TIFT #37 Changing Thought and Behavior

To direct or not to direct change?

Should therapists be invested in a particular target change? Psychodynamic as well as Rogerian Client Centered Therapy have a tradition of holding back opinions and not telling clients what to do. I’m going to argue that our actions should be guided by the same principle as parents. When our clients don’t have a reasonable chance of making a wise choice, then we do them a disfavor by standing by as they flounder. When they are capable, then doing for them what they can do for themselves is infantilizing, sending a message that we don’t respect their abilities. We need to vary the level of active intervention according to the client’s readiness and ability.

Of course, there are pitfalls, discussed below, when we develop opinions about what is best. We need to be thoughtful and ready to let go of our arrogance. We also need to be open about our position and help our client get up to speed in understanding so that they can develop their own informed opinion and, therefore, consent. The worst of both worlds is a therapist who is invested in a goal, but feels obligated to appear neutral. Inevitably, they give off a stream of clues about their own feelings and desires. Of course these are eagerly picked up and interpreted by clients. In the end, being open about our own biases and wishes is less pushy and also less subject to misinterpretation. Openness allows the client to take credit as well as feeling responsible for the outcome.

This is background to the idea that the goal of psychotherapy in general is helping clients trade in EMPs (entrenched maladaptive patterns) for healthier or more satisfactory ones. Implied in this notion is that early in the therapy, we may have more clarity about what EMPs need to change and what might be a better goal. In the course of the therapy, collaboration allows the client to become informed and to take control of the direction of change. If not, mismatch of goals is a well researched reason for treatment failure, so it is vital, in the end, to come to a meeting of the minds.

Readiness for change

A fundamental area where alignment of goals can be at issue is Prochaska and DiClemente’s stages of readiness for change. Unless we are in sync with the client’s level of readiness we are creating a break in the alliance that will need to be attended to. Better not do that. Besides a mismatch in readiness, some people are more resistant to outside influence than others. Motivational Interviewing is designed for people who are more “reactive,” that is, resistant to being told what to do. Alcoholics, for example, often come with years of experience fending off others’ efforts to change them. They learn to resist outside influences and develop a repertoire of techniques and rationalizations such as, “I know what’s best for me.”

Nondirectiveness can be enabling

Sometimes a failure to advocate for change can end up as enabling. If we are too passive, we may become part of a system that locks in the status quo. We may need to face that truth and accept the need to disrupt the relationship to avoid becoming part of the problem. Again, this is most dramatic with addictions, where, at the rare extreme, I have told myself that my role is to be the messenger who names the problem and gets fired for doing so. Hopefully one day, the client, working with some other therapist, will profit from recalling my truthful words.

Interpretation

“Interpretation” is historically one of the first techniques therapists used to help steer clients in what the therapist judged to be a better direction. While an interpretation can be a statement of reality, it can also serve as covert pressure. Suggesting that a thought or behavior has origins in the distant past amounts to code for saying the pattern is pathological. We might as well be aware of the impact of those words. They may be accurate and helpful but they are not neutral. Even if we don’t have a bias, absent an explanation, the client may take our interpretation as a judgment. It might be best to say: “I’m really not sure if this (action or idea) is good for you or not. Let’s consider the alternatives.”

When the client is of more than one mind

Clients are often, if not usually, ambivalent. That means parts of their mind are on board with the alliance, while others are not. We may have the good fortune to find ourselves working with an adult client whose conscious self is strongly allied with a plan for change, though a less dominant part may have opposing ideas. That makes life easier and our influence can be very helpful. As we interact with the adult observing self, besides providing information and experience, our emotional support can be of real help, too. We may carry some weight of authority, but much of what we can do works by principles little different from the encouragement of friends or family. Beyond support, we can strengthen motivation by pointing out progress, painting a picture of the pot of gold at the end of the rainbow, tallying new levels of success, defining goals, and holding our client accountable. There might even be room on occasion for humor and a tiny bit of chiding. These aspects of the alliance make use of ordinary human interaction to support a mutually agreed upon change process.

When the inner mind takes over

Working successfully with the adult client may be ideal, but more often, other parts have different goals “in mind.” Much of psychotherapy is dealing with the “nonconscious problem solver” who has a different solution from the plan we have developed with the conscious adult. This can be manifested as different states of mind and they can change from moment to moment. Just when you think you have an alliance with your adult client, you may find yourself talking to a person who has no awareness of ambivalence and is at odds with you. Not infrequently, clients have trouble splitting into an observer and an experiencer, and the one who is experiencing the therapy may not be on board.

"Neutrality"

One solution from psychoanalysis and psychodynamic therapy is to maintain a relative neutrality, staying in the middle between conflicting desires of psychic agencies. For clients with a strong adult self (ego), this can work out. Just as in Client Centered Therapy, in the absence of the therapist taking sides, the client may still have a good chance of muddling through to a healthy outcome. It is my feeling that in many other circumstances where nonconscious problem solving leads to maladaptive decisions, avoiding clear alignment can do harm. Even if the goal is to minimize tension in the alliance, this kind fo neutrality leaves all sides unhappy. My feeling is that we do better to accept the problems and risks that go with taking the side of health, as ultimately determined by the client.

Working with an active inner self

When we are at odds with the inner problem solver, what can we do? We need to relate to who is there. I have tried arguing with the version of the self in front of me, but I can’t report much success. Perhaps the most effective thing we can do is to model being a good parent to the inner child, showing understanding and compassion, but preventing harm. If the inner child remains obstinate, we  may need to be more quiet and passive. When the childlike part feels more alone, it may trigger a return of someone more adult and better allied with the therapy. In the meantime, the long term solution is to work towards helping the observing self develop understanding of their own inner self. With that, we can turn to helping the adult develop compassion and appreciation for their less mature responses and, essentially, parent a child who has a strong will but does not understand what may be best. I have written elsewhere (TIFTs #1 and 2) about working with the inner child.

Traps that come with taking sides

It is utterly essential to be aware of potential traps that go with active support for change. The more active we are, the higher the stakes. Here are some common dynamics. 

• The client has a pattern of revolt against (parental) authority and the therapist steps into this negative transference. A simple break in the alliance, where the client objects overtly to being pressured, is the easiest to deal with, simply by backing off. More problematic is when the client doesn’t is not aware of the revolt, but quietly thwarts the therapist and blocks change.
• A more troublesome version of this is when the client is unconsciously set on showing how wrong the therapist is. This can involve letting the therapist make suggestions, then, like an unhappy civil servant, following them to the letter to show how wrong they are. The client ends up damaged, and so is the relationship. The only remedy for this dynamic is to withhold suggestions until there is enough therapeutic progress and evidence to bring the whole pattern to the client’s awareness.
• Especially teens and people with addictions are susceptible to playing “cat and mouse.” Here, client and therapist come to represent opposite sides of the client’s own internal ambivalence or conflict. As the client projects off the "good" values, the therapist usually ends up being the killjoy enforcer. In this case, as in the cartoons, the cat (therapist) always loses. We can't take responsibility for another's choices. In this dynamic the client transfers responsibility for one side of their ambivalence, the healthy behavior, to the therapist (or parent), then becomes solely responsible for the unhealthy behavior. Harry Stack Sullivan said we are “participant observers.” This is where we get drawn into the role of participant. Once we become aware of what is happening, we need to use our prerogative to step back into the role of observer and make the client aware of the dynamic. “Oops, I think you are expecting me to be able to make you do the good behavior. Actually I can’t make you do anything. What is it you really want? Let’s explore that.”

The tradeoff

I often find myself in the position of having to let go of my idea or direction to stay close to the client’s. Otherwise, I would risk a breach in the alliance. On the other hand, it may be possible to make a kind of deal. “I won’t push my direction, but I want you to observe this in yourself.” I’m giving the client at least some of what they want, while asking for self-observation in return. In doing so, I’m laying groundwork for later, when the client may be fully ready for the insight.

The influence of social systems

When we want to help clients change thoughts or behavior, we need to have the humility to realize that we are part of a social network and there may be other parts that have equal or greater influence. A common example is the adolescent who wants the therapist to support their independence but has internal ambivalence. Part of the young person wants to stay close to the family even though they are not wholly supportive of independence. A therapist who takes sides may get thrown under the bus when the adolescent reports to the parents that the therapist is against them.

Enabling by family, peers, or even well intentioned government agencies rewarding unhealthy behavior, are often powerful enough to ensure failure to advance towards therapeutic goals. Especially when disability is tied to material support, few humans have the strength to resist, and there is a strong tendency to turn against the therapist who might wish otherwise.

Finally, in situations where there is ambivalence about positive change, therapists may find themselves on the other side of values, personal or cultural.  In such a case, we are risking a serious break in the alliance. Values can be part of pressure from outside, but they can also be internalized and owned by the client such that they are independent of  the social network. These can be just as powerful, if not more. Either way, as I have pointed out many times, values don’t change easily, and when they become impediments to healthy change, we are at a significant disadvantage. An example might be the young adult who is struggling to take on responsibility for their own life, but decides that rescuing a dog or cat is the “right thing to do.” We might believe the rescue to be a way of avoiding responsibility, but if we try to discourage the decision, we become animal haters and the alliance is likely to suffer. Anyway, it is also possible that the rescue is exactly the thing that would allow the client to grow into adult responsibility. In the end, we need to be aware of the power of culture and values and be circumspect about opposing them.

Some thoughts about what to do

What follows is a very informal listing of thoughts that may be of interest in actually supporting change of thought and behavior. Of course a great deal has been written about this, especially in the CBT world. We all need to expose ourselves to those who have specialized in the techniques a certain situation might demand.

Changing thoughts

I’m discussing change of thought before behavior because behavior change is usually built on a foundation of thought, that is, cognitive clarity that behavior change is needed. In both change processes, we are acting much like sales people helping our client look at pro and cons. Many of the same principles apply, including the one that “the hard sell” is not effective. Here are some other principles:

• While being careful not to break the alliance, try all kinds of approaches. It is hard to know what will work, what won’t, and when.
• Stay focused on a positive goal, rather than first criticizing and asking the client to give something up.
• Analyze what needs to change and the reasons in favor of change in the clearest, most specific, and sharpest conceptual terms. It helps to make the difference between the old unhealthy pattern and the new one as sharp as possible in terms the client will relate to.
• Use metaphors and explanations that your client can understand.
• Find the clearest markers for progress and follow them.
• For more difficult kinds of change, use simple slogans that touch the emotions. This is why AA uses sometimes hokey slogans.
• Swallow your pride when the client suddenly “gets it,” having been exposed to information from some outside source.
• Appeal to existing values, such as gaining maturity or greater success.
• When dealing with maladaptive values, be very thoughtful before challenging them. 

Special challenges of behavior change

These are some factors other than psychodynamics that make behavior change difficult. Being aware of them and tackling them using available tools may be an important part of supporting change.

• Bad experiences in the past
• Failed previous attempts
• Lack of hope or positive goal
• Lack of experience (maturity)
• Social pressure
• Enabling
• Personal values supporting unhealthy behavior
• Ideas and rationalizations supporting unhealthy behavior
• Habit patterns (where automatic decisions lead the wrong way)
• Posture and bodily habits that support unhealthy feelings, thoughts, values

Tools especially applicable to behavior change

Besides working on thoughts to support healthy patterns of behavior, some tools are especially useful in supporting behavior change.

• Point out past success
• Humans have a capacity, when absolutely necessary, to put feelings aside and take action. (This may go against today’s values, but sometimes makes the difference.)
• Measure and monitor progress
• Explore reasons for not changing
• Ask who wins (when an unhealthy pattern comes from abuse)
• “Partialize:”  If a step is too big, then cut it in half.
• Suggest accepting that one has to persist in ”Leaning into change"
• Suggest enlisting individuals and groups that will support change.
• Play the roles of coach and cheerleader to the extent that this works.
• Support “experiments” with high likelihood of success.
• Foster a sense of inevitability about success.
• Most people can recognize immaturity and value growing, which is done by practicing new behaviors.
• Elicit the pleasure and excitement of trying new behavior.
• Find ways to reward small successes.
• Explore likely causes of slips and plan to avoid them.
• Plan for and handle slips so they don’t lead to giving up.
• Maintain new patterns for at least 60 days, to increase likelihood of behavior change becoming permanent.
• Pit existing healthy values against unhealthy values.
•  Pit social instinct against unhealthy instinct, for example wanting to belong to AA group vs. instinct to seek substance.

I hope these ideas may help support therapists' willingness to consider active but thoughtful advocacy for change and a deep toolbox when doing so. 

Jeffery Smith MD

 Photo by Tingey Injury Law Firm on Unsplash.