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.

Juggling

I heard an analogy the other day that was simple and effective.  It might be just the thing to help a client come to terms with the need to prioritize, and find a useful perspective on that process.  While this need may be seen more as the business of a life coach than a therapist,  the mental images people use in coping with life’s challenges can either support their mental health or erode it.

We often hear people say they are overwhelmed with all they have to juggle, or they “have a lot of balls in the air.”  It can be a way of describing the anxiety they experience about “dropping a ball,” disappointing someone in their life, failing to carry out one of their responsibilities, or even just failing to meet their own expectations of themselves. Life in the 21st century is often quite complicated.  Keeping track of our tasks as worker, spouse, parent, friend, homeowner, citizen, etc., can be a tall order.  However, our tasks don’t all have the same level of importance or urgency, and sorting that out is a great help.

One way to look at juggling many balls is to think of the balls as being made of different substances.  One ball might be a tennis ball – able to bounce if dropped – actually, DESIGNED to be dropped.  Another ball might be an apple or an orange – something that, if dropped, will end up bruised, perhaps, but still edible.  Yet another might be made of glass, or china – unable to survive even a short drop without shattering.

We might ask our client to try to characterize the various balls they are juggling.  Which are the glass ones?  The ones that, if dropped, would break and cause significant damage in their lives?  Which are rubber, or plastic, or balls of yarn, frustrating to drop but not really causing lasting trouble?  If you think of the balls you are juggling in terms of the materials they are made of, it may be easier to know which ones you must keep your eyes on – and which ones you can afford to ignore at times.

Clients with depression are often feeling overwhelmed.  Clients with anxiety may be quite fearful  of the consequences of dropping any ball in their life.  This image may help clients narrow their attention to the “glass balls” in their lives and thus manage their distress more effectively.

To sum up – when juggling many balls, ask yourself ‘Which ones are glass, and which ones are rubber?”

 

Getting the tires realigned

Ever drive a car that was way out of alignment? Do you remember how much energy it took just to keep the car going in the right direction? It feels as though one is fighting with the car. And remember how easy it is, by comparison, when the tires are aligned properly?

Of course, there is a cost to getting one’s tires aligned. There is a financial cost, it takes time, it may require juggling other items on one’s schedule. Sometimes it has to get pretty bad before we decide it’s just too difficult to manage anymore; we have to take action. Often, though, once we do, it is such a relief to have things back on track. It’s absolutely worth it.

I think this experience provides us with a good analogy to share with our depressed clients.

There is a cruel irony about depression. When one is depressed, the motivation to do the things that would improve one’s mood is often exactly what is missing. One may know that getting some exercise, or going to a support group, or getting together with friends would help – but it is the nature of depression that those things seem to require more energy or force of will than usual. Hopelessness is also a feature of depression; it is hard to talk oneself into carrying out those actions when depression convinces you that it won’t do any good. Instead of fighting with the car, as with tires out of alignment, it can feel as though we are fighting with life.

We might want to share with our clients the analogy that being depressed is like having one’s tires out of alignment – it makes living, a task that ordinarily take little effort, much more difficult. However, using the tools of mental health (some examples are therapy sessions, exercise, enough sleep, good nutrition, minimal substance use, support groups, social connections with healthy people, keeping a gratitude journal) is like getting your tires realigned. As with tire alignment, using those tools will require time, money, energy, commitment. It takes some effort, but the payoff can be quite remarkable. What was previously burdensome is now undertaken with a lighter heart – perhaps even with pleasure. This sense of working with life instead of fighting it is absolutely worth the effort.

Feature: Tracking Calendars

[NOTE: Until now, all posts in this blog have concerned the use of analogies in psychotherapy. This entry is the first departure from that format. All entries on other topics, like this one, will be titled “Feature:_____________.” These entries will still be concerned with issues and strategies for clinicians. Your feedback about this change is encouraged.]

For a number of years I have been using tracking calendars with some of my clients. In cases in which I think it would be helpful, I describe the process to them and encourage them to try it, and most agree. These are ordinary one-month calendar pages (included in some word-processing software and also available online) that I give to my clients, along with individualized instructions, usually written at the bottom of the calendar. In most cases I ask them to record their mood each day, using a number from 1 to 10, 10 being the best. In addition to this I ask them to record other aspects of their lives, using some letter or symbol we have agreed upon. These may include:

E – days when they have gotten some exercise
S – days when they have had some kind of social contact
A – alcohol use, along with a number for number of drinks
W – a work day on which they did go to work
WX – a scheduled work day when they didn’t go to work
B – a day when they bathed
GJ – completing a gratitude journal
G,FB, D – Gambling, Food Binge, Drugs – incidents of carrying out a compulsive activity
M – any meds taken as prescribed

I also normally ask them to write down a key word if anything particularly important occurs that day – good or bad – the key word being enough to remind them what happened so that they don’t forget to share that in their session.

Sometimes clients have a very hard time choosing one number for their mood on a given day. I tell them to do their best, perhaps looking at it as their average mood for the day – but in some cases have suggested they record one number for the earlier part of the day and another for later.

No client has to track all of these behaviors. It might help to keep the number of items they are tracking quite low, especially at first. Additional items to track might be unusual and/or unique to the client, such as hours on the computer (not at work), incidents of enuresis or encopresis, number of phone calls to a given individual, or number of times they checked to make sure a door was locked.

Research suggests that what we track, we improve. It may be an increase in a given behavior we are after, or it may be a decrease, but whatever we are trying to change, it is more likely to change in the desired direction, if it is tracked. So one of the purposes for this assignment is to facilitate the changes that the client desires.

Another purpose is to “connect the dots” between changes in mood and other factors, such as substance abuse, exercise, and social contact. By keeping the tracking calendar, the client may provide evidence for the theory that exercise and/or social contact improves their mood. In another case, they may see the pattern between drinking days and days immediately following, when their mood worsens.

Yet another purpose is diagnostic. The client may not be able to give the clinician a good picture of their functioning; they may not be able to guess how often they experience a sad mood, or how their personal hygiene routine has changed, or how often they get out socially. If they are willing and able to keep the calendar, that data becomes available. It may change in the process – the client may push themselves a little so that the calendar shows they are making progress – but that’s fine; if the calendar functions more as an impetus to change rather than as tool for assessing a baseline, there’s nothing wrong with that – baselines are useful, but unless we’re doing formal research, they may not be needed.

Some clients will lose their calendars and/or forget to keep them. I have certainly given up on some clients with regard to tracking calendars. But I am fairly tenacious about it and have tried some tactics which have been helpful. I have given the same client a new calendar every week for several weeks in a row, not criticizing, just handing them a new one with the remark that we’ll try again. I have encouraged some clients to keep them in their car so that they wouldn’t get it mixed up with other household items, and so that it would be with them when they came to their next session. In a couple of cases, I had the client fill it out in the first few minutes of their session, once I found out they’d forgotten it, going back over the week in their memory and doing their best to recall. This sends the message that I take this tool seriously and also that any passive-aggressive “forgetting” will not work; they’ll have to do it eventually. In one case the client started to remember to do it at home on her own after a few times of filling it out in the office.

Of course some clients are not entirely honest about the report. This may not really be much of a problem. Whether the client is recording accurately or manufacturing data, the tracking process keeps these various behaviors on their mind and may still lead to improvement, even if less than reported.

Perhaps a more vaguely-defined reason this technique often helps, is that it provides some very specific things for the client to do and sends a message that their issues are not stable aspects of their identity, but rather, aspects of their behavior that are in flux and can be observed. It separates the client from the symptom. It wraps a rational process around what they may see as their own irrationality, and may make it seem more manageable. It may give them hope.

Whatever the purpose, using tracking calendars with a wide variety of clients, to record a wide variety of symptoms and behaviors, has proven useful to me in providing good care.

Power Outage?

In other posts I have written about analogies which present strategies (“shoot an arrow, don’t throw a hand grenade” from The Arrow and the Hand Grenade, April 9, 2013, for example) and analogies which demonstrate empathy to the client (see Analogies as Empathy, July 23, 2013). This entry, unlike these other categories, is about what I will call an analogy of inspiration – one to provide, in broad brushstrokes, an injection of hope or encouragement to a client who is discouraged.

Many of my clients have struggled in relationships – at work, or with a romantic partner, or with their sibs, parents, or children – due to a perceived lack of power. They describe feeling controlled by others, unable to stand up for their own needs or wants, ineffective in setting appropriate boundaries. They truly believe there is nothing they can do about these things – they say they have tried, and it didn’t work, so that’s that.

To such clients we might suggest: It is as though you are living in a house which has electrical power – but there are only three electrical outlets and all three of them are behind large pieces of furniture. You can’t see them, you don’t know where they are, and you can’t access them. But that doesn’t mean they aren’t there. One of our tasks in therapy will be to move the furniture and find the outlets, and help you plug in. It’s not hopeless – it’s just a process.

Teaching , for example, parents how to access the power they have in their families is a complex and often arduous task. Sometimes our task is to show a person who is accustomed to asking politely for power – sometimes even begging – that they don’t have to wait for someone else to bestow power on them, rather, they need to claim what is already theirs. This is not easy, and involves several unfamiliar action steps and a lot of trial and error. But it also involves, early in the process, a shift in perspective – a new belief that, rather than having a power outage, they just can’t find their electrical outlets; the power really is available to them, once they plug into it. This is just as true with coworkers, friends, and adult family.

On a similar theme, we might tell them: “Ever tried pulling on a door you are supposed to push? You can push really hard – you can actually wear yourself out! – and it gets you nowhere. It’s not for lack of effort. You are just exerting energy in the wrong direction. It’s amazing how easily the door opens when you are moving it in the right direction!”

Standing at the Conveyor Belt: Ideas from Marsha Linehan

Marsha Linehan, Ph.D., ABPP, is a professor at the University of Washington. She has written extensively about mindfulness, a mental health strategy that is gaining increasing recognition among clinicians as well as laypersons. In an entry on the website for her training organization (Behavioral Tech), she discusses an analogy comparing our awareness and response to our feelings to standing at a conveyor belt. I cannot cut and paste her work here due to copyright laws, but you can find this fascinating essay here:

http://behavioraltech.org/resources/mindfulness_exercises.cfm?utm_source=Announcing+the+Linehan+Institute+Lectures&utm_campaign=March+31%2C+2014+suicide+eNews&utm_medium=email

At the top of this page, you will find links to three essays. All are worth reading, but the one I’m referring to is entitled, “Watching Your Mind.” The three essays appear to rotate on this page. If the one that comes up on this page is not “Watching Your Mind,” click on that title to find it. The other two essays are “Distraction” and “Participate in Laugh Club.”

If you read this essay and have thoughts about it you’d like to share, please consider posting them below.

If the Shoe Fits……

Sometimes a therapist and a client are just not a good fit. People have reactions to little details about other people that are not rational. Perhaps one of them has a physical feature or mannerism that reminds them of a person who hurt them in some way – but the memory is old and fuzzy and the search for the reason is likely to take the focus away from the presenting issue, and not really yield much help for the client. Perhaps their communication style is out of kilter – they just don’t “get” each other. We encourage clinicians to self-disclose judiciously – but we do a great deal of self-disclosure just by the way we dress, wear our hair, choose our business cards, and decorate our offices. Perhaps something in that first-level self-disclosure puts a client off. Perhaps the reason for the lack of fit is something else altogether – but what it is, is not the point. The point is, it happens. Sometimes there just isn’t a fit.

When this happens, clients may just disappear (miss an appointment and not return phone calls), or cancel and reschedule frequently, or just spin their wheels in the treatment. Or they may say that they’ve changed their minds, they don’t really think they need treatment, they’re not coming back. Unfortunately, at the same time they often decide not to pursue treatment elsewhere – they give up on therapy all together – although working with another clinician might have been extremely productive.

I like to tell clients, finding the right therapist is sort of like shoe shopping. You walk into the store with an idea in your mind of what you’re looking for – and then you think you see it. It’s just the right color, just the right style. You look it over – it’s well-made. And – how about that! The price is even reasonable! So you try it on. Uh oh. It doesn’t fit. It pinches here, it bulges there, it hurts when you walk. That doesn’t mean it is a bad shoe, and it doesn’t mean you have bad feet. All it means is that there isn’t a good fit between your foot and that shoe. Time to go back to searching.

We might suggest to clients that, when you realize that the therapist you are sitting with is just not a good fit for you, the thing to do is NOT to give up on therapy. It is also not to disappear. Tell the clinician that you’d like to transfer to someone else. Your therapist knows these things happen and knows not to take it personally. (And as clinicians, we should know that, if we ARE taking it personally, we need to address that in supervision. This is the case if it happens from time to time. However, if it happens quite frequently, perhaps we do need to explore, in supervision, what we might be doing that sabotages the engagement process.)

So – uncomfortable differences with others don’t mean either party is “bad” or at fault; it’s just not a fit. This idea is relevant in other areas as well. We don’t all want the same things in a partner, coworker, employee, roommate, or therapist, because we don’t all have the same needs and tastes. One person’s ideal roommate might be neat, quiet, and always have their part of the rent paid two days early. Another person’s ideal might be someone who is quite social, a good listener, great with decorating ideas, and willing to live in some disorder. Intimate relationships can be the source of great enjoyment and growth in our lives – but if there is not a good fit, they can also be quite painful. Rejection isn’t pleasant for anyone. Nevertheless, it is possible to tell oneself, “N not being interested in me doesn’t mean I’m a worthless or undesirable person – it just wasn’t a fit.”

When clients begin working with a therapist, or interview for a new job or a new roommate, and the hoped-for connection doesn’t work out, they can remind themselves of the analogy of the shoes: it can be a beautiful, well-made, appropriately priced shoe – but sometimes, despite all its good qualities, it just doesn’t fit. Having to continue the search may be disappointing – but it is not a disaster. Much better to find the right shoes!

A Whole Bookful of Metaphors!

Thanks to a colleague and reader of this blog, I recently learned about a new book that may be of interest to my readers. Here’s a link to the amazon page:

The Big Book of ACT Metaphors: A Practitioner’s Guide to Experiential Exercises and Metaphors in Acceptance and Commitment Therapy, by Jill A. Stoddard, Ph.D., Niloofar Afari, Ph. D., and Steven C. Hayes, Ph. D.

I have not been able to get a copy yet but I would love to post a review. Please contact me if you read this book and are interested in writing a review. Please see “How to Contribute Content” on the Home page in order to contact me.

Guidelines: Strait-jacket or life-saver?

There are two unhelpful approaches that clients may have to the existence of rules, limits, guidelines in their lives. One is to embrace them in a rigid fashion, so that anxiety about breaking rules becomes debilitating, the client has little or no flexibility in adapting to changing circumstances, and relationships are strained to the breaking point. The other is to see Rules as The Enemy, the source of all pain and trouble, the thief of one’s individuality and choices – to be resisted as thoroughly as possible, in all times and places and ways.

Neither of these approaches enables the client to function well in the world, in the major spheres of love and work. However, helping a client to let go of one of these approaches may be a challenging task. Often, a person adopts one point of view or the other relatively early in life – “Rules are my friend,” or “Rules are my enemy,” and may also incorporate an element of this into their sense of identity: “I am a rule-follower,” or “I am a rule-breaker.” Aspects of identity are tough to change.

In my clinical work, I have probably had more clients with the latter attitude than the former, although this may not be true for most clinicians. Some people are not only oppositional as children but take on an oppositional stance as their personal “default procedure” as adults. For these clients, “Rules” often have a strong association to an image of a mean, shaming parent or teacher, someone who seems to be determined to prevent all pleasure in life. I have found that images and analogies are often more effective at enabling a paradigm-shift than logic and reason. Here is an analogy that may enable a “rule-breaker” client to see rules and guidelines in a different and less antagonistic way. (Clients who are at the other end of the spectrum, rigidly embracing rules as a matter of course, may need a gentle introduction to the value of flexibility.)

In the days of the prairie pioneers, during winter storms, livestock kept in the barn needed to be cared for despite the disadvantages of leaving the house. Prairie blizzards could be so severe that visibility was virtually nil, and a person could lose their way traveling even the short distance between the house and the barn. More than one person froze to death because they lost their way on those short errands, and never found it again. So the pioneers developed the practice of erecting “guidelines,” pieces of clothesline, wire, rope, strung from the house to the barn or other outbuildings, before the weather got bad. When visibility was poor, the pioneers would hang onto the guidelines when they needed to go to other buildings. Staying within the limit defined by those guidelines literally saved their lives at times.

My own grandfather was in a flood at the age of 17. He was trapped with some others in a building they feared might catch fire due to a gas leak – but the roadways between were filled with rushing water. After a rope was thrown and secured between their building and one across the street, he and some others escaped by transferring, hand over hand, along the rope through the water. This “guideline” truly saved their lives.

We might see “guidelines” as tools which enable one to navigate a potentially dangerous situation safely, rather than seeing them as a cruel parent or a shaming teacher. The pioneer who erected the “guideline” was not trying to steal anyone’s individuality – he was trying to preserve the person for future freedom. While rule-breaking doesn’t always involve life-threatening situations, many guidelines lead to fewer crises, less drama, more enjoyment, more productive work, and happier, more satisfying relationships. Thinking of these boundaries – whether they are rules, policies, laws, or agreed-upon limits in personal relationships – as guide-ropes to promote safety rather than as a strait-jacket may help clients to establish new feelings, thoughts, and behaviors.

Another image that might work for some clients is that of a lighthouse; the lighthouse says, “here are rocks; here are places where you may wreck, damage your ship, run aground. Steer clear of this place and you will be safe.”

While taking some risks is normal and appropriate, clients who struggle to respect boundaries in their lives often take on unwise risks and end up in avoidable crises. Developing more discernment about boundaries is likely to enable them to function more happily and productively.

Weeding the Garden

Removing weeds without planting something . . . only produces more weeds later.
Eugene Cho

In the treatment process, the client is usually trying to make some changes within themselves or their life. Often the first step seems to be getting rid of something – the self-defeating habits of thinking, the alcohol or drugs, the dead-end relationship. The client may think that, once the offending person, place, thing, or habit is removed, their problems will be over. This is almost never true. Once the removal has taken place, there is a space – and something will soon fill it. What fills it may be constructive – or it may be worse than what was in that space before – or something in between.

In the case of addiction, the client has been living as though their addictive substance or process is the answer to every problem. Bad day at work? Pour a drink. Argument with family member? Have a beer. Car won’t start? Pop open a cold one. Too many bills and not enough money? Time to go see my buddy Johnny Walker. As a result they fail to develop other coping strategies or forget some they used to know – and when they stop drinking, they don’t suddenly have those other strategies. They still have their problems but now, instead of having one inadequate way to cope, they have no way at all. That’s why relapse is so frequent and relapse prevention is so essential. The space that has been left by the alcohol is going to be filled either by healthier strategies – or a return to drinking.

This is true for any addiction – alcohol, other drugs, gambling, food, porn, overwork. The addict is the classic case of the person with only one tool, a hammer, who begins to think everything looks like a nail – meaning, their addiction is their tool and the problems in their life all seem like nails, like they can be dealt with by turning to their addiction. The lack of flexibility in their coping style is a major disadvantage of an addiction.

When they have given up the addiction, their most important immediate need is for something healthier to fill that space. For some it might be exercise. For others it might be 12-step meetings or a spiritual/religious practice. Usually the answer is multi-faceted. It will not be an easy or quick transition – but the alternative is more difficult. If someone’s time has been filled mostly by sitting in front of the TV drinking, and they try to shift to sitting in front of the TV not drinking, they are unlikely to succeed.

This is just as true of other types of changes. If a client breaks up with their partner but has no other supportive relationships and isn’t connecting to healthier people, they will probably begin to feel pretty lonely. That empty space will not stay there for long. The old partner will stop by and, in a lonely frame of mind, the client will chat longer than they might have intended – and before long, they’ll be back together. Or someone else will show up in the client’s life – someone who has no more to offer as a partner than the last person did – but the client will be too lonely to notice that this new road leads to the same place.

This can happen as well with habits of thinking and relating. A client can be determined to stop the self-berating internal dialogue, or the tendency to blame and judge others, or a pattern of trying to run other people’s lives – but unless she works to adopt more affirming or grateful or otherwise positive approaches, she will soon be back into the old habits. One use of therapy may be to identify and rehearse new ways to think or relate, to replace the old ways.

Eugene Cho’s analogy, in the quote above, suggests that if gardeners remove weeds from a patch of ground, but plant nothing in their place, weeds will soon take over once again. Once weeds are removed, something more desirable can be planted – and as it grows, it will crowd out the weeds (with some careful tending). I think this is true – and this analogy may be accessible to many clients. Whatever change the client is hoping for involves both removing the old behavior, habit, or situation, and incorporating something new into his life, to stop the old from returning. Often there is some anxiety involved in incorporating something new – but skipping this step is simply not an option if the client wants the old trouble to stay away. The therapist’s task may be to help the client figure out “what to plant,” and how to nurture it so that it takes root in his life.