The following article was written for this site by Marilynne Ramsey, PhD LCSW, Indiana University South Bend. She states: “I thought that people dealing with alcohol would be glad to know that there is a kind of therapy that respects their ambivalence about treatment, and that it might assist people in getting help, not just therapists.” The article seems useful for both therapists and those seeking treatment.

Changing the Change Agent

My Sunday paper has a feature that reviews current self-help books briefly. The writer reads a self-help book, and then produces a list of the “Ten Things I Learned From…” which sum up the book’s main points. On a recent Sunday, a book on the topic of dealing with change was subjected to this treatment. The number one thing learned about change was “Don’t resist it!” Ha! What a joke! All “change agents” know that resistance to change is inherent in people. Change agents include doctors, therapists, counselors, life coaches, bosses and parents to name a few. Change recipients include patients, clients, subjects, employees or children. And the one thing change agents know for sure is that people resist change-or do they?

A prime example of a “change agent” is the drug and alcohol therapist. Clients appear with all levels of motivation, including none at all. The client may have had a run-in with the law and had been ordered into counseling by a judge. His wife may be planning to divorce him and agreeing to treatment may reverse the process. She may have lost her children to Protective Services because of her drug use, and is required to seek treatment before reclaiming her children. These clients would not be in treatment if it was up to them, and they don’t hesitate to make that clear. Therapists have long been trained that this attitude represents “resistance” and “denial” on the part of the clients. Those words often stand in for a judgment of “hopeless case.”

…Resistance is portrayed as an unwarranted and detrimental response residing completely “over there, in them” (the change recipients) and arising spontaneously as a reaction to change, independent of the interactions and relationships between change agents and recipients.
(Ford, Ford, & D’Amelio, 2008, p. 362)

Ford et al. describe this view as “change agent-centric” (p. 362). This view assumes that the change agent has made an unbiased assessment and reality is that the client possesses this undesirable quality. The change agent is not considered as part of the environment, and no consideration is given to the behaviors of the change agent. No mention of the therapist’s level of frustration is any part of declaring a client “resistive to change.” This is changing. The good news is that this attitude on the part of substance abuse counselors is being challenged!

Motivational Interviewing is a new approach using the Transtheoretical Model. It starts with assessing the clients’ readiness to change and employs specific techniques depending on the clients’ current motivational level. Clients with no desire to stop smoking, drinking, or eating themselves to death are not hopeless unmotivated individuals resistant to change. They are just “precontemplators.” Therapists do not need to judge them, or try to coerce them to change. You need only engage in an open collaborative conversation with the client, who remains responsible for his or her own change. Weigh the advantages and disadvantages of using. It’s okay to talk about the benefit that comes from drinking when you visit your parents, or the advantages of methamphetamine use when driving cross country. Also discuss the downside of the behavior, but never use that information against the client in a confrontational way. Motivational interviewing is about tipping the balance between the pros and cons of using through open and respectful discussion.

The Transtheoretical Model identifies stages in the process of changing: precontemplation (not ready to change), contemplation (thinking about changing), preparation (preparing to change), action (actively changing), maintenance (continuing to support the change), and then either termination or relapse (slipping back to the previous behavior). In this process the therapist listens for “change talk” and responds to it strategically. The therapist doesn’t take an authoritarian role. The therapist elicits and draws out change. The client retains his or her self-determination, and acts or doesn’t act with autonomy. No one has to admit that they are powerless over life. Therapists don’t have to argue the benefits of abstinence. Confronting the clients’ denial is a waste of breath. Ambivalence is a normal part of change and not pathological.

So, change agents need to change themselves. Create an environment that is helpful to all, including your “precontemplators.” Clients have the ability to right themselves when off balance. Change takes place in stages, and the counselor carefully builds on the level of change that exists. All of these ideas are consistent with Strengths Perspective (Saleebey, 1997), which views clients in a positive light as people with abilities and strengths, capacities not incapacities. This view of therapy has been a welcome relief to therapists dissatisfied with the deficit-based theories of the past.

This has been the briefest of introductions to this new way of helping people, Motivational Interviewing. For further information on Motivational Interviewing read “Treating Addictive Behaviors” by Wm. R. Miller and Nick Heather. Other authors on the subject include Steve Rollnick, Mary Velasquez and Carlo DiClemente. You might also want to download The Change Book from the Addiction Technology Transfer Center Network web site (www.nattc.org/thechangebook ). It includes a list of needs assessments and readiness to change instruments, an annotated bibliography of seminal works in the field of technology transfer, research articles and links to pertinent Web sites.

Ford, J., Ford, L., & D’Amelio, A. (2008). Resistance to change: The rest of the story. Academy of Management Review 33(2), 362-377.
Saleebey, D. (1997). The Strengths perspective in social work practice. NY: Longman.

Category: Mental Wellness · Mind