Motivation to Grow: Utilizing Adult Learning Principles to Increase Patient Buy-in

"Motivation for change must be generated before change can occur." - Irvin D. Yalom 

Twelve men sit in a room. Many don't want to be there, a few are court-appointed, and none feel particularly well; sleeping is an issue for most. How do you motivate these men to engage in a group session centered around "I" statements and talking about feelings? 

If the scenario above seems all too familiar, you're not alone. Therapists, counselors, social workers, and even interns lead group therapy daily in the United States. One major challenge is that most licensing and degree programs do not provide formal practical training in group facilitation or the effective delivery of evidence-based practices, one of which is building motivation in resistant populations (Carroll, 2012; Beidas & Kendall, 2010). 

Obtaining patient buy-in in a group therapy setting is a skill that can be particularly challenging given the diverse individuals who all have their own thoughts, opinions, and background experiences; what may convince one will do little to move another. But motivation is a critical component of learning, progress, and speed of development. In this article, we will take a deep dive into the fundamentals of learning, motivation, and barriers to obtaining buy-in. We will also explore practical solutions to motivating resistant patients in group therapy.  

Motivation and the Principles of Adult Learning 

Dr. Malcom Knowles was a prolific educational theorist who coined the term andragogy, a synonym for adult learning and education, in his search for the most effective ways to help adults maximize the acquisition, retention, and ability to recall the knowledge and skills they were introduced to in formal and informal learning environments. Knowles developed five aspects of adult learners: 

1) Self-concept - Adults are independent and self-directed; they like to take ownership of their learning and decision-making; they don't like being told what to do, and doing so is likely to result in internal or external resistance. While it might be easy to assume what patients might need, guiding them to reach conclusions on their own will be more effective in terms of creating buy-in (Knowles, 1975; 1984). 

The importance of autonomy in adult learning and patient interaction is not lost on experts in the behavioral health field; William Miller states, "To tell people that they can't do something (drink, smoke, or leave the city) is not only inaccurate but can also promote the forbidden. Efforts to enforce external control can even undermine autonomous motivation for change... Accepting and affirming your clients' autonomy to make choices represents a powerful therapeutic stance and one that can be genuine and empathetic as well" (2021). 

2) Connection to life experiences - Adults bring a wealth of past experience that can be applied and connected to topics; even if the concepts and skills you're introducing are new, past experience can still be applied. For example, one way to restructure negative thoughts is to put the thought "on trial," gathering factual evidence to disprove whatever negative connotation the patient has about him or herself. 

I can be a thoughtful and loving person because I ensured my mother had food that week when she was sick in bed. 

Anyone who is a fan of crime dramas or who has served on a jury can connect their previous knowledge and experience to the CBT skill they are learning to use in group. Furthermore, adults will be more motivated to engage with the content and contribute to the conversation and community healing if they feel they have something worthwhile to contribute (Knowles, 1975; 1984).

The counselor or therapist can help scaffold and connect the session topics to relevancy by encouraging the sharing of personal stories within the group. Group discussions, debates, and mingles are all activities that allow patients to evaluate, reflect, and review their own experiences in light of whatever the session topic is. Furthermore, allowing patients to provide one another with praise and advice backed up by evidence (usually grounded in life experience), is another way to enhance learning among the group. 

3) Relevance connects to a readiness to learn - Unlike children, who are often compared to "sponges" that soak up all new information they can as they grow, adults are more selective in where they dedicate their conscious attention and effort to learn (Knowles, 1975; 1984). Relevance ties in significantly to the "why" behind learning, and the facilitator can help patients see the relevance by clearly connecting the topic to patients' life goals. Patients will engage more deeply in the session content if the material relates to their everyday life, so facilitators leading groups should always strive for high practical relevance. 

Patients need to be shown concrete examples and see how topics relate to them, thus making the concepts less abstract and scary. For example, many patients will have trouble quieting their minds during times of stress or when having trouble sleeping; connecting these real-life situations to the research behind how mindfulness and meditation help with calming and sleeping issues can increase the motivation to engage with the content.   

4) Orientation toward learning through real-world problem-solving - While problems that are too simple can quickly lead to patient disinterest and disengagement, and those that are too challenging can cause distress and frustration, adults thrive on real-world problem-solving at achievable levels. When formidable obstacles are overcome, patients will feel a sense of accomplishment and an improved self-image (Knowles, 1975; 1984). 

The therapist can help foster real-world problem-solving opportunities by addressing the topics relevant to patients in recovery, such as setting and sticking to schedules and boundaries, assertive communication, and self-care. Planning for and practicing responses to stress or triggers under various contexts and conditions will be the best way to prepare patients for success outside the safety of the therapy space. 

Take, for example, building a continuous recovery plan. Triggers and cravings are real-world problems that patients will face. Creating a continuous recovery plan will help patients to recognize high-risk situations and respond to triggers with positive thought patterns and actions. The therapist or counselor can encourage the group to come up with common triggers individuals in recovery face on a daily basis. Based on that list, small groups can work to devise action plans for each scenario. Once complete, the small groups can give one another feedback, both positive and negative, on the plans so revisions can be made. Once the final plans are complete, practice scenarios can be created to allow patients the opportunity to practice executing their plans in as close to real-world conditions as possible. 

5) Motivation to learn is more effective if it comes from within - While the previous four attributes of the adult learner can be utilized to promote motivation, the fifth principle of adult learning is tied to motivation itself.

Extrinsic motivation, or the use of external rewards or punishments to encourage patients, is generally painted in learning and growth situations as the enemy of good facilitation. This is true to a certain extent because if we compare learning situations to exploration, the use of rewards or punishments tends to outline a boundary around how much a patient should do. While the fear of incarceration or losing relationships (punishment) can be a powerful motivating force, creating drive from within is far more beneficial long term.  After all, the therapist or consoler will not be there to reinforce rewards outside of treatment (Kyndt, E. et al., 2011).

Therapists can help build intrinsic motivation by clearly connecting the session topic to relevant challenges to solve and brighter future outcomes. For example, if a patient doesn't believe that the HALT strategy will help to prevent a relapse, they will be less inclined to engage with the session and give it their all when it comes time to practice HALT strategies. Hearing others' success stories of how HALT has helped them or learning some of the scientific reasoning behind how understanding and taking care of one's physical and emotional needs can lead to more thoughtful and conscious decision-making are two ways to help patients build motivation in your group sessions; we will cover more practical application examples later in the article. 

Building Motivation and Overcoming Barriers Through Communication 

Communication is the foundation for which relationships and expectations are established and normalized. While assertive communication is a skill that patients in recovery will benefit from mastering, the communicative skills of mental health professionals responsible for helping patients heal directly impact outcomes.  

When discussing effective communication aimed at lowing resistance and increasing motivation, we need look no further than William Miller, the mind behind Motivational Interviewing. Miller asks and answers, "When two chefs are working with the same ingredients, how different will their meals be? The answer here is startlingly clear. There are often large differences among therapists who are offering the same or similar treatment over time" (Miller & Moyers, 2021).  

Miller and Moyers state that the way sessions are delivered matters. Effective communication helps build patient motivation, while poor elicitation techniques impede patient progress. Empathetic facilitators who ask the right questions can significantly improve a patient's outcome. When discussing patient positive change talk, which is tied to motivation, Miller describes, "What is often underestimated, however, is the extent to which you shape your clients' speech. Consciously or not, you do influence the content of your clients' in-session speech by the particular questions you ask..." (Miller & Moyers, 2021) Words and tone matter. Facilitators who ask the right questions can help build motivation to change in their groups.    

Communication can also be utilized to overcome obstacles standing in the way of motivation. Misunderstandings, which can take many forms, can be a barrier to obtaining buy-in. Individuals will frequently color what they share and leave room for interpretation. The therapist may interpret what was said differently than intended. Sometimes things are just misheard.  

Similarly, a lack of understanding on the part of the patient will decrease motivation, so it is essential to elicit responses that demonstrate competence or understanding of the topic; this will allow the clinician to address misconceptions and get patients on track before knowledge or skill gaps lead to frustration. 

To address misunderstandings and lack of understanding, facilitators may utilize concept-checking questions, a tool to measure where a patient is in relation to a particular topic. Concept-checking questions are targeted to allow patients to show what they know. Look at the example below:

How can your understanding of epigenetics help shape your future choices?

I understand that my genes determine my choices. 

This response shows a misunderstanding of the topic, which the facilitator can now address. 

I know that I may have stronger urges to use than my friend, so I need to be vigilant in avoiding the triggers that I can and dealing appropriately with the ones that I can't. 

I understand that while my genes play a part in my cravings and addiction, the choice to use is mine, so I need to think through things carefully and use my coping skills. 

These responses show comprehension of the topic and a connection to recovery. 

Mental health professionals can catalyze patient progress through effective elicitation techniques, interpersonal and delivery skills. Using researched-based tools correctly, clinicians can overcome roadblocks to motivation-building, such as misunderstanding, lack of understanding, or resistance.  

Motivation in Practice 

1)  Returning to the room of 12 men, how can the therapist motivate these men to engage in a group session centered around "I" statements and talking about feelings? 

My partner at The Institute for the Advancement of Group Therapy, Nick Jaworski, faced this exact situation when he led a group last September (2022). This is how the conversation went: 

Nick - Do you all have relationships that are important to you, that you want to hold onto, or that you want to rebuild? 

Group - Yes 

Nick - Today, we’ll look at a communication tool that might help you with that goal. This tool is used when we feel defensive or angry or if others are upset with us, but we still need to communicate with the person so whatever the problem is can be resolved.  

Have you ever been in a situation where you communicated with someone, and the situation dissolved? Maybe it turned into a screaming match, you left more frustrated, and the problem, whatever it was, got worse.

Group - Yes

Nick - So, do you think it would benefit you to know how to use this tool?  

Group - Yes

Nick - Alright, today we are going to talk about using "I" statements... 

By approaching the group using elicitation questions that connect to real-life experiences and a relevant real-world problem to be solved, patient curiosity is elevated while resistance is lowered. Once patients make the connection that this tool might benefit them on their own, Nick allows them to autonomously decide if this is a tool they want to learn. They unanimously agree, and the motivation to learn, the buy-in, is achieved.  

2) Next, let's take the example of a psychoeducation section on the genetics of addiction. How is this information valuable to the patient? Many patients might think, "Genetics sure do seem to have a big impact on my addiction; I guess I shouldn't even try because I can't change my genes."

What line of elicitation questions could a facilitator use to motivate patients to move toward a more positive outlook on the topic conducive to recovery? 

Do you know anyone that has found recovery? 

Do you think people find long-lasting recovery after leaving here?

What does this tell us about how to view genetics?

Recovery is absolutely possible, right? We see it all the time. Millions of Americans are in active recovery right now. So is there hope for everyone in this room?

This line of questioning allows patients to reflect on their own life experiences to come to the conclusion that genetics are only part of addiction and recovery on their own. More importantly, acknowledging that others who have had similar struggles have successfully found recovery is internally motivating because it reinforces the reality that it is possible for the patient. 

3) Now, let's look at a situation that most patients can relate to; trouble with the family. Often, patients in recovery have endured adverse childhood experiences, and in many cases, those negative memories are tied to their parent(s) or guardian. Even those who had stable home lives growing up are likely to have had trouble when they were in active addiction. For this example, let's imagine the therapist wants patients to work through challenging emotions by writing a letter to their parent(s) and expressing all the things that weren't said. How can the therapist motivate patients to take part in this exercise? 

What is your idea of an ideal parent? What kinds of characteristics do you think a parent should have? 

How do your conceptions of an ideal parent stack up to your own experience with your parent or parents? 

Often, individuals want to explain to their parents the impact of their (the parents') decisions on them, but it can be challenging. Have you dealt with situations like this? 

In some situations, we may not be able to have these conversations because the parent is gone, the relationship is unsalvagable, and maybe you wouldn't want to salvage it even if you could, and that's okay. But, there is a strategy that has been shown to make people feel better and more at peace that you can try, even if you don't end up sharing these things with the person in question. Is that something you'd be willing to attempt? 

By beginning the conversation with an open-ended question that puts patients in the driver's seat, once again, curiosity increases and resistance decreases. The connection to life experience is the next step. Because most people have family contention in their past, the guiding question regarding "words never said" is likely to result in an affirmative answer. From there, patients are given a choice if they want to participate in an activity to help them; because the line of questioning gently guided them toward accepting the proposed task, buy-in is achieved. 

4) Finally, let's look at a scenario where a patient who may be opposed to abstinence is asked to create a recovery plan. What line of questioning can help motivate this patient? 

All of us are different, right? We may share common struggles, but we have different backgrounds and life goals. Does that sound about right?

One thing we probably do share is that it makes us feel good when people come to us looking for advance. I know it makes me feel good when people ask my opinion and really listen. What about you?

Well, right now, we are becoming more aware of recovery, coping strategies, and confronting some challenging emotions so that we may improve our lives. There are a lot of people out there who have already found recovery. Others are currently struggling and maybe haven't found help yet; if someone like this came to you for advice, what might you say? 

Based on your personal experience and what you've learned in treatment, could you help this person solve their problem by building a continuous recovery plan?  

It is entirely possible that a situation like this could happen in the future. So it's good to prepare. You could really help someone one day. 

Beginning with an assured commonality helps hook patients into the conversation. By connecting the natural desire to help with a relevant, achievable real-world problem to solve, patients are motivated to complete the exercise, even if they don't support abstinence at that point in their life. 

Motivation is vital to any learning situation, and group therapy is no different. An effective facilitator will utilize adult learning principles, including autonomy, relevance, a connection to life experience, and real-world problem-solving, to build intrinsically-motivated patients ready to engage with the content, conversation, and community healing. Elicitation strategies combined with effective communication can help foster buy-in and break down barriers to building motivation. Before you walk into your next session, keep these learning strategies in mind, and you will see your group's participation and motivation grow. 

References: 

Beidas, R. S., & Kendall, P. C. (2010). Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective.  Clinical psychology: a publication of the Division of Clinical Psychology of the American Psychological Association, 17(1), 1–30. https://doi.org/10.1111/j.1468-2850.2009.01187.x

Carroll, K.M. (2012), Dissemination of evidence-based practices: how far we've come, and how much further we've got to go. Addiction, 107: 1031-1033.  https://doi.org/10.1111/j.1360-0443.2011.03755.x

Kyndt, E. et al. ( 2011). The direct and indirect effect of motivation for learning on students’ approaches to learning through the perceptions of workload and task complexity.” Higher Education Research and Development 30.2: 135–50.

Knowles, M. (1975) Self-Directed Learning. Chicago.  Follet. 

Knowles, M. (1984) The Adult Learner: A Neglected Species (3rd Ed.) Houston, TX.  Gulf Publishing.

Knowles, M. (1984) Andragogy in Action.  San Francisco. Jossey-Bass.

Miller, W. R., & Moyers, T. B. (2021). Effective psychotherapists: Clinical skills that improve client outcomes.  The Guilford Press. 

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). Basic Books.