August 2021

Five key principles in helping people change; Skills to implement those principles; Vaccine hesitancy and using the five principles of the Better Arguments Project

In SAVVY and SKILLS, I share the wisdom of Marvin Goldfried, Ph.D. who presented in one paper five key principles on how people change. He wrote about the common principles of change that he distilled from hundreds of schools of thought and approaches to change. For each principle, I offer a few SKILLS to help implement it.

In SOUL, I don’t plan on talking with my daughter and her family about their vaccine hesitancy.  I respect their right to make their own choices.  But in case the topic of vaccines arises, I want to be grounded and centered to know what to say and do. So I used the five principles of the Better Arguments Project to help guide me.

Savvy & skills

Two years ago, I came across an academic paper from Dr. Marvin Goldfried who pulled together decades of research on psychotherapy and distilled all that into five key principles in helping people change. I love it when smart people can focus me on the most important points that I can now pass onto you.  

For each of the five key principles, I suggested some SKILLS to implement the principle.

Tip 1

Why it is difficult to develop consensus to explain how people change

1. Disagreement Across Theoretical Orientations

  • There has been a proliferation of different schools of thought to explain how people change.
  • This tendency toward proliferation has continued over the years, and a recent estimate is that there are now over 500 different schools of thought (Prochaska & Norcross, 2018).
  • No consensus or agreed-upon core of knowledge across all these different schools of thought and models.  This is because each model has a specific theory and techniques associated with each approach as well as it unique language and terminology.
  • Three major theoretical orientations: (a) psychodynamic, (b) behavioral/cognitive–behavioral, and (c) experiential/humanistic. Each has specific clinical techniques and procedures that are associated with each orientation, be it interpretation, self-monitoring, or reflection.

2.  Human behavior is too complicated to have a single theoretical orientation.   

  • Common principles, rather than the more abstract theoretical orientation or specific techniques, is where we may find consensus across schools of therapy. 
  • The specific intervention techniques may be thought of as methods of implementing a given principle. 
  • As an alternative to a given school of thought, general principles of change may be used as a starting point for research, practice, and training.

Tip 2 

Hundreds of different schools of thought and approaches can be distilled down to five key principles in helping people change

In looking at (a) the theoretical explanations of different approaches to therapy and (b) their specific clinical techniques, it is possible to find commonalities that appear to underlie different approaches to therapy, and so identify the following principles of change (Goldfried, 1982):

I.   Promoting client expectation and motivation that therapy can help – HOPE

II.  Establishing an optimal therapeutic alliance – ALLIANCE

III. Facilitating client awareness of the factors associated with his or her difficulties – AWARENESS

IV. Encouraging the client to engage in corrective experiences – DO

V.  Emphasizing ongoing reality testing in the client’s life – KEEP DOING



Tip 3 

Principle I – Promote client expectation and motivation that therapy can help – positive expectations and motivation to change

1. Hope and the Possibility of Change

  • Treatment can be helpful by instilling hope in the person and the possibility that change can happen. (Jerome Frank (1961)
  • Many clients have low self efficacy – lack of confidence and optimism that they can really succeed. So even if they want to change, they may not try, thinking they will just fail again.

2. Motivation to Change

  • Clients who have not yet contemplated the necessity of change are unlikely to respond well to therapy (Prochaska, Norcross, & DiClemente, 2013).
  • Motivational Interviewing validates the patients’ reluctance to change and then gradually helps them to recognize the consequences of not changing and the benefits of doing so.

SKILLS:

  • Use Motivational Interviewing to start where the client is and increase the participant’s expectation that s/he can get what they want, which is usually avoidance of a negative consequence (get my children back; stay out of jail; keep a job or relationship) rather than lasting change and recovery.
  • Help shift the client from a position as a victim of the system needing to comply, to an empowered position responsible for their life and getting what they want.
  • Increase self-efficacy and optimism and confidence that they can change.  Examine with them what worked when they had custody of their children or were able to stay out of jail. Building on those strengths, skills and resources can increase hope for change.

Tip 4

Principle II – Establish an optimal therapeutic alliance

1. Importance of the therapeutic relationship interacting with the specific interventions of the different therapy models

  • Regardless of the different therapy approaches, a good therapy relationship is needed as a context in which to implement the therapeutic intervention (Muran & Barber, 2010).
  • The argument of which is more important—the technique or the relationship—fails to recognize the important interaction of the two (Goldfried & Davila, 2005). 
  • As any therapist well knows, the goal of Session 1 is Session 2, and the nature of the therapeutic connection with the client plays an important role in making this happen.


Graphic of Scott Miller PhD

2. What is the therapeutic alliance?

Based on the writings of Bordin (1979), the therapeutic alliance is defined as: 

(a) the existence of not only a good bond between therapist and client;

(b) an agreement between the two as to the goals of therapy 

(c) an agreement on the methods that may be used to achieve these goals. 

  • Following this clinical observation by Bordin, there have been several decades of research to demonstrate the importance of the alliance across different therapeutic orientations (Muran & Barber, 2010; Norcross, 2011), making it a most important transtheoretical principle of change.

SKILLS:

  • I’ve written before on the Therapeutic Alliance – Here are a couple of relevant skills – How to develop a therapeutic alliance in ten minutes or less in the May 2012 Tips & Topics.
  • In February 2010, I wrote about the treatment plan as a “written expression of the therapeutic alliance” with the client. 
  • If you are working on abstinence and recovery; and the participant is working on a goal of getting their children back, you don’t have an agreement on Goals.
  • If your methods are to go to Alcoholics Anonymous (AA), take this medication and change all your friends; but the client hates AA and medication and loves their friends, you don’t have agreement on Methods.
  • If your client is frightened to be honest about a flare up of addiction and substance use, then you don’t have a safe and Good Bond with the client and you don’t have a Therapeutic Alliance.  The likelihood of getting a good outome is very low

Tip 5

Principle III – Facilitate clients’ awareness of the factors associated with their difficulties

1. Recognize and make use of life experiences that help participants change

  • Sullivan had an interesting concept to describe this when he spoke of “selective inattention” (Sullivan, 1973); people are often unaware of what causes them to have certain problems in living and what can be done to improve their lives. 
  • Depending upon one’s theoretical orientation, the process of stepping back and observing oneself has been called self-observation, executive functioning, decentering, reflective functioning, insight, observing ego, witnessing, metacognition, and mindfulness. 
  • Although different labels are used, it involves clients’ getting a better awareness and perspective of their thoughts, emotions, behavior, needs, and wants; the significance of life events; the impact the behavior of others makes on them; and the impact that they make on others.

2. Help clients know what works or not in their lives and the reason for this

  • The specific formulation of therapists may differ, and the way in which they may facilitate this better understanding may vary, but it all reflects the principle of therapeutically increasing clients’ awareness. 
  • At times, this awareness in itself can produce important changes, such as when clients recognize that their interpretation of the motives of a significant other are incorrect. 
  • At other times, the awareness may be preparatory to some actual changes in how they deal with others, such as asking a significant other for something rather than getting angry in the anticipation that they might not get what they want. 

SKILLS:

Assessment questions, for example, to increase awareness of a client’s lying:

  • Why did you lie? What was going on that you chose to lie rather than be honest?  
  • When has lying and lack of integrity manifested itself in your life before and how has it gotten you into more trouble? 
  • Do you even see dishonesty as an issue you need to work on? If so, why; and if not, why?
  • What can we do to make it easier for you to be honest and open?
  • What are you fears or obstacles if you were to be honest?

Assessment questions, for example, to increase awareness of a client’s substance use:

  • What are your top three favorite substances (alcohol and/or other drugs) and what do you like about them?If a client names some substances and what they do for them, then ask: “Why would you want to stop using them? Or are there some you want to stop or not want to stop at all?”
  • At any time since starting to use alcohol or other drugs regularly, how long have you been able to stay abstinent?Whatever amount of time e.g., 1 day, 1 week, 1 month, 1 year, respond: “That’s great, how did you do that? How did you change your thinking, feeling, behavior, who you hung out with etc. that you were able to not use for 1 day, 1 week, 1 month, 1 year…”
  • This increases the clients’  self-efficacy – optimism and confidence that they can change, by helping them become aware of skills and resources that they have already used to function well, even if for a short time.

Tip 6

Principle IV – Encourage clients to engage in corrective experiences

1. The corrective experience is doing something they have not done before despite apprehensive thoughts and emotions and discovering all went well

  • The corrective experience is when clients do something that they have not done before—despite thinking and feeling that something negative might happen—only to learn that their unrealistic predictions didn’t materialize. 
  • For example, an individual who fearfully avoids speaking up and expressing themselves because they unrealistically expect a negative reaction from others may have a corrective experience by taking the risk of saying what they want to say and learning that the reactions of others were not negative—and at times may even be positive.

2. Examples of corrective experiences in different therapy models

  • Relationally oriented psychodynamic therapists see this corrective experience as occurring within the therapeutic interaction.
  • CBT therapists place a greater emphasis on between-sessions homework experiences, such as those that provide clients with “exposure” that serves to reduce avoidance behavior. 
  • Regardless of where the experience takes place, or whether the label that is used to describe it is phenomenological or observable, the corrective experience appears to be an important principle of change. 

SKILLS:

Examples of Corrective Experiences to suggest to participants:

  • Attend one AA meeting and see if you can identify with anyone’s story and report back to group.
  • Role play asking someone for their name and number as practice for actually doing that at a meeting.
  • Practice being totally honest for one day in treatment and see what feels good or bad about that and report back to group; e.g., when someone asks “How are you?” practice pausing and answer honestly rather than a quick automatic “Fine”.
  • Practice progressive relaxation as a corrective experience to deal with anxiety.
  • Discuss what would help you stay in treatment and not give up and dropout.
  • Practice peer refusal skills in group and then try that next time you meet a friend who offers drugs.
  • Role play an angry situation with a fellow client and show everyone how good your anger management skills are. (A “Discovery” strategy for the person who doesn’t think they need anger management)
  • Ask for a difficult parenting situation and demonstrate to the group how to handle that in a non-violent, calm way using your parenting skills that you believe to be very good. (A “Discovery” strategy for the parent who doesn’t think they need parenting skills group).

Tip 7

Principle V- Emphasize ongoing reality testing in the client’s life

1. Encourage additional corrective experiences to develop lasting change in thoughts, feelings and behaviors

  • Because one such experience is unlikely to lead to long-lasting change, therapists need to encourage clients to have additional corrective experiences, in essence engaging in ongoing reality testing, until there exists a critical mass of corrective experiences to allow for more stable and long-lasting changes in expectations, feelings, and behavior.
  • Ongoing reality testing involves an increased awareness that further facilitates corrective experiences—involving changes in thoughts, feelings, and behaviors—which further feeds into an increased awareness that can be used to again facilitate corrective experiences.

SKILLS:

  • I’ve written before on rethinking “Graduation”, “Treatment Completion”, “Discharge”.  These terms convey that no more ongoing corrective experiences are needed, when it is exactly the opposite.
  • Rename the Graduation or Treatment Completion Ceremony perhaps, the RCA – the Reflection, Celebration and Anticipation ceremony or event.
  • Instead of saying “Discharge”, perhaps “Transfer” or “Transition” to convey that the participant has done a good piece of recovery work, but is now transitioning to ongoing ‘doing’, reality testing and corrective experiences.

References:

Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252–260. http://dx.doi.org/10.1037/h0085885

Frank, J. D. (1961). Persuasion and healing. Baltimore, MD: Johns Hopkins University Press.

Goldfried, Marvin R (2019): “Obtaining Consensus in Psychotherapy: What Holds Us Back?” Stony Brook University American Psychologist 2019, Vol. 74, No. 4, 484–496

https://pubmed.ncbi.nlm.nih.gov/30221947/



Goldfried, M. R. (Ed.). (1982). Converging themes in psychotherapy: Trends in psychodynamic, humanistic, and behavioral practice. New York, NY: Springer.

Goldfried, M. R., & Davila, J. (2005). The role of relationship and technique in therapeutic change. Psychotherapy: Theory, Research, Practice, Training, 42, 421–430. 42.4.421

Muran, J. C., & Barber, J. P. (Eds.). (2010). The therapeutic alliance: An evidence-based guide to practice. New York, NY: Guilford Press.

Norcross, J. C. (Ed.). (2011). Psychotherapeutic relationships that work: Evidence-based responsiveness (2nd ed.)

Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy (9th ed.). New York, NY: Oxford University Press.

Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (2013). Applying the stages of change. In G. P. Koocher, J. C. Norcross, & B. A. Greene (Eds.), Psychologists’ desk reference (pp. 176–181).

Sullivan, H. S. (1973). Clinical studies in psychiatry. New York, NY: Norton.

soul

As a citizen but especially as a parent, I have been concerned about the spiking cases of COVID-19 and the Delta variant.  Both my brother and I have three children and both of us have one child who has decided against being vaccinated, at least for now.

Having trained in the medical and public health culture, the statistics seem to speak for themselves.  So I face the dilemma of how to relate to my daughter about her vaccine hesitancy and choices.

Last December, in SKILLS, I highlighted the dimensions and principles of the Better Arguments Project, a group with an initiative to heal America in the aftermath of the 2020 election. I revisited the Five Principles of a Better Argument to help me think through what I should do. I don’t plan on talking about this with my daughter and her family.  As concerned as I am, I respect their right to make their own choices.  But in case the topic of vaccines arises, I want to be grounded and centered to know what to say and do.

1. Take Winning off the Table

It is easy to enter an argument with a goal of winning, or at least reaching resolution. Instead, I will join her with the goal we both share – to be safe with mutual respect for each others’ decisions.

2.  Prioritize Relationships and Listen Passionately

My relationship with my daughter and her family is at the center, and requires that we truly listen to one another. I will listen to learn, not to win.

3.  Pay Attention to Context

I will acknowledge her culture. She lives in a culture of friends and a local environment that is alternative and skeptical of Big Pharma and Big Government.  Many share those views.  In fact 59 million Americans spend money out-of-pocket on complementary health approaches (medicines and procedures), and their total spending adds up to $30.2 billion a year.

My culture is one of medical science, public health principles and a perspective that is not shared by my daughter and her friends.

4.  Embrace Vulnerability

My natural impulse is to share my concern about my daughter’s vaccine hesitancy with my family and friends who share and confirm our own worldviews. If my daughter and I start talking about vaccines, I will enter the space of argument and discussion and make myself vulnerable to stay open to her convictions.

5.  Make Room to Transform

If I follow these principles for a ‘better argument’, it could be a transformational experience for both of us. Without a goal of winning or even reaching resolution, my goal is to engage with my daughter in order to keep our relationship strong, respecting each other’s choices on how to stay safe in the era of COVID.

No matter what your personal views are about vaccines and masks, the goal of Better Arguments becomes to change how we engage with one another in order to build a community. 

Right now, a bit of respectful engagement and community building would be nice.