This class explores how to build motivational interviewing into case formulation, using stages of change, adapting for the impact of cultural factors on sessions, and building person-centered culturally responsive interventions. The class explores a model for integrated treatment plan development that uses three core factors: a) Culturally Grounded Understanding of Individual, b) Theory Based Grounded Understanding of the Problem a person faces, and c) Motivation Grounded Empowerment for patient-centered care. The presentation explores a five factor model for adapting interventions to the impact of culture on clinical work. Cultural factors affect: 1) Clinical symptoms and diagnosis, 2) Experiences of self, 3) Biological Impacts (Stress and Health), 4) Relationships, and 5) Access to Cultural Support Structures. This lecture explores stages of change, the core hallmark of each stage of change, and how to adapt clinical interventions for those stages.

1. Motivating Change
Class 8 – Engaging the Stages of Change

2. CONNECT
AND
REFLECT
This week in
learning MI?
Share 1 Thing
from That
Mattered to
You From the
Reading?

3. Motivating Change
Review Clinical Theory and Cultural
Adaptions

4. BRINGING IT ALL TOGETHER FOR
INTEGRATED CHANGE PERSON, PROBLEM
AND MOTIVATION
1. Culturally Grounded Understanding of Person: Having
an understanding of the cultural realities,
interpersonal needs, relational style, experiences and
strengths a person has helps you move with them to
create meaningful change.
2. Theory Grounded Understanding of the Problem: A
clear formulation of the core common factors in a
mental health challenge, a problem or a behavior
change allows you to adapt and create MI
interventions that support change e.g. depression,
anxiety, PTSD, OCD, ADHD or other mental health
condition.
3. Motivation Grounded Empowerment: MI MI spirit,
interventions and tools support individual
empowerment for change and enhances the capacity
to engage with interventions, heal, address cultural
traumas and become more connected to themselves.
Motivationally
Grounded
Empowerment
Theory
Grounded
Understandi
ng
Intervention Choices
and Meeting Client in
Their Change
Clinical Change
Building a Life that
Matters e.g. to Work,
Love and Play
Culturally
Grounded
Understandin
g

6. CLINICAL
ENGAGEMENT
WITH
CULTURAL FACTORS
IN MOTIVATIONAL
INTERVIEWING
5 CONSIDERATIONS
1. Clinical symptoms and diagnosis: Experiences of bias, othering,
disconnection can increase multiple mental health symptoms in
specific ways. Assess for the factor that directly impact the
diagnosis.
2. Experiences of self: Cultural factors often create spaces of safety,
wholeness and connection with in safe social location. Experiences
of oppression, privilege, power dynamics, societal oppression
impact the since of self, beliefs about self and how one acts towards
one’s self. Knowing this can lead to more effective intervention
formulation.
3. Biological Impacts (Stress and Health): Cultural factors impact stress
levels, safety, health and overall wellbeing.
4. Relationships: Expiries of support and connection and calibration of
cultural self can increase connection, relationship and trust.
Experiences with power, privilege and oppression impact mood,
stress, anxiety, hope and trust in connection with others. This can
impact rapport building.
5. Access to Cultural Support Structures: In places where one’s identity
is supported there are often easy access to the larger cultural
support structures. One of the core ways privilege and oppression
manifest is through blocking access or support from social systems,
cultural support.

7. CULTURALLY GROUNDED
FORMULATION OF ANXIETY
____________________
HOW DO COMMON CULTURAL
EXPERIENCES OF POWER,
OPPRESSION, PRIVILEGE AND
COLONIALISM IMPACT MOTIVATION
AND DEPRESSION?
WHAT CHANGES WITH DIFFERENT
TYPES OF INTERSECTIONALITY?
WHAT CHANGES IN DIFFERENT
SOCIAL LOCATIONS? Woman, Gender Fluid, Gender
Non-Conforming, Transgender,
Intersex

8. MI WITH
PEOPLE
WITH
PSYCHOSI
S
Let’s discuss a good clinical formulation of
MI for people with psychosis. What are
some common symptoms that negatively
impact a person with psychosis life and
how could MI help?

9. ROLE PLAYS
RULERS OF
CHANGE
Role Plays

12. SMALL
GROUPS
ROLE PLAYS
MI
Use Ask-Evoke-Ask
model to work
through a role play
using the Rulers of
Change
Take 10 minuets each
with a client.
Practice being with
your client in the
ambivalence and
using tools that keep
the conversation
going forward.
Sustain Talk
Listen, Understand,
Resist Righting
Reflex, Empathize
Ambivalence
OARS – Open ended
questions,
Affirmations,
Reflections,
Summary
Change Talk
Explore, Affirm,
Reflect, Summarize
Challenge to
Change
https://www.naadac.org/assets/2
416/agnieszka_baklazec_ac17ppt.

13. Difficulty Controlling Worry: Worry is highly demotivating
and can consume the energy that some one is working on to
effect change. Develop ways to build new beliefs, change
fear-based cognitions and interrupt rumination can help with
generalized anxiety symptoms.
Worry and Anxiety in Many Areas of Life: Developing an
understanding of triggers, emotions and feedback loops in
anxiety as well as tools to interrupt rumination, reduce
psychological and biological aspects of worry and increase
control can help change GAD.
Indecisiveness and Fear of Decisions: Fear of outcomes,
exhaustion from emotional stress, and difficulty with
concentration can impact the ability to make decisions.
Practicing acceptance, understanding and normalizing
difficulty, and addressing perfectionistic paralysis can help
reduce indecisiveness.
Biological Stress Response/Difficulty Feeling Safe:
Developing tools to regulate affect states, tolerate affect
states and enhance feelings of safety are core to GAD
treatment.
GENERALIZED ANXIETY
DISORDER AND MOTIVATIONAL
INTERVIEWING

16. GAD EXERCISE
Your client wants to feel better, but they are
feeling anxious, exhausted and overwhelmed
all the time. Their anxiety started when they
were in the late teens and now they are in their
late 20s and it is difficult to go to work each
day with their anxiety.
Making the situation worse they identify as
genderfluid but are not sharing this fact in the
workplace and their boss and several
individuals at work have been making more
derogatory comments and microaggressions
based on gender differences.
Your client wants to feel better and hopes you
can offer some tools, skills and ways to reduce
their anxiety. They also want skills to feel
better again after biased statements in their
workplace. They are considering options for

17. Motivating Change
Three Factors: Person, Problem and
Motivation

18. SPIRALING UPWARD THROUGH
STAGES CHANGE
CONNECTION THROUGH CHANGE

23. Pre-Contemplative:
Not yet
acknowledged that
there is a need for
change. No intention
to change, low
awareness of need
to change.

24. PRECONTEMPLATION
RULER NEED: Low since of need and urgency.
RULER ABILITY: Lack of consideration of
ability, low belief in ability to change, or
belief change not needed.
RULES COMMITMENT: Low to no
commitment for change.
Metaphor for Intervention: During the pre-
contemplation stage, therapists can take the
role of a nurturing parent. They can show
understanding, empathy, engage active
listening, resist the righting reflex and roll
with resistance. They can raise discrepancy
between beliefs and actions, hopes and
impact and increased understanding.

25. Contemplation:
People are aware
of the problem,
know change is
needed, they are
considering
deeply the needed
change. They may
make comments
such as, “I know I
have a problem,
and I think I
should do

26. CONTEMPLATION
RULER NEED: Aware of need but need can
be tend to be moderate to high.
RULER ABILITY: Ability is an important
focus and often is a transition between
contemplation and moving to preparation.
RULES COMMITMENT: Low to moderate
commitment to change.
Metaphor for Intervention: During the pre-
contemplation stage, therapists can take
the role of a Socratic Teacher – asking
important questions, seeking shared
understanding, help client grow new
insights about needs and behaviors.

27. Preparation Stage:
People are aware of
the problem, are
engaged in learning
about change,
growing ability and
strengths and
learning how they
can change.

28. PREPARATION
STAGE
Watch out for rushing this stage: ”If
bypassed, individuals tend to plan
insufficiently, without thoughtfully
considering the impact the change will play
in their lives.”
RULER NEED: Aware of need, need tends to be
moderate or high.
RULER ABILITY: Ability can fluctuate and needs
support to maintain. Often there is a moderate
or high level of ability to change or there is a
belief in the ability to learn how to change.
RULES COMMITMENT: Moderate to high
commitment to change.
Metaphor for Intervention: During the
preparation stage the therapist can take the
role of ‘Experienced Coach.’ The clinician can
help develop a clear plan, understand how to
change, get ready to change but remember to

29. Action Stage: People
are working on the
engaged plan of
change, taking
action, learning
from challenges,
seeing new areas of
growth and getting
support.

30. ACTION STAGE
Change is close often abstinence will
occur in under 6 months.
RULER NEED: Aware of need, need
tends to be moderate or high.
RULER ABILITY: Ability tends to be
moderate to high, changing with
setbacks and challenges. Support is
needed.
RULES COMMITMENT: Moderate to
high commitment to change.
Metaphor for Intervention: During
the preparation stage the therapist
can take the role of ‘Consultant.’ The
individual is actively using the
relationship, asking questions,
bringing in challenges for growth.

31. Maintenance Stage:
Change is moving
and people are
doing the actions of
change and
developing the skills
of working through
challenges.

32. MAINTENANCE
STAGE
Day by day change and problem
solving, lapses and relapses.
RULER NEED: Aware of need, need
tends to be moderate or high. May
fluctuate based on confidence and
setbacks.
RULER ABILITY: Ability tends to be
moderate to high and working with
success challenges and set back
challenges.
RULES COMMITMENT: Moderate to high
commitment to change. May fluctuate
with success and failures.
Metaphor for Intervention: During the
preparation stage the therapist can
take the role of ‘Consultant.’ The
individual is actively using the
relationship, asking questions,

34. ROLE PLAYS
RULERS OF
CHANGE
ANXIETY
DISORDERS
Role Plays

35. SMALL
GROUPS
ROLE PLAYS
MI
Use Ask-Evoke-Ask
model to work through
a role play using the
Rulers of Change
Take 10 minuets each
with a client who has
Generalized Anxiety
Disorder
Practice being with your
client in the
ambivalence and using
tools that keep the
conversation going
forward with out falling
Sustain Talk
Listen, Understand,
Resist Righting
Reflex, Empathize
Ambivalence
OARS – Open ended
questions,
Affirmations,
Reflections,
Summary
Change Talk
Explore, Affirm,
Reflect, Summarize
Challenge to
Change
https://www.naadac.org/assets/2
416/agnieszka_baklazec_ac17ppt.

36. Self Evaluation Form… Committments
for Change.
What are you able to commit to for
exploring and increasing MI Skills in
your patient interactions?

37. CLOSE AND REFLECTION
Working on Embodying these Skills in Life

38. REFERENCES
1. Hooks, B. (2014). Teaching to transgress. Routledge.
2. Hooks, . (2000). All about love: New visions. New York: William Morrow.
3. de Haan, A. M., Boon, A. E., de Jong, J. T., & Vermeiren, R. R. (2018). A review of mental health treatment dropout by ethnic minority
youth. Transcultural psychiatry, 55(1), 3-30.
4. Domenech Rodríguez, M. M., Baumann, A. A., & Schwartz, A. L. (2011). Cultural adaptation of an evidence based intervention: From theory to practice in a
Latino/a community context. American journal of community psychology, 47(1), 170-186.
5. Davey, M. P., Davey, A., Tubbs, C., Savla, J., & Anderson, S. (2012). Second order change and evidence‐based practice. Journal of family
therapy, 34(1), 72-90.
6. Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior
therapy, 47(6), 993-1014.
7. Li, X., Yang, S., Wang, Y., Yang, B., & Zhang, J. (2020). Effects of a transtheoretical model-based intervention and motivational interviewing on the
management of depression in hospitalized patients with coronary heart disease: a randomized controlled trial. BMC Public Health, 20(1), 1-12.
8. https://www.verywellmind.com/what-is-community-psychology-
2794898#:~:text=First%2Dorder%20change%20involves%20fostering,fit%20better%20into%20their%20environments.
9. Prilleltensky, I. (2014). Meaning-making, mattering, and thriving in community psychology: From co-optation to amelioration and transformation. Intervención
Psicosocial, 23(2), 151.
10. William Miller & Stephen Rollnick. Motivational interviewing: Helping people change (3rd edition). (2013). New York, NY: Guilford Press.
11. Wyatt, J. G., Soukup, S. M., & Blomquist, M. E. (2021). Motivational Interviewing Skills.