Motivating people to make changes (iv)

Most of us are ambivalent about making change – we know there are good things about doing things differently, but there are some really comfortable things about sticking with things the way they are.

And if someone tried to ‘make’ us change – we’re more inclined to argue for our old patterns than agree that change would be good!

There are a couple of ways that can help us work through ambivalence without getting into the ‘yes but’ argument that goes no-where. I’ve already mentioned starting with what the person identifies as important to them (that is, what they are already ready to do), as well as offering a number of choices so they can indicate preferences, and retain a sense of control.

But what about the person who has been referred to do something that they either don’t think is important, or that they have little or no confidence that they can achieve? A good example is returning to work…

Here is a heavily disguised example based on a number of ‘real’ cases from my caseload over the years.

Angela is a 37 year old woman who has been receiving compensation for her generalised body pain since she stopped work in 1997. Over this time she has received many therapies including physiotherapy, pain management, various medication trials, and she has also been referred for vocational management to help her to return to work. At the time of the onset of her work disability, she was a bank teller, and her pain was particularly troublesome in her arms, shoulders and neck. Any attempt to help her consider returning to employment has not succeeded, although she has had two children who are now 8 and 6 years old. She is married, and says that her relationship is good.

She maintains her own household, does not receive any home help and can manage most of the usual tasks such as hanging out washing, doing her vaccum cleaning, grocery shopping, and is able to drive. She is involved with her children’s schooling and out of school activities. She exercises daily, taking a 45 minute walk but avoiding any activities when her pain levels are high, and especially involving her upper limbs. She identifies her main coping strategies as medication, exercise and rest. She describes resting as her form of ‘pacing’ because it helps her manage in the latter part of the day.

She identifies her problems currently are excessive fatigue, ‘pressure’ from her case manager who is ‘trying to get me to go back to work’, and of course, her pain. She also says she is bored at home, and thinks she should remain doing her two hours voluntary work a week because ‘that is all I can manage’.

One way of managing this situation is to tell her that she ‘needs to go back to work’ because she is bored. And that she has ‘all the pain management skills she needs’ as she is managing her household tasks and running around after her children. And that now that her children are older, she doesn’t need to be around for them during the day, so she should at least think of working part-time.

In the words of a kiwi brewery advert – yeah right! Those arguments may well be based on logic, but they will go down like a lead balloon! What do you think she will say?

‘But I’m hardly getting through the day now! And I need a nap every afternoon just to get through the day, and no employer is ever going to let me do that. I can’t go back to being a bank teller, that’s how I got this problem! And I’m not really getting bored, I do have my voluntary work which gets me out of the house, so I think I’m doing as much as I can manage, you’re just wanting to get me off the case manager’s case load, and I can’t cope’

Yup, not going anywhere very fast!

An alternative way?

What about reflecting back to her that she seems to be in a bit of a dilemma?

On the one hand even though you do so many things like your walking and housework and kids, you’re feeling pressure to do more, while on the other hand you do feel a bit bored and that’s why you started into the voluntary work. Even though you’ve done some pain management, and as a result you’re exercising, avoiding flaring your pain and keeping on going with your housework, you’re still finding it difficult to keep your energy levels up. So you maybe feel that even thinking about going to find full time paid work is just impossible.


What this does is demonstrate that you are hearing her – even though you are not necessarily agreeing with her.


Then asking her to tell you what is good about her current situation…


Could you tell me what is good about how you’re managing at the moment?


Then ask her to talk about what is not so good about her current situation…


Would you tell me what is not so good about how things are going now?


Then ask her ‘what do you think is the next best step for you?’ or ‘what do you think your options are?’


At this point, it can be helpful to reflect her points back to her – again to ensure she hears that you understand where she is coming from. It’s also important to be clear about the reality of her current situation – that her pain is remaining, her case manager won’t stop ‘pressuring’ her, and that she has some choices. Even not making a decision is a choice with consequences!


Another way of doing this is to present her with a ‘decisional balance’ chart. This is very like the old ‘pro’s and con’s’ chart where the respective options are listed along the left margin, and the ‘good’ and ‘not so good’ at the top. By looking systematically at the ‘good’ and ‘not so good’ things about each option, it’s possible for new options to be discovered, and to clarify and reality test the consequences of each choice.


Good things

Not so good things

Remain on compensation

Regular income

Can maintain lifestyle with children

Keeps pain under control

Case manager keeps hassling

Getting bored

Income doesn’t increase

Can’t stay on it forever

Return to work

Chance to become independent

More interesting

Better socially than remaining on compensation

Develop as a person


Scared pain will be out of control

Difficulty finding an employer

Don’t know what my skills are

Less time with kids

Other options?


Identifying an individual’s values is another way to help them work out which of the options best suits them – the things that are important to them are values, so a ‘good’ choice will help the person maintain things that are important while leaving things that are less important. The therapeutic role is to elicit the person’s values while remaining clear about the consequences of choices made.


In the above case example, it will be important to reassure Angela that her pain won’t get out of control (she does have pain management strategies, although they might need some refining), that she values independence and feels out of control when her case manager starts ‘pushing’ her. You can be clear that at some stage, her compensation will stop, and it is better for her to use her case manager and compensation as a resource (make the most of it) than have it withdrawn unexpectedly.


The next article I will post will cover ways to work with both motivation and confidence. For more in-depth resources on the decisional balance and working with motivation and confidence, the Motivational Interviewing website is a great place to start, as is Botelho’s website. I’ve drawn on those and the ‘Health Behaviour Change’ book by for this post.


Motivational Interviewing: Preparing People for Change (2nd edition) (Miller/Rollnick) (April 2002)
Health Behavior Change: A Guide for Practitioners Stephen Rollnick, Pip Mason, and Chris Butler

Motivate Healthy Habits (Rick Botelho)

Date last modified: 1 March 2008

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