Enhancing Motivation to Change


Published on

Published in: Health & Medicine
  • Be the first to comment

Enhancing Motivation to Change

  1. 1. Enhancing Motivationto Change Heather Durdle, PhD, R. Psych Karen Pellerin, MSW, RSW
  2. 2. Stages of Change (Prochaska, DiClemente, & Norcross) Precontemplation Contemplation Preparation Action Maintenance
  3. 3. Stages of Change Successful changers use different tools depending on their stage of change A series of tasks need to be completed before moving on to the next stage The tasks must be matched to the stage of change NOT A LINEAR PROGRESSION
  4. 4. Precontemplation “Everyone else needs to change” Typically deny having a problem Usually present to treatment under pressure from others Usually feel demoralized and hopeless so they avoid wanting to think, talk, read about their problem Free of failure and guilt Traditionally labeled as “resistant”
  5. 5. Contemplation “I want to stop feeling so stuck” Acknowledge they have a problem and begin to start thinking about how to address it May be stuck in this stage for a long time (e.g., two years for smokers) At transition to Preparation:  Begin to focus on solution rather than problem  Begin to think about future rather than the past
  6. 6. Preparation “I will stop drinking on Monday” May be committed but might not have resolved their ambivalence Awareness is high A short preparation stage may not lead to success
  7. 7. Action “No thanks, I don’t smoke anymore” Make the move for which they have been preparing Changes are visible to others, tend to get the most support during this time This has been the focus of traditional interventions
  8. 8. Maintenance “I’m in recovery” Long, ongoing process People may “test” themselves during this stage Often return to precontemplation or contemplation stages Relapse is the rule rather than the exception
  9. 9. Assessing Stage of ChangeI don’t think I smoke too much (P)I am trying to smoke less than I used to (A)I enjoy smoking but sometimes I smoke too much (C)Sometimes I think I should cut down on my smoking (C)It’s a waste of time thinking about my smoking (P)I have just recently changed my smoking habits (A)
  10. 10. Assessing Stage of ChangeI am at the stage where I should think about smoking less (C)My smoking is a problem sometimes (C)There is no need for me to think about changing (P)I am actually changing my smoking habits right now (A)
  11. 11. Helping Precontemplators Defensive Thinking Styles:  Denial and minimization (“Maybe I do drink too much but I can handle it”)  Rationalization/Intellectualization (“I need one vice, it may as well be cigarettes”)  Projection and displacement (“I drink because my wife nags me”)
  12. 12. Helping Precontemplators1) Address defenses2) Consciousness raising • Amount spent on cigarettes/drugs/alcohol, etc. • Normative data on peers’ use • Biological data • Number of risk factors/Negative consequences
  13. 13. DANGER!!
  14. 14. Helping PrecontemplatorsWhat not to do:• Don’t push someone into action• Don’t nag• Don’t give up (apathy looks like approval to the precontemplator)• Don’t enable
  15. 15. Helping Contemplators Define the goal Understand the purpose of the target behaviour (Functional analysis: Antecedent Behaviour Conseqence) Resolve ambivalence
  16. 16. Decisional Balance Benefits/Pros Costs/Cons Making a changeNot changing
  17. 17. Decisional Balance Benefits/Pros Costs/Cons • I’d be healthier • I’d lose my friends • People would stop nagging me • People would make fun of me • I’d fight less with my parents • I’d be bored Making a • I’d have more money change • My grades would get better • I’d get to keep my friends • I’ll get kicked off the chess • I’d be able to cope team • I won’t get all my credits thisNot changing year • My parents might kick me out • I’d have to keep coming to CHOICES
  18. 18. Helping those in Preparation Focus on the future Normalize and address anxiety Set a date (realistic but ASAP) Create a detailed, well thought out, multidimensional plan
  19. 19. Change Plan WorksheetThe changes I want to make (or continue making) are:The reasons why I want to make these changes are:The steps I plan to take in changing are:The ways other people can help me are:I will know that my plan is working if:Some things that could interfere with my plan are:What I will do if the plan isn’t working:
  20. 20. Helping those in Action Create a healthy substitute Relaxation techniques Address irrational self-statements (e.g., “I can’t resist the urge to drink”; “I can’t control my anger”) Address cues and triggers Build in rewards
  21. 21. Helping those in Maintenance Relapse Prevention Address overconfidence Educate that a lapse is not a relapse
  22. 22. Motivational Interviewing
  23. 23. Motivational Interviewing (MI)(Miller & Rollnick) Empirically-based, client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence Intrinsic motivation: within the self
  24. 24. MI and Stages of Change Motivation is what provides the impetus for moving through the stages of change MI is an excellent counseling style to use particularly for individuals in the early stages “Natural fit” with each other
  25. 25. The Push and Pull The more a client argues against change during a session, the less likely change will occur One year later: The more a counselor confronted during treatment, the more a person drank
  26. 26. Three Critical Conditions1) Accurate empathy2) Warmth3) Genuineness
  27. 27. Three Critical Conditions1) Accurate empathy2) Warmth3) Genuineness Why isn’t this person motivated?
  28. 28. Three Critical Conditions1) Accurate empathy2) Warmth3) Genuineness Why isn’t this person motivated? For what is this person motivated?
  29. 29. Ambivalence Approach- avoidance conflict is normal Passing through ambivalence is a normal phase in the process of change Brief interventions may work to get them unstuck Ambivalent people are not always logical
  30. 30. The Righting Reflex We all want to set things right Especially in the helping professions, the desire is to put people back on the right path People develop an opinion on the “right” course of action The ambivalent person argues against this The two act out the ambivalence This strengthens the commitment to not changing
  31. 31. The Wrong Questions “Why don’t you want to change?” “How can you tell me you don’t have a problem?” “What makes you think you’re not at risk?” “Why don’t you just…?” “Why can’t you…?”
  32. 32. How do your sessions feel? vs.
  33. 33. Motivational “Inter-viewing” Clinician elicits and selectively reinforces change talk Directive method Not about teaching new skills; it is a way of being with people Not incompatible with other methods Should be offered as a prelude to other services
  34. 34. Spirit of MI Fundamental approach of MI Mirror Image Opposite Collaboration Confrontation Evocation Education Autonomy Authority From Miller and Rollnick (2002)
  35. 35. Four General Principles1) Express empathy2) Develop discrepancy3) Roll with resistance4) Support self-efficacy
  36. 36. Express Empathy Fundamental Attitude of acceptance (not agreement or approval) Desire to understand the client’s perspective
  37. 37. The Use of Reflection Unlikely to provoke resistance Encourages talking/exploration Communicates respect, builds alliance Clarifies what the client means Can be used to reinforce ideas expressed by the client
  38. 38. Examples of ReflectionClient: “My parents are always telling me I’m an alcoholic” a) What’s wrong with that? They probably have some good reasons. b) Why do they think that? c) And that really annoys you.
  39. 39. Examples of ReflectionClient: “My parents are always telling me I’m an alcoholic” a) What’s wrong with that? They probably have some good reasons. (JUDGING) b) Why do they think that? (QUESTION) c) And that really annoys you. (REFLECTION)
  40. 40. Examples of ReflectionClient: “If I quit using, what am I supposed to do for friends?”a) I guess you’ll have to get some new ones.b) Well, you could just tell your friends you don’t drink any more.c) It’s hard for you to imagine living without drugs
  41. 41. Examples of ReflectionClient: “If I quit using, what am I supposed to do for friends?”a) I guess you’ll have to get some new ones. (ADVICE)b) Well, you could just tell your friends you don’t drink any more. (SUGGESTION)c) It’s hard for you to imagine living without drugs (REFLECTION)
  42. 42. Develop Discrepancy Create and amplify a discrepancy between present behaviour and the client’s goals and values Coercion: Discrepant with someone else’s goals and values Client presents arguments for change
  43. 43. Roll with Resistance Resistant behaviours are a reminder to shift approaches Turn a question or problem back to the client Assume the client is a capable and autonomous individual
  44. 44. Support Self-Efficacy Good predictor of treatment outcome Goal is to enhance the client’s confidence in their abilities to cope with obstacles and deal with change
  45. 45. Traps to Avoid Question-Answer Trap  Can be the result of anxiety  Elaboration is needed in motivational interviewing  Subtlety implies an expert role  Open-ended questions…with reflective listening
  46. 46. Traps to Avoid Trap of Taking Sides  Natural and predictable response  The “opening moves” can set the direction of the outcome Expert Trap  Shift into problem solving, answers, solutions  Encourages passivity  Should be a collaboration
  47. 47. Traps to Avoid Labeling Trap  Recommend de-emphasizing labels and diagnoses in motivational interviewing Premature Focus Trap  Pressing concern for the client may not be their “problem” Blame Trap  Make blame irrelevant
  48. 48. Signs of Readiness to Change Decreased resistance Decreased discussion about the problem Resolve Change talk Questions about change Envisioning Experimenting
  49. 49. Effectiveness of MI Effective across a wide variety of behaviours Often works as well as longer interventions Most effective when used as an enhancement to other treatments May be most effective with individuals who are most angry/resistant to change May be contraindicated for individuals who have already changed Effective for minority samples
  50. 50. MI and Adolescents Adolescents push against authority Often face a great deal of ambivalence Often curious and open to philosophical questions MI can also be consistent with harm reduction goals Effective way to engage youth in services May help transition external internal motivation
  51. 51. Take Home Messages It is important to recognize your client’s stage of change and tailor your interventions appropriately Help the client develop discrepancy and voice their own reasons for changing Avoid the “Righting Reflex”  This strengthens the commitment to not changing
  52. 52. Useful Resourceswww.motivationalinterview.orgNational Institute on Alcohol Abuse and Alcoholism. (1995). Motivational Enhancement Therapy Manual. Available at www.niaaa.nih.govMiller, W.R., & Rollnick, S. (2002). Motivational Interviewing (2nd ed.). The Guilford Press: New York.Prochaska, J.O., Norcross, J.C., & DiClemente, C.C. (1994). Changing for Good. HarperCollins: New York.