What next for patients and service users?

Let’s pull out some salient parts of Kevin’s video. Notice how he said last night he felt one thing and today something different? These differing intentions are common. For instance, we may have just had a warm meal, or feel supported and close to our loved ones, and so think we can take an important step into something new. Then the next morning, we may have had some frightening dreams, we are alone in our flat, we’ve forgotten about that state of mind where we felt secure, and the idea of therapy feels impossible.

These dilemmas are especially salient for individuals who have not always had reliable and consistent care.

Recall the various theories of behaviour change? Well for Kevin, the best intention in the world, even coupled with strong motivation, will not always be enough, because different states of mind may take over, perhaps making other more basic psychological needs relating to safety a priority. Any motivations and intentions will need to be coupled with opportunities and support in his environment, and in his relationships.

Notice, it was someone on the forum who had completed therapy that acted as a motivator, as the voice of his therapist had been last week.

Pause: take a moment to reflect on how you could draw in those around you or resources in your environment to make changes in the coming months.

Can you spot any other factors that have helped or hindered Kevin in the way he has managed so far and the way he might approach the coming weeks and months?

Exploring how to engage meaningfully with the world is a seam that runs from the beginnings of psychotherapy to contemporary practice, where clinicians and service-users examine not only how to alleviate distress but how to engage in value-based action and work towards goals.

• In CBT we hear about SMART goals. Those that are: Specific, Measurable, Achievable, Realistic, Time-limited.
• In third-wave approaches like Acceptance and Commitment Therapy, we hear about the importance of values for guiding behaviours. What matters to us? To Kevin it is thinking about his identity, feeling accepted by peers, and having a space to share and feel useful.
• Contemporary Psychodynamic approaches would emphasise that if something significant in our relationships or embodied experiences is ignored or avoided in our goals, aims, or routines, we may run into difficulties. Let’s say, for example, that you want to stop drinking alcohol after the COVID-19 pandemic to live a healthier life, but drinking with friends is the only time where you feel relaxed, close to others, and can speak forthrightly about things that matter. These are worthwhile values that you will lose unless you think further about how to achieve them without alcohol, making you at risk of relapse.

From the beginnings of psychotherapy, right through to contemporary approaches, there has been a recognition that if our aim is for a happy, untroubled life, we won’t get very far. But, if we aim to live a meaningful one, engaged in what matters to us, we may fare better. We can see how such insights from psychotherapeutic practice can enrich our understanding of the stages of change model and inform how we can think about motivation, opportunity, and capability in the COM-B model.