Thank you to everyone who responded to our January Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
January Quandary: Many of my clients like to talk about their New Year’s resolutions, like eating better, exercising more, being kinder to their spouse. But I’ve found over the years that as excited as they may be at first to change their habits or behaviors, they often get discouraged, even despondent, when big changes don’t occur and they don’t meet their expectations for themselves. What are some concrete strategies, or even metaphors, I can use to help my clients start the new year with hope and not get overwhelmed with disappointment?
1) Experiments, Not Obligations
There’s nothing like the start of a new year to inspire efforts toward growth and change. It’s the proverbial turning of the page, with exciting next chapters full of possibilities. But almost everyone can identify with the experience of past New Year’s resolutions falling by the wayside. When this happens to clients—and myself—I give a reminder that having a goal is always better than not having one. Positive change is more likely to happen with an objective in mind. Instead of seeing resolutions as a test they pass or fail, I encourage my clients to view them as experiments or opportunities. Even if they don’t end up sticking with a goal, they’ve probably moved the needle a bit and learned things along the way that they can apply down the road.
Examining so-called “failed” objectives presents an opportunity for us to get curious about why these goals feel important to us—why they matter, what changes they might bring about, and what unconscious blocks might be undermining our efforts.
Personally, I draw from Motivational Interviewing when helping clients set goals. I try to stay as empathic and optimistic as I can when working to understand a client’s challenges. It takes a lot of active listening. Through that, I get a full picture of the resolution’s meanings, obstacles, and the client’s frustrations. Only afterward do we begin the collaborative process of making the goal S.M.A.R.T., as I like to say—Specific, Measurable, Attainable, Relevant, and Time-based. I help clients make their plan flexible and palatable, too. Last, I try to inspire joy and help clients discover fun and meaningful rewards in the small achievements along the way.
In goal-setting, we tend to think too much about the end product and not enough about the process. If the journey is the reward, then any movement toward a goal is better than not taking the journey at all.
Mary Garwood Yancy, PhD
2) Take a Systems Approach
Our difficulty with keeping promises goes all the way back to Adam and Eve and the forbidden fruit. We all know how that worked out!
If precedent isn’t enough to give us pause, consider the research: a recent U.S. News and World Report survey found that nearly 80 percent of New Year’s resolutions fail by February.
Despite our good intentions, part of the problem is that all such resolutions contain an unacknowledged lie. The changes we’re fully motivated to make are ones we usually implement right away, without waiting until New Year’s Eve or some similar occasion. Thus, resolutions begin with two strikes against them—they’re changes we hope to force upon ourselves, and only when the time comes. In the meantime, an often-unacknowledged purpose of the resolution’s timing is to permit us to engage in whatever detrimental behavior we’re engaging in for just a little while longer.
For a resolution to be effective, it can be helpful to bring other people into the equation. It’s one reason why people trying to stop drinking who regularly attend Alcoholics Anonymous have better abstinence records than those who don’t. A Philadelphia study of patients with hypertension by primary care doctor Tana Fishman found that patient compliance improves when doctors ask their patients to identify someone in their life who loves them and can help them stick to treatment. In the study, patients called these loved ones in front of their doctors and asked them to help them stay on track. It worked. We can do the same with our clients.
When it comes to helping clients meet their goals, there’s also room for us to get creative, even with the consequences. We’ve known therapists who arranged wagers with their clients. One made a bet to write a check to a nonprofit of the client’s choice if the client met his goal. If the client didn’t, then the client would mail a check to a nonprofit of the therapist’s choice. Whatever the outcome, both the client and therapist could have a good laugh afterwards.
Jay Lappin, MSW, LCSW
The Minuchin Center for the Family
Jay Efran, PhD
3) Motivation Goes Both Ways
The fact that clients talk about wanting to better themselves but don’t follow through can indicate ambivalence, a lack of responsibility, or a strong self-critic.
As the therapist, I’d first ask the client about their motivation for wanting to improve. Is it coming from within, or from some external factor? Do they really want to change? Do they believe if they lose weight, for instance, they’ll be more loved? That they’ll have a better self-image? When we explore motivations with clients, we help them reorient and set realistic goals. They might still want to make improvements, but perhaps by talking with a trusted professional, they’ll think and behave more rationally.
If I was working with a client who had trouble setting goals, I’d encourage them to write a list of pros and cons to see what they’d gain or lose by reaching their goal. Often, there’s a hidden gain in not changing that people aren’t aware of. Many times, it means not having to take responsibility for something.
If this is the motivation to not change, we’d work on that. There’s an exercise called contraskill that’s great for this. Let’s say the client’s goal is to get in better shape, but they aren’t taking any proactive steps to do so. I’d ask the client to teach me how to not get fit: What’s their process? What do they do (or not do)? How long do they spend doing it, and what techniques do they employ to stay unfit? This exercise shows the client a) that they’re an active participant in their own reality, and b) how much time and effort they dedicate to this behavior. Then, we think about what choice they’d like to make now that they have this new perspective.
Since it sounds like these clients do a fair bit of self-berating, I’d also want to help them confront their inner critic. I’d have them ask it questions like, “Why are you sabotaging me?” “What do you want?” “What’s your goal?” I’d explain to the client that sometimes this inner saboteur wants to protect us from disappointment, and while it might have good intentions, the result , paradoxically, can still be disappointment. I’d ask the client to try to understand the inner critic’s intent, thank it for trying to help, and if they agree with any part of what it’s saying, to acknowledge that. From there, the client can decide on a path forward.
Mirka Jelic, psychologist
St. Neots, United Kingdom
4) Take Baby Steps
If I was working with a client like this, I’d first advise them to set smart goals, ones that are specific, realistic, and timely. Specific goals are measurable, and because they’re measurable, they don’t seem so out of reach. They seem achievable, and the goal-setter has a realistic expectation of how long it will take to achieve.
I’d also encourage the client to create small, daily objectives that contribute toward these goals. Meeting these objectives could be celebrated with small rewards that encourage the client to continue. For example, someone who’s working towards eating healthier might celebrate accomplishing an incremental objective with a few chocolates (but not the whole box!).
My second piece of advice would be that they focus more on being than doing, and that they try to stay present and resist the urge to try to anticipate the future. This way, the goal won’t feel so out of reach. There are other things they can do to keep their eyes on the prize. For example, the client who’s trying to eat healthier could make a photo of healthy food their laptop or cell phone wallpaper.
I’d also help keep the client on track, asking how they prepare their healthy meals, using positive affirmation, and encouraging them to do the same with themselves. The latter tactic could be a source of strength if, outside the therapy room, the client feels the urge to eat something unhealthy. By using continuous visualization and affirmation, we help people get into a mindset where they always feel like they’re making progress. The result is that new habits seem to come naturally, and our clients are happier and healthier for it.
Nande Gantsho, social work student
University of Cape Town, South Africa
5) Look for Context
It’s not unusual to hear that this therapist’s clients treat New Year’s resolutions like a big deal. It’s very common. People set big goals and expect quick results. But unrealistic standards are also an opportunity for therapists to help clients develop more self-awareness around change.
They might start by asking the client how they’ve previously gone about making changes. It might lead to a conversation about previous failures in goal-setting and how they’ve potentially contributed to their current frustration.
For clients who look back on their past efforts positively, narrative therapy could be a good intervention, making clear how the client “stories” their life and reminding them of their abilities and previous ways they’ve gone about making changes.
For a client who doesn’t look back fondly on his or her previous efforts, I’d recommend a cognitive behavioral approach that helps them investigate whether they hold any deep, negative self-beliefs that could be influencing irrational behavior and hindering their progress. Afterwards, we’d work on skill-building. To reduce the chance that they become discouraged, I’d make sure we break the big goal down into smaller, more measurable, more attainable short-term goals.
All the while, I’d make sure to celebrate and validate the client’s efforts. Whatever approach the therapist decides to use, the therapeutic relationship is the most important ingredient in the mix: the trusting bond that allows clients to explore the challenges in their lives with curiosity, acceptance, expression, and growth.
Christa Orfitelli, OTR/L, LISW
Next Month’s Quandary: I’m working with a client who has started expressing some very strong and misinformed views—rooted in conspiracy theories—around not only social and political issues, but the COVID vaccine. Do I confront him with real information? And if so, how? What if it derails our therapy?
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