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?

Changes in Group Membership

Most groups will eventually face the challenge of changing membership. In open groups, people may be joining or leaving the group at any time. Closed groups may have a longer period of stable membership (though people do sometimes drop out), though these groups typically do accept new members at predetermined intervals. The only kind of group that never has to integrate newcomers is a truly time-limited group where members terminate at the end, rather than rolling over into a "new" time-limited group.

Changing group composition through the addition and subtraction of members can be disruptive and distressing. How many clients - perhaps especially those referred for group therapy - have issues with relationships, attachment, abandonment, etc.? And while group work in general is likely to bring out all of these issues, they are most strongly present during hellos and goodbyes.

Goodbyes are hard because they obviously signify a loss. People who are staying in the group may feel abandoned by those leaving (especially if they have abandonment issues). If someone is leaving because they no longer need the group, remaining members may compare and feel bad about their own level of functioning, feel jealous, etc. If someone has had to leave the group because they were not a good fit or unable to participate appropriately, or needed a different level of care, people may worry that they may somehow "mess up" and get "kicked out." Whatever the reason someone leaves, everyone is likely to think about the nature of the connection between them, and what happens to that bond if they are no longer together. Some may wonder whether the ending of the relationship negates its value from the beginning. Then, the remaining members may worry about how the loss will affect group dynamics. Who will take on the roles played by the person who left? Will the group function as effectively? And so on.

Hellos are hard because they can trigger fears of the unknown, as well as personal insecurities (which may, again, be particularly present in those referred for group therapy). People may wonder whether the new person will like them, and whether other group members may like the new person better. They worry how their role in the group will change, and how the overall group dynamic will change. Often, people assume the worst, and may even act as if it were true, disrupting the whole group dynamic. Some people may make assumptions about, or even judge the new person as well. And, of course, the new person is coming in with their own fears about what type of people will be in the group, whether they will fit in, be liked, etc. The group may revert to an earlier stage of group development as it tries to find a new equilibrium with this change in membership.

While both hellos and goodbyes are hard, potentially emotional transitions, they are also incredibly rich opportunities for therapeutic growth, if the group can tolerate them enough to continue doing the work at hand. Sometimes simply naming the fact that it is hard and emotional can allow the work to proceed. Other times, hello and goodbye rituals may facilitate the process (and processing).

Also bear in mind that these issue come up not only for therapy groups, but for all kinds of groups - classes, clubs, teams...even treatment teams. While the challenges may not become a manifest topic addressed by these groups, it helps to consider what members may be experiencing when membership changes. Expect some bumps in the road, and perhaps a period reduced cohesion and productivity as the group tries to sort out everything going on under the surface. However, just as the original group established itself as a unit, we trust that the same thing will happen again.

Do you have any hello or goodbye rituals that you use to ease the way during membership transitions, in any kind of group?

Change is Uncomfortable

A colleague described an interesting part of a training she attended: participants were all asked to move their watches to the opposite wrist. 

If you wear a watch (and most therapists do, since checking the time on your phone isn't really appropriate during a session!), try it for yourself. What do you notice?

Most people feel at least a little discomfort with this activity (and perhaps resistance), even though which wrist you wear your watch on has little actual importance or emotional significance. It's just a habit, based on social convention, which is based on the inconvenience of trying to wear a watch on your dominant arm. The fact that it still makes us uncomfortable to swap wrists highlights how very uncomfortable change really is.

Something about our neurological or psychological make-up makes us creatures of habit. In fact most creatures are habit-driven (if you don't believe me, pay attention to your pet's daily ritual). When our routine is disrupted, it provokes varying degrees of anxiety (depending on the significance of the disruption, our temperament, and other stressors), and we typically want things to go back to the way they were.

This is an important fact to keep in mind as we encourage our clients to change. Change is uncomfortable! It's uncomfortable when it's inconsequential, and it's downright painful when the change has deeper emotional significance. 

Even when change is good, necessary, and desired by the client, it's still going to be uncomfortable. That means that it's quite understandable - normal, even - for a client to experience anxiety, resistance, avoidance, or reverse progress when attempting to make a change they have said they want. It's easy for therapists, and other supporters, to feel a little exasperated when we look only at the "facts:" my client says she wants to change, and then does the opposite! Why is s/he even coming to therapy if s/he doesn't really want help?

Instead, we are better therapists when we remember that change is always uncomfortable, and expect and empathize with the resulting difficulties our clients experience when they consider or attempt change. 

"Underlying Issues"

When people seek therapy to address a problem behavior, whatever that behavior may be (e.g., addictions, eating disorders, impulsive or compulsive behavior), they also usually bring up the issue of "underlying issues" early in treatment.

Some want to focus on behavior change, and bring up "underlying issues" only to request that they not become the focus of treatment, either because "there aren't any," or they're irrelevant to the problem at hand. They are highly skeptical of the stereotype of therapy delving into one's childhood, and assume that changing behavior will be sufficient. Others take the opposite stance, expressing frustration with a focus on behavior change, and asserting that the problem is not the behavior itself, but the "underlying issues" that have caused it. They assume that behavior change will happen automatically if underlying issues are resolved, but intentional behavior change will be transient if these issues are not addressed.

While such requests immediate arouse my curiosity/suspicion about what the person may be avoiding or defending against, or what past experiences are informing their request, I also understand the dilemma. After all, therapeutic approaches have been similarly divided on the most appropriate and efficacious focus for treatment. Psychodynamic and analytical approaches take the latter stance, that behaviors are simply markers of underlying issues, which should be the focus of treatment, with the assumption that resolving underlying issues will also resolve any problematic behaviors. Consequently, interventions focus on uncovering whatever the "underlying issues" may be (for example, via free association, transference/countertransference, etc), and resolving them through analysis, interpretation, and the resulting development of "insight." 

Behaviorism developed in reaction to psychoanalysis, almost as an antithesis. It is no surprise, therefore, that its descendants (e.g., Cognitive Behavioral Therapy) have a reputation for "no-nonsense," short-term interventions targeting behavior change, either by focusing on the behavior itself, or the thought process in which it is embedded. The assumption is that changing behavior, either on its own, or by changing thinking, is sufficient to achieve symptom relief (and avoids the lengthy and therefore costly therapy required to resolve those pesky "underlying issues").

However, most therapists I know (including myself) subscribe to a both/and, rather than either/or, approach - in other words, many of us espouse an approach that integrates the faster symptom-relief of approaches such as CBT, with the longer-term but longer-lasting resolution that comes from addressing "underlying issues." We've probably adopted this stance because we've seen incomplete or transient improvement as a result of a behavioral focus, but also witnessed clients' frustration or discouragement at the slow rate of behavior change when the focus is exclusively on underlying issues.

Because I subscribed to this kind of integrate stance, I was intrigued by the following defense of CBT as a potential access point to "underlying issues."

CBT's focus on symptoms is not meant to be a superficial intervention that has no implications for what lies beneath. Instead, by beginning with the symptoms that are present and accessible, the therapy process has access to what is fundamental and significant in determining the emotional and psychological health of the individual and thereby has the potential to facilitate meaningful and profound change. If CBT were merely a superficial intervention, it would be like weeding a garden by snipping off the top leaves. Instead, CBT interventions begin with the top leaves and follow the organic connections until the roots of the problem have been identified and weeded out. (Pike, Devlin & Loeb, 2004)

What do you think about this question of behavior change vs. underlying issues? How do different approaches you've learned navigate the question? What does it really take to "facilitate meaningful and profound change?"

A Psychodynamic Slant on Motivation for Change

When we think about a client's motivation, probably the most common lenses we use are stages of change and motivational interviewing. We think about ambivalence, and how to shift the balance of pros and cons. We think about resistance, and the overall function of the behavior in the person's life. But we may not always think about identity.

However, the role of identity deserves consideration here, as psychodynamic theorists well know. Specifically, motivation to change seems to be closely tied to whether the behavior in question is ego syntonic or ego dystonic. Something that is ego syntonic is seen as an acceptable part of the ego (i.e., one's self-image, or identity), while something that is ego dystonic is seen as unacceptable to or in conflict with one's self-image.

These terms were developed by Freud, in reference to repressed material and ego defenses, but I learned them in the context of diagnosis. Specifically, I was taught that many of the personality disorders are ego-syntonic (which makes sense if they are based on personality structure), and some Axis I disorders can also be experienced as ego-syntonic, including dysthymia and anorexia nervosa. Various forms of addiction may initially be experienced as a choice, and therefore ego-syntonic, and not become ego-dystonic until well after physiological dependence has locked someone into continuing the behavior. In contrast, the majority of Axis I disorders are ego-dystonic; in other words, they are experienced as being at odds with one's identity, almost like a foreign incursion into the self. As a result, people are generally more motivated for treatment and change.

It makes sense, right? If something feels authentic to your self, you don't feel the need or desire to change it - you don't see it as a "problem," but a reality or state of being. However, if it feels like it's interfering with your true self, it's natural to want or need a solution to the problem. (Note, however, that wanting change to happen does not necessarily translate into feeling like one can or should do anything to bring about change - for example, people who are depressed universally want to feel betterm, but often feel unable to make the behavioral changes providers recommend).

Nevertheless, people enter treatment at all levels of motivation (sometimes because they want change, and other times as a result of external pressure to change) - that means that we are likely to encounter, from time to time, clients who experience the "presenting problem" as ego-syntonic. What can we do to raise these clients' awareness of the dissonance between the problem and their selves?

Two possible interventions spring to mind:
1) Externalizing conversations, a la Narrative Therapy - this therapeutic approach frames the problem as something separate from and external to the client, often by objectifying or personifying it. Then, by beginning to see it as something external, clients are helped to recognize the discrepancies between their own feelings, beliefs, goals, and values, and those the problem seems to be pursuing. For example, my clients with eating disorders can come to recognize that while they're trying to achieve perfection, their eating disorder is trying to kill them. These two goals are mutually exclusive; therefore the eating disorder begins to feel ego-dystonic.

2) Values-based action, a la ACT - while this approach does not intentionally externalize the problem, it does seek to elucidate clients' most deeply held values and goals, and encourages clients to identify and pursue goal-directed behavior that is in line with their values, irrespective of "inner experiences" (symptoms, feelings, thoughts, sensations, urges or memories). This in achieved, in part, through mindfulness and acceptance skills.

Are there other approaches you use or think might be effective with clients who experience their presenting problem as ego-syntonic?

Change Talk

One of the principles of Motivational Interviewing (MI) is that people are more likely to change if they hear themselves arguing in favor of change. However, most people considering change have some degree of ambivalence - arguments both in favor and against change. When someone around them voices only one side of the ambivalence, they are likely to voice the other. All too often, other people who are concerned about someone argue in favor of change, which causes them to voice the other (anti-change) side of the ambivalence. Hearing themselves argue against change then makes change less likely.

Since the goal of therapy is generally to facilitate change, it's important for therapists to avoid that trap, and instead find ways to get clients to voice the pro-change side of their ambivalence. MI includes the follow techniques designed to facilitate this process, which it refers to as "eliciting change talk."

1) Evocative Questions

Assume that the client is ambivalent, and therefore has some concerns suggesting change may be necessary. Ask open-ended questions designed to evoke these concerns. Specifically, ask about the disadvantages of the status quo ("What worries you about this problem? How has this problem gotten in your way?"), advantages of change ("How might things be better if you made a change? What would you like to be different about your situation?"), optimism about change ("What do you think would make it possible for you to change? What supports and abilities do you have that you could draw on? How have you made changes successfully in the past?") and intention to change ("What would you be willing to try? What do you think you might do next?"). Then, when the client offers change talk in response, reflect it back to them (so that they hear themselves saying it again), and reinforce it, while not reflecting or reinforcing aspects of their response that are not change talk.

2) The Importance Ruler

Ask the client to rate how important it would be for them to change, on a scale of 0 - 10 (where 0 = not at all important, and 10 = absolutely crucial). Then ask why they chose that number, rather than 0. (Note that asking the reverse question, why they chose that number rather than 10, elicits arguments against change, and is therefore counterproductive). You might also ask what it would take for them to move from the number they chose to a slightly higher number (e.g., from 3 to 6 or 7).

4) The Decisional Balance

Ask clients what the advantages of the problem are. Sometimes asking about the advantages will lead people automatically to the other side. If not, follow up by asking about its disadvantages. You might also ask about the disadvantages of change, followed by the advantages (note the reverse order - the idea is to end with change talk rather than arguments against change)

5) Elaborate

When a client identifies a reason for change, don't just rush on to find other reasons. Asking the client to elaborate, or provide supporting information for the reason they've identified, reinforces the motivation, and can also elicit more change talk. Ask for clarification, specific examples, descriptions. Make sure that the topic has been completely tapped before moving on.

6) Querying Extremes

If nothing comes of other techniques, try asking about extremes: the most extreme concern the client or others in their life have about the problem ("What concerns you most about this problem in the long run?"), the most extreme possible consequences ("What would be the worst thing that might happen if the problem continues?"), or the best possible outcome of change ("If you changed, what would be the best thing that might happen?").

7) Looking Back

Clients may be able to remember life before the problem began. Ask them to compare these memories with the present situation. This strategy can help develop the discrepancy between the problem, and how life can be without the problem. It may also increase optimism that life can actually improve.

8) Looking forward

Ask the client to describe how they imagine life would be if they were able to successfully change, and what it would be like if they did not make a change.

9) Exploring Goals and Values

Ask about what is most important in the client's life. Exploring what is really important helps develop the discrepancy between the problem and their real goals and values.

To learn more about these techniques, see Motivational Interviewing: Preparing People for Change. Have you tried any of them? How have they worked or not worked with your clients?

Reap Some Rewards

A few weeks ago, I wrote about how clients sometimes get "cold feet," and may change their minds about treatment and change because the positive goals of change take awhile to happen, but the negative discomfort of change happens right away.

From the perspective of operant conditioning, we know that immediate reinforcement is much more effective in shaping behavior than long-term consequences. If the immediate results are negative, and positive results are much more remote, the natural tendency is to decrease rather than increase the changed behavior. Unfortunately, the reverse is also true of many unhealthy behaviors we're trying to change, such as addictions, self-injury, and eating disorders: the immediate result is relief, while the negative consequences generally take longer to develop, with the overall effect of increasing rather than decreasing the unhealthy behavior.

I sometimes suggest to clients that they try to offset this by adding their own positive reinforcers for the changes they are making. Most simply, that means rewarding themselves for small, short-term changes while they are still waiting to see long-term positive results. A slightly more complex way of conceptualizing it is the Premack Principle (named after the researcher who identified it). Premack found that people will willingly engage in a less-desirable activity in order to engage in a more-desirable activity that is contingent upon it. For example, if you tell a child he can go to the park after he cleans his room, he is more likely to clean his room than if you just telling him to clean his room with no contingency. Similarly, I might decide that I will make a favorite meal after going to the gym, as motivation to exercise.

How do you keep yourself and/or your clients motivated through short-term discomfort, to get to long-term rewards?

The Milieu

Merriam-Webster defines milieu as "the physical or social setting in which something occurs." Milieu therapy is treatment that intentionally utilizes physical and social context to intervene with multiple clients, typically as part of inpatient, residential, or day treatment. Specifically, it involves proximity within a safe physical space, and group therapy that builds on a sense of community that forms among clients. While a protective physical environment is obviously a primary purpose of inpatient treatment, I think the social environment has greater overall significance for treatment across levels of care.

Of course, while the physical environment is largely under staff control, the social environment is...not. Sure, we influence it - we establish group guidelines, reinforce adaptive/positive/recovery-oriented behavior, and redirect maladaptive/negative/non-recovery-oriented behavior. However, the specific makeup of individuals in the milieu always influences its atmosphere. Anyone who has worked on a milieu knows what I mean. It may be sunny weather...or the atmosphere may be charged with tension, cloudy with depression, slowed like it's under water, or chaotic with manic or anxious energy. Like mood, attitudes also spread easily from person to person so that a stance taken by a subset of the population can spread to the rest of the clients in the milieu. I'm not sure the exact mechanism by which this happens, but I suspect it is some combination of subtle norming, peer pressure and feedback, and modeling.

Since opening at the beginning of February, we have been lucky to have enough positive and motivated clients coming to our partial and IOP programs to bring the whole milieu up to their level. However, as the more motivated and positive people have discharged, the milieu has recently shifted into a more ambivalent or even negative space. I find it more draining to facilitate groups when the milieu takes on this attitude - it takes more out of me to be advocating for change against the current of the population. There is more undertow. And there can also be more momentum in counterproductive directions. As a colleague said yesterday, the group can "get away from you."

However, even - and perhaps especially - with that kind of group, effective redirection can create a course-change that spreads among the population, and ultimately becomes momentum toward change. It's often the case that people become more positive and motivated as they progress in treatment. When they discharge, there can be a less-positive period (like we're having now), but that is (usually, hopefully) just growing pains in the milieu's development, which ultimately lead the group to a higher level of recovery.

Informed Consent

I'm in an uncomfortable position with one of my clients (at the eating disorders partial hospital program) where there is a mismatch between what she wants and what the program requires - specifically, she is already in what can be considered a healthy weight range, but the program "requires" weight gain up to a BMI of 21. Disagreements over this requirement are not an uncommon occurrence, given that individuals with eating disorders are often highly ambivalent, and have highly distorted thinking. However, it does raise some interesting clinical and ethical questions.

I'd like to frame the issue in terms of two ethical concepts. First, all healthcare providers are required to obtain informed consent for all treatment services. That means clients have the right to be fully informed about the suggested treatment, along with its possible risks and benefits; have the right to accept or decline, with possible consequences of both choices outlined; and have the right to withdraw their consent at any time. Informed consent assumes that individuals are legally competent to make decisions for themselves - i.e., adults with sufficient cognitive functioning to fully understand and weigh the risks and benefits, and make treatment decisions accordingly.

Second, informed consent is closely related to another core ethical standard for social work practice (as outlined in the NASW Code of Ethics): self-determination. Self-determination is the freedom to make decisions for oneself, without coercive influences. It means that clients have the right to decide their own goals and values, whether or not we agree with them. This is the basis for a push toward more collaborative treatment planning, with client-identified goals. The only exception recognized by the Code is when a client's choices present a "serious, foreseeable, and imminent risk to themselves or others;" that is usually interpreted to mean suicidal or homicidal intent. According to Miley, O'Melia & DuBois, in all other circumstances, "When social workers impose solutions, give direct advice, assume the role of expert, treat clients as subordinates, or in other ways control decisions, they thwart client self-determination."

So back to my dilemma. When clients are severely malnourished, it causes cognitive impairments, and may prevent someone from providing truly informed consent. In those cases, it is easily justified for the treatment team to require weight restoration as part of responsible treatment. Even so, it is very difficult (though not unheard of) to get a court order to treat a client against her will - they usually have to consent to be admitted to treatment, though as with all psychiatric admissions the legal status is "conditional voluntary," meaning that their ability to make informed treatment decisions may be impaired.

However, when someone is no longer malnourished, but we're still pushing them to gain weight against their will, that seems to violate the principle of self-determination. Yes, a client's unwillingness to weigh more than ___ lbs may be a "symptom," but over a certain point, it's not a risk issue, so they should be free to make their own choice (of course, this begs the question of what that point is). It seems like our role would be to give the information needed for them to make an informed decision - the physical and mental reasons why we recommend weight gain, along with the possible outcomes of gaining or not gaining. If it's more important to someone to feel comfortable with her weight and still somewhat preoccupied with food, vs. less preoccupation but more body image issues, that's a legitimate decision. Hopefully therapy can begin to shift the centrality of weight and body image in self-worth, which may then lead to willingness to gain additional weight.

An additional issue with consent is that we don't talk with clients about weight gain protocols at the beginning of treatment. It would definitely scare a lot more people off, but it would also be more in keeping with informed consent to tell people that they will be put on a weight restoration meal plan until they reach a BMI of 21. Without that information, it seems a little like a bait and switch - people get involved with treatment, connect to the group and team, and delve into underlying issues, and then find out that, in order to keep those positives, they have to do something they aren't willing to do.

I think that forced weight gain beyond clients' level of consent is a significant reason for relapse. If someone isn't on board and willing to be that weight, they're going to try to get back into their comfort zone as soon as they leave treatment, and getting back into the comfort zone is going to trigger the behaviors that rapidly become compulsive. We might better help clients with long-term recovery by taking things more slowly. But that's just my opinion.

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.

Attrition and the Stages of Change

As I've discussed in the past, there are a complex array of factors that influence the seemingly simple fact of whether someone shows up for treatment. While absences can be a factor at any point in the treatment process, I'm reflecting today on a special kind of absence: attrition. Attrition (in other words, the drop-out rate) is a concern across programs and levels of care, because it affects productivity and financial sustainability. Managers have meetings, and more meetings, on how to reduce attrition. However, in this business, some attrition is inevitable.

To understand why attrition is inevitable, it helps to begin with the Stages of Change, a model developed by Prochaska and colleagues. This model suggests that people go through several stages as they move toward change (though these stages may not progress linearly, and people often go through them several times before reaching long-term change).

1. Precontemplation - The person does not recognize the existance of a problem, or see a reason to change. Denial is a significant factor. If someone enters treatment at this stage, they are just going through the motions to appease someone else.
2. Contemplation - The person is aware that there is a problem, but is ambivalent about change. They weigh pros and cons of both the problem, and of change. Which side is "winning" may vary from day to day, or even moment to moment. People may enter treatment to help them resolve the ambivalence, or when the balance tips more strongly toward change.
3. Preparation - The person has resolved the ambivalence in favor of change, but may not yet know how to go about changing. They begin to take small steps toward change, which may include seeking treatment.
4. Action - The person makes a significant commitment to change, and the time and energy it takes. They begin to actually change their behavior in meaningful ways. This stage may include finally making treatment a priority.
5. Maintenance - Change has happened, and the person works to maintain the changes, and prevent relapse. Changes solidify and stabilize over time. People in this stage may be preparing to leave treatment.
6. Relapse - The person reverts to the pre-change state.

People presenting for initial intake assessment at any level of care may be at any stage of change, but are most likely in the contemplation, preparation, or action stage (because earlier they are unlikely to seek treatment, and later they are likely to have already begun treatment). I would wager that a significant proportion of those who schedule, but do not attend an initial appointment, or drop out after one appointment, are in the contemplation stage. Sometimes people can even verbalize that, and say they're not ready, changed their mind, or were too anxious.

Attrition may also occur during the preparation stage as people try to determine what sort of treatment would be the best fit for them, and during the relapse stage as people either cease to be interested in change, or feel embarrassed about the relapse. In contrast, my sense is that people in the action and maintenance stages are more likely to have planned terminations.

Do your experiences line up with these hypotheses? How do you make sense of attrition?

Coping with the "F-its"

I bet we've all experienced it in one form or another: that feeling that you just don't care anymore right now, that you're tired of fighting, and ready to wave the white flag. I call them the "F-its."

While having this experience is pretty normal, it can also have unfortunate side-effects if it leads to impulsive behavior, or giving in to our worst judgment. For clients trying to change problematic, impulsive, compulsive, or addictive behaviors, the "F-its" create a high risk for relapse. "F-its" may also be more common for people trying to change behaviors, simply because behavior change requires sustained, hard work. It can be draining, and leave little extra energy to cope with life's other challenges. So how do we help clients both reduce, and cope with, the "F-its?"

Reducing the "F-its" is best accomplished by reducing overall vulnerability as much as possible. In addiction treatment, clients are often advised to avoid becoming to Hungry, Angry, Lonely, Tired or Thirsty (HALT). In DBT, clients are taught the acronym "PLEASE MASTER" - to reduce vulnerability, treat PhysicaL illnesses, Eat a balanced diet, avoid Alcohol and drugs, get the right amount of Sleep, Exercise, and do something that gives you a feeling of MASTERy.

Coping with the "F-its" once they occur is a little trickier, for the simple fact that, in that moment, the person doesn't care about coping, or the consequences of not coping. It's only later on, after the "F-its" pass that regret occurs. As a result, recognizing the "F-its" as they're creeping up on you, and responding early is crucial to effective coping. The best response that I've found for that moment is to find ways to rest from the hard work of change. Improving the moment is one set of strategies for giving oneself a break. Distraction, enjoyable activities (other than the problem behavior), socialization, and sensory self-soothing are other examples.

"F-its" can be tackled from cognitive and motivational angles. Cognitively, there is often a train of thought contributing to the "F-its" (for example, "I shouldn't have to work this hard to be normal," "I'm tired of this," "I was better off before," "who cares if I ____ anyway?"), and leading from the "F-its" to action via the road of justification ("just this once," "nobody will notice or care," "I'll get back on the wagon tomorrow," etc.). CBT can be used to identify and challenge these thoughts. At the same time, alternative thoughts supporting efforts to cope can be brought out by helping clients to re-focus on what motivated them to change in the first place.

Finally, normalizing the "F-its," and helping clients regroup and get back on track after behavioral slips is crucial, to prevent a slip from becoming a full relapse.

What do you do to help clients get through the "F-its" without derailing their recovery process?

Reservations

When people talk about recovery - from addictive, compulsive, and problem behaviors of all shapes and sizes - they also talk about relapse: the return of behaviors after a period, short or long, without them. Relapse happens for any number of reasons, usually boiling down to either complacency (having convinced oneself that the problem is in the past and one no longer needs to work at maintaining recovery), or ambivalence - more specifically, having reservations about recovery.

To have reservations means to hold something back, to not be 100% for recovery, but instead to hold on to the possibility of returning to the behavior if necessary, or under the "right" circumstances. Reservations aren't all bad, because they mean that the dominant motivation is toward recovery - the reservation is there "in case." Sometimes reservations are what make it possible for someone to move forward in recovery when they've previously been paralyzed by their ambivalence. For example, someone with anorexia once told me: "It's ok to gain weight now, because I know I could lose it again. It doesn't have to be permanent." While that may sound unnerving, I also know that gaining weight and going through the motions of recovery can bring about biological changes that may put her in a better place to embrace recovery.

Of course, while reservations in recovery may be better than no recovery at all, they can still be problematic. They prevent a full and lasting recovery, and the only way to make one's recovery full and lasting is to come to terms with - in other words, let go of - the reservations. Easier said than done, right? 

The first step is to acknowledge that there are reservations. Because reservations make people anxious, there is a tendency to mislead both other people and oneself about the strength of one's commitment to recovery. Normalizing reservations can help people move past denial.

Once people acknowledge having reservations, it's time to get to the bottom of what they're about - what is the purpose, meaning, or symbolic value of the reservations? Of the behavior? What does the person fear if s/he lets go of reservations?

Just naming that underlying significance can make it easier to let go of reservations. If that's not enough, though, the task becomes figuring out other ways for the person's deeper needs to be met without resorting to problem behaviors. 

All the while, however, it's important to remember that the person may have slips or small relapses along the journey of recovery, and reservations can resurface, or new ones can come along. Recovery is not linear; it's a winding road with unexpected pitfalls. However, it's also an opportunity for deep learning and growth that carry forward, even through the bumps on the road.

The Power of Observation

As every student learns in introductory science (and psychology) classes, all research has a caveat: the act of measuring or observing a phenomenon changes the phenomenon. These unintended observation effects, called Hawthorne Effects, are both unavoidable, and hard to distinguish from the rest of the data.

Now, you may not be interested in research, but you should still be interested in the Hawthorne effect. Why, you ask? Well, as therapists, we are in the business of both observing people, and bringing about change. If observation itself has the potential to create change, it warrants serious thought.

I'm pretty sure the police have been using this idea to their advantage for years. Think about it: everyone is a great driver...when there's a police cruiser in sight. Observation creates change. A trooper only has to hang out in a particular location for a little while, every now and then, in order to get drivers to consistently slow down just in case. Of course, when the police want to catch people being less cautious drivers, they have to stay out of sight - but that's another story.

So, how might this apply to therapy?

1. As we all know, people aren't always accurate self-reporters. There are many reasons for this, but at least one of them is that people adjust their self-presentation when they're with other people, especially when they want the other person to perceive or respond to them in certain ways. This process is usually subconscious, rather than intentional, but it means that we should consider the possibility that we're not hearing the absolute truth. This is most important with actively suicidal or homicidal clients who may be telling us they are fine, in order to have the freedom to act.
2. On a more positive note, expressing a desire or intention for change (whatever the target behavior) increases action toward change. Even simply signing up for treatment can lead to progress, without any other intervention. In fact, a premise of brief treatment is that people tend to have more momentum to pursue a circumscribed change within a limited time period after starting treatment.
3. Wherever someone is the treatment process, we can harness the Hawthorne Effect by judiciously adding more direct observation. For example, having a client observe and track a target behavior, thoughts, feelings - whatever - is likely to change the frequency of the target. You do have to think it through, though - observation has the potential to increase the desired behavior...or the undesired behavior. For example, in the work I do with eating disorders, we sometimes ask clients to track their eating. Some of them find it helpful to have the accountability of tracking it. However, for others, tracking is triggering and leads them to eat less rather than more. This is also another great argument for individualizing treatment - the same intervention can have different effects with different people.

There are probably other ways that the Hawthorne Effect could be a resource (or a liability) in therapy? Are there other examples that spring to your mind?

New Year, New You?

I suppose this could be considered a continuation of my last post on New Year's Resolutions, but while that post focused on the change process, today I want to focus on what, specifically, our culture suggests we try to change as we turn over a "new leaf" for the New Year.

I'm struck by the catch-phrase "New Year, New You," seen in print and television ads (and of course, on line), linked with a plethora of products to help us "upgrade" to a newer, better version of ourselves. Many, if not most, of these products are related to weight loss (diet pills, appetite suppressants, scales, nutrition shakes and bars, pre-made low calorie meal plans, exercise plans or equipment, etc, etc, etc). Then, for those who don't want to lose weight, come the "healthy living" products - super foods, supplements of everything under the sun, probiotics, more nutrition shakes and bars, more exercise plans and equipment.... And of course, we have programs and advice for finding that "special someone" - books, events, and dating websites galore. I've also seen books and television clips on making more money, changing spending habits, communicating more effectively, getting a new job or house...you get the idea.

We all get the idea: We're not ok the way we are, and if we're not working to change and improve...something...there's even more wrong with us.

I don't know about you, but I spend a lot of time trying to help my clients to feel better about themselves for who they are, the way they are. Sure, therapy is about change...but often about changing all the problems that have arisen from the client's belief that she or he is not ok, but inadequate, flawed, worthless, ugly, a misfit...etc. Indeed, one of the dialects in DBT is acceptance and change. The premise is that, while a sole focus on acceptance negates change, focusing on change without acceptance of oneself/the client the way one/she or he is can be demoralizing and interfere with change. Conversely, accepting oneself paradoxically makes it easier and less threatening to work toward change.

So, instead of a "new you" this year, considering trying out a new attitude toward the "same old" you. You may be surprised by the results!

New Year's Resolutions?

Have you made any New Year's resolutions? Have your clients?

As I mentioned a few days ago, I am wary of the whole phenomenon of New Year's resolutions, because they so often take on extreme or black-and-white terms. Think about it: New Year's resolutions most often involve "resolving" to do or not do something from now on. We decide to quit smoking, or lose 15 pounds, or exercise 3 times a week, to put $__ into savings each month, or stop spending money on clothes. Such resolutions are concrete (as we've learned goals "should" be), so it is possible to categorically determine whether or not a person is keeping his or her resolution. You've either kept it or broken it. Black or White.

What's wrong with that? It creates problems both theoretically and practically. Practically speaking, we're all imperfect, and therefore likely to be imperfect in keeping a resolution. In other words, we all break our resolutions sooner or later. If the resolution offers no room for imperfection, the logical response is to give up on the resolution once it's been broken. After all, if we resolved not to smoke in the new year, and we smoked one or two cigarettes one night, then no matter what happens moving forward, we already smoked during the year. Since we broke the resolution regardless, why keep trying?

The end result in practical terms is that we don't manage to maintain a change, and we feel worse about ourselves as a result. Not a result I want for myself, or my clients!

Theoretically speaking, the problem with resolutions is that they ignore what we know about how people change - specifically that it is a gradual and cyclical process rather than a linear or categorical switch. Change is hard! The status quo usually exists for a reason - for example, smoking is relaxing. We have to account for the factors supporting the status quo when we prepare to make a change. For example, if we don't come up with some other ways of relaxing, we're going to have a hard time not smoking! In more technical terms, we have to resolve any ambivalence about the change.

Then, after beginning a change, we have to expect that the new behavior will be tenuous at first. There are going to be days when it is easier and harder, and most likely there will be times when we revert back to the old status quo. If we're measuring success in black-and-white terms, these slips will be seen as failures, and may cut off further efforts at change - in other words, after a slip, we feel like we've failed, and so give up, with a full return to old behavior as the result (i.e., a relapse). However, if we go into the change process knowing that there will be slips, and seeing those slips as an opportunity to learn more about both old and new behaviors, and make adjustments to fine tune our plan for maintaining change, we're more like to ultimately experience lasting change.

Now, I suppose it's possible to make a resolution and be flexible and self-forgiving about the foibles inherent to the change process. It's just hard to maintain that dialectic. For myself, I prefer to frame goals for the new year in alternate forms. For example, what about choosing a theme? For example, healthy lifestyle, or financial stability. You can identify changes that might be part of that (smoking, exercise, spending) but not back yourself into a corner by framing them as resolutions. If you prefer more concrete goals, set the goal for the end of the year (more like we do in treatment planning, where the change becomes the end result, rather than something we expect to see from the beginning). For example, I will be down to 0 cigarettes per week, or be exercising 3 times per week, by the end of the year?

What other strategies can capture and harness motivation to change in the new year, while also taking into account the difficulties inherent to the change process?

Year in Review?

There's something about the New Year that compels people to look back and take inventory of the year that's ending, cataloging the good, the bad, and the ugly. News specials offer a postmortem on the year's political and world events. Other programs remind us of all of the year's celebrity and media gossip. Closer to home, communities and families remember losses and achievements.

As individuals, we and our clients are likely to think back over personal losses and achievements, opportunities seized and missed, regrets and relief. Yet, somehow, saying goodbye to the year itself seems to make the grief and regrets more poignant than the successes. We should expect clients to revisit their losses, real and metaphorical, in one ways or another during the transition between years.

Yet, in spite of the almost-inevitable phenomenon of the year in review, we can work to keep the review from becoming a distortion - magnification, minimization, overgeneralizing, personalizing, and other cognitive distortions may all be applied to experiences from the year. Catastrophizing and fortune-telling may be used to then project negative events into the year to come. However, all of that runs counter to mindfulness (which is, by definition, focused on the present moment) and contentment. Cultivating awareness that an experience was just an experience - a discrete moment in life that need not define the rest of the year, the year to come, or the life in general - can help our clients (and ourselves) move forward unencumbered. 

I will close with these lyrics from the song Seasons of Love, from the musical Rent, which suggest a different mindset for the "year in review:"

How Do You Measure - Measure A Year? In Daylights - In Sunsets - In Midnights - In Cups Of Coffee - In Inches - In Miles - In Laughter - In Strife 

In - Five Hundred Twenty-Five Thousand Six Hundred Minutes. How Do You Measure A Year In The Life? 

In Truth That She Learned, Or In Times That He Cried, In Bridges He Burned, Or The Way That She Died?

How About Love? Measure In Love.

"Measuring" Progress in Therapy

I met with a client's parents today, and was slightly taken aback when the father pulled out a rather elaborate, multi-variable observation plan that he hoped to use to quantify his daughter's progress in treatment. Like many clients and their families, he feels frustrated that mental health care isn't more like other medical care - that we can't run tests and get a definitive diagnosis, nor can we then run more tests to demonstrate a measurable response to treatment. Insurance companies share the idea that a medical model should apply to mental health, and want concrete, observable, measurable treatment goals that demonstrate response to treatment (or lack thereof). However, this desire for black-and-white certainty runs counter to the organic, non-linear process of diagnosis and treatment in mental health treatment.

The challenge for providers is to find a meaningful way to recognize progress, without trying to impose a system of "measuring" or quantifying progress that oversimplifies or runs counter to the therapeutic process.

An example of oversimplifying would be considering complete abstinence the only meaningful measure of recovery from an addiction. In reality, relapse is an expected part of the recovery process for most people, and does not necessarily indicate an absence of progress, or a return to square 1, because the relapse may bring a new level of insight, allow underlying issues to be further integrated, and ultimately result in a new level of mastery over the addiction.

An example of measurement running counter to the therapeutic process would be asking someone to monitor/track their anxiety-related thoughts. To track anxiety thoughts, you have to think about having the thoughts. In other words, the process of self-monitoring actually increases the thoughts we want to decrease. Similarly, trying not to think about something also ends up triggering the thoughts you hope to avoid. In both cases, trying to quantify progress actually causes the symptom treatment is trying to reduce.

So, what is the alternative? How do we help ourselves, our clients, and insurance companies recognize real progress, or the lack thereof?

I think about it from two perspectives. First, I invite the client to imagine and describe their desired end result (e.g., the Miracle Question from Solution Focused Brief Treatment) - both because desired outcomes differ from person to person, and because getting specific about the end result offers insights into what changes need to happen, and what signs to look for to see progress occurring. That leads into the second perspective: looking - carefully and consistently - for incremental (minuscule, even) signs of change.

I look for tiny signs of change, for the better or for the worse, in any facet of functioning: cognitive (e.g., insight, thought process or content, concentration), emotional (e.g., type, intensity, range, appropriateness), social (e.g., isolation, communication), behavioral (e.g., frequency of adaptive and maladaptive behavior), occupational (e.g., academic, work, or volunteer role functioning). It takes careful listening and attention to detail to notice the little changes, little successes or experimentation with new responses...but I see the art of noticing and calling attention to these changes to be a vital aspect of my role as a therapist, because people often don't recognize small changes, but seeing progress, however small, can make or break one's motivation to keep going.

How do you think about/define progress in your work?

Medical Necessity, Revisited

Several months ago, I wrote about the intricacies of "medical necessity" - the criteria insurance companies use to determine whether to pay for treatment. Most basically, treatment is deemed "medically necessary" if:
1) there is a diagnosable (i.e., DSM or ICD classified) mental disorder, with evidence of specific symptoms supporting the diagnosis.
2) the mental disorder causes significant impairment in functioning, in areas such as social, occupational, educational, self-care, and judgment
3) the proposed treatment is consistent with accepted standards based on disorder and level of impairment

Ideally, it boils down to this: the client has a mental health problem that is getting in the way of functioning; treatment is offered that is appropriate for the client and problem; treatment follows a plan and results in improvement. The treatment continues to be deemed medically necessary as long as there is some improvement in response to treatment, but symptoms and impairments continue.

Unfortunately, even this isn't always enough for insurance companies. I have been dismayed to have several conversations with insurance reviewers lately in which they were reluctant or unwilling to cover "medically necessary" treatment (i.e., diagnosis, impairment, clinically appropriate intervention, improvement in response to intervention, and continued impairment) - just because the client was ambivalent about recovery.

I've also written in the past about ambivalence...and so have people far wiser than I. An extensive body of literature has been developed around the centrality of ambivalence in all kinds of behavior change. Much of this literature hinges upon the Stages of Change model, which suggests that people go through five stages during the change process (though not necessarily in a linear fashion, and often several times before lasting change occurs):

1) Precontemplation - the person is not aware of, or at least not acknowledging, the existence of a problem or need for change 

2) Contemplation - the person is aware of the problem, but is torn between staying the same and changing (i.e., ambivalent) 

3) Preparation - the person has decided to make changes and is getting ready to act 

4) Action - the person is actually working on change 

5) Maintenance - the person is working on maintaining changes

Relapse - a return to an earlier stage (e.g., a resurgence of ambivalence) and/or reverting to pre-change behavior - can happen at any point, and the process of change resumes. The ultimate goal is to transcend the maintenance stage - to get to the point where the person no longer has to work on maintaining the change because it has become ingrained. Motivational Interviewing is largely designed to help people work through their ambivalence and progress through the stages of change.

The bottom line of all this is that ambivalence is absolutely normal and to be expected in the course of changing longstanding behaviors. Good treatment - treatment that adheres to acceptable standards in the mental health professions - works with this ambivalence and helps people to resolve it in a way that affirms life. I consider this early part of treatment absolutely necessary, because actual changes can't happen (or at least can't last) until ambivalence is addressed.

I find it deeply disturbing that insurance companies do not want to pay for treatment when the client is ambivalent. I find it even more disturbing when we consider that many behaviors that are a focus of treatment can cost people their lives - drugs, alcohol, eating disorders, self-injury.... If my client has a life-threatening problem and is on the fence about changing, I see treatment as beyond medically necessary - treatment is often the thing that tips the balance in favor of change, and therefore moves the client toward life-preserving change.

If an insurance company sends my client away until they're "ready" and 100% committed to change, what will the cost be? What will the literal cost be to the insurance company when that client keeps needing a higher level of care, and more importantly, what will the cost be to the client in lost relationships, opportunities, or even life itself?

I think it's time to redefine what we as a society consider medically necessary.

Mixed Responses to Recovery Speakers

Anyone who has dealt with problematic or compulsive behaviors (addictions, eating disorders, OCD, etc.), either personally or professionally, has encountered the "self-help" movement in one form or another. The label "self-help" is really a misnomer, however: this movement is really rooted in mutual aid between individuals at various points in recovery from a shared problem. As a result, I prefer to call it the "peer support" model of recovery.

A cornerstone of the peer support model of recovery is the recovery speaker. Most widely recognized as a feature of many 12-step meetings, the speaker is someone who has made significant progress in recovery, and is no longer engaging in the problem behavior. He or she shares a narrative of recovery in order to motivate and guide listeners newer to recovery. Though speakers usually have a great deal of latitude in how they present their stories, a general framework involves talking about how things were when the problem was active, how they managed to stop the problem, and how things are now, in recovery. Examples are included in the text of the AA "Big Book," and many memoirs of recovery from a range of problems.

Many people find these stories moving, and say the stories help them progress in their own recoveries. However, there are also people who find such "war stories" triggering, saying they increase rather than decrease the desire to engage in the problem behavior. 

Sometimes this paradoxical response is related to a specific speaker's approach. There are some speakers who subtly glorify the problem when talking about their lives before recovery - as if they are reminiscing about "the good old days." Some may not glorify the problem...but may also not have a clear sense of how they recovered, and may therefore struggle to offer guidance to listeners. Sometimes the speaker simply spends too much time on the pre-recovery part of the story, and too little time talking about recovery and life thereafter.

The listener's response also depends upon where he or she is in the recovery process. Those who are new to recovery, are highly ambivalent, or feel hopeless/helpless about change seem less likely to find speakers helpful - the message doesn't "meet them where they are." Just hearing about problem behaviors, even when they're described in a negative light, can be triggering for these people. Others' successful change may also serve to heighten a sense of inadequacy or discouragement about one's own less effective change efforts. Finally, if the listener expects to be motivated - or triggered - by the speaker, it tends to become a self-fulfilling prophecy. 

I'm reflecting on this topic today because I accompanied a group of clients to hear a speaker on recovery from anorexia. My clients responded positively, but a few clients from other programs we so triggered they had to leave. Unfortunately, they left just as the speaker transitioned from talking about the problem to talking about recovery. I thought she had some good things to say, that reflected solid clinical theory and intervention...but I also thought some of what she said was potentially triggering, anxiety provoking, or both. If I felt those things, how much more so did the clients?

So, what are your thoughts on recovery speakers? When are they a positive tool for recovery, and when are they counterproductive?