Tips on Motivating Reluctant Clients

The "Grand Tie" across treatments suggests there are common pathways to change, regardless of how people are treated in therapy. At first I thought there would be common factors in therapy. However, I realised that clients spend less than 1% of their waking hours in therapy sessions. Then I learned that less than 25% of people with DSM-IV diagnoses ever participate in psychotherapy. Next I noted that less than 10% of the population is plagued by the major killers of our time (e.g. smoking, sedentary lifestyles, and unhealthy diets) ever seek professional assistance
(Prochaska, J. (1999) "How do people change, and how can we change to help many more people?" In M.A. Hubble, B.L. Duncan & S.D. Miller (Eds), The heart & soul of change: What works in therapy. Washington, DC: American Psychological Association).

Have you ever felt that you have got stuck with the people you are working with? Ever thought, what am I supposed to do here? Ever wondered what makes it so hard for this person to change ingrained patterns of behaviour? Relax, we have all been there and will in the future probably find ourselves in the same position. As the introductory quote by James Prochaska illustrates, as people we do not put a lot of time and energy into working on some of the most critical issues that we face. In other words we put a lot of time into avoiding change. This is often as much the case for those of us who work with others, and the people we work with.

We often leave situations until they get to a very serious stage before we decide, or are forced to really consider what to do about the problem. By then the pattern of behaviours have often become serious. Are we generally lazy when it comes to change? I think not. If we can understand the change process, then it is possible for us to engage with people in a way that is most helpful for them, and I might add, more rewarding for us.

Early on in my career as a social worker I was searching for the right tools to make me a better practitioner. Although I was using what I had been taught at University, somehow I was just missing the boat. Let me share with you an experience that occurred very early on in my social work career. I was a newly appointed social worker in a hospital team, just out of a four-year degree programme. I received a referral from a general medical ward to visit a man who was admitted after collapsing at work. All the signs indicated that he had a significant alcohol addiction as the toxicology report and liver functioning tests showed. In addition there were reports on his notes that he would regularly come home drunk and urinate in the wardrobe, thinking it was the toilet.

As a new social worker I walked up to this man and said, "Hello, my name is Ken McMaster and I am a social worker here at the hospital. I want to talk with you about your drinking." What occurred next is indelibly etched in my mind. The man looked at me and said, "F... off." By this stage other people in neighbouring beds were listening in on the conversation and I felt a great sense of stuckness. I said a few more things and then got out of there as fast as I could, went back to my office and wondered what I had done wrong. This experience taught me a great lesson and got me very interested in motivating techniques. Let's face it, it was either that or find a different way to make a living.

In my enthusiasm to do things right and assuming that the man would want to talk with me about a particularly sensitive issue, I had really managed to alienate him. I had failed to do the very things that would assist the man to even contemplate what might be important to him and his family, and that was, to engage him in a conversation around decision-making regarding the role that alcohol played in his life and that of his family/whanau.

For any of us, contemplating change is dangerous. It has the potential to take us to places that we may or may not want to go to. In the above example, for the man to acknowledge that alcohol has a profound grip on his life, meant he had to face several possibilities. One possibility was to live with the knowledge that he has a major problem with alcohol and that it is killing him and his relationships with others. Another possibility is in the knowing, he would have had to make the necessary lifestyle changes to live with the reality that alcohol and him are not a great mix. I missed my opportunity to join with this man, assess his level of interest in talking with me about such a serious issue, and invite him to position himself in a place of responsibility. This interaction taught me a fundamental lesson that all of my training had not: create the space for the conversation before you attempt to have it.

This interaction and many more created an interest that I have followed for the past twenty years and that is, how do I engage with people to create the space to even begin to consider the possibility of change.

The Cost/Benefit Analysis 

The Cost/Benefit Analysis is one of the most powerful tools that you can use and I regularly use it in my practice. Draw up a chart like this:

It assists clients to clarify their position regarding their decision to either continue, or to stop, a particular behaviour. Below is the sequence of steps that are useful in developing an effective cost/benefit analysis.

1. Put the ‘change option' in the first space on the left.
2. Put the ‘remain the same' option on the space below
3. Put the ‘costs' in the first column
4. Put the ‘benefits' in the second column
5. Get the client to identify three or four things for each quadrant
6. Go to the quadrant ‘benefits of change' and open up each issue by inquiring:
- What would you notice?
- What would that look like?
- What would that mean to you?
(I avoid what would that feel like as this does not generate tangible differences). The challenge is to generate at least ten benefits by digging down. For example if someone said the benefit was "To have a good relationship", then I would want to know what a good relationship would look like. The person might identify some of the following: to feel valued, to have less tension, talk more openly, share some of my dreams, to do more things together (again we might inquire as to what things the person has in mind) and so forth
7. Go to quadrant ‘costs of staying the same' and open up each issue.
(The purpose is to generate up to ten benefits of change for every one cost in order to generate enough energy for the person to successfully proceed through to the action stage of change)
8. Have the client take a position on their next steps
The purpose of the Cost/Benefit Analysis is about generating a picture of hope. When we are confronted with serous problems, we often only notice the negative things that happen in our lives. Ambivalence is the killer of change so we are inviting the person to take a position - to go with the vision and hopes or stay with same. What would you choose?

Ken McMaster is principal trainer and director of the HMA team. For more information about how HMA can help you with your training needs contact info@hma.co.nz