Motivating people to make changes (i)


The first of a series about using values and empathy to help people make choices

While I was completing my occupational therapy training, one of the lecturers said our roles was to be ‘professional motivators’. At the time I thought nothing much of it, but today I feel the hairs lift on the back of my neck at the thought of ‘motivating’ people. Motivation can come from an external forcebut how sustainable and deep is the motivation that comes from a loaded gun pointed to the head?

So, how do we introduce a new concept to someone who is doing what they have always done, and landing up with the same result – and a result they apparently don’t want?

Prochaska and DiClemente describe what they call the ‘transtheoretical’ model of behaviour change. They note that people typically move through several phases as they adopt a new behaviour:

  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance

At every point there is a chance of relapse, and people may not spend either much or any time in every phase

This model is great in helping us think about how we engage with the people we work with. Guess what? Some people we work with are nowhere near ‘Action’ phase – they’re thinking ‘What? Who me? You think I should do what?’

Unfortunately, most of our training in health care provision assumes that:

  • the people we will be working with are ready to receive our knowledge/expertise
  • we know more than they do (about what they should do)
  • their health status is the most important thing in their lives (well, we health is important, don’t we?)
  • all they need is for us to tell them what to do and they will go away and just do it

And if they don’t – they’re ‘resistant’, ‘not motivated’, ‘noncompliant’, ‘nonadherent’.

In other words, they should really be listening to us, because we know best.

Even with the best interpersonal skill in the world, if we believe we have the wisdom and the person we are working with doesn’t but needs it, we are putting ourselves one-up, and our client or patient will know it.

How do our patients/clients show us they are not ready for action?

They may

  • say ‘yes but’ to any suggestions
  • become silent
  • become angry
  • deny they have a problem
  • interrupt
  • avoid making a commitment
  • not come back to see you
  • pretend they are doing what you suggest, but actually do nothing

I’m sure you’ve seen any and all of these!

And how do we respond if we notice these things happening?

  • try very hard to convince with logical arguments
  • become prescriptive and judgemental ‘you should’
  • become frustrated and talk about ‘that difficult patient’
  • give them the bare minimum and think ‘I’ve offered it, they have to choose to take it’
  • get very tired and emotionally exhausted

Perhaps we need to think about their response in a different way – could we think instead that the person is just not ready for what we are suggesting, and that we need to understand where they are coming from.

If we think about behaviour change as lying along a continuum from ‘not at all ready’ to ‘chugging along nicely thank you’, one of our first jobs is to identify where this person is in relation to the behaviour change we think is important. Then our job is simply to help the person move one stage along that continuum. That’s all. Some people may indeed take off and just do it, while others may not. Provided we don’t close the door on that person ever moving forward, we can feel satisfied that we have done what we can do.

It’s maybe a little more complicated than that…

Instead of first identifying where this person is in relation to the behaviour change we think is important, what might happen if we asked the person what they think they could do next. Or ask them whether they would like to find out what we can offer (before we go right ahead and offer it!).

And how we go about it may also be worth thinking through.

What would happen if we really tried to understand the good things about their current behaviour? And what they think might be drawbacks of making any changes?

What if we used our empathy and those listening skills we learned about waaaaay back in our training, and reflected to the person at multiple levels just what we understand about them?

Do we leave it there?

No – there is no way I am going to endorse someone continuing with destructive behaviour! I will, however, ask permission to tell them what I know before I provide it, then ask them what they think about what I say.

And I also ensure that they know both my position, that they have a choice that is entirely up to them, and if they decide that now is not the time that they haven’t completely blown their relationship with me.

‘nuff said for now – the next installment will go into more detail on ways to establish rapport and develop those really important interpersonal skills.

Prochaska, J. O., & DiClemente, C. C. (2005). The Transtheoretical Approach: Norcross, John C (Ed); Goldfried, Marvin R (Ed).

Some great references:
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

9 comments

  1. I’m glad I came across this discussion on motivation. Great to hear someone think through this topic. I couldn’t agree more that we seem to think that we are all things to all people and then wonder why they don’t embrace our wonderful advice!

  2. Thanks Linda – I think not only occupational therapists, but probably most health care professionals are taught to give advice rather than assess readiness then elicit self-motivational statements. This approach has really changed my practice, and made it much less likely that I will end up in a ‘yes but’ conversation with the person I’m working with!

  3. Hello again, I have been looking at the topic of empathic intelligence which I suspect relates to this discussion. Roslyn Arnold is an interesting read but with a school focus. The attitude of wanting to get to grips with the perspective of another person makes a huge difference to the reasoning.

  4. Hi Linda
    I guess this would mean that people who can’t interpret social cues (eg Aspergers) would be at a distinct disadvantage in helping people to become ‘motivated’? And that part of ‘getting to grips with the perspective of another’ involves having a strong appreciation of your own self concept so that one doesn’t risk losing sense of self when trying to be empathic with another. So it may be partly about feeling secure in one’s own identity, knowing how to set limits on self and others, and being able to maintain distinct boundaries between self and others. Hmmm, food for thought.

  5. I can’t resist this discussion!! Have been analysing video data in a research project where students and OTs interviewed a client (home visit). My observations were that they were all orientated to solving problems rather than ‘framing’ them. Its not that they didn’t notice that the client had issues around wanting to do more, they just chose to not deal with it – rather they got on with the task of fixing the immediate problems such as bathing. I’m sure the client was happy that bathing was sorted but you do wonder about the rest – how well do we listen? Apart from being secure in our own identity – perhaps we also need to feel secure in our professional role/identity?? Are we governed by the funders?

  6. Linda, this is something I’ve known about occupational therapists since forever! And it’s one of the biggest criticisms that psychologists have of occupational therapists – some therapists are so keen to fix the problem rather than understand the range of contributory factors and address some of the underlying issues.
    I guess that’s why I feel more comfortable personally with conducting a longer than average assessment, and developing a case formulation with a number of hypotheses about what may be a contributory factor – then presenting this to the client and then working together with the client to determine what to do next. I posted on this in one of my first posts on the interdisciplinary team, but wait! there’ll be more coming!
    ps I am still registered as an occupational therapist, but I know I practice a broader than ‘typical’ range of approaches from many…!

    Oh, and yes a lot is about confidence in the professional identity, as well as constraints from funders/purchasers – but remember they probably drew up contracts on the basis of their knowledge about ‘what [x] therapy does’.

  7. I like the idea of a case formulation. Can you give me the fuller ref to the Bond & Bond article that you cite for this? The assessment of the problem is the critical issue – the best therapists take time to do this before deciding what possilbe courses of action may be taken. I remembered being very impressed by a Physio who took considerable time to do an assessment which involved observation and questions about life style mainly – the intervention was spot on. (compared to, here’s another back!)
    You might like to look over my comments on CCT – the conversation still rambling on.
    http://lrobertson.wordpress.com/2007/09/10/student-centered-client-centered/#comment-81
    Cheers, Linda

  8. Hi Linda
    The reference is http://www.amazon.com/Beyond-Diagnosis-Case-Formulation-Approaches/dp/0471982229
    This is the book that I referred to – it’s very cognitive in its approach, but very clear for all that – I also draw some from the case formulation information that is part of the clinical psychology curriculum at Canterbury University. The main person I think of is Dr Fran Vertue who has written some really good work on the topic (but off the top of my head I can’t remember any specific refs – but you could contact her at Canty Uni, Psych Dept)

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