The full quote is actually:
“It’s not that some people have willpower and some don’t… It’s that some people are ready to change and others are not.”
― James Gordon
Oh how true is that. And any health professional will tell you that there’s just no point pushing for change when the person isn’t ready for it. So often we encounter people who are unhappy with their lot in life, struggling with this and that, and yet they just don’t make changes that seemingly sit right in front of their faces. It’s SO frustrating!
Or, in my case, it used to be so frustrating – because a few years ago I discovered an approach that revolutionised my practice and made me take another look at my expectations and beliefs about motivation. More about that shortly.
This post arose out of the recent publication of a paper by Sarah Hardcastle and colleagues from the Health Psychology and Behavioural Medicine Research Group at Curtin University in Perth. “Motivating the unmotivated: How can health behavior be changed in those unwilling to change?”
This paper outlines several theoretical approaches that have given health professionals some powerful tools to use when working with people who could change but haven’t. In order to help people in this space, the authors argue that we really need to understand why it is they don’t have “motivation”. So, what is motivation? Simply put, it’s the desire to do things. And for many of us, we think of it as a “thing” that you either have, or you haven’t. But motivation is a tricky thing – ever been disinclined to go visit someone who’s invited you to dinner, dragged yourself there and then had a fantastic time? Or had one of those ideas that flash through your mind, get all excited about it … but never get around to it? Motivation is a fluid thing and doesn’t always equate to action!
Amotivation, or lacking in motivation, is quite specific to a particular action or set of actions. It may be because a person doesn’t think he or she will be successful if they try. Why bother if you know you’re going to fail? This is about having low self-efficacy, or low confidence and thinking it’s not possible to obtain skills or capabilities to be successful.
Amotivation can also occur if a person thinks it’s going to take more out of them than the rewards from doing it. The costs outweigh the benefits. And it can occur when the effort needed to overcome barriers or to push through feels too much, or the change just doesn’t seem worth it because it’s not that big a deal.
Here’s where I come back to my revolution a few years ago – I found that by using motivational interviewing, I was able to shift the responsibility for making a decision to change back to the person (instead of trying to “make it” happen), but at the same time, recognising the reasons for the person staying where they were. To me, it boils down to respecting that people don’t do dumb stuff for fun. There’s usually very good reasons for them having made a decision, either to make a change, or NOT to make a change. What they’re currently doing works, at least to a certain extent.
Using motivational interviewing, the first and most important thing to learn is to respect the person and take the time to understand the good things they recognise about their current situation. Because there are always some good things about being stuck – it’s easier, for one, than making a change. It’s familiar. It’s worked once or twice. People know what to expect. Change always means disruption somewhere, and that’s not comfortable or easy.
If we look at the reasons I outlined for NOT making a change, and work through them, I think (and so do the authors of this paper!) that there are some things we can do to make change less difficult, and in so doing, build momentum for change.
- Lack of self-efficacy – if someone doesn’t think he or she will succeed, why would they even begin? Personally I think this is a big part of “lack of motivation for returning to work” which is something I’ve seen written in way too many clinical reports. If someone doesn’t think they’ll be successful, how could we make the change less challenging? Increase support? Make the steps smaller? Look at other things the person has been successful in? Find out how they’ve made changes successfully in the past and use that?
- Not valued highly – or, something else is more valued than this right now. Respecting that there is a time and place for things to be done, and that other things in life can over-ride making changes is both authentic and human. It means that this change isn’t yet important enough – so, how do you build importance? To me, importance is about values and what a person wants in his or her life. There are often discrepancies between what we want and what we’re doing, and sometimes this is because it’s too difficult or messy to think about it. I think part of our job as health professionals of any discipline is to help people consider things that are tough. To reflect on the short and long-term outcomes of carrying on in status quo, and the same if we made a successful change. Things we do because they’re more comfortable in the short-term can be incompatible with what we really want long-term. It’s part of my job to help people think about this. NOT, I hasten to add, to “make” them decide in any particular direction. That’s not my job, I’m there to help people think about how their actions today might affect the future, and let them make their own decisions. At the same time, I can choose to reflect the reality of the long-term effects of today’s actions. That’s being responsible as a health professional.
- Feeling the end result isn’t worth it, or that there are too many things in the way – again, to me this feels a lot like addressing self-efficacy. If there are things in the way, or it feels too hard, then part of my job is to help the person find a way that is within their capabilities, and to grab a vision of what it might feel like to have successfully achieved that end result. Asking the person to “look forward” to a few months, years down the track – what would it look like if they made a change that worked? How would this affect what’s important to you? If you decided not to make a change, what would things be like? Would that be what you want?
- Habits making it hard to think about changing – It’s easy to over-indulge on chocolate when there’s one of those “treat boxes” in the workplace. It’s easy to go home and stay at home rather than go for a run if you don’t have running shoes and a change of clothes in your car. Environmental triggers where it’s easier NOT to do a healthy thing make it difficult for someone who’s just not even thought about making a change. Employers, healthcare facilities and both local and central government can make it harder for people to do unhealthy things simply by structuring when and where people can access them. So the carpark a little further from the workplace can make it easier to get more exercise each day, banning smoking from healthcare facility grounds makes it harder to get a smoke break, having healthy options in the “treat box” can make it easier to choose something healthy. This set of changes can feel a bit “nanny state”, but they’re effective and useful when it’s those simple little changes that make the difference between living well, or not.
Motivating for health behaviour change starts with building confidence and importance. Maintaining behaviour change involves a lot more – but that’s for another post. In the meantime, I think Atoine de Saint-Exupery had it right when he said:
“Quand tu veux construire un bateau, ne commence pas par rassembler du bois, couper des planches et distribuer du travail, mais reveille au sein des hommes le desir de la mer grande et large.
If you want to build a ship, don’t drum up people together to collect wood and don’t assign them tasks and work, but rather teach them to long for the endless immensity of the sea.” Antoine de Saint-Exupery
Hardcastle, S.J., Hancox, J., Hattar, A., Maxwell-Smith, C., Thøgersen-Ntoumani, C., & Hagger, M.S. (2015). Motivating the unmotivated: How can health behavior be changed in those unwilling to change? Frontiers in Psychology, 6, 835. doi: 10.3389/fpsyg.2015.00835
This is all so relevant in palliative care. Especially thinking about values, and how what’s important changes when you know time is shorter than you want it to be. The other thing people receiving palliative care have taught me is that for many, it’s fear and misplaced beliefs about what’s happening in their body, and about ‘how you’re supposed to behave’ when you’re seriously ill. I find you’re blog and posts so interesting, there is a significant cross over from what is being learned and researched in the field of chronic pain and long term conditions to palliative care. Thank you for all the work you do to disseminate knowledge and stimulate thinking and debate.
Exactly. I think motivation depends so much on what is valued and what isn’t – as well as confidence. So if you can work through importance and confidence, and really listen to the person, you’re in a better place to help them resolve any ambivalence they have towards doing more healthy things.
Hi Bronnie, this resonated with me too – but in the area of technology adoption. I am so interested in finding the magic path to assist unwilling users to say “yes” to technology (specifically in my world- to use technology well to improve teaching and learning practices). Your summary re-states the findings in my PhD research.
Thanks again for the blog – always a great read!
Thanks Anita, I think it applies to so many situations. In technology I think it’s often about not feeling confident, not thinking it’s important, or worrying about cost/keeping up/feeling dumb. Thanks for taking the time to comment!
Thanks for this post – now I can finally (and practically) see what “motivational interviewing” is all about.
I also appreciate hearing I’m not the only one that believes people aren’t stupid or lazy – they are doing what they have reason to believe is best for them. It makes sense that giving them information and resources is an effective way to change their calculations of “what’s best”.
Yep, MI can be a game-changer, but applied poorly or just without due regard to the spirit of MI, it can be manipulative and ineffective. The perspective is really one of hearing what is keeping the person “in place” – and usually it’s a combination of importance and confidence, and then providing sufficient reinforcement (verbally) and by using values and visualising the alternative futures, plus appropriate support, things seem to work out. And sometimes it’s just not the right time, and then I think it’s most important to “keep the door open” by indicating that you’ll be there when the timing is right.
great post Bronnie and so relevant for people that clinicians often feel are just not wanting to work
What are some good books or other resources you like to learn more about motivational interviewing?
Probably the best site ever is http://www.motivationalinterviewing.org which has heaps of FREE information on it. Then I’d go for the Rollnick, Mason and Butler book (I think there’s a more recent version) – it’s called Health Behavior Change: A guide for practitioners.
There are many training videos on YouTube as well.
Thanks so much.