Motivation
Personality disorder integrated care pathway
Up to 75% of people with personality disorder will be treatment-resisting, in other words they neither seek, nor wish to undertake treatment. Of the 25% seeking treatment, levels of motivation to change vary from patient to patient and over time. Treatment is invariably challenging, frequently requiring intense sustained effort. For this reason, it is important to build and maintain motivation for change. In fact, this is frequently the major focus of treatment for people at the pre-contemplation, contemplation and preparation stages of change.
Strategies for increasing motivation include:
• Instilling hope and an optimistic stance. This can involve education about the disorder, effective treatments, and the relatively positive prognosis.
• Creating other alternatives. This often involves time spent teaching problem and solution analysis.
• Identifying incentives for making changes and incentives for not making changes. This often involves pros and cons of changing versus not changing.
• Managing ambivalence. This involves exploring the tension between fear of change versus desire for change, highlighting and amplifying the discrepancy between current and desired experience, encouraging consideration of the benefits of change, and attending to the fear of change and associated concerns.
• Encouraging patience and persistence including highlighting that longstanding patterns of experience and behaviour take a long time to change.
• Identifying internal and external obstacles to motivation and change.
In aiming to build and maintain motivation, professionals should avoid taking responsibility for the patient or engaging in confrontational and coercive interventions. This is often difficult because professionals frequently feel a sense of responsibility when progress is slow. Occasionally, clinicians may find themselves pressuring the patient or giving advice. While this may not be unwelcome for the patient, it undermines the necessary position of the patient accepting responsibility for change. The only option open to the patient when professionals adopt these overly-directive behaviours is to behave in a dependent manner.
Maintaining clinician motivation during what can often be slow, challenging work is also important. A collaborative relationship with the patient, recognition that progress can sometimes be slow but that significant recovery is possible, setting realistic treatment goals, maintaining self-observation and reflection, and regular supervision all contribute to the maintenance of therapist motivation.