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Triad of Unconscious Motivation and Helping Services

Posted on October 3, 2014

Last week I introduced the Triad of Unconscious Motivation put forth by Lisle and Goldhammer in their book, The Pleasure Trap. In The Pleasure Trap, Lisle and Goldhammer state convincingly that we have powerful and often unconscious motivations to use our limited energy as efficiently as possible, which explains behavioral patterns and habits. In addition, we are naturally inclined to avoid pain and to seek pleasure. If we are not mindful of our thoughts and actions, these motivations can dominate our lives and, as with many of our clients, can lead to destructive behaviors and addictions.

The question I want to explore this week is whether these same motivators can also teach us something important about how we create and deliver programming for traumatized clients? As I’ve thought about this post this week, an analogy came to mind that helped me think about this question. I would like to start by sharing this analogy, which will allow us to explore the Triad’s role in healing and change.

The analogy is constructed around an airplane and a pilot (I know little about planes so if my aviation knowledge is flawed, forgive me!). Our airplane, which flies between the same two cities (let’s say Denver and San Francisco) multiple times a day, is a high-tech marvel, as it can run on autopilot from the moment the pilot turns on the engine until the engine is shut back off after the flight. This special autopilot has an artificial intelligence component, which allows it to learn through experience. It can ensure proper functioning of its own parts, but needs to be shown the route before it can take over flying responsibilities.
This autopilot quickly learns from experience how to get from Denver to San Francisco and back. The pilot initially must fly the plane for the entire trip. Each trip back and forth provides the autopilot with more data, allowing it to take more and more control of the plane. Soon the plane is flying itself and uses a simple program to make any inflight adjustments.
The autopilot has a simple algorithm, which the pilot is unconscious of, that guides it during the flight. First, the plane is programmed to save as much fuel as possible. On a normal day, this entails flying the route that has been shown to be most efficient in the past. Second, the plane is designed to avoid any potential harm to itself by flying around severe weather, avoiding mountains, and staying clear of other planes. Finally, the plane is programmed to maximize the pleasure of its passengers by not making sudden turns or changes in altitude and flying as smoothly as possible under the conditions. Over time, the plane collects data on how it is doing on these three aspects, makes small adjustments over time, but basically travels the exact same flight path, trip after trip, day after day.
The pilot is no longer needed and can relax, read, and even take a nap as the autopilot does all the work based on its past experience and simple algorithm. Over time, the pilot loses sharpness and power as the autopilot is always in control. In our high-tech plane, the pilot quickly becomes no more important than any other passenger.
In our analogy, as you might have guessed, the autopilot represents the brain, the pilot is the mind, and the trip is a habit. With each flight, the autopilot becomes more efficient and the pilot plays less and less of a role. For our traumatized clients, the trip from Denver to San Francisco and back is too often representative of managing an addiction or just surviving in extreme poverty or homelessness.
Let’s now say instead of going to buy drugs (San Francisco in the analogy), we are working with the client to become free of the addiction, get into permanent housing, and attend a job training program (let’s use Chicago to represent this new destination). The plane, or brain, has no capacity to do this on its own. Managing an addiction and surviving homelessness is something it has learned to do efficiently, while maximizing pleasure and avoiding pain is accomplished through the use of substances.
Once again it needs the pilot or mind to take over. Unfortunately, the pilot has gotten lazy from years of just enjoying the view from the cockpit and doing little else. Like in the analogy, many clients who have lived in high-stress and traumatizing situations for years might seem to have little insight, mindfulness, or volition to control their thoughts, behaviors, or other key aspects of their lives. You can talk to the autopilot all you want about Chicago but all you’ll get back are some flashing lights and little or no movement towards changing ingrained habits. Even if all the passengers board the plane thinking they are going to Chicago and the pilot tells the autopilot to go east, all the plane knows to do is fly over the Rockies to the Bay.
As helpers, it is important that we acknowledge this reality and adjust our expectations and program requirements to meet clients where they are in their journey. Harm Reduction has shown us clearly that programs with abstinence or other immediate behavior change requirements fail compared to programs that utilize the client’s current behaviors and life situation as the starting place for change. It has been great to see over my career that fewer and fewer programs have these hardline requirements, opening services up to those that need them most.
Often when clients enter our programs, the last thing on their mind is stopping an addiction or making other big changes. They are often just looking for a bed or other resource to help them avoid or minimize the pain of their situation. This pain might be sleeping outside in freezing temperatures, fear of getting their children taken away by social services, pain caused by hunger, withdrawal from heroin, or being afraid for their lives in a domestic violence situation.
Pain is the unconscious motivator that brings people into our programs. Entering helping programs is rarely efficient, as it often requires finding transportation, going through intense intake processes, and the new ways of thinking and behavior required to get the desired resources. Having success in helping organizations requires a much different skill set than surviving on the streets, in violent relationships, or extreme poverty. Also, we are rarely in the business of providing short term pleasure for our clients! Compared to getting high or having sex, your intake process, medical exams, and group therapy are very devoid of pleasure.
While the avoidance of pain is the motivator that brings clients to our programs, we must also address the other two motivators of seeking pleasure and maximizing energy efficiency. Too often, these are not immediately obvious to either the client or helper. Let’s look at an example in HIV care to demonstrate what we are often up against.
According to the CDC, of the 82% of people who know they are HIV positive, only 37% are retained in care and only 25% are virally suppressed (the goal of most HIV medical treatments). I was shocked by these numbers when I first started working in HIV. Today we have medications that turned this horrible terminal disease into a manageable chronic illness, but only 37% are in care to receive this treatment. Can we use the Triad to explain this seemingly illogical situation?
Is HIV care efficient? Simply, the answer is no. Figuring out transportation, child care, and appointment times all add stress to our clients’ lives. Add to this that remembering to take HIV medications daily, at the right times, and in conditions to minimize side efforts can also be difficult. Until the client’s health deteriorates to a certain point, it is much more efficient in the short term to avoid the challenges and requirements necessary to manage their HIV.
Does HIV care avoid pain? Let’s look at two levels of pain: physical and emotional. Stigma, shame, fear, and many other intense feelings are often experienced when someone is diagnosed with HIV. I think these reactions go a long way in explaining why nearly 20% of those diagnosed are never linked to care, even though, thanks to Ryan White HIV Services and now Medicaid Expansion (in some states), treatment is often free or, at least, very affordable. If these emotions are not addressed and the client is not able to integrate having HIV into their view of self, the same emotions can keep clients from attending appointments and confronting the reality of their disease. It is often much easier to fall into denial than face the emotional pain that too often accompanies an HIV diagnosis.
What about physical pain – isn’t it surely better to take a cocktail of pills than die of AIDS? Unfortunately, most HIV medications come with side effects that can at best be annoying and at worse be life-altering. Without a strong mind or pilot, the unconscious brain will choose to avoid the pain of the moment caused by side effects at the expense of longer term health consequences. The mind needs to convince the brain to endure short term pain for an ambiguous future benefit. This delay of gratification takes an incredible amount of volition and strength, which, as we learned, is also not efficient for the brain.
HIV treatment is not efficient and often causes more pain than it helps clients avoid. So what about seeking pleasure? Most clients wouldn’t state that treating a disease with high levels of stigma, side effects, and adherence challenges is pleasurable. Living a long healthy life can be seen as a pleasure, but it takes a great deal of mindfulness to override the pain and inefficiencies. Many clients with HIV are also struggling with poverty, mental health/substance abuse issues, and other problems. This keeps their brain locked in the present, and we can all think of many things more pleasurable than going to a medical appointment.
The miracle might be that 25% of those with HIV are virally suppressed! I used to get depressed when I looked at the CDC Cascade, and while I still think we need to find ways to do better, in context of the Triad of unconscious motivators I understand the reality driving the data in a new light. HIV is only one example of how as helpers we confront these motivators, which make achieving the outcomes we want for clients incredibly difficult.

Next week, we’ll bring the conversation to the level of interventions with clients. How can strategies like Motivational Interviewing and Mindfulness utilize our knowledge of the Triad to help our clients make positive life changes and heal from past trauma? My challenge to you this week is to think about your services and clients in contrast to the Triad. How are these powerful and often unconscious motivators impacting your ability to be successful and achieve outcomes both you and the client desire?

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