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by Kennon M Sheldon, Geoffrey Williams and Thomas Joiner Yale University Press, 2003 Review by Roy Sugarman, Ph.D. on Sep 3rd 2004 
It was William Miller in the 80's
who began to investigate human motivation and ambivalence, the great leveler of
motivated action. In essence, human beings see where they are and know where
they want to be, but the distance between the two may seem daunting, and saps
our will. Festinger's concept of cognitive dissonance applies here as well.
Giving up things, even when they are harmful, like drugs, involves sacrifice,
and this may be hard.
In illness, 'power' relationships
involving complementary stances are common and endemic: doctor-patient,
nurse-patient, doctor-nurse, medical and mental health settings are political
hotbeds for personality dysfunctional patients, as well as those others who are
ill. Larry Diller spoke of the patient's loss of sense of efficacy, loss of the
sense that what THEY as person did, makes a difference to the outcome.
Consumer pressure, in the form of a
'recovery' revolving around a patient's return to wellness, even though
technically still ill, has at its core the sense of personal efficacy in the
journey towards recapturing the premorbid position in society, or at least,
replicating it in the new world of mental disorder. Patients became clients,
then consumers, and now I am told, they just want to be known as service users,
distinct from providers.
The health worker is thus being
thrust from what David Manchester calls the 'sage on the stage position' to the
'guide on the side position', an empowered position in which the consumer
dictates a series of needs around entitlements, and the provider accesses those
and creates clinical competencies in the community to deal with the change in
consumer status which has resulted in a loss of position and status in
society. Mental illness and more medical illness is thus not a specter without
cure, cure is not possible but that is not a sine qua non for survival and
happiness: empowerment, self-efficacy, recovery, self-esteem, these are the
features of Anthony's work, and Deegan's laments about her care and wellness
dilemmas.
The humanitarian stances of the
recovery/rehabilitation groups have not been entirely integrated into mental
health care. Although the Meyerian, Boston, Rochester, and other
biopsychosocial model philosophies have begun to dominate the psychiatric
world, empirical science or sometimes pseudoscience still prevails against the
more humanitarian, non-medical, non-linear, seemingly unproven and unscientific
methods of care. Along the way, Laing, Szasz and others have seemed too
radical and hippie to be of value. Here, the authors of this book are doing the
same for medicine in the mainstream, but avoiding the radical stance.
Sheldon, Williams and Joiner have
set out to address the above historical issues by applying a more humanist and
general-systems informed approach, which also has the benefit of an evidence
base, within mainstream clinical medicine:
Unfortunately, the products of
humanistic research were often unimpressive, sometimes presenting laborious
descriptive analyses of trivial personal experiences, and other times seeming
to make hopelessly naïve assumptions about the inherent "goodness" of
human nature…..There was also a general shying away from causal analysis, as if
scientific explanation itself were taboo….By seeking to reform both theoretical
and methodological psychology simultaneously, the humanists overextended
themselves and diluted their message. Further, their attack on empirical
methodology was wrong, and it undermined their credibility. Research methods
are, after all, only tools, not ideologies, and like all tools, they can be applied
more or less thoughtfully (pages 8-9).
This is what the authors set out to
do, integrating humanism with cognitive science, in creating a basis for
self-determinism theory in a thoughtful, scientific way (SDT).
They begin with examining
self-determination theory's supportive research base, heavily reliant on Edward
Deci's and Richard Ryan's works. Concepts of mastery or 'effectance' in
efficacy are taken from Robert White's work in the late 50's in combating
social withdrawal and disengagement. Obviously if one is to recover one's
premorbid social position, one has to engage with the environment in an
effective way, and may need help to do so. Volition is, after all, problematic
to achieve with severe mental illness dominating, and surrogate frontal and
executive scaffolding seems called for. As with ambivalence, issues of
intrinsic motivation are important to, as exemplified in Deci and Ryan's work
which overturned much of the behaviourist approach by demonstrating that people
will often choose internal rewards rather than external, and seek their own
satisfaction choosing their own poison so to speak, punished by reward rather
than the other way round. Following on Plato, James, Piaget, Dewey, SDT is
thus an 'organismic' perspective (page 15). It assumes that we are naturally
curious and often seek challenge above other rewards. In this way too, we are
complicators of our lives, 'entropyreducing systems' in other sort-of words – I
shall avoid describing the concepts of entropy and enthalpy and autopoesis and
other thermodynamic/constructivist notions, which cloud the issue here. The
stance is that we seek to create, and evolutionary trends in the brain have
driven this organ to thrive on increasingly complex and creative situations,
not shrink or die off when stressed in this way. We are thus engagers in
creative complexity on different levels, and facilitating and integrative
process with this complex entity to empower movement out of pathological stasis
is a goal of healing.
This is presented as a dialectic:
thesis and antithesis interact to form a gestalt-like greater whole, a
synthesis, of inner and outer selves, and we seek to master our internal and
external environs, drives and impulses, a dialectic that evolves around the
synergic of the cognitive approach and the humanism that this approach has lost
so much of, sliding backward into the mechanistic reductionism that
characterized the early behaviourists. In essence, we are either pawns or
autonomous in the potentially alienating contexts of work and play, or of
wellness or illness. Hegel still has Marx on his head, with a bit of
Rousseauian romanticism showing itself in the lineage of the arguments put
forward here, and in the arguments reminiscent of dialectic versus scientific
materialism. SDT thus has a humanistic orientation supported by quantitative
and experimental research, makes positive assumptions about human nature,
whilst still accepting how the bad stuff can accrue anyway, assumes that there
are three human needs that constitute wellness, namely autonomy, competence,
and relatedness, focuses on people's need for ownership and mastery of
motivated behavior towards wellness, and the target of this thin book is to
show how those at the upper end of the complementary loop can best motivate the
one-down sick people so that they internalize suggested behaviors and self
regulate them (see page 22).
As they put it, SDT begins with the
concept of intrinsic motivation, viewing it as the basis of the prototype of
the self-organized state, and in this way we are epitomized as doing things in
the interface of the environment for the challenge of it, not the external
reward, but for the satisfaction that mastery of the self and other brings. We
all need to find what our intrinsic motivators are, so we can follow them, and
not master things that are not reinforced internally, but merely supported by
the environment: it's a kind of leaving home, leaving mum and dad's view of the
world, and following our own view, if we know what that is. In this way,
psychosocial competency and maturity means we can also do what is aversive to
us, mastering the external boundaries of the self, and relating therefore to
other selves which are critical to the sense of relatedness above.
Such latter changes are thus
unpleasant, and require abandonment of unhealthy in favor of healthy, changed
behavior, and this book is about how we facilitate that in the use of our
services. Or rather, how we promote ownership of not-so-enjoyable behaviors,
and how we get people to acquire motivation which is not intrinsically
reinforced, not immediately gratifying anyway, lets say.
In the unequal, complementary
situation, a power structure, supporting autonomy is thus the key, again a Deci
and Ryan concept. In, this is often a meta-complementary stance, providing
help. The first challenge is to stay with what the user of service sees as
illness perspective, letting them decide what to do, the most difficult part
for any service provider to play in Anthony's recovery model anyway. Providing
of choice wherever possible is vital too, and finally, providing a meaningful
rationale when choice is not offered, is a necessary part of the support game
too.
Concepts of client resistance come
into play here, some are less dutiful than others in following the clinicians
prescriptions. Ownership of recommended behavior is the goal here.
From chapter four, SDT is applied
to medical practice and physical health. Here, the concept of motivation is
examined closely with some clinical research, and chapter five becomes more
specific with regard to tobacco dependence
Following on Prochaska and
DiClementi, as did William Miller with MI and MET, time frames are allowed to
extend, relapse is expected and accepted, each failure doing more to guarantee
a better outcome next time, rather than worse, and relating this process to
many health related behaviors. Case studies are used, as they are in the next
chapter, where compliance in the face of ambivalence in diabetes mellitus is
supported.
As expected, mental health has its
turn here, and so they seek a unified psychology, of science and clinical work
coming together. The authors make good use of the controversy that emerged
around the Temple University finding on the outcomes in child abuse, and the
social pressure that arose rapidly when a survivor, rather than a victim
perspective was adopted, in positive psychology frames. Rind and colleagues
were pilloried, after peer review and acceptance, to boot, as were Herrnstein
and Murray when they published The Bell Curve, condemning the averaged
sum of some to the lower, middle or upper ranks in a deterministic fashion, but
with careful science to back them up. Again, the public often confuse the
statistical person with a real one. One of course cannot divide 10 000 results
by 10 000 to get one, one does not have the results of statistical averaging to
create perfection, or regression to the mean.
Neither technical skill nor
motivational abilities are enough, both are necessary and neither is sufficient
(see page 113). The human condition is such that in the interaction, both
expertise, and the capacity to sell that in such a way as to promote ownership,
is the challenge of clinical work. We knew that, and thanks to these authors,
in some part, we learn how to better achieve that end: wellness, empowerment
and recovery in medical settings.
Their final chapters look at
substance abuse (predictable), and finally, and acceptably, motivational
interviewing gets its time in the spotlight. Anxiety and eating disorders also
get attention, OCD, PTSD, bulimia gets a page or so, that is all. Mood and
personality are focused on in chapter 10, and here, the Cognitive Behavioral
Analysis System rises to the fore, as does interpersonal therapy for
depression, both focusing on manageable specificity.
They conclude:
What matters is not weaving a spell
of inspired speech, but, rather, creating an interpersonal context and
relationship in which clients can encounter their own resolve….There is a huge
gap between clients' intended and actual behavior (page 185).
The book is more than mere
philosophy, yet not enough. It is more than hocus-pocus, but the evidence base
is a tad thin. I think however they are really where they need to be in
providing a brief and somewhat scholarly, very readable and concise guide to
becoming a better person, and more importantly, to quote Jack Nicholson, in his
OCD laden compliment to Helen Hunt, they make me want to be a better person.
© 2004
Roy Sugarman
Roy
Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal
Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer
in Psychiatry, University of New South Wales, Australia.
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