Rethinking Motivation

At a recent case consultation with a group of respected therapists in my clinic, I presented a patient case causing me some frustration. I have been working with said patient for several years. Despite good rapport, consistency of appointments and stated desire to make changes to address symptoms related to Obsessive Compulsive Disorder and Agoraphobia, my patient had made little demonstrable progress toward their stated goals. After a solid and thoughtful discussion, my coworkers and I concluded, as we often do when feeling “stuck,” that perhaps the patient simply is not motivated to work towards stated desired changes.



My group needed a tidy ending point before we moved on, and although I nodded along with this conclusion, the inadvertent judgment contained in labeling the issue of lack of motivation didn’t sit well with me.



After all, if a patient seeks therapy and identifies a desire to make a change, is that not the core definition of the word “motivation?” It isn’t that our patients lack in wanting change. It’s overly simplistic and even condemnatory to cite a lack of desire.



We have long known that shame, be it from our own selves or others, is an antagonist toward progress. If we feel hopeless or undeserving of healthy changes, by definition, that desired change becomes unattainable. If I believe the message that every attempt leads to failure, I will not try. If I believe I am fundamentally broken, I am not deserving of good and healthy behaviors. Internalized shame can deepen mental health symptoms, play upon our innate fear of rejection and chip away at trust within the therapeutic relationship. As Brene Brown writes, “shame is about the fear of disconnection…we are afraid that we’ve exposed or revealed a part of us that jeopardizes our connection and our worthiness of acceptance.”

Goal-oriented people, therapists and patients alike, find it satisfying when they demonstrably move towards our desired targets. As therapists, we may personalize the dissatisfaction of not making “progress,” by interpreting it as our own ineffectiveness. Patients may interpret “stuckness” as evidence of their own inadequacy. This may be heightened if a therapist is working within a practice in which there is an emphasis on tracking measurable goals within treatment plan updates or if there is pressure from insurance companies seeking evidence of “progress” in order to justify payment of services.



Inaction may be perceived as unhelpful, but perhaps ambivalence is more essential to a forward movement than is apparent. Rarely does a change simply occur in a flash without contemplation and planning, as proposed by Prochaska and DiClemente in their groundbreaking work to conceptualize distinct stages of change. A therapist’s role is to serve as a guide through the sometimes murky sea of ambivalence, working with patients to tolerate distress and minimize suffering through the journey. There may also be innate value in non-doing. In Laziness Does Not Exist, Devon Hayes argues that rest has been so stigmatized through our Puritanical roots and capitalist influence, that we overlook the value of stillness and restoration. Not only can rest offer a buffer to burn out, but “with a rejuvenated, relaxed mind, we see new solutions to old problems and find new reserves of strength we didn’t know we had.”

In Self Compassion, Kristin Neff writes that “self-compassion involves wanting health and well-being for oneself and leads to proactive behavior to better one’s situation, rather than passivity.” Most therapists will value and advocate self-compassion to our patients, but this is interrupted if our own judgment and frustrations translate to shame. Therapists can and must authentically identify countertransference and validate our own frustrations, but if we don’t work toward compassion, shame will influence the way we communicate with our patients about their progress. We can’t shame our patients and encourage self-compassion at the same time. Only when we can clearly, nonjudgmentally and empathetically validate our patients, can we then compassionately identify barriers to change. Then, and only then, can we gently be that “agent of change” and work toward problem-solving, and perhaps, that elusive movement toward behavior change.



So where then do we go with “stuckness?” As helpers, we want to work toward diminishing suffering. At the same time, there is no simple set of steps to follow to guarantee the change we and our patients would like to experience.



In my case consultation, we identified symptoms, pathology, social and environmental vulnerabilities that make task-initiation and substantial change difficult. This was useful to an extent, but when the shame talk about “lack of motivation” is removed and a sense of authentic compassion is applied, we can approach these barriers with gentleness and validation.

I would argue that we may always be left with the unsatisfying and intangible alchemy of change. When I work with a patient who has implemented a challenging behavioral change—sometimes after very long periods of ambivalence or perceived “lack of motivation”— I will ask the patient to reflect upon what factors prompted change, with as much detail as possible. The question “how were you able to do that?!” is as much about having the patient reflect upon the mechanism of their change process as it is my genuine wonder and awe about the process of moving from desiring change to actual action. I don’t pretend to believe that I will be the therapist who isolates some theretofore incomprehensible means of change. However, I do believe I will be a better clinician when I can spend as much time and effort working to validate and empathize my patients as I do working toward problem-solving.