COMMON FACTORS ACROSS ALL CHANGE PROCESSES

In these first few blog posts I aim to cover some of the principals involved in helping people make changes. Following that we will get down to some specific interventions for a whole variety of clinical presentations. I want to make these posts both informative and useful for day to day consultations. I encourage you to feedback your responses and make requests for specific areas you would like me to cover in the future…

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I don’t know about you, but I have always been fascinated by how change occurs. And particularly by the way some people respond better to some approaches rather than others. You may well have experienced how one method bore no fruit whatsoever, yet another, coming from a completely different kind of mindset altogether, seemed to hit the nail on the proverbial head.

There are many, many different approaches to treatment, therapy and helping people make changes. In the last 50 years, (and especially the last decade alone), there has been an exponentially increasing number of interventional modalities, each with its own theoretical underpinnings, rationale and techniques of encounter. There is no doubt that many of these methodologies can help some people at some time with some problems…but not all.

I wondered just how such diverse interventions could get results with different people who shared similar problems…

Back in the late 90’s Hubble, Duncan and Miller in The Heart and Soul of Change pondered the same question. They suggested that all approaches shared four common factors through which all successful change is mediated. Rather than getting results by the explicit techniques that differentiates them one from the other, it seemed that these common factors catalysed the change process. They even allocated percentages for how much each factor played a part in the overall course of events.

Patient, Person, Client (40%)

Even though our patients are coming to a consultation with a particular problem – or even set of problems – it is important to remember that they also have a personal history that is replete with particular strengths, resources and skills. All there just waiting to be unearthed.

Too often, in the pain of the clinical encounter, it is easy to forget that in other unrelated contexts of life our patients have often displayed commitment, focus, determination and resilience – the very stuff required to sustain change. The trouble is, they often overlook these things themselves and it may require considerable re-framing on our part to re-vivify and put these resources to good use.

Other key determinants are patients’ personal beliefs and values, how they’ve previously coped with and caused change to occur and how confident they are in their belief that they can change in the future – self-efficacy.

In essence, we must highlight and harness these strengths, putting them to work effectively.

• Therapeutic Alliance (30%)

No matter what the clinician’s theoretical position, all successful change modalities seem to require the presence of factors such as rapport, empathy, acceptance and encouragement. If we believe that it is possible for our patients to change then this can act as a self-reinforcing prophecy – and vice-versa.

It’s the patient’s perception of the degree of support that is important here. It doesn’t matter whether we believe we are being supportive – their view of how the alliance is going is paramount.

There is however a paradox that is worth mentioning. Very occasionally there may be someone who complains bitterly about how un-supportive and un-helpful we have been – yet they changed “despite” this. (More on this in a later blog).

Together, patient strengths and therapeutic alliance account for the majority of a successful intervention. We must pay close attention to both.

• Expectancy, hope and placebo (15%)

Whenever patients begin a process of changing they have certain ideas about how it may turn out. They may hope for one thing yet underneath it all expect something else to happen. Ideas can have a direct influence on how things will turn out.

As clinicians, we also have beliefs about the current therapeutic model we are utilising. The congruency with which we perform the therapeutic ritual is paramount. Yet it is not necessarily the particular methodology we use that gets the result. It is the belief that both parties share about the model that may be key.

The placebo effect is really a mix of different physiological processes that are present to one degree or another in every consultation. What they are and how you can elicit them therapeutically deserves an entire blog post to themselves – and this is something I will most definitely cover soon.

• Technique (15%)

Techniques are the specific rituals of intervention you use with patients to get the results they want. They provide ways to elicit and utilise particular resources so that you can direct them with finesse into current trouble spots. They provide templates which can help us not only see ingrained problems in a new light, but actually do something different about them.

Techniques afford both a rationale and convincer to patients that they can alter previously entrenched behavioural patterns thereby increasing their inner locus of control. There are many useful techniques in the various change methodologies and I encourage you to learn as many as you can. The more you have at your fingertips the greater your flexibility to get results across a wide spectrum of presenting problems.

THE NLP PERSPECTIVE ON THE COMMON FACTORS

Now, one of the great things about NLP as a premiere change technology is the sheer scope it gives to develop and amplify the effects of these four areas. One of the foundational principles of NLP is the presupposition that People have all the resources they need to change within or can acquire them. We can debate whether or not that is “really true”. However, adopting this as a belief in any change consultation can often catalyse almost magical outcomes.

NLP has numerous formats for identifying, optimising and utilising patient strengths in any clinical encounter. It is one thing to say that patients’ past resources are vital in the change process – quite another to have so many specific means of re-vivifying them and bringing them fruitfully to bear. You will find many of these very powerful formats and techniques in the free downloads section.

Many change methodologies strongly endorse therapeutic rapport yet have little specific to offer other than “adopt an open and inviting body posture and keep eye contact”. NLP has closely studied what happens when people are in deep rapport and has numerous matching and mirroring techniques to enhance it. Rapport is a state, with a set of beliefs and intentions that can be incorporated in any encounter. You can learn to develop this state to get the right depth of rapport for the current situation.

You can also be in rapport through recognising and utilising the information that people project into space all around them all the time. This is completely unique to NLP and opens up a fascinating world for bespoke interventions. It also means you can do so without getting embroiled in and taking on your patients’ negative emotions.

Hope and expectancy are particular constructs that have a specific submodality makeup for each individual that can be elicited, enhanced and used to even better effect. Knowing the key details that drive these constructs in differing situations can allow you to strengthen the impact of your interventions over time. Helping someone find something to live for can fuel re-mission.

One of the mechanisms of the placebo effect is through conditioning (anchoring in NLP terminology). Another is through the framing (and re-framing) of meaning. Both can be used to enhance therapeutic effects. Placebo effects have had a negative press in medicine for far too long. NLP skills can help you utilise them in many positive ways (more later).

One of the things that attracts people to NLP is the sheer number of techniques that can be used across the board of presenting problems. NLP is a meta-discipline: you can use it as a tool to code the interventions of other methodologies, strip them down to their essentials, and then rebuild them to be even more robust, powerful and elegant in their application. This kind of reverse-engineering means that once you have learned the basic model and toolkit, you can custom build your therapeutic interventions to suit any situation.

If there is one take home message from the above then it is this: key to any successful intervention is identifying and amplifying patient strengths within the context of therapeutic rapport. Keep this clearly in mind and you will stay firmly on track.

In the next blog I will take a look at Prochaska and DiClimente’s Stages of Change Model and how you can bring it effectively into change consultations using NLP.

Until next time…

Lewis

5 Responses to “COMMON FACTORS ACROSS ALL CHANGE PROCESSES”

  1. Michael says:

    Nice post Lewis! Thanks for a nice overview of the therapeutic process. It’s fantastic to have someone with experience writing on such interesting topics!

    I have a few questions…

    1. Steve Andreas has talked before about client/patient belief in an NLP process or practitioner being NOT important simply because otherwise the process would be placebo only. I agree that utilizing the placebo effect is a wonderfully important tool to enhance results, yet do you not believe that we should be focusing on processes that work regardless of a patients belief like the rest of science?

    2. Rapport is such a talked about topic — yet having studied NLP for 13 years I would have to say that I’ve never found the non-verbal matching and mirroring techniques effective (when used with me by famous trainers, or me using them in my life with clients or other situations). Psychological studies (can’t remember the journal reference) have seemed to indicate that body matching is probably a RESULT of rapport, not a cause. What’s your take on this?

    Feel free to answer any of these questions in a future blog post if better for you :)

    Thanks again… I can’t tell this is going to be a great blog!

    Michael

  2. admin says:

    Hi Michael

    Yes, both your questions deserve a detailed blog post to themselves….until then, an overview response…

    1. I think Steve is right for problems that are a direct result of conditioned responses such as simple phobias though not for more complex issues where beliefs about what has happened/why it has happened/why “I” can’t change etc are deeply intertwined with the presenting issue. Simple conditioned responses occur without much cognitive input and from that perspective it often doesn’t really matter whether or not a patient believes change is possible, a counterconditioning stimulus will usually work well, especially for uni-contextual issues that have clear boundaries. For more complex issues, whilst the initial sensitising event may have been stimulus-response in nature, the pervasive knock-on effects on beliefs/attitudes/values etc in many other life contexts are often the “glue” that keeps things going. And even after this sensitising event has been seemingly adequately dealt with by the requisite process the cross-contextual issues and negative expectancies may still override it. (Dilts would call this the difference between a capabilities based problem and one at identity level, though I wouldn’t want to get into a debate about the validity of his logical levels model).

    And also please note that the placebo response is now thought to have a variety of mechanisms of action one of which includes conditioning which itself seems irrespective of belief and another which is dependant on expectancy (beliefs about the future) and can be modified by opiate antagonists. It really is impossible for science to completely outwit the placebo response, especially since we are now finding it has a scientific basis! One over-arching definition of the placebo effect is that it is the meaning response someone makes about a situation….given that a key intervention (and one of the earliest used approaches) in NLP is re-framing I would say that NLP enhances the placebo effect and makes it even stronger!

    For what its worth though, I think NLP is more a balance of “art” and pure science and how an intervention is performed and by whom has a big part to play in the effect. As a famous NLPer, I think it is difficult to sort out the strong placebo effect Steve Andreas undoubtedly has as a result of reputation from the intervention itself. (My understanding of Steve’s position from previous discussions is that there is a difference between “Faith healing” where change is all down to client belief and the science behind an intervention that “works by itself”…the “truth” is likely to be somehwere in the middle)

    2. As for rapport, this is a common response. However I don’t think this is an either/or phenomonen, rather it’s a both/and. I have certainly had significant experiences where “behaving” my way into rapport has had profound effects on me and the patient. And equally when I have simply set up the intention beforehand to get good rapport and just let my body do what it needs to whilst I forget all about the behaviours. It’s a real chicken and egg though…the state of rapport naturally leads to the exhibited behaviours and vice versa in my experience. What I think happens in the psychological studies is that the practitioner’s attention is solely on what he/she needs to do body-wise so that the split attention required to continually do this actually causes a disconnect.

    When I see a patient in a standard general practice consultation, whilst they are making their “opening” statement (anything form 30-90 seconds usually) I do some mirroring at that point as I let them talk, then forget all about it thereafter. This seems to work well. I think medical practitioners do need to be wary of getting “too much” rapport with patients who are depressed, anxious, asthmatic, etc, etc as it is all too easy to take on that state.

    In my view though, the emphasis on Rapport can be overdone. Sometimes it’s really important to establish good boundaries which may mean being out of rapport with the patient. At others it can be far more informative to track the information that people project into the space all around them at all times. Getting “informational rapport” may be more effective in the longer term than emotional rapport…and healthier for the practitioner ;)

    Thanks for the Q’s Michael

    Lewis

    BTW, you wrote : “I can’t tell this is going to be a great blog!”….hope that was either a slip of the keystroke or you can tell now ;)

  3. Michael says:

    Thanks for the great responses Lewis. Sorry it was a slip of the keys… I CAN tell this is going to be a great blog! ;)

  4. Michael says:

    BTW… I would love to get your take on how you go about identifying the beliefs in the glue that keeps a persons problem so stable, and how you go about helping your patient modify them in useful ways — even though sometimes those beliefs can sometimes make it hard for people to even be receptive to change. But I think THAT is a big enough topic for one or more blog posts for the future (or even some sort of training)!

  5. admin says:

    Agreed Michael!