CHANGE TALK AND MOTIVATIONAL INTERVIEWING

Adopted from Overcoming Obstacles to Change presentation by Dr. Deborah Dobson, Ph.D., R.Psych. For Presentation at Supportive Living Program Team Meeting. April 21, 2011, Marguerite House.

CHANGE

Most of us, at one time or another in our lives, reach a point when we know that something in our lives has to change, and that we have to be the ones to change it. The status quo is no longer satisfying our needs, and it’s time to do something about it. However, it is often a difficult task to make change. Much more difficult for persons with mental illness diagnosis.

Examples of difficult changes

Starting a new job, Starting an exercise , Stopping smoking , Loosing weight , MOVING..HOUSING CHANGE , Changing any interpersonal patterns , Stopping addictions, Cooking , attending activities, ..for our clientsANY EXAMPLES ………BRAINSTORMING….

OBSTACLES TO CHANGE

WHAT INTERNAL AND EXTERNAL OBSTACLES CAN YOU MENTION???..

Two minutes of Brainstorming Session.

OBSTACLES TO CHANGE

INTERNAL / INTRNSIC Lack of readiness Lack of motivation Lack of skills involved Cognitive barriers Belief about self/others. Liking

the statuesque, relative comfort, self defeating thought

Avoidant behavior procrastination, indecision

Fear and anxiety…… Mental Illness …….

EXTERNAL/ EXTRINSIC Lack of resources, finance, Other peoples attitudes- stigma

(could be internal too). Poor reinforces (AISH, EI

Benefits..). The cost for change is too high. Excessive work pressure

involved.

THE FAILURE TO CHANGE IS RELATED TO A COMBINATION OF FIVE FEARS (DENNIS O’GRADY), :

FEAR OF THE UNKNOWN: The fear that when change occurs, one will lose control,

feeling of uncertainty.FEAR OF FAILURE: The fear that change entails a chance for failure.FEAR OF COMMITMENT: The fear that fear demands increased work pressure, and

dedication and increased hard work beyond ones abilities.

FEAR OF DISAPPROVAL: The fear that after change, significant others would show

rejection/ isolation/ or be critical of ones behavior. FEAR OF SUCCESS: If I change, other people expect too much from me.

Obstacles to Change due to mental illness

Mood disorders…depression, BPD, Feeling worthlessness, helplessness or

hopelessness, having difficulty concentrating or making decisions, loss of interest in taking part in activities, avoiding other people, overwhelming feelings of sadness or grief, loss of energy, feeling very tired, thoughts of death or suicide. 

MANIC STATE extreme optimism, exaggerated self-esteem, racing thoughts • Extreme irritability, Impulsive and potentially reckless behaviour

Obstacles to Change due to mental illness

Anxiety disorders. GAD, PD, OCD, Phobias

Feelings of apprehension or dread, trouble concentrating, feeling tense and jumpy, anticipating the worst, irritability, restlessness, watching for signs of danger, Feeling like ones mind’s gone blank

Obstacles to Change due to mental illness

Other Schizophrenia and psychotic disorders,

Delusions and/or hallucinations, lack of motivation, social withdrawal, thought disorders, ccognitive and intellectual barriers,

mental health diagnosis related barriers ????????????

STAGES OF CHANGE

Psychologists Prochaska, Norcross, and others, have developed a theory/model about the process of change called the Transtheoretical Model.

The model involves a number of steps people go through in the process of change.

The model proposes five stages. See the model below.

Transtheoretical Model: Stages of Change

Stages of Change (contd.)

PRECONTEMPLATION STAGE- I HAVE NO PROBLEM In this stage, a client is unaware that he or she has a

problem, or is under-aware of the problem. There is no expressed desire to make any changes, and no real concern or immediacy for anything to be different. If asked, clients might say that things are fine, and that if nothing is different a year from now, it would be okay.

Any client experiences ? CONTEMPLATION STAGE- I THINK I SHOULD CHANGE In this stage, a client has become aware that there may be

a problem, and one has begun considering doing something about it.

Stages of Change (contd.)

COMMITMENT STAGE: I WILL CHANGE Clients have become more than aware that they have a problem

or a situation that demands change. Clients are motivated to do something to change it. Clients go beyond saying “I should” and begin saying “I will.” Interestingly, this is a difficult stage to get to. Clients often enter this stage and commit to change only when the alternative is no longer tolerable. The thought of NOT changing is unbearable. It is in this stage that change—and progress—are born.

PREPARATION: YES I CAN CHANGE, READY TO TAKE STEPS

This is a “could” stage. Clients think of every possible alternative and resources.   Clients look at options, and they choose the ones that will work for them. Clients devise a plan, and are intent on following it through. Clients are ready.

Stages of Change (contd.)

ACTION STAGE Clients are committed. Clients have prepared. Clients are

physically, emotionally, and spiritually ready to embark on a journey by which it will improve their lives. Clients take steps.

MAINTENANCE STAGE Clients feel proud. They love the change . Clients hold their head higher.

Clients have more self confidence. SUCCESS.

RELAPSE STAGE When a client falls or slides back into a former state. This will

imply the start up of the whole cycle all over again:

THE MAIN QUESTION IS

HOW DO WE BRING ABOUT

A SUCCESSFUL CHANGE?

MOTIVATIONAL INTERVIWING, A STRATEGY FOR BRINGING FORTH

SUCCESSFUL CHANGE.

MI, KEY POINTS

Motivational Interviewing (MI) is a client-centered counseling style for enhancing intrinsic motivation to change by identifying and resolving ambivalence. Motivational Interviewing (MI) has been developed over the past 25 years by William Miller and Stephen Rollnick (Miller, W.R. & Rollnick S., 2002).

The central goal of MI is to examine and resolve ambivalence in order to create an opportunity for self-change. Ambivalence is defined as the conflict between wanting to change a given behavior and maintaining the status quo.

KEY POINTS (contd.)

MI focuses on an individual's interests and concerns, reflecting the work of Carl Rogers on Client-Centered Therapy. Rogers views the therapist’s role as merely offering three critical conditions to prepare his/her client for natural change: empathy, unconditional positive regard and genuineness.

The therapist uses reflective listening to clarify and amplify the meaning that the client places on events. Reflective listening, which uses statements instead of questions to uncover the meaning of the client’s discourse, is an effective approach to self discovery and, therefore, change.

KEY POINTS (contd.)

Motivation to change is elicited from the client, and not imposed from without.

Emphasis on coercion, persuasion, constructive confrontation and the use of external contingencies go against the spirit of motivational interviewing.

It is the client’s task, not the therapist’s, to articulate and resolve his or her ambivalence. The therapist’s task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that leads to behaviour change.

KEY POINTS (contd.)

Direct persuasion is not an effective method for resolving ambivalence.

While tempting to be helpful by offering persuasive arguments for change, therapists usually create resistance to change in their clients. Never argue with a client. Help the client become engaged as a primary resource to find hi/her own solution to the problem

KEY POINTS (contd.)

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

The therapist respects the client’s right to make choices about behaviour and consequences of the chosen behaviour. Client centered trust relationship.

MI : PRACTICE

Find the Target Behavior (e.g. moving to the next step in mental health recovery and wellness such as housing arrangement)

Clarify the target behavior about which there is ambivalence. Ask about the positive (good things) aspects of the target

behavior. Why Apt/ Hunter House is better than Miner House

– What are some of the good things about _______?– People usually____ because there is something that has benefited

them in some way. – Summarize the positives

MI : PRACTICE (contd.)

Ask about the negative (less good things) aspects of the target behavior:

– Can you tell me about the down side?– What are some aspects you are not so happy about?– What are some of the things you would not miss?– Summarize the negatives

Explore client’s purpose, life goals and values. – What sorts of things are important to you? Independence, control,– What sort of person would you like to be?– If things worked out in the best possible way for you, what would

you be doing a year from now?

MI : PRACTICE (contd.)

Ask for a decision. – Restate their dilemma or ambivalence then ask

for a decision.– After this discussion, are you more clear about

what you would like to do?– So have you made a DECISION?

MI: PRINCIPLES YOU NEED TO TAKE IN TO ACCOUNT DURING MI PRACTICE.

Use Evocative Questions – Use Open-Ended QuestionsExamples:- Why would you want to make this change? (Desire)- How might you go about it, in order to succeed? (Ability)- What are the three best reasons for you to do it? (Reasons)- How important is it for you to make this change? (Need)- So what do you think you’ll do? (Commitment)

Use ElaborationWhen a change talk theme emerges, ask for more detail:

- In what ways? - How do you see this happening?- What have you changed in the past that you can relate to this issue?

MI: PRINCIPLES YOU NEED TO TAKE IN TO ACCOUNT DURING MI PRACTICE (contd.)

Ask for Examples– When was the last time that happened? – Describe a specific example of when this happens.– What else?

Look Forward Ask about how the future is viewed:

- What may happen if things continue as they are (status quo).

- If you were 100% successful in making the changes you want, what would be different?

- How would you like your life to be in the future?

MI: PRINCIPLES YOU NEED TO TAKE IN TO ACCOUNT DURING MI PRACTICE (contd.)

Explore Client’s Goals and Values Ask what the person's guiding values are.

- What do you want in life? - What values are most important to you? - How does this change into your value

system?

Strategies for Handling Resistance:

Simple Reflection: Simple acknowledgement of the client’s disagreement emotion, or perception.

Double- sided Reflection: Acknowledge what the client has said and add to it the other side of the client’s ambivalence.

Clarification: Verify your understanding matches the client’s perspective.

Shifting Focus: Shift the client’s attention away from what seems to be a stumbling block.

Emphasizing Personal Choice and Control: Assure the person that in the end, it is the client who determines what happens.

REFERENCES:

Addictions Foundation of Manitoba’s website (http://www.afm.mb.ca/) on their home page under “Learn More” and “Tools of AFM”.

Miller, W.R. & Rollnick S. (2002) Motivational Interviewing (2nd Edition): Preparing People for Change. New York: Guilford.

Deborah Dobson, Ph.D., R.Psych. Overcoming Obstacles to Change , Paper presented onMarch 3, 2011, CNIB Calgary Ab.

THANK YOU so much.

VISIT MY BLOG AT:www.mental-health-therapy.org

www.mentalhealththerapy.wordpress.com

THE END