The first of its type
Motivational Work (MW) is the first of its type. So far there has been no cohesive theory and method of help to motivate a person who does not appear to want to receive help. All current methods are built on some existing form of cooperation between the motivational worker and the client; e.g. that it is possible to talk with each other, that the client appears to be listening and so on.
The method is aimed particularly at those clients considered to be hopeless and not treatable. Nobody is hopeless. Everybody can be motivated, irrespective of his diagnosis, age, social problems etc.
Per Revstedt is a licenced psychologist and psychotherapist with supervisor expertise and is a specialist in clinical psychology. He worked in inpatient psychiatric care and therapeutic treatment in residential care for many years. He also has many years’ experience as a supervisor and trainer in the social services, the penal system and psychiatry.
How I started
I am trained in Rogers’ client-centred therapy, psychodrama and individual psychodynamic therapy and I have worked for more than 40 years with unmotivated clients and patients.
The easiest way to introduce both motivational work and myself is by explaining how I started. In 1974 I began working at a therapeutic community institution. The treatment was aimed at drug abusers, but other groups of clients were accepted as well, mostly from the penal system and psychiatry.
The approach of the institution was that clients must be motivated in order to be admitted for treatment. They sought to accomplish this by putting many demands and constructing several “needles’ eyes” to pass through:
- a prospective client must personally make an appointment for an introductory interview, where his suitability and motivation would be assessed. He had to be detoxified before coming to the interview.
- If he was accepted, he would then have to wait up to two months before he could move into the institution. In the meantime, he had to return to his destructive life situation.
- When the client was registered at the institution, he had to be free from drugs throughout his stay. He would not be expelled for using drugs, but he would only be allowed one or two relapses.
- If he threatened anyone or used physical violence of any kind, he would be automatically expelled.
- If he disappeared from the institution without saying where he was and did not get in touch within 24 hours, he was not allowed to stay on.
Even though we went through the eye of the needle, most clients were unmotivated to varying degrees – as are virtually all clients from the social services, prisons and psychiatric units. The staff, including myself, were trained in Rogers’ client-centred therapy, and we tried to adapt the method to unmotivated clients. In this way, you could say that we were working with the same method as Motivational Interviewing back in the 1970s.
Our experience of working with this method was that the clients who were least unmotivated completed the treatment programme and were helped by it. People in this group applied to join the group themselves, they were active participants in the treatment programme, they tried to open up emotionally, they were not threatening or aggressive and did not have many relapses. Those who, in relative terms, needed the treatment least gained the most from it.
The more unmotivated clients either did not apply for the programme or quit it prematurely by not following the department’s rules and demands. They did not voluntarily come to our institution or they joined through others’ initiatives, they only participated sporadically, they did not open up emotionally, they were menacing and aggressive and they had many relapses. Those who were most in need of help received the least. It is this dilemma which arises if we build treatment programmes on motivation in the sense of the client cooperating constructively with his behaviour, i.e. that he agrees to the treatment, follows the practitioner’s method and seems able to reflect on his life situation.
The motivation paradox
As a therapist, I did not want to accept this motivation paradox. Rather than rely on the notion that the client must meet the requirements of the method, I wanted to adapt the method to the client and her situation in life. In this way, I tried to motivate unmotivated clients who would otherwise never have applied for the treatment. I also tried to motivate the remaining clients, who would otherwise have been rejected as a punishment or would have left the program themselves.
From these experiences, a theory and a method of how to motivate people evolved. Relatively soon I began to teach and supervise motivational work, while continuing to work at the therapeutic community institution.
How I have continued
After nine years I left my job at the environment therapy institution and decided to work in psychiatry with very unmotivated and very destructive patients who were committed to the institution. My post as psychologist was in the locked wards, which had the most difficult patients in terms of treating and managing at the psychiatric hospital. Many of them had been diagnosed with schizophrenia. There were also patients that the courts had sentenced to closed psychiatric care. They were murderers, rapists, incest offenders, violent abusers or had committed other serious crimes. In this environment, I had the opportunity to further develop the theory and practice of motivational work. I worked in the psychiatric institution for seven years. During this period I also continued with various counselling and training commissions.
I resigned from my job in psychiatry in 1990 and since then I have been self-employed at my own psychotherapy practice in Malmö and have carried out training and supervising commissions.
Through my own motivational work with clients and supervision of personnel, I have become even more convinced that there are no “hopeless cases”. It is possible to motivate everybody, including those who are regarded as unmotivated.
Spreading knowledge about motivational work still lies close to my heart: that those people who most need help really receive it. Most programs are still organized on the principle of voluntary participation and motivation.
There also seems to be a parallel to the motivation paradox. The personnel who have to treat so-called unmotivated clients meet a personnel paradox. The more unmotivated the clients are, the less help and support the personnel are given in their work. I do not mean to disdain in any way the efforts made by different groups of personnel working with motivated clients, but they often have more resources at their disposal.
I would like to improve the working conditions of the personnel who treat unmotivated clients. It is my experience as a supervisor for these personnel that, despite their often difficult work situation, they do an impressive job with their clients.
Motivational Work picks up where MI leaves off
MW is a method that has evolved from my work in cooperation with different groups of personnel. According to those personnel that I have met, it differs from MI by being more comprehensive and general. MI is more specific and originates from a non-confrontational psychotherapeutic method (Roger’s client-centred therapy), which is then applied to unmotivated clients.
During my first period with unmotivated clients I worked with Rogers’ client-centred therapy. I learned then that you could only help those who were least unmotivated (see How I started), and so I developed my own theory and method for motivating those with least motivation. Since Motivational Interviewing is based on Rogers’ client-centred therapy, you could say that my method starts where MI ends.
One advantage of Motivational Work, which is clear to personnel, is that it is aimed at all types of clients and even those with most destructive behaviour. There is no preconceived technique to which the client must be adapted, but instead the method is adapted to clients’ behaviour. Nobody is hopeless. Working in this way, one has a different paradigm from other methods which are based on psychotherapeutic thinking.
After having completed a textbook on motivational work in Swedish 1986 (until now printed in four editions, also translated into Danish, three editions), I then decided to write an English manuscript (with the help of two English translators) so that I could convey ideas to the whole world. At the same time I wished to develop my theory and methods so that everybody can fully understand what I mean.
The writing process has taken 21 years to complete. During this time I have been constantly working full-time and have used my evenings and spare time, including holidays, to write. From the beginning I had no idea that the work would be so extensive. I was surprised at how much theory it is necessary to formulate in order to fully describe motivational work.
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Motivational Work – details
VALUES AND THEORY
Motivational work has its roots in humanistic psychology. This approach includes, for example, gestalt therapy, most forms of family therapy, Rogers’ client-centered therapy, psychodrama, transactional analysis and therapeutic community. Humanistic psychology has a humanistic approach as its core value. This foundation is shared by motivational work.
The humanistic approach
The humanistic approach means that we believe that in every human being there is an inner core that is good. Destructiveness and evil do not exist in humans per se, but come from the environment. The newborn infant has a positive inner core through and through; it has only pure goodness.
In motivational work, the inner core consists of constructiveness; no person deep down really wants do to harm to himself or others.
This means, among other things, that no one wants to destroy herself with drugs or harm others. No biological parent, deep down, wants to hurt his children. This view of people can neither be proven nor disproven – either one believes in it or not. No external confirmation is required to be sure that the client has a positive core. No matter how unreasonable she seems to be in her behaviour, we can still believe that she has a positive core behind all of this.
One conclusion from the humanistic approach is that there are no hopeless cases. Because everyone has a positive core, there is a potential in all people which can be kindled and encouraged to evolve. This basic belief leads to the motivational worker always having hope for change in the client. He is thus able to keep up a positive commitment and not become burned out. Motivational work is never meaningless. There is always the possibility of change.
In addition, the motivational worker gives out positive expectations all the time. The client is acknowledged and feels that there is hope for her.
The positive core is, quite simply, the fundamental motivation of every person: to live as constructive and meaningful a life as possible. In the same way, the aim of motivational work is to reinforce the positive core of the unmotivated person.
Resistance is a contact rebus
In addition to the humanistic approach, the motivational worker also needs a theory of the defence. The characteristic of an unmotivated client is that she puts up resistance to receiving help from others. In motivational work we do not see the primary function of defence as protection, but rather as an indirect attempt at contact.
It is a way of approaching others without being openly rejected and, at the same time, testing how much you can trust others. In motivational work defence is called the contact rebus instead. It is an indirect attempt at contact in the form of a puzzle. Seeing opportunities in the client’s defence will further reinforce the motivational worker’s own motivation and help him to keep committed to the client.
The motivational process
Motivational work also includes a theory of how the client’s motivation changes over time and with the bonding process to the motivational worker. This theory is the single most important support for the motivational worker in order not to lose commitment. The finding is based on my own experience of motivational work and my work as a supervisor for motivational workers. The motivation of a client changes like a wave. an increase in motivation is always followed by a recoil, during which the client acts destructively. This destructive recoil is often the hardest part for a motivational worker to deal with.
After a client appears to have made progress there follows a setback, which seems to indicate that that there has been no positive change. The greatest risk here is that the motivational worker loses commitment to the client and gives up. However, if he can instead see that the recoil is a positive confirmation of the earlier positive change in the client, this will increase the chances that he can continue the motivational work. The destructive recoil is a necessary part of the change process, which he can never avoid seeing in his work.
THE MOTIVATIONAL RELATIONSHIP
The motivational relationship with the client is the practical application of motivational work values and theories. It is through this that the motivational worker conveys certain emotional attitudes to the client, who receives emotional power to his positive nucleus. This strengthens the client’s motivation. The humanistic approach, the theories of the contact rebus and the destructive recoil all act to support the motivational worker in giving life energy. There are three emotions above all that the client’s positive core needs. These are commitment, hope and trust.
Commitment is the most important part of the motivational relationship. It means that the motivational worker communicates the fact that he cares about the client and considers her important. As well as this, the motivational worker expresses emotional reactions to the client, such as anger, sadness, or anxiety, on the basis of her commitment. The unmotivated client is often a suspicious person who finds it difficult to believe that someone cares about him.
Although the motivational worker shows emotional reactions, further confirmation is also needed for the client to start believing in her. This means that she must also communicate her commitment in actions in order to be credible. These actions may involve contacting the client, helping in concrete terms to improving the client’s social situation, offer a meal, etc. The motivational worker must show that he cares about the client both in feeling and in actions. To be credible in his commitment to the client also means that he tries to limit the client’s destructive behaviour through actions and words. Setting limits is an essential part of the motivational relationship for this very reason.
The second part of the motivational relationship, hope, is really the practical application of the humanistic approach. As before, the aim is to convey a feeling to the client: that he is able to change. The motivational worker cannot guarantee that things will be better, but he can convey the idea that it is possible.
Trust means that the motivational worker conveys the feeling that the client has her own capacity that she can use. The motivational worker communicates this at a general level, and in the context of a specific task that the client must perform. In the latter case he must first determine that the client really has the ability to carry out the task, otherwise the trust will not be genuine.
An indispensible condition for conveying the three emotions of commitment, hope and trust is that they are genuine. You cannot fake them. This means that the motivational relationship places high emotional demands on the motivational worker. He must be strong enough to be emotionally involved in the client without apparently receiving anything positive in return. However, through the humanistic approach, the theories of the contact rebus and the destructive recoil, the motivational worker is able to see these positive affirmations.
The motivational relationship and the client
To be motivated the client needs to gain the three feelings of commitment, hope and trust from outside himself. He has a lack of commitment to himself, feels hopeless and lacking in confidence in his abilities. This emotional force must be mediated by someone else. In this way, the motivational relationship is one-sided, which is demanding on the motivational worker.
METHOD AND TECHNIQUE
The motivational relationship is at the centre of all motivational work. Communicating commitment, hope and trust is sufficient for a client to become motivated. The motivational worker can also use certain methods and techniques. The key condition, however, is that there is also a motivational relationship. Without it there is no point in using any technique. There are several advantages of methods and techniques. They can speed up the motivational process, so that the client becomes motivated earlier. The motivational worker also finds his motivational work more structured, which can be a support for him. If, for example, he has a particular interview technique, it helps him to structure the conversation.
Confrontation and Continuity
The two main methods of motivational work are confrontation and continuity. Confrontation is an interview technique where the client is put under emotional “pressure”. Continuity means that the motivational worker is responsible for contact with the client in two ways. He has sole responsibility for the continuation of meetings with the client. Since the client is unmotivated, he will find it difficult to maintain contact himself. The motivational worker is also responsible for his own motivational relationship to the client – that he maintains his commitment and thus also ensures continuity of emotional contact. Continuity includes different methods and techniques that can be used to achieve a continuous relationship.
If you are looking for an introduction to the method and working procedure, the best option is one or more lectures. They give you time to gain a general understanding of the approach as well as to ask questions.
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If you want to deepen your knowledge of motivational work, a course is the best way. The actual method can be covered in a more thorough manner than during lectures. A group meets over a time period on several occasions. Here you will have the opportunity to combine theoretical knowledge with practical application.
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Legitimerade Psykoterapeuterna Revstedt & Hartman AB
SE-203 13 Malmö
Tel/fax +46 40 30 37 72