "sell" a client on change? Was it helpful/effective? Why or why not?

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