How to motivate depressed clients
By Margaret Wehrenberg
Q:“I know how to treat depression, but sometimes, clients just don’t act on my suggestions. How do I motivate a depressed client who says ‘I can’t’?”
A: Getting depressed clients moving is like starting a freight train from a dead stop. The wheels don’t begin by turning rapidly. With groaning and straining, they inch along, slowly completing one revolution. Then, the next revolution is a little faster, but is still an effort. With each passing turn, however, the wheels pick up speed, until the train is clicking along. The energy required to start the movement may be enormous, but the goal isn’t 0–60 in a few seconds: the goal is a few inches.
Depressed clients’ low energy often blocks them from using therapy and making changes in their lives. They may feel physically exhausted, and lack the motivation and mental energy to solve their problems. Depressed clients believe that their low energy means that they can’t comply with therapeutic suggestions. They often respond with, “It’s too much for me,” or “I don’t have the energy,” or “I know I should have. It was really bad of me not to.” These three forms of “I can’t” will stop therapy in its tracks, unless the therapist can turn them into “I will,” by one of the following methods.
Confront the “I can’t” for What It Is
Karen reported, “I know you suggested that I tell my daughter she can’t use my car on the night of my quilting group, but I can’t say no.” When a client says “I can’t,” I suggest she try saying “I won’t” instead, and pay attention to how she feels saying it. Many clients balk, saying, “But I do want to!” I examine with the client whether the reluctance to say “I won’t” is that they want to believe in their “I can’t.” “I can’t” gives them permission not to try. “I won’t,” I explain, gives them power. With “I won’t,” a client takes the responsibility for her misery back from the depression. Simply changing the language can be the first step that creates a little movement.
Encourage Any Step, No Matter How Small
Every action increases energy for another action, so my therapeutic goal is to find a step that a depressed client is willing to take. Sometimes, this takes ingenuity and remembering that even the smallest step is a step forward. For example, if you want a client to take a walk, ask, “Can you imagine yourself walking around the block?” “How about walking one extra block in the morning by getting off the bus a block before your stop?” “No? How about walking to the mailbox?” “No? How about just putting on your walking shoes each morning?”
Break down the action to the smallest first step they think they can do, and that becomes their homework. Apply this to every kind of task. Can a student read one page of the text? Can an office worker make one phone call? Can a house cleaner pick up just one towel? What’s the smallest imaginable step you could take that would require almost no energy to do?
I tell clients that I expect them to feel more energy after they take the step, and if they want, they can capitalize on the “I could do a little more” feeling. On the other hand, there’s no requirement to do more. I honor the client’s effort to overcome her low energy, even for a moment.
Borrow on Future Energy
Saying “just do it” isn’t enough by itself to get a client over the hump of “I don’t want to.” We’re aiming for “I don’t want to, but I will.” To achieve that, I stir clients’ motivation for taking action by having them imagine how they’ll feel afterward. A depressed executive stays home “sick” to avoid returning business calls. Rather than discuss the avoidance, I ask how he’d feel if he did return the calls. He imagines he’d feel competent, which, I explain, would increase his sense of self-worth and give him energy. I suggest he “borrow” on the energy by imagining the outcome, remembering how much he enjoys feeling competent, then, while fully immersed in the sense of competence, make one call. After the one call, he could check his energy and, if he wanted, make another call. But only one call is fine, too. Once the client is motivated to take a small action, I ask if he can commit to it by saying, “I don’t want to, but I will.”
Another way to borrow on future energy is to find out what clients do with their time while depressed. What do they have the energy for? watching TV? reading novels? playing video games? taking naps? You can use that activity as a reward for the one small action they agree to do. The minute they’ve made the phone call, washed the pot, written a paragraph, etc., they may do what they want to do. (This, of course, excludes self-destructive activity, like taking drugs and overeating.)
Jane, a homemaker, was so depressed she was doing the bare minimum: taking the kids to school and opening cans of stew for supper. The rest of the time, she read romance novels and played solitaire on the computer. We worked out a plan to use the activities she had energy for to rev up her energy for tasks around the house. She picked an activity that she really had to get done, but hadn’t had energy for—cleaning the bathroom. We broke it into small steps she was willing to take: carry the cleaning products into the bathroom, pick up towels, scrub the sink, clean the toilet, and so on. Her reward for each activity was 30 minutes of solitaire. When she found herself not wanting to do the next small step, she was to focus on the fact that she was only minutes away from the relief of playing solitaire. Gradually, she began to do more and more of the steps before her reward. Eventually, she did a whole morning of housework, and felt more alive, proud, and in control of her depression.
The process of creating energy in a depressed client is generally slow, but as in the movement of a locomotive wheel, once it’s begun, it gets easier with every turn.
Margaret Wehrenberg, Psy.D., has been in private practice as an addictions counselor and psychologist for more than 20 years. She also specializes in trauma and anxiety, working with adolescents and adults. Address: 4513 Lincoln Ave (Rte. 53), Suite 110, Lisle, IL 60532. E-mails to the author may be sent to firstname.lastname@example.org. Letters to the Editor about this department may be sent to Letters@psychnetworker.org.