The Mystery of the Unmotivated patient

As a moderately seasoned counselor, one of the frustrating aspects of working with individuals suffering from substance use is the lack of motivation and engagement in their treatment and recovery. I become frustrated because they appear to be unmotivated, and underachieving. In my attempt to work with these individuals I am experiencing some consternation. This article focuses on alerting clinicians, like myself,  how ineffectual interactional patterns may prohibit a patient’s ability to thrive.

Despite our clinical perception of being powerful agents of change, we tend to use ineffective ways of communicating with patients we perceive as unmotivated.  Therefore, I need to change how I perceive those patients in order to encourage them to modify and adapt a new way of perceiving their own sense of worth.

Throughout the treatment process, the focus is on communication. This is accomplished when we utlize the best evidenced based tools (e.g. motivational interviewing and cognitive behavioral therapy). What we may forget to understand is the messages patients are attempting to communicate through their maladaptive behavior. By understanding how the patient perceives and projects their image, we are able to constructively adapt and modify our own therapeutic expectations.

Therefore, the focus rests on counselors to be more attentive to the needs of unmotivated patients.

The Mystery of the unmotivated patient

One of the common casualty of being unmotivated may have something to do with a person’s living environment. Research suggests that those patients who thrive in recovery and treatment have stable housing and peer support (Polcin, Korcha, Bond, Galloway). Patients struggling with living environment deficiency tend to develop a permeated sense of hopelessness and helplessness.

This vicious cycle of poverty and despair become inhibitors for patients to engage in a holistic recovery process. Lack of sober support alliance and peer support is another factor that  may be an inhibitor.

As a counselor myself, I may not fully understand the underlying key of the surface behavior. All we may perceive is lack of motivation and engagement on the part of our patients. This includes the frustrating observation of how the individual is failing to comply with the recommended treatment. And there is a reason these patients struggle. How this struggle is being communicated through the individual’s lack of engagment. The key is for myself, and other clinicians, to understand what is behind the behavior.

What I have observed is this: an established and entrenched set of attitudes and beliefs the patient has of self and others. This is based on attachment theory and addiction counseling. In general, human existence thrives on close interrelational and emotional bonds. Those with healthy emotional bonds with family and social network tend to thrive toward stable and healthy lifestyles. However, those with unhealthy, detached, co-dependent, and toxified emotionally damaging relationship (or relational trauma) become indicators of a person’s inability to form secure attachments. This influences the attitudes and beliefs of distrust of self and others, inhibits ones ability to develop and sustain a sense of worth, and evokes sense of inadequacy. It also projects an ideal expectation of others as being unwilling to help.

These patients struggle with chronic feelings of emptiness, dissastifaction in all areas of life, anxiety, shame, guilt, and anger. They are unable to either:

  1. Reach their full potential in order to thrive and sustain a holistic recovery based program by engaging and actively participating in treatment.
  2. Develop and sustain meaningful and fulfilling relationships.
  3. This latter includes their inability to develop a healthy therapeutic alliance with clinical staff.

In order for these patients to begin developing secure attachments, I need to understand their desire of two basic needs:

  1. A sense of safety and security in their engagement with clinical staff and peers
  2. Ongoing support and validation in how they are exploring their own path toward recovery

What I am discoverying is that the message my struggling patients appear to be communicating is their need for security, support, validation, and how I fulfill the role of caretaker. It is our responsibility to establish a secure base within the therapeutic alliance and relationship.

Furthermore, we assist those stable peers in modeling an established secure base, especially within a group therapy setting. This helps clinicians understand the importance how our patients internalize an image of themselves and how others may perceive them.

How our patients view themselves is key in moving them from lack of engagement and into active participation that leads to a thriving recovery based program.

Confronting False images, beliefs, and attitudes in a holistic therapeutic way

The founding false belief, patients hold, is the self-image of one who is unloveable and unhelpful. By operating under this illusion, the unmotivated patient may engage in those behaviors that appear to validate and enhance their perception. It stems from their view of how inadequate they are and the sense of insecurity they feel. And, when they enter into treatment, verbalize the need of recovery, express how active substance use has negatively impacted their life’s, these false perceptions persist and inhibit an individual from engaging. Because of how perpetuating this internalized image of self and others erodes the patients ability to interact with clinical staff and peers.

In the manner in which our struggling patients behave, may induce those around them to behave within the perception of the individual’s internal expectations. This is because, when the individual feels they have no secure base, their perceptive thought (and belief) rests on the idea of how others are judgmental, critical, unhelpful, and even rejecting. Unconciously, they are projecting their own image of self. And, every negative response, appears to reinforce their reflections and established expectations.

This creates a vicious cycle that motivates the individual to not engage in treatment, to be unmotivated toward change, and not be compliant with treatment recommendations. And, through their maladaptive behaviors, reinforce the false beliefs and attitudes that are self-perpetuating and eroding any sense of worth in order for them to engage in a process whereby they may gain mastery and develop a collaborative and therapeutic alliance to thrive in recovery.

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