Clients come to therapists feeling that something in their life doesn't work. Either they want someone or something else to change, or they want to change how their beliefs, low self-esteem, tendency toward bad relationships, lack of confidence, or lifestyle is causing depression, anxiety, or just isn't working for them.
For clients who have been mistreated or hurt by families, others, or negative life events, they want to be able to deal with life's blows with equanimity, and release fear and shame.
My first supervisor in graduate school told me, a total neophyte therapist, that by the end of the year, she wanted me to be able to tell her how therapy works to help people change. What a tall order. I've been pondering it ever since.
If you ask clients who have been in therapy-what brought on change? What happened? Was it the relationship with someone you could trust? Was it learning new more adaptive ways of thinking and feeling from the therapist?
Jim Johnson talks about steps to motivate change in his book The Sixty-Second Motivator. Two factors are needed to have good motivation to change. One is finding importance to change behaviors. If there is high importance that is personally meaningful to you to give you something you really want, you are more prone to change the behavior. Also you have to have confidence that you have the tools, skills and knowledge to change. Someone who wants to stop smoking has to be very motivated, and then the appropriate tools, whether it's medication, hypnosis, group support, can help you change.
If you ask clients about motivation to change, they may say they really want to change, but feel stuck in negative patterns of shame, self-doubt, and feeling hopeless. How does the belief that you can't change deter the therapeutic process? If the therapist tries too hard to motivate the client, the client doesn't feel accepted for being where s/he is.
I have had the experience of urging clients to reach out, attend support meetings, get medical help, consider antidepressant medication, only to have the clients leave therapy because they needed for me be in the dark place with them, while still complaining about how terrible it was.
I have also had the opposite happen, but this happens when the client is more open to change. So the question is, how does a person open to change?
Clients who make significant life changes often start not knowing what their goals are or what path they want to take to change. Let's say Jim starts therapy because his significant other has many complaints about his depressed, unmotivated mood and lifestyle. At the time he starts, he might just want his partner to be less critical and more satisfied with him. As it turns out, he is able to gain the confidence in himself to make significant changes in his life and relationship in therapy. But how does this happen, when at the start the waters are so murky and motivation and goals aren't clear?
Is it our caring for the clients, convincing them, plying out the resistant parts and reworking them that creates change? What happens in the brain and from trauma to bring people to the hopeless, devastated place where they don't feel capable of change? They are coming to us begging for us to change them, yet telling us all the reasons they aren't capable, it's too hard, they are not good enough, smart enough, strong enough to change. One client had been unable to work because of traumatic flashback memories of his terrible childhood where he was neglected by parents, beaten by bullies, and frightened most of the time. He has been able to use somatic resources and EMDR to process negative memories so he can live more in the present, but it seems to be more the strength of our relationship, his trust in my explanations and counsel, that have helped him let go of paranoid thoughts and live more fully in the present.
In his article, "Change or Die" in Fast Company Magazine, Alan Deutshman talks ab how we fight change, even in a health crisis. " Severe heart disease is among the most serious of personal crises, and it doesn't motivate-at least not nearly enough. Nor does giving people accurate analysis and factual information about their situations. What works? Why, in general, is change so incredibly difficult for people? What is it about how our brains are wired that resists change so tenaciously? Why do we fight even what we know to be in our own vital interests?"
Dr. Dean Ornish, who motivates heart patients to make radical change, believes you have to appeal to people's emotions, to reframe their ideas of themselves to believe that they can have joy, not through fear of death. Fear isn't a good motivator, joy is. He also found that radical, sweeping, comprehensive changes are often easier for people than small, incremental ones. "People need to make big changes to get immediate rewards, whether in health, weight loss or gains in physical ability. Then they see that the changes are worth it. It's a paradox, that big changes are eaiser for people to make than small ones." For example, patients often stop taking a cholesterol-lowering drug, he says, because they don't actually see the changes or feel better.
While this may be true for physical changes, many clients are too fearful to embrace sweeping emotional or relationship changes.
They need to take it a step at a time.
In spiritual circles, the Law of Attraction, which was highly touted in The Secret, claims that if you believe you can have something good in your life, you will have it. If you order something good off the cosmic menu and put your high vibrational attention on it, the universe will deliver it. Is it the universe delivering, or is it that positive belief in the self motivates you to do the work to get the degree, the job, the good relationship?
One area where we can see big movement toward change is the recovery movement. People may have to "hit bottom", but Anonymous groups using the Twelve Step model of recovery support groups has helped many people let go of various addictions, from drinking and drugs, to food, sex, gambling, debt, and even cluttering. Something about not being alone, seeing others who have recovered, sharing publicly and coming out of the shameful secret places of dysfunction can bring about change. Others may use faith in religion or God to change to become better people.
Are most people motivated to get better, that is, happier, more stable, healthier, more fulfilled in work, love, and meaningful engagement in life? Most would say yes, but feel unable to get there.
Looking at people not being able to take action, I think of clients who feel they don't really want to work to make changes, but want their depression to lift. They fear trying to do things that would increase confidence or help them have relationships because of the tremendous fear of being humiliated by rejection or failure.
What I came to realize in graduate school, was that there is something about the relationship with a safe, trustworthy, understanding therapist that helps promote change. Psychoanalysts call it transference and focus on interpreting the patient's reactions to the therapist, which sometimes seems too much for some clients. Meta-analyses of therapy outcome research from the famous Smith and Glass study and forward show that it's the relationship that matters to clients, no matter which style of therapy the therapist claims to use.
Clients also learn to be more accepting of who they are in the present, when they explore the past with the therapist explaining why they turned out like they are. Negative parents shame and blame the child, who then internalizes the inner badness and carries it forever. "It is better to be a sinner in a world full of saints that a saint in a world full of sinners." Ronald Fairbairn, famous Object Relations Theorist, stated this explanation that the child takes on the badness, thus protected the parents' goodness, since s/he needs to believe the parent is good for her survival. Often this is carried through life, with clients fearing saying anything negative about their parents, even after they have died. One patient I saw over many years learned to take on less burden and take care of herself after gaining more compassionate understanding of her difficult childhood. Was it my having sympathy for her childhood self or reflecting her negative patterns that helped and her "take me in" and change ?
Her change was slow, letting go of dysfunctional relationship and reworking it into a close friendship, taking a long time to finish a Ph.D. and making healthy lifestyle changes, rather than less.
I have led groups for compulsive overeaters. Often change is easier to see in groups, if there are profound or moving moments where members either confront or support each other. Two members really made a mark on each other and acknowledged this, with my reminding and prompting them to think about what they had gotten from each other. N was severely bulimic and had been for years. When she told the group, G was so upset for her health and shared her heartfelt concern. I had been doing this for a few years, but something about G saying this to her made it more real. I told her I would do nightly check-ins with her, since this was her difficult time with overeating and throwing up. She was able to let go of her bingeing and purging within a few weeks, after working on it for years. Both G's and my concern for her helped her to have more concern for herself and stop bingeing and throwing up. G was able to accept the positive feelings of gratitude from N, which was a big deal too, since G has a hard time accepting positive regard from others.
Both in groups and with individual clients, working on boundaries teaches clients it's okay to say no, not do things, give too much away, or worry so much about others' opinions, or work so hard.
People change when they learn from a credible source that conflicts with others can be worked through, needs can be expressed and often met, concerns about personal image can be less pervasive, and feelings can be tolerated and understood.
Is it suggestion of new ideas by believable sources, i.e., the therapist or other group members who have conquered an obstacle? In the group, R admitted she is afraid to go to a gym, because she is so self conscious about her body. N told her she used to feel this way and now she doesn't care about it at all and can enjoy going to a gym, riding her bike, and doesn't worry.
There is something more that happens in therapy. We can see that therapy creates a safe relationship with a trusted expert, fosters self-acceptance and self-awareness, and offers tools for changing beliefs, habits, and patterns. Is there something more that seems more spiritual or magical even? One of my dearest consultants had a sign in her desk for clients that said "Magic costs more."
But maybe there is something that happens when "two or more are gathered." There is genuine caring, cheerleading, enthusiasm, pride, nurturance and even love. Ronald Searles believed that you had to be in love with clients for them to change, kind of like being the good parent they didn't have. There is truth in this.
Jim Johnson P.T. The Sixty-Second Motivator. Dog-ear Publishing, 2006
Alan Deutschman. "Change or Die" in Fast Company Magazine. May 2005.