The focus on wellness, particularly on the management of overeating, in therapy can be a double-edged sword. While clients often readily embrace the vector of self-care, goal-specific treatment planning and clinical homework can trigger the games of avoidance. Suddenly, the validating therapist is thrown into the role of a wellness expert and becomes an accountability check.
Before too long, mere inquiry into the client’s progress runs a discordant parallel to punitive supervision. With this actual or perceived change of hats, the process of the therapy changes, the wellness goals are eventually abandoned and the closet of therapy fills up with the skeletons of failed objectives. This – in my experience – has been an inherent complexity of problem-focused treatments such as behavioral medicine.
Such experiences have taught me that a non-directive, harm-reduction, humanistic angle of engagement works best in facilitating clients’ wellness goal of weight management. In particular, I have enjoyed better “compliance luck” from the clinical position in which I frame success in overcoming overeating as more of a know-how issue than a motivational issue. With this in mind, as part of the role-induction to behavioral weight management, I let clients know that I am aware of a variety of behavioral exercises that can help them transition from mindless reactive eating to a more mindful and more conscious eating stance, and I then offer the client to look at their weight management “homework” as a kind of experiential journey of gradual acquisition of mindful eating skills, and not as a frantic blitzkrieg of change.
This gradual, exploratory behavioral goal-frame, in my experience, reduces the often arbitrary urgency of the need to change (with the example of arbitrary urgency being: “I need to lose weight to look good at my son’s wedding”). An open-ended stance on behavioral homework (“You have the rest of your life to gain control over this issue and I have several exercises for us to try, so let’s just take time to see what works best for you”) also pre-empts and obviates “compliance relapse.”
Furthermore, a humanistically-permissive therapeutic posture allows the clinician to accept the client’s level of motivation for change such as it is. As a result, instead of taking the client on a problem-specific “detour” of motivational enhancement, the clinician merely joins the client’s skill-acquisition journey as part-coach, part-witness, with the therapy being a forum for a client to process the scenery of change, rather than walk the red-carpet of accountability.
I realize that the theoreticians of motivational interviewing might insist that motivation necessarily precedes change and that embarking on clinical homework any sooner than Prochaska’s boom barrier of Action Stage is premature. In my experience, the motivational process is not always linear. It would appear that sometimes homework can increase motivation. In particular, my work in the correctional substance use setting taught me that precedents of behavioral success can lead to a sense of self-efficacy which, in turn, leverages the motivation to change.
Case in point: teach a mandated substance use client how to control his/her cravings and, all of a sudden, the extrinsic motivation for treatment gets an intrinsic boost. The skill-focused homework – even when embarked on prematurely (from the motivational stand-point) — can leverage self-efficacy, and the realization that one “can” change paves the way for “I want to change.” The key here, however, is “to test,” “to experiment,” “to try and see what happens” – i.e. an exploratory verbal framing of the behavioral homework which makes it “optional” and, therefore, safe to fail.
When approached as such, the behavioral medicine intervention (with its accompanying homework) becomes an ongoing “wellness check” without the goal-performance pressures typically associated with behavioral homework. This kind of “in-parallel” positioning of behavioral medicine goals allows weight management to remain a primary focus of the therapy but without eclipsing the rest of the therapeutic issues.
The trick – as I have “discovered” – is to keep clients interested in clinical homework by diversifying it. As a behaviorally-minded clinician, I have long realized that I cannot bank on any one given exercise. Typically, with the exception of that rare, self-motivated client, the folks in therapy give an exercise a week-long try and then forget about it. In my earlier training days (as if training is ever over!), I’d “follow-up” on the homework, explore what worked and what didn’t and why the client stopped trying. In my experience, no amount of clinical tact could seem to prevent slight relational rifts when clients, projecting their transferential shame onto the provider, would end up feeling chastised or criticized. Many a client would admit to having wanted to cancel a session so as to avoid the “homework check.”
It goes without saying, I didn’t want to do that kind of therapy. It occurred to me that if I only had more of the same kinds of exercises at my disposal, then each exercise could be presented as but one way to shed light on a particular issue. It would be then understood that the exercise would be tried on for a week or two and would be subsequently replaced by yet another exercise. As such, each exercise would then offer a temporary self-help angle at the issue at hand and its expiration date meant that there was no performance pressure to turn the exercise into a life-long habit. With multiple homework choices up my clinical sleeve, I thought, I could simply “throw” them at a client until they “stuck,” so to say. That, however, meant more homework for me.
Which brings me to the following point that I want to make as directly as I can: we, as clinicians, need to do our own homework before “prescribing” homework for our clients.
Clinical homework can be a double-edged sword and as such, clinical homework, if prescribed light-heartedly and irresponsibly, is a potential clinical risk. While it can teach clients a specific skill, it can also do so at a cost of self-efficacy – that is, if the client is unable to translate a given skill-focused homework assignment into a new habit. With this in mind, I recommend that a clinician wanting to assign a specific skill-focused homework first identify multiple alternative ways of practicing the skill in question. Armed with a “menu of choices,” the clinician can then offer the client, hopefully, half a dozen different ways to achieve the behavioral goal in question. This way, with each homework assignment being a kind of experiential appetizer that may hold the client’s interest for a week a time, we can help our clients log in a month or two worth of skill-practice on a particular point.
With more practice-time under the belt and no immediate performance pressure, the client stands a better chance of internalizing the essence (rather than the form) of the homework that we “prescribe.”
As an added benefit, processing weight management clinical homework – whatever it might be tactically about (increasing mindfulness of the process of eating, awareness of satiety signals, trigger awareness, etc.) – yields to strategically valuable discussion of the habit formation know-how in the client’s life. Furthermore, weight management, as a behavioral medicine objective involves training in alternative coping and/or emotional self-regulation and craving control strategies – as such, it offers “value added” generalizability that can catalyze the progress of other non-wellness goals in therapy (such as anxiety management or substance use).
In developing one’s homework repertoire it helps to divide the behavioral exercises into awareness-building and habit-modifying exercises, with the former raising the awareness and inadvertently leveraging motivation for change, and the latter turning the awareness into an actionable platform for habit modification. I find that it helps to be explicit about whether a given homework exercise is awareness-building or habit-modifying. As suggested above, awareness-building homework is psychologically safer to fail. In regard to habit-modifying exercises, it helps to not exactly assign them as homework but to make clients aware of these exercises so that they can “try” them and decide if they want to officially commit to these changes.
I also find it helpful to offer clients exercises which allow them to integrate the specific wellness goals into a broader existential framework (for example, in the case of weight management, a life-modifying exercise prompts the client to formulate his or her “philosophy of eating” in light of how much emphasis they place on health, hedonism, social justice).
In sum, approaching behavioral medicine objectives such as weight management from a gradual, humanistic, creative, harm-reduction homework stance helps avoid the classic behavioral therapy “do-or-die” head-on collision with homework non-compliance. Approaching weight management not as a phase of therapy or a treatment module but as an ongoing clinical theme allows us to calibrate our clinical attention to this objective as it understandably goes in and out of client’s focus, in proportion to client’s motivational ebb-and-flow. Given that the interplay of motivation and skill-efficacy appears to be in an intricate feedback-loop, an ample stock of problem-specific behavioral homework allows the clinician to match the client’s non-linear motivation for change with ever-fresh homework options and ideas. But towards this end, of course, we have to do our own homework first.