Feature: Motivating Clients

Why the photo of the antenna?  It may become obvious as you read this post – but if not, there is an explanation at the end.

It is not unusual for us to have clients in our offices who don’t want to be there – due to court or employer requirements, or even relationship requirements, such as the spouse who threatens to leave if the other doesn’t get help, or the parent who tells the adult child that (s)he must either get into treatment or move out.  However, even those clients who appear to want to be there, often don’t really want to change.  They are more interested in having someone listen to them, as they talk about all the ways the people in their lives have hurt or disappointed them – and leaving it at that.  While this kind of verbal processing can sometimes lead to new insight and subsequently to change, this is unusual. One session of “venting” leads to another, and another, and unless the clinician is clear on the treatment goals and focused on helping the client implement change, the treatment process could just as easily be replaced by a chat with an old friend or a good beautician or barber.

I think part of the clinical process is motivating the client to take action to pursue their goals.  For a client who is depressed, motivation may be a key element that is missing for the client.  The client is often convinced they are incapable of making positive changes in his/her life; that hopelessness is symptomatic of depression.  An anxious client may fear that, no matter what they try, they will fail, so what’s the point?  Our clients want to feel better and function better, but they come to us because they haven’t been able to make that happen, and they don’t really know anything else to try.  They want us to help but they have no idea how that process might work.

Telling a client to take specific action is not what we are about, normally. As much as possible, competent clinicians elicit goals and commitments from a client in a way that respects their own self-determination – but that is often a slow process. Some clients are so stuck (and, sometimes, our work is so circumscribed by brief treatment requirements) that a gentle, well-placed bit of direction is the right thing to provide. Some clinicians might say, “Here are 3 ways to advocate for yourself with your boss (or fight with your spouse more effectively, or improve communication with your teen, etc.) – let me know how those work,” but wonder why they are not getting anywhere.  We can lay out a list of actions we know support one’s mental health (exercise, enough sleep and nourishing food, reducing substance use, increasing social contact, meditation/prayer) but presenting this list doesn’t incorporate these practices into a client’s life. Making those suggestions gradually over the course of a number of sessions is a good practice, but a wide, strong thread of encouragement needs to be woven into those efforts if they are to be effective.

One approach I have found quite powerful in terms of motivating clients is identifying and commenting to them on the small steps they are making toward their goals – and I do mean small steps.   In one agency where I worked, the required Progress Note form included a question to be answered for each session:  “What progress is the client making toward their goals?”  My responsibilities in that office included reviewing other clinician’s files, and I was often surprised – at least at first – by the number of progress notes in which no answer was given to that question, session after session.  I don’t believe that those clients were all making no progress; perhaps the clinicians were just trying to save time by skipping steps in their documentation, or perhaps they couldn’t think of examples quickly and so let that step go.  But I think another explanation is that the clinicians themselves sometimes didn’t notice the progress their clients were making.  If they didn’t notice, they didn’t remark on those steps to the client, and they missed out on an opportunity to affirm and encourage.

Most of us don’t change quickly.  Change is quite incremental. For some clients, showing up at all for a session is progress. Someone with social anxiety may start with just walking into a coffee shop, or making brief eye contact with others in a safe social setting, or saying hi and then quickly looking away.  If we think about the types of activities used in overcoming phobias – exposure and response prevention – and the level at which we start the exposure, that gives us clues about the level at which progress may begin.  One client who wanted to go back to school but had a great fear of being in an academic setting began by driving into the campus and sitting there for a couple of minutes in his car.  Another bit of progress for him was looking at the college website online for a few minutes.  These actions are real progress.  For someone who has been quite depressed (staying in bed, not bathing, etc.) spending a little more time out of bed and/or dressed and/or bathing more often is a step to celebrate. For a client who has been drinking too much or losing their temper with their children, putting their hand on their phone to call a friend rather than on the bottle (or the child) is quite significant. Asking our clients about these symptoms and how they are changing, and attending to the small successes with them, is motivational for the client – and sometimes, even for the clinician.

If we are to attend to those small successes, we need to know about them, and clients often don’t volunteer that information. Saying, for example, “When you had your first session, you mentioned that you were not sleeping well at all.  How is your sleep now?” is helpful for ongoing assessment.  Another way to get that information is to ask our clients to rate their mood or their functioning on a scale of 1 to 10, and compare it to previous sessions.  Often they don’t remember their previous responses – but we can share that.  “Do you remember that, at your first session, you said your rating was a 2?  Two weeks later it was a 3, and now it’s a 5.  It seems like things are improving for you!”

Another tool for assessing progress is working with the Stages of Change (from Prochaska’s transtheoretical model).  When clients come to us unwilling to change, they are in the Pre-contemplation phase.  As they become more aware of their behavior and related thoughts/feelings, they move toward Contemplation. They have begun to realize how they contribute to their problems, and they have begun to consider the possibility that they could take a different approach. This is progress.  They – and we – may not identify this as progress at the time.  But if we can, and if we affirm their openness to new perspectives, that in itself can be motivating for them.

Sometimes a change is not what they are doing but what they are stopping.  A client who begins treatment obsessed about a former relationship, unable to stop talking about that person, may bring them up less and less.  They may not realize this.  But observing, “You could barely talk about anything but X when you started coming, but in the last couple of sessions you’ve talked about other things more than half the time!”  can help the client realize that, not only is change possible for them, it is actually happening.

The next stage of change is Preparation.  Examples are looking into opportunities for self-improvement, such as joining a gym, taking a class, or beginning to attend a support group – finding out costs, times, etc.  It can involve rehearsing ways to speak to someone the client has previously found intimidating.  While these steps are not yet in the “action” category, they show real movement toward change.  Again, noticing and remarking on these changes helps the client to gain some momentum and hope in their journey.

From this point on in the change process, the progress is more obvious and it is more likely that the clinician will observe it and remark on it.  But the earliest steps toward change are most crucial, and having a sensitive “antenna” through which to notice those steps, as well as remarking on them, can be powerfully motivating for our clients.