Written by Victor Camille Lebouthillier
In our last blog we have discussed about numerous treatment approaches that have been developed over the last century that have all been demonstrated to have equivalent clinical efficacy.
A. The Expectation of Change
It is the nature of all living things to change. When we stop changing, we stop growing, we stop achieving our potential; basically, we stop moving. The process of recovery is built upon the concept of movement and that movement is found in change. We move from having behaviors, cognitions, and perceptions that interfere with our ability to work, learn, and participate in our communities, to behaviors, cognitions, and perceptions that enable us to develop and maintain positive, constructive relationships and contribute to our communities. Positive change means developing the resiliency to be able to deal with all that life throws at us in a healthy way without being sabotaged by dysfunctional behaviors, perceptions, and cognitions. Change involves learning, developing, and honing the skills that will increase our resiliency and future recovery if needed.
The desire for change is the first step in any recovery program. Essential to any process of change is having a realistic expectation of change. For an individual to consider engaging in any program designed to improve mental health, they need to first have an expectation that change is possible. All too often, people see their thoughts and actions to be as permanent as their height or eye color. As a result, they resign themselves to a life filled with unhappy consequences, seeing no alternatives. For example, an individual may come from a family whose prevailing philosophy is that life is sorrowful and the only solace for that sorrow is work. It could very well be that the family represents a cluster of low-grade depression and a little treatment could open the doors to all of Life’s potential.
Ultimately, any program, whether the focus is on increasing resiliency, bringing about recovery, or both, must first bring about a change in perceptions about the immutability of our psychology. The possibility of change, itself, becomes clear when we learn and understand that our psychology is, in fact, mutable.
But any expectation of change needs to be grounded in reality. For many people, the fact that permanent change does not happen rapidly confirms their view that change is not possible. The notion that change can or must occur quickly is detrimental to not only the process of change, but also to the expectation of change. A good case in point are New Year’s resolutions. People create lists of behaviors they wish to change in the next year. Aside from the fact it is easier to change one thing at a time rather than entire lists of behaviors, these resolutions to change are more often than not unsuccessful because they expect permanent change to occur quickly and easily. The individual’s inability to permanently stop smoking, lose weight, or be a nicer person in a week or two confirms the person’s self-identification as a smoker, overweight, or just a mean person. It also confirms in their mind that change isn’t possible.
The perception that change is not possible poses a challenge to any program designed to improve mental health. Successful programs need to begin by assuring people that change is possible. They need to educate people about the process of change and teach that change results from a gradual learning process. Most people who are successful in quitting smoking or losing weight do so after multiple attempts because they have to learn how to engage in behaviors that are incompatible with smoking or weight gain.
B. Reinforcing Change
The sense that behaviors are permanent is a common misconception. Such beliefs are a contributing cause to why people don’t seek help for their mental health problems and illnesses. Everyone has the capacity to bring about positive change in their lives. The real trick is to bring about lasting change.
All of our behaviors are motivated by the outcomes they provide. These outcomes strengthen, or reinforce, the behaviors, cognitions, and perceptions that preceded them. People will continually engage in dysfunctional behaviors e.g. problematic alcohol consumption, because the perceived rewards of the behavior outweigh any potential negative consequences.
Replacing dysfunctional behaviors with functional behaviors is a two-fold process. First, the process of change itself needs to be reinforced. In other words, change needs to be perceived as a rewarding experience rather than something to be feared. Without this perception, people are less likely to be engaged and, thereby, will not be able to achieve the changes they desire. Second, the new behaviors need to be reinforced. This means that the value of the outcome resulting from the new, functional behavior needs to be increased, while the value of the outcome resulting from the old, dysfunctional behavior needs to be decreased.
Reinforcement tends to be idiosyncratic - what works well with one person doesn’t necessarily work well for another. Nonetheless, reinforcement can broadly be seen as social (better personal or work relationships), physical (better physical health), or psychological (achieving self-set goals).
Bringing about lasting, successful change is a challenge, even when that change is reinforced. Often, the most effective way to bring about lasting change, particularly when changing complex behaviors and cognitions, is to break the process of change down into small, incremental steps. Each of these smaller, more manageable changes are reinforced. An added bonus to approaching change in this manner is that change itself can become reinforcing. In other words, successfully achieving ones goals of change, whether small or large, can provide the individual with the self-confidence to take on the process of continued change with courage.
C. Evidence-based Practices
In the early part of the 21st century, the American Psychological Association (APA) recommended the implementation of the “evidence-based practice” into psychotherapy. The introduction of the evidence-based practice led to a more official incorporation of science and scientific findings into the field of psychotherapy. In other words, any therapeutic approach should be evaluated on its efficacy and clinical utility. Incorporation of the evidence-based model into psychology has led to the development of the concept of “best practice,” or the integration of the client’s unique characteristics and needs, experience of the therapist with empirical findings derived from advanced behavioural science.
Around the same time that the APA was making its recommendations for improving the effectiveness of psychotherapy, The President’s New Freedom Commission on Mental Health recommended that psychotherapy should be approached as a team effort between the therapist and that the client. Furthermore, the client should be part of the decision process for determining therapeutic goals. This approach, of course, is crucial to the success of the recovery movement. After all, it is only the client who can determine what they need to achieve the therapeutic goals of recovery.
Likewise, it is only the client that can determine whether their mental, emotional, and relationship goals are being achieved. Most people lack the training to objectively determine whether progress is being made towards achieving their therapeutic goals. This is part of the role of the therapist. The challenge for the therapist is measuring that change or lack thereof.
To assist therapists in engaging their clients in the process of change and measuring that change, a number of tools have been developed to solicit feedback from clients. One example is MyOutcomes, a Health Masters’ sister product that has been listed on SAMHSA’s National Registry of Evidence-based Programs and Practices, Outcome Rating Scale (ORS). Each therapeutic session, the ORS measures the client’s perceptions of key psychological and social areas, enabling the therapist to evaluate the client’s progress towards achieving their mental and relationship goals. Using this evidence, the therapist can determine if progress is being made or not. If progress towards recovery isn’t being made, the therapist is able to make appropriate adjustments to the therapeutic program.
Unique to these sort of evidence-based tools, MyOutcomes also offers the Session Rating Scale (SRS). The SRS is a measure of the therapeutic alliance, a critical factor in successfully achieving therapeutic goals. The SRS helps the therapist evaluate whether their view of “best practice” for a particular client matches that of the client’s. Put another way, the SRS can be seen as a team building tool.
D. Engagement & Engagement Theory
It is an understatement to say that in order for change to occur, a person needs to be engaged in the process. Although countless research in learning and memory has demonstrated the value of engagement, all too often is seems that little is done to ensure the presence of this factor in the clinical setting. The ability to engage the client in the therapeutic process of change may be a critical factor that differentiates highly successful therapists from those who struggle with their clients in achieving therapeutic goals. The use of therapeutic tools e.g. MyOutcomes that support feedback-informed therapy may contribute to engaging clients in the process of change.
Engagement Theory is an approach to learning that takes advantage of the developing distant education technologies. Recognizing that many human activities involve participating in groups, it incorporates group engagement strategies with modern technologies for communication and education. Although mental health problems and illnesses are such because of the stress they pose for the individual, much of this stress originates in the disruptions these mental and emotional issues cause in group settings or interactions e.g. the workplace, family, etc. The basic elements of Engagement Theory lend themselves readily to treatment models for mental health problems and illnesses because of the focus on group participation.
There are three components to Engagement Theory. The first component is that learning involves “collaboration.” Collaboration refers to the members of a group working as a team. This team work requires communication, planning, management, and social skills. As a result, there is a need to develop these skills to a sufficient level of competence so that the team can be successful. The second component is that learning needs to be “project-based,” where a purposeful activity lends itself to using newly learned ideas in a specific situation. The third component is that the process of change needs to be authentic, applying learned activities to real-life aspects of the individual.
E. Social Influence
Human beings are social creatures; we act and self-identify within the framework of various social factors and settings. For most of us, our individuality is important. So too are our group affiliations. In order to fit into the group, we readily adopt behaviors that will make us “normal.” Of course, what is “normal” is defined by each group. Many of our behaviors that are dysfunctional were most likely acquired from belonging to a dysfunctional group where those behaviors were the norm.
This natural tendency to modify our behaviors and cognitions to fit into a group can be utilized into treatment models. Others, who are going through the process of change, can normalize that process as well as the new behaviors or cognitions that are being introduced. Group members can provide needed support, offering advice and feedback to individuals about their performance. Belonging to a group, because of these factors, increases the likelihood that we stick with the program.
Social groups are also just generally good for our psychological and physical health. Just as married men tend to show a lowered risk for cardiovascular disease and married women with involved and supportive spouses are at lower risk for clinical depression, group membership provides benefits. Research indicates that those who walk in groups show better body-fat ratios, cholesterol levels, lung function and scores that measure depression. Such findings would suggest that treatment models for mental health problems and illnesses that utilize a group approach might see better improvement as a consequence of that group participation.
Mentoring is a form of social influence that has a more directly prescribed purpose. Mentoring involves an individual, who has gone through the process, providing support and guidance to an individual who is currently going through the process. It is a model of social influence that has been used in a vast array of activities. In academia and business, it is common practice for a more senior member to be assigned to a new hire in order to guide them towards success. This concept of using mentors is not new for programs that focus on bringing about constructive mental-emotional changes e.g. Alcoholics Anonymous or the Big Brothers/Big Sisters programs. The mentor is seen as providing both support and facilitation for change. Evidence shows that individuals with peer support are discharged from a long-term hospital 116 days earlier than those without peer support.
Consistency is a double-edged sword. On the one hand, consistency is essential to learning and producing long-term behaviors. As most parents are aware, the key to raising children who demonstrate appropriate behaviors is to send consistent messages of what is expected, as well as have consistent outcomes. In this respect, adults are no different than children.
In this framework, treatment models for mental health problems and illnesses need to be consistent with how they approach the problem. Clients need to be encouraged to be consistent in using new behaviors to ensure theirincorporation into the individual’s behavioral repertoire.
At the same time that consistency can play a key role in bringing about successful, constructive change, consistency can be the enemy at the gate as well. Humans have a natural tendency to prefer and gravitate towards consistency rather than inconsistency. Cognitive consistency creates mental states of calm, whereas cognitive dissonance creates anxious states. If we experience cognitive dissonance, we will engage in processes that return us to a state of calm i.e. cognitive consistency. There are a number of ways we approach this. For example, in this day and age, being a smoker can lead to numerous experiences of cognitive dissonance. As a smoker, you might come across information emphasizing the reduced life expectancy associated with smoking. The dissonance occurs as a result of the conflict between your behavior and this information. If you are a typical person, you will likely use rationalization e.g. “we all die eventually” so that you can avoid change.
This tendency towards cognitive consistency can pose a problem for any treatment program. People’s natural inclination is to avoid change. However, this tendency can be exploited to help increase the likelihood of making needed changes. By creating a state of cognitive dissonance, the therapist can guide the individual towards making a change. Thereafter, the individual’s tendency toward consistency will help insure that that change becomes permanent.
H. Cardiovascular Activities
Lifestyle changes are often critical aspects when addressing mental health problems and illnesses. Dysfunctional lifestyles can be a contributing factor to developing mental, emotional, and relationship problems or dysfunctional lifestyles can be a consequence of these problems. Either way, changing lifestyles is often a major step in bringing about recovery or improving resilience.
Cardiovascular activity is important to our physical health. It is also important to our psychological health. Exercise has been demonstrated to reduce anxiety, depression, negative moods, and social withdrawal, while improving cognitive functioning and self-esteem. The more immediate benefits or reinforcement of behavioral changes that include increases in cardiovascular activity include stress relief, improved sleep, increased energy, increased sexual interest along with the physical benefits of weight and cholesterol reduction.
I. Distant Education Technology (DET)
The development of the internet along with associated technologies over the last twenty years or so have been a boon for distant education. Distant education allows the instructor and student(s) to be in different places during times of instruction. With inexpensive computers and easy access to high speed internet, instructors and students can all be in different locations or some may be offsite, while others are participating from the same classroom or conference room. DET can take two forms. There is synchronous distant education where participation is occurring in real time. Video conferencing, web conferencing, and live streaming are all possible avenues for this type of learning. The second form of DET is asynchronous. This is the “go at your own pace” sort of learning. Students can view videos, read materials, work on exercises, and write in a journal that are part of the learning experience. Typically students have access to the teacher and/or other students via email or discussion groups for discussing and asking questions.
Distant Education Technology lends itself readily to mental health treatment programs. In a time when mental health problems and illnesses are the leading health problem worldwide and, if the status quo is maintained, the situation is predicted to worsen. DET may be a significant key in addressing the problem facing us for a number of reasons. First, given that the financial resources available aren’t sufficient to currently meet the problem, DET is an inexpensive way to provide highly effective treatment to groups or to individuals. Second, provided internet access is available, DET can provide services to more rural areas where traditional therapy is not available. Third, because of the nature of DET, programs that utilize this technology can provide programs and access to specialists to groups e.g. minorities with unique needs and who live in areas with inadequate support. Finally, limited time may make it difficult for couples or other family members to regularly meet with a therapist or another specialist to address relationship and other issues. DET is ideal for the development of “come to the workplace” skill-building workshops.
Don’t miss our next blog for even more tips on how to use advanced science for effective solutions.