Provoking (non-oppressive) social change

One to one client interchange

STATUS QUO VERSUS CHANGE

• Active listening, open questions, and summarising; being reflective-exploring the client’s current behaviour i.e. pros and cons.

• Subsequently, engaging in the same process in respect of the pros and cons of him/her changing behaviour.

• Remember the approach is non moralising and non confrontational.

• Explicitly change oriented -delineation from Counselling. {Consider}

MI IN PROFILE CONTEXT

• Individual as isolated and ambivalent.

• Your professionalism: His/Her willingness to change {recessed}.

• Eliciting the change potential within the client.

• Risk of temptation to know what’s best for him or her. {relate to issues around values-whose; claiming to know the truth…}.

EXTRINSIC-INTRINSIC DIALECTIC

• Miller and Rollnick {2002} Preparing People for Change.

• Client centred/directive approach.

• “enhancing intrinsic motivation to change.”

• Exploration and resolution of ambivalence.

CYCLE OF CHANGE

Pre-contemplation

Contemplation

DecisionActive Changes

Maintenance

Relapse

STAGES OF CHANGE

• [1] PRE CONTEMPLATION: avoidance/resistance/denial.

• [*] Moving On: the seeds of change?

• [2] CONTEMPLATION: embryonic consideration/midst resistance.

• [*] Moving On: signs of cognitive & affective arousal.

S of C {cont}

• [5] MAINTENANCE: by now process in train/dynamics of personal change.

• [*]Moving On: emphasis on nurturing and enhancing hard won changes; keeping clear of old environments/influences.

• [6] TERMINATION or RECYCLING: ‘the new life’ or recognition of relapse as a manifestation of imperfection. Uncertainty as learning.

S of C {cont}

• [7] CONTINUING TO GROW: the individual as free from….or else relapse. Freedom via painful journey versus relapse as learning.

[8] RELAPSE: one step back two steps forward?

• Learning the lessons of relapse.

• Most people need more than one attempt, and to budget more time, energy and money.

• Being prepared for complications.

• Being aware that small decisions lead to big ones.

• Being aware that distress precipitates relapse.

FOUR GENERAL PRINCIPLES OF PRACTICE • Express Empathy: the capacity of the

facilitator to be as if in the other person’s boots.

• Develop Discrepancy: working assuredly, but without resorting to moralising, with the contradictions in what the client is saying to you, as facilitator.

• Roll with Resistance: clients are likely to resist change; effectiveness in this context is about not getting sucked into providing them with your solutions/knowing what’s good for them.

• Support Self Efficacy: in pursuing the previous 3 stages a practitioner using MI is helping create a safe space for the individual to renew and grow.

CENTRALITY OF AMBIVALENCE

• A seeming yearning to move beyond an addictive behaviour yet retaining an attraction to it {Miller and Rollnick, 2002. Ch1].

• Yet at the same time it can be taken as a normal component of human behaviour [ibid.].

• As the authors contend: “Ambivalence is a reasonable place to visit, but you wouldn’t want to live there.”

•

• Ambivalence is preferred to resistance in order to explore the dynamic interrelationship. [Arkowitz et al, 2008]

• Approach-Avoidance-moving betwixt and between e.g. just one more drink, play on the gaming machine, slab of chocolate……..

• Eclipsed by Double Approach-Avoidance i.e. moving away from option A only for it to become again attractive as B looms closer.

MI HEALTH CONTEXT

• Rollnick, Miller & Butler {2008, p.4.}-twenty first century emphasis on ‘those things that people can do to improve their health.’

• p.5 ‘MI works by activating patients’ own motivation for change and adherence to treatment.’

• P.5. Assumptions can be readily made in relation to a person being unwilling to change i.e. that they are the matter and things are stuck: ‘These assumptions are usually false.’

• p.7. Instead of being prescriptive re client lack MI seeks to activate what they already have. This may include recognition of his right not to change.

SOME DANGEROUS ASSUMPTIONS

• This person ought to change; wants to change.

• This person is essentially motivated by ‘xyz.’

• The intervention is only a success if s/he agrees to change.

• ‘I’m the expert, it’s up to her to follow my advice.’

• ‘S/he needs a tough approach, these people respond best to it.’

In practice

OPENING APPROACHES

• Open Questions

• Reflective Listening

• Summarising

• Affirming

• Eliciting Change Talk

REFLECTION AS CORE

• Repeating

• Re-phrasing

• Paraphrasing

• Reflection of feeling

• Double sided reflection

• Amplified Reflection

AMBIVALENCE

• I don’t want to change………I ought to change

• Don’t want to talk about it…..I want to talk about it

• It’s not necessary……………I could put my mind to it and…

BELIEFS THAT OPEN THE DOOR

• My current behaviour is bad for me {person gives emphasis}.

• I would be better off if I change {again person giving emphasis}.

• If I try to change I can be successful {here person draws on own confidence reserves}.

• This is a good time to do it. {person seizes on the moment/drawing on own confidence}.

RESPONDING TO CHANGE TALK

• Reflect it back to the person.

• Encourage more change talk.

• Encourage person to illustrate with examples.

• Affirm her in efforts, highlighting change oriented values and behaviours.

• Summarise to affirm where ‘she’s at’, to hold clarity.

BUILDING CONFIDENCE

• Key art/skill of brainstorming, using permissive questions.

• Accent on enabling person to develop clarity with review ongoing.

• What has worked/not worked for you in the past/previous attempts?

• Have you been impressed by anything that has worked for someone else?

DEVELOPING DISCREPANCY

• All of us exhibit discrepancies between where we are and where we want to be in our development processes.

• Facilitate the person to affirm her key values.• Identify gaps in consistency in a non

judgemental fashion.• Encourage the person to look at the

consequences.• Remember arguments for change must belong

to the person herself.

READINESS TO CHANGE [signs of]

• Decreasing resistance.

• Less emphasis on the problem.

• Change talk; person gives off increasing resolve.

• S/he is posing her own questions about her own change process.

• Envisioning-how the future might look, could look.

• Genuine experimentation.

References

• Arkowitz, H. Westra, H, Miller, W. & Rollnick, S {Eds} {2008} Motivational Interviewing in the Treatment of Psychological Problems. The Guilford Press: New York.

• Edward L. Deci and Richard M. Ryan. The “What” and “Why” of Goal Pursuits:Human Needs and the Self-Determination of Behavior. Psychological Inquiry 2000, Vol. 11, No. 4, 227–268.

• Fuller, C & Taylor, P {2nd Ed. 2005} A Toolkit of Motivational Skills. John Wiley & Sons Ltd.

• Miller, W. { Second Edition} {2002} Motivational Interviewing: Preparing People for Change. The Guilford Press: New York.

References {Cont}

Prochaska, J. Norcross, J. and Di Clemente, C. {1994} Changing for Good: The Revolutionary Program That Explains the Six Stages of Change and Teaches You How to Free Yourself from Bad Habits . William Morrow and Co.

Rollnick, R. Miller, W. & Butler, C. {2008} Motivational Interviewing in Health Care. Helping Patients Change Behaviour. The Guilford Pres: New York.

Richard M. Ryan and Edward L. Deci. Self-Determination Theory and the Facilitation of Intrinsic Motivation,Social Development, and Well-Being. January 2000 • American Psychologist