Marmor's (1987) common factors in psychotherapy

Nature of the relationship

Cognitive learning

Operant conditioning

Modeling and identification

Suggestion and persuasion

Rehearsal and repetition

Prochaska, DiClemente, Miller & Rollnick: Stages of Change

Precontemplation Stage

Contemplation Stage

Preparation Stage

Action Stage

Maintenance Stage

There is no "right" or "wrong" stage to be in. It is extremely important, however, for the therapist and client to know which change stage they are in. That way, the treatment strategy can match the change stage. Of course, many clients move from one stage to the next stage while remaining in therapy. But others benefit from, or seem to need, a break from formal therapy. In a sense, after completing one change stage, they take a "sabbatical" before moving on to the next change stage. These sabbaticals are extremely important, and valuable. They allow people to rest, to take stock, and to consolidate gains before moving on. So, although therapy may have ended, growth continues. When a person is ready to move to the next change stage, he or she may come back for additional therapy or counseling.

We call this form of therapy "intermittent developmental psychotherapy." It is intermittent because it moves in spurts. It is developmental because it moves in a discernible sequence, with one stage forming the foundation of the stage that follows it.

The building blocks of motivational approaches (A-H): (from Miller & Rollnick, 1991, p. 20)

Giving ADVICE.

Removing BARRIERS

Providing CHOICE, Intrinsic motivation is enhanced by the perception that one has freely chosen a course of action, without significant external influence or coercion.
d. Decreasing DESIRABILITY
i. An important motivational task for the counselor is to identify the client’s positive incentives for continuing his or her present behavior.
ii. Behavior is more likely to be altered if affective or value dimensions of desirability are affected.
iii. A more general counterbalancing approach is to increase the person’s awareness and salience of adverse consequences of the behavior.
e. Practicing EMPATHY
f. Providing FEEDBACK. Feedback must be compared with some standard. It is this process of self-evaluation--comparing perceived status with personal standards--that influences whether or not change will occur.
g. Clarifying GOALS
h. Active HELPING. Two general themes:
i. Taking the therapeutic initiative
ii. Expressing your caring
3. Brief Intervention
a. Active Ingredients of Effective Brief Counseling (FRAMES approach)
i. Feedback: a structured and often comprehensive assessment, through which the client is given feedback of his or her current status.
ii. Responsibility: an emphasis on the client’s personal responsibility for change.
iii. Advice: clear advice to the client to make a change.
iv. Menu: a menu of alternative strategies for changing the problem behavior.
v. Empathy
vi. Self-Efficacy: reinforcing the client’s self-efficacy, hope, or optimism. “It is also worth mentioning here that the therapist’s belief in the client’s ability to change can also be a significant determinant of outcome.” (from Miller & Rollnick, 1991, p. 34)
4. Principles of Motivational Interviewing
a. Five General Principles
i. Express empathy.
(1). Acceptance facilitates change.
(2). Skillful reflective listening is fundamental.
(3). Ambivalence is normal.
ii. Develop discrepancy.
(1). Awareness of consequences is important.
(2). A discrepancy between present behavior and important goals will motivate change.
(3). The client should present the arguments for change.
iii. Avoid argumentation.
(1). Arguments are counterproductive.
(2). Defending breeds defensiveness.
(3). Resistance is a signal to change strategies.
(4). Labeling is unnecessary.
iv. Roll with resistance.
(1). Momentum can be used to good advantage.
(2). Perceptions can be shifted.
(3). New perspectives are invited but not imposed.
(4). The client is a valuable resource in finding solutions to problems.
v. Support self-efficacy.
(1). Belief in the possibility of change is an important motivator.
(2). The client is responsible for choosing and carrying out personal change.
(3). There is hope in the range of alternative approaches available.
b. Strategies for Handling Resistance
i. Simple reflection.
ii. Amplified reflection: reflect back what the client has said in an amplified or exaggerated form--to state it in an even more extreme fashion than the client has done. If successful, this will encourage the client to back off a bit, and will elicit the other side of the client’s ambivalence.
iii. Double-sided reflection: within the realm of reflective listening, to acknowledge what the client has said, and add to it the other side of the client’s ambivalence.
iv. Shifting focus: shift the client’s attention away from what seems to be a stumbling block standing in the way of progress; going around barriers rather than trying to climb over them.
v. Agreement with a twist: offering initial agreement with the resistance, but with a slight twist or change of direction.
vi. Emphasizing personal choice and control.
vii. Reframing.
viii. Therapeutic paradox: prescribing the symptom; giving rationales for why the client can not change. [Use with extreme caution and supervision.]
d. Final Points
i. The importance of hope and motivation.
ii. Therapist congruence; a general rule of thumb seems to be that we can not ask clients to do what we would not do, or to take risks and grow in ways that we would not. It may happen, but if it does it is in spite, rather than because, of therapy.
iii. An appreciation of the reality of growth and processing outside waking awareness (unconscious processes).
iv. An appreciation of mystery and chance events (the “surprise factor”)
vii. The need to facilitate absorption.
viii. The need to access tools and resources:
(1). Immediate relief and/or inculcation of hope of relief.
(2). Improvement of skills (ego strengthening).
ix. An appreciation of irony.
(1). The only absolute truth is that there is no absolute truth.
(2). Sometimes people change in spite of, rather than because of, the therapy.
(a). Sometimes the message gets through even when the relationship is poor.
(b). Sometimes the message gets repeated by others the client does relate to, and this brings back the original message.

Marmor, J. (1997). The evolution of an analytic psychotherapist: A sixty-year search for conceptual clarity in the tower of Babel. In Zeig, J. K. (Ed.). The evolution of psychotherapy: The third conference. New York: Brunner/Mazel, pp. 23-33.
Miller, S. D., Duncan, B. L., & Hubble, M. A. (1997). Escape from Babel: Toward a unifying language for psychotherapy practice. New York: Norton.
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.
Prochaska, J. O. (1999, June). The process of behavior change: From individual patients to entire populations. Clinician’s Research Digest, 17 (6), Supplemental Bulletin 20.
Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 19, 276-288.
Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Homewood, IL: Dow Jones-Irvin.
Rogers, C. (1951). Client-centered therapy. Boston: Houghton Mifflin.
Roth, A., & Fonagy, P. (1996). What works for whom? A critical review of psychotherapy research. New York: Guilford.
Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist, 50, 965-974.