Ms Ang Bee Lian, 12 November 2018
As social service practitioners, many of you would have been introduced to various techniques and models of interventions that help you in your work with clients. These may include social casework, cognitive behavioural therapy, narrative therapy or solutions focused therapy. While each model has its theoretical underpinning and can be useful in helping to bring about change in clients when it is applied selectively, it is important to keep in the mind the bigger context within which change takes place.
Change often happens as a result of the interaction of various factors of the system, and cannot be attributed solely to one factor alone. Scholars have come up with a four-factor model of change (Miller, Duncan & Hubble, 1997) in a therapeutic relationship. Change, or the lack of change, happens as these 4 factors interact. The 4 factors include: client and extra-therapeutic factors; relationship factors; models or techniques; and expectancy factors. I will explore in greater detail these 4 factors.
Client factors, such as personal motivations, abilities, hopes, goals and expectations, play an important part in determining whether change happens and whether the goals of the helping relationship are achieved. While the techniques or skills employed by the practitioner are crucial, we need to be reminded that change can only happen hand in hand with clients. As practitioners, it is important then to know clients well enough in order to pace appropriately with them through the stages of change (Prochaska & DiClemente, 1983). Seek to understand how their life experiences and worldviews shape their motivations, goals and hopes; and what their fears and barriers to change are. Motivational interviewing for example is useful in directing clients towards change by exploring the causes of their ambivalence.
It will also be useful for practitioners to help clients develop a “growth mindset” (Dweck, 2015). A growth mindset is the belief that one is on a continuous journey of learning and improving as opposed to a belief that one is unchangeable. Having this mindset will result in a greater ability to change. A practitioner can prime clients for a growth mindset through the use of words such as “improve, develop, learn and grow”. Listening for a growth mindset means focusing our attention on people's strengths, goals and possibilities. In essence we are listening for potential - for what a person can develop or grow to be with improvement.
In addition to client factors, there are also what scholars have termed “extra-therapeutic” factors such as the level of social support or life events, that affect the change process of the client. This reminds us that the client is a “person-in-environment”, where his or her behavior is largely influenced by environmental factors. Understanding that client and extra-therapeutic factors have a role to play in affecting change will help social service practitioners to look beyond the models employed in therapy towards a more holistic assessment of and intervention for clients.
According to Michelle Thomas (2006), relationship factors refer to the “strength of the therapeutic alliance between the therapist and client(s)”. Some would estimate that this accounts for about 30% of change (Hubble, et al., 1999) in clients. According to Martin (2003), “a good relationship is almost certainly healing in and of itself, but it is also powerful because it contributes to keeping the client actively involved in the treatment process”.
This should not be new to those who have been working in direct practice for some time. Relationships of trust and respect are foundations from which positive change can happen. Clients must be able to know that their worker does not judge them, is listening to them, and is seeking to understand them. It is from a foundation of a strong relationship that practitioners are also able to encourage and even challenge clients in their journey.
As such, social service practitioners should invest time in developing strong relationships of trust with clients. One way in which practitioners can do this is by taking part in continuous reflective and reflexive practice in order to be more self-aware.
Another factor that affects change is the model or techniques employed by the worker. This consists of the theoretical orientation of the worker, as well as the therapeutic methods or strategies used by the worker in the helping relationship (Thomas, 2006). While models or techniques used by the practitioner may be secondary to the helping relationship, they are nonetheless important in facilitating change in the client. Practitioners should be aware of what works with different groups of clients (e.g adolescence, clients with depression, etc), and use these models when working with them. At the same time, practitioners should also be flexible in adapting these models and techniques to fit the specific needs and characteristics of the client. In upholding ethical practice, social workers should also use the therapeutic models that are grounded in research and that they are competent in.
The last factor affecting change is what is known as expectancy factors. This refers to how hopeful and believing clients are in the credibility of the treatment and the helping relationship (Sprenkle & Blow, 2004). The ability of the worker to present the helping relationship in a way that is in alignment with client’s expectations will contribute to successful change (Johnson & Talitman, 1997). Practitioners should celebrate little successes with clients along the helping journey in order to engender hope in them.
It is easy to get lost when presented with many theories, perspectives and models in the course of your work. But it is important to remember that change in our clients do not happen in silo, but as an intertwining of various factors. May these 4 factors serve as a helpful framework for all of us as we continue with the helping journey with our clients.
Dweck, C. (2006). Mindset: The New Psychology of Success. New York: Ballantine Books.
Thomas, M. (2006). The Contributing Factors of Change in a Therapeutic Process. Contemporary Family Therapy, 28, 201-210.
Hubble, M.A., Duncan, B. L., & Miller, S. D. (1999). The heart and soul of change: What works in therapy? Washington, DC: American Psychological Association.
Martin, D. G. (2003). Clinical Practice with Adolescents. Belmont, CA: Cengage Learning.
Sprenkle, D., & Blow A. (2004). Common factors and our sacred models. Journal of Marital and Family Therapy, 30, 113-129.
Johnson, S. M., & Talitman, E. (1997) Predictors of Success in Emotionally Focused Marital Therapy. Journal of Marital and Family Therapy, 23, 2, 135-152.
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MS ANG BEE LIAN
Director-General of Social Welfare