The University of Hawai'i clinical studies program in the 1970s was a hotbed for learning theory applications to clinical problems, with the likes of Leonard Ullmann, Roland Tharp and Arthur Staats. But newly arrived from Hans Eysenck's laboratory was a young, captivating and rather charming Englishman who soon became very popular with graduate students, both because of his broader theoretical reach and his ability to draw theory so effectively into the clinical encounter. It is not surprising, therefore, to see these qualities in abundance in Ian Evan's new book blended with his rare insights about how people change, gleaned from the ensuing 40 years of teaching, researching and practising the art.
This text has 12 chapters that review and explain a range of key theories and interventions that address behaviour change. He sets the scene by arguing for a unified account of change, and the need for a basic deconstruction of terms and principles used by different treatment methods, so that their fundamentals are revealed. Next, he considers ‘What changes?’ and the metaphors and forms of change that can be measured and evaluated. Change theories are explored across several chapters, including Motivational Interviewing, the Health Behaviour Model, Theory of Planned Behaviour, and Behavioural Conditioning (classical conditioning, contingencies, and aversion). The text moves on to the many influential components of change, highlighting clinician variables, client variables (i.e., self-efficacy, intention to change, support to change), the function of the behaviour, and environmental and cultural influences on behaviour change. Evans draws out three primary considerations he believes all clinicians should remember when helping clients: change is difficult; clients can be reluctant or unable to recognise the need for change; and clients do not like to be told that they need to change. To better illustrate Evan's deeply thoughtful perspective, we'd like to give a bit more detail on three chapters we found especially interesting.
The opening chapter, ‘Why we need a theory for change,’ provides a rationale of why therapy needs to focus more on what is to change (viewed as the client's behaviour) rather than the current preoccupation with treatment per se (viewed as the therapist's behaviour). This chapter sets the scene for the rest of the book, arguing that: (1) behaviour change would benefit from investigations into unrelated disorders to determine if they share an underlying process (p. 4); and (2) addressing the client's goals and reducing their distress levels (i.e., problem solving) may be a more effective approach than viewing disorders as discrete or separate to each other. Evans further states that when assessing client motivation, it is important to identify what the client expects to achieve from therapy (regardless of presenting problem) so that therapist knows what the client is seeking before change goals are negotiated. Another important component of motivation for client change is the development of a good therapeutic alliance between client and therapist. Throughout this chapter, Evans integrates his own clinical experiences about motivation to change across a range of disorders, and in relation to key evidence-based treatments such as behavioural therapies, cognitive-behaviour therapy (CBT) and both the second generation (dialectical behaviour therapy) and third generation (Acceptance and Commitment Therapy) CBT treatments.
The chapter ‘Motivation to change’ explores the importance of developing an awareness to change in the client, as well as distinguishing between a client's motivations to change versus motivations to sustain their current behaviour. Enhancing client motivation to change during treatment is then explained through the two motivation frameworks of drive theory and goal theory. From these two frameworks, Evans examines the stages of change model, motivational interviewing, the theory of reasoned action (including the theory of planned behaviour) and the function of the behaviour. In the context of clinical behaviours, he then pursues two therapeutic steps: goal setting (for change) and developing the client's strengths to achieve the goals set in treatment.
The ‘Self influence’ chapter is very interesting in that it focuses on what the client brings to treatment. Here, Evan's highlights that it is the client's responsibility to change, and that people often change their own behaviour, thoughts and goals without assistance from a health care worker. However, the chapter then proceeds to explain how a therapist can facilitate autonomous self-change in the context of various clinical presentations (such as depression and social anxiety). Therapist strategies to facilitate client self-change can involve teaching the client skills such as setting their own goals, managing antecedents and consequences of their behaviour, and developing self-rewards and coping strategies. The importance of individual differences between clients is acknowledged and the chapter finishes by comparing the differences between self-help interventions and therapist-delivered treatments.
Overall, this book is comprehensive, thought provoking, reflective and highly engaging. It is an excellent text for any health professional interested in understanding change and why or how people change. Evans successfully applies change theories to clinical settings and real life (client) presentations. However, those seeking a beginner's level practical workbook with instructions on how to implement behaviour change skills will need to look elsewhere. This text is more like a mature red wine, imparting a deeper and satisfying understanding of this complex phenomenon with each sip. Finally, Evan's work is also recommended for inclusion in any educational or training courses on change, as well as a key reference text in any university library.
