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Tuesday, May 7, 2013

Motivational Interviewing Preparing people for change: Miller and Rollnick



Contents
Part 1. Context    2
Chapter 1. Why do people change    2
What is motivation?    2
Chapter 2. Ambivalence    3
Conflict and ambivalence    3
Chapter 3. Facilitating change    4
Change talk    5
Part 2. Practice    5
Chapter 4. What is motivational interviewing    5
Chapter 5 Change and resistance    6
Consonance and Dissonance    6
Change talk and resistance    6
Counsellors role in resistance    7
Chapter 6 Phase 1    Building motivation for change    7
Importance and confidence    7
Some Early traps to avoid    8
About the first Session    8
Chapter 7 Responding to Change talk    9
Directive MI    9
Non directive MI    10
Chapter 8 Responding to Resistance    10
Reflective Responses    10
Other responses beyond reflection    10
The drama of change    11
Chapter 9 Enhancing confidence    11
Confidence Traps    11
Eliciting and strengthening confidence talk    12
Chapter 10 Phase 2 Strengthening commitment to change    13
Recognising readiness    13
Phase 2 Hazards    13
Initiating Phase 2    14
Negotiating a change plan:    14
Transition    15
Part 3. Learning Motivational Interviewing    16
Part 4. Applications of Motivational Interviewing    16
Summary                            17


 

Part 1. Context

Chapter 1. Why do people change

The following are aspects of why, when and how people change, they represent fragments of the answer.
1.       Natural change
a.       People change without formal treatment. Therefore treatment should build on this process
2.       Brief Intervention effects
a.       Even one or two counselling sessions can trigger change, probably building on the inherent natural change
3.       Dose Effects
a.       The amount of change does not always relate to the amount of change. A lot of change occurs in the first couple of weeks of treatment, before formal treatment has begun.
4.       Faith\hope effects
a.       A persons expectancy for therapy correlates with outcome.
5.       Counsellor effects
a.       The way the counsellor interacts with the client predicts outcome, i.e. therapeutic alliance.
b.      Empathy, that is clarifying and amplifying the clients experience without imposing your own is key
6.       Waiting List effect
a.       People on waiting list given self-help material make improvement. People put on waiting lists do exactly that, they wait.
7.       Change talk effects
a.       A person’s predictor of change is a good indicator of outcome.
b.      Levels of change talk relate to amount of confrontation and reflection, the more you reflect the more change talk you here, the more you confront and the less change talk you hear.

What is motivation?

Ready, willing and able!!

Willingness

When there is a discrepancy between how one is and how one wants to be then and this is seen as valuable, then change desire kicks in.  Of course people have multiple and contradictory hierarchies of values, so discrepancy in one area, may be stasis within another.

Ability

This also relates to confidence, so I want to change but haven’t got confidence in my ability to do it.  If someone really wants to change, sees the discrepancy and the importance but hasn’t the ability, then they may embark on defensive strategies.

Ready

There are also priorities at play, I may be willing and able, but I need to do something else first.

What triggers change?
People have thought if you are in enough discomfort then people will change. However clients suffer and this can weaken their feelings about their ability to change.  Constructive behaviour seems to result when someone sees how important something is, how valuable to them.

Chapter 2. Ambivalence

It’s more common to feel some ambivalence rather than 100% certain about something. Ambivalence if often seen in addiction in that they both want to do something and desperately don’t want to. Passing through ambivalence is a natural part of the process of change.  Problems come when you stay there, to change you need to resolve ambivalence. Lack of motivation may well just mean stuck in ambivalence.

Conflict and ambivalence

3 types
1.       Approach\Approach
a.       Both choices are exciting
2.       Avoid\Avoid
a.       Both choices are unpleasant
3.       Approach\Avoid
a.       One choice exciting the other unpleasant
Approach avoid is the one that keeps people stuck as the same object is both attractive and repellent at the same time. This results in a yo-yo effect of resisting and then indulging.
The grand champion of conflicts is the double approach\avoidance. So stuck between two lovers both you are exciting and repellent, as you move closer to one lover you become aware of the repellent of them and the exciting of the other. Yo Yo!!
If you think about stopping an addiction, then there are pros and cons to continuing and pros and cons to stopping so you are in a double approach\avoidance pattern.
The experience of ambivalence can be confusing, perplexing and frustrating.
The balance sheet if you like whilst not consciously held or static, is constructed out of social context, and a longitudinal context. Well really it’s just values, so where do values come from, society and historical experience!
Ambivalent people may not respond in a logical manner. So if you punish people for certain behaviours it may increase. They may become more determined, more entrenched.
So the real question isn’t why isn’t this person motivated, but what is the person motivated for, they may be motivated in two different ways thus creating stasis.
Within the costs and benefits of a certain action, there are values I like x, and also a prediction of outcomes, if I do y then z will happen. So rather than exploring why there is a good reason to stop something find something better that gives the client what they want, so if they like the high of alcohol are there better ways to get what they want?
So with ambivalence you can’t increase punishment or persuade. Rather an approach to this can be to highlight the costs\benefits or staying the same, and the costs\benefits of changing. Then looking at if there are better ways to get what you value, to test out maybe some of the assumptions that are within the analysis.

Chapter 3. Facilitating change

There is a natural tendency of humans to put things right, e.g. untied shoelaces.  So if there is a discrepancy between how things are and how things ought to be, there is a motivation to right these things. If someone with a righting reflex meets someone with ambivalence, they try to right them and the person with ambivalence doesn’t react well.
If R-man offers alternatives, then A-man, gives yes but. Yes but is the language of ambivalence.  With ambivalence we need to inhibit the righting reflex. If R-man argues the a part of the ambivalence, then A-man will argue the b part of the ambivalence, the reverse could be true. Now as we talk we learn to believe, so this strengthens A-man’s belief in b.  It’s like skidding you need to do the opposite to what you think and turn into the skid.
Motivation is seen as an internal state, but in many ways is an interpersonal state.
It is the client not the therapist who voices the argument for change! Discrepancy is the key to motivation, between what you want and what you have.  The discrepancy for change is a perception of the two perceptions how things are and how you want them to be. Change in either one results in a change of the perception of the discrepancy for change.  The larger the discrepancy the larger the motivation for change.  This discrepancy between how things are and how you would like them to be, is complex. This is because the meaning of each is informed by the rest of your understanding of your life.  So for instance when understand you’re drinking as more important than your parenting, then this provides a change in the meaning you attach to drinking.  When a behaviour comes into conflict with a deeply held value it usually is the behaviour that changes.
Ambivalence is the first step towards change. Discrepancy develops out of ambivalence and when it reaches its peak motivation comes.

Change talk

Falls into four categories
1.       Disadvantages of the status quo
2.       Advantages of change
3.       Optimism for change
4.       Intention to change
Inter-view is looking together. Motivational interviewing seeks through client centred means to elicit the clients current ambivalence and to help them resolve it such they are motivated, i.e. ready willing and able to change.

Part 2. Practice

Chapter 4. What is motivational interviewing

·         Be collaborative and create an atmosphere that is conducive, not coercive to change
·         Be evocative, look to elicit rather than impart, look to draw out rather than indoctrinate, elicit rather than instil
·         Responsibility for change is with the client
·         Aim for intrinsic motivation, rather than extrinsic. The client should present the arguments for change
·         MI is useful for people to get unstuck

Four principles
1.       Express empathy
2.       Develop discrepancy
3.       Roll with the resistance
4.       Support self-efficacy

Empathy

Understanding and accepting a client as they are, emotionally and cognitively, and letting them now that, helping them explore and understand themselves as they are.

Discrepancy

Here the aim is to illicit the different sides of the stuckness, of the ambivalence and to amplify them.  This could be how things are and how you’d like things to be. Discrepancy is to do with the importance of change.  There is a big difference between the behavioural gap, i.e. what you would need to do to complete the change and discrepancy. A big behavioural gap can be demotivating, however discrepancy relates to how important a change is to make. You couldn’t imagine a change that was too important to make.  Again this discrepancy is within the person, to develop discrepancy that results in intrinsic motivation.  This discrepancy between current behaviour and goals and values.

Resistance

To evoke change then you must avoid advocating change whilst the client argues against it. Direct argument, may produce a direct defence, which will then consolidate the clients current position.  Resistance that a person’s offer can often be reframed towards change. Take what you want and leave the rest can be a useful phrase for psychoeducation. Giving client advice can end up in a yes but game. When you see resistance then you need to respond to it.

Support self-efficacy
This is the clients belief in their own abilities, specifically here their ability to make the changes they want.  This can be enhanced the by therapists beliefs in their ability to change.  The therapist message is if you wish, I can help you change.

Chapter 5 Change and resistance

Consonance and Dissonance

When MI works well it’s like two people dancing, it’s going badly when it feels like two wrestlers grappling for control.  Resistance is not a property of one person but is a property of the interaction between two.  When there is dissonance within the relationship.
What causes dissonance?
·         Differing goals
·         Differing strategies to achieve the agenda?
o   This can be either the wrong strategy, or the wrong time for the strategy
·         A request for change is not at the same level as the readiness for change
·         Lack of agreement in terms of roles (who’s in charge, tell me what to do don’t collaborate)

Change talk and resistance

Client resistance behaviour is a signal of dissonance in the counselling relationship and indicates a poor outcome.  Resistance behaviour has an opposite which is change talk.
4 types of change talk
1.       Disadvantages of status quo
2.       Advantages of change
3.       Optimism for change
4.       Intention to change
4 types of resistance
1.       Arguing
a.       Challenging
b.      Discounting
c.       Hostility
2.       Interrupting
a.       Talking over
b.      Cutting off
3.       Negating
a.       Blaming
b.      Disagreeing
c.       Excusing
d.      Claiming impunity
e.      Minimising
f.        Reluctance
g.       Unwillingness to change
4.       Ignoring
a.       Inattention
b.      No answer
c.       No response
d.      Side-tracking
In some cases resistance may be towards the wrong type of change. So you need to see how the above types function.

Counsellors role in resistance

·         Advocacy
o   Arguing for change
o   Assuming the expert role
o   Criticising, shaming or blaming
o   Labelling
§  This focusses on what the client is or has, rather than on what they do
o   Being in a hurry
o   Claiming pre-eminence (I know what’s best for you)
Taking an advocate position is not always wrong, sometimes the client asks for it.

Chapter 6 Phase 1     Building motivation for change

Phase 1 involves building intrinsic motivation for change. Phase 2 involves developing a plan to accomplish it.  Phase 1 aims to resolve ambivalence and build motivation for change.  You would only stay in Phase 1 if someone doesn’t have sufficient reason for change.  A person also has to have the confidence that they can change. Ready, yes, willing yes, able, they doubt.

Importance and confidence

How important do they think the change is, how confident are they of making the change?  If there is either low importance or low confidence then phase 1 work is needed.  There is also readiness to change as a factor, so someone may feel their change important, have confidence that they can do it, but have other more important things to do at the moment.

Some Early traps to avoid

Question\Answer trap

This is to say asking closed questions, this also leads to active\passive, expert\patient dichotomies.
Also avoid asking question after question, so question, then active listening. Make sure there is empathy to the client’s response.

Trap of taking sides

If the therapist argues for one side of the ambivalence, then the client will argue for the other and entrench that position.

Expert trap

If you become the expert then they could become passive and the student.  Interview=looking together.

Labelling trap

Labels carry stigma so you may want to avoid, although some people like labels as it gives them a direction and a problem to be solved.

Premature focus trap

The therapist can focus on what they consider most important when the client doesn’t think so.  Then trying to draw the client back to your problem.

Blaming Trap

Avoid getting in to who is to blame conversations, its judges who judge, therapist rather work on how you can improve your situation.

About the first Session

Five Early Methods

1.       Open Questions
a.       Ask questions that don’t require a one word answer, don’t ask three questions in a row without reflecting
2.       Reflect
a.       Replay back what you think the speaker means, amplify it maybe, but centrally allow a person to hear their thinking for the first time really. You should use statements as questions require a response and will distance a person from what they are saying. So MI reflective listening is aiming to pick up what the client means, and almost move slightly past what the client has said to the implicit meaning, although this is slightly difficult as you would appear to be leading the client, but I guess you could say this was amplifying, drawing out the implicit.  When reflecting emotions err on the understatement or the client may deny it.
3.       Affirm
a.       Can be done in the form of compliments or statements of appreciation.
4.       Summarise
a.       Collecting summary, i.e. picking up all that has been said and putting it into a block
b.      Linking summary, i.e. with previous material, synthesising.  When reflecting ambivalence then use and to synthesise not but. Yet and but soften discrepancy.
c.       Transitional summary: this wraps up a point or a session, or links from previous session. Ask the client to add in anything that has been missed.
5.       Eliciting change talk
a.       Whilst the previous 4 methods all aim to produce ambivalence this is the directive one that resolves it.
b.      Look at the disadvantages of the status quo
c.       Look at the advantages of change
d.      Try to elicit optimism and intention for change

Methods for evoking change talk

1.       Ask evoking questions: e.g. do you think you have a problem here
2.       Using the importance ruler: how important is it to you to change, why are you at x not zero, what would take you to be ten higher.

Exploring the decisional balance

Elaborating
When you get one reason for change, don’t skip onto another one, but ask for more details, operationalize, get SMART.
Querying Extremes
If you can’t get change talk then look to see what the future will look like of status quo and of the change.
Looking back
Make comparison between how things are now and how they were before the change was needed
Looking forward
Look at the impact in the future of status quo and change
Exploring goals and values
If some is unmotivated to change make a comparison with a person’s values and their action in status quo.

Chapter 7 Responding to Change talk

Moving towards the goal is change talk, moving away is resistance.

Directive MI

Here there is a sense that the therapist sees one side of the ambivalence as the functional choice.

Elaborating change talk

As soon as you here some change talk get them to be more specific, find out what else they can do, build on their ideas, think about obstacles and how they would overcome them.

Reflecting change talk

Again reflect what is being said and bring out the implicit meaning, so the client can see it.  You will naturally reflect part of what is said, this can be reflecting one side, which can encourage the client to maintain the other, in which case, reflect both sides.

Summarising change talk

As you summarise, you may want to use the past tense for resistance, and the current tense for change talk, although this could get the client defending the resistance, but could be useful.  Whilst and is a useful conjunction to enhance ambivalence, when summarising you may want to use but, so the resistance comes first, with a but, then then change talk, and the change talk conjoined with a but has the impact of minimising the resistance.
Other conjunctions that reduce the impact of the first part of the conjunction are yet, however, but and although.

Affirming Change Talk

Change talk from client, then sounds like a good idea, that could work, that’s a good point, etc.

Non directive MI

Here the therapist sees both choices within the ambivalence as valid choices.  The skill here is not tipping the scales in terms of one choice, and also not negating change statements and entrenching ambivalence.

Clarifying ambivalence

To avoid the frustration of going back and forth between each side, make it clear that you’re going to look at one side first and then the other.  So do a pros and cons of each side.

Clarifying values

Once ambivalence is understood and elaborated, then to resolve it, you need to go to goals and values. Also what is the impact of each choice in five and ten years.  So what do you care most about, what is important to you, what do you value, what do you want to do with your life.
So what you could do here is do the advantages of each side, and the disadvantages that aren’t merely the negation of the other side.

Chapter 8 Responding to Resistance

Resistance arises from the interaction between client and therapist, If the client is resisting, then you need to go back and find the reason for the resistant behaviour, is the therapist too directive, are you on the wrong path.  Resistance is like a red light, change talk is like a green light.

Reflective Responses

Simple reflection

A good general principle to respond to resistance is non-resistance.

Amplified reflection

So if they say, the studies on smoking don’t prove it gives you cancer, then you say, so you’re saying that lung cancer doesn’t have anything to do with cancer, then it just happens.
You need to be careful with your tone here or this could be seen as hmm, not taking them seriously.

Double sided reflection

So a client is resistant on one side of the argument, then reflect this and the other side. Use and to conjoin these ideas.

Other responses beyond reflection

Shifting focus

So go around barriers rather than over them.

Reframing

For instance my partner is always nagging me…it sounds like he cares about your health, but I guess the way he expresses it makes you angry.

Agreeing with a Twist

Offer initial agreement but with a slight twist or change of direction.  So don’t tell me what to do=>You are the best person to know what’s right for you, so we will need to be partners in this. Which means client=I’m in charge to therapist=you know what’s right for you, so let’s be partners.

Emphasising personal choice and control

Any time the client has their choices restricted by the therapist then you are likely to meet resistance.  A good way to deal with this, is to let the client know the choice of what they do is always up to them.

Coming Alongside

If you take one side, the client is likely to argue the other. So by this function then you can use a paradoxical mechanism where you can stress the less functional approach to get the client to argue against it.  The thing is here that you need to do this authentically, to be congruent: so it sounds like what you are saying is that carrying on drinking would be a good thing to do.  You can also use a variant of point\counterpoint, where you take the clients dysfunctional view and the client argues against you

The drama of change

When the client has resistance, then it is likely they will be replaying a script they have used many times before. There is an expected role for you to play.  If you speak the expected script the outcome will be the same.  Therapy is like improvised theatre!

Chapter 9 Enhancing confidence

Confidence is the able part of ready, willing and able.  Ready is the last thing you need as you can’t be ready unless you are willing and able. If the importance of change increases, then people start to find out ways to change. So generally the sequence is willing, able ready (WAR!).
Sometimes ability to change blocks development of willingness, then it should be addressed first.  Confidence is best understood as ambivalence as it is unlikely that the person thinks, they couldn’t possibly do it, i.e. 100%.

Confidence Traps

I’ll take over now, thank you

Don’t meet low confidence with prescription.  This leads the therapist taking responsibility for the can side of the confidence argument and the client the cant side.

There there you’ll be fine

I’m sure you can do it attitude, is avoiding the ambivalence of their position.

Gloom a deux

Don’t fall into the client’s pessimism, at least one person in the room needs some optimism, or realism, or exploratory zeal.

Eliciting and strengthening confidence talk

Evocative questions

Ask questions about:
1.        how they might go about making change
2.        what might be the first step
3.       What obstacles they might see
4.       What gives them confidence that they have done this
5.       Have they done anything like this in the past

Confidence Ruler

How confident are you that you can do x out of 10. What makes you n rather than 0, what would take you to n+1.

Review past successes

What you are looking for is times the client has made changes on their own, without being coerced.  When you have a couple of events then ask
1.       Did you prepare in anyway
2.       What did you do to initiate the change and maintain it
3.       Where there any obstacles you had, how did you surmount them
4.       What attributes(resources, skills) do you have that accounted for this success

Personal strengths and supports

What is there about you that could help you succeed in making this change? There’s a list on p115 of useful change attributes.

Brainstorming

Brainstorm how a change might be accomplished, generate all ideas without censoring them, then at the end mark-up which seem most likely or achievable. You can chip in ideas, or directions, but it must be the clients work. Also review what the process was like, when you didn’t censor yourself di you become more creative.

Giving information and advice

When the client asks for it, information and advice can be useful, however avoid advocacy. Also ask permission to give information, would it be helpful?

Reframing

Reframe failure, see it as trying.   So did you learn things from each failure, will you take this onto the next attempt, will you use it in other areas.  Do you think when scientists invent things they get success first time? Try to move internal attribution for failure externally.

Hypothetical Change

Imagine you made the change:
1.       How did you succeed
Imagine the big obstacle wasn’t there
1.       How would you approach the change

Responding to confidence talk

Important through this is the client talking about how change will occur and their confidence in changing.  As soon as you hear confidence talk then build on this by getting concrete about change and smart about goals.

Radical Change

Sometimes there is a complex problem, which is unlikely to respond to a simple solution. Sometimes here a radical change, as opposed to tackling each problem may be the answer. Each of the problems relate to each other, so incremental change is difficult, so a big bang might be appropriate.

Chapter 10 Phase 2 Strengthening commitment to change

Recognising readiness

When you have some willingness and ability then you need to strengthen commitment to a change plan.
Phase 1: Enhancing importance and confidence
Phase 2: strengthening commitment to a change plan
At phase 2 they are on the brink of readiness. This is the sales person’s equivalent to closing the sale
When the client recognises an important discrepancy, i.e. the ambivalence has been fully fleshed out, the pain of dissonance can only be managed for so long, so there is a window for change open.
Signs of readiness for change
1.       Decreased resistance
2.       Decreased discussion about the problem
3.       Resolve, the client has some resolution to their ambivalence, this can be a state of calm, or have the tone of some loss for the past self, or some resignation to the old self
4.       Change talk
5.       Questions about change
6.       Envisioning: i.e. how life would be after the change
7.       Experimenting: i.e. with possible change actions.

Don’t expect eureka moments in the room, they usually happen outside it!
Phase 1 work can be like climbing up a mountain, phase 2 like skiing down the other side, well sometimes.

Phase 2 Hazards

Underestimating ambivalence

Once signs of readiness are shown, it doesn’t mean ambivalence is dealt with.  So don’t be over eager at the first signs of change.

Overprescription

Once you see readiness, don’t prescribe or be an advocate for an approach, rather work collaboratively with the client. Elicit motivation, elicit change strategy.

Insufficient Direction

When the client ask what can I do, then in phase 2 a list of alternatives can be useful, do try to elicit, if that fails, ask what other people have done, if that doesn’t work then offer ideas.  So you need to navigate between giving enough direction without being over prescriptive.

Initiating Phase 2

Recapitulation

As you move from Phase 1 to Phase 2, then use a transitional summary to draw Phase 1 to a close, which should be translated to the client, is now you have resolve to change, let’s work out how to do this.

Key questions

These are again open questions, and their theme is what’s next.

Giving information and advice

There are two times you might give advice or information:
1.       When the client requests it
2.       With the clients permission
Before giving advice or information ask yourself, have I elicited the clients own ideas on the matter, is this going to enhance the clients intrinsic motivation for change.
To get ideas
1.       Elicit from clients present and past
2.       Elicit from clients knowledge of others
3.       Ask for permission to Offer advice or information
As you ask for permission, you increase or maintain a client’s self-efficacy.
I can give you my opinion but you will need to find out if it works for you. This is what some people find work in such a situation. If you’re asked for advice, say, well I can give you some, but it could be useful to have a look at what ideas you have first as I don’t want to block your creative thinking. You can also if asked for advice give a cluster of opinions to enable the client to decide. So: well there isn’t one way that works for everyone, but some things people have found success with are….
 If you give advice then the client is likely to be disempowered\tell you why it won’t work, i.e. build resistance.

Negotiating a change plan:

1.       Setting Goals
2.       Considering change options
3.       Arriving at a plan
4.       Eliciting commitment

Setting Goals

Motivation is driven by a discrepancy between a person’s goals and this perceived present. So you must set a goal, which the client may choose as one that you would not choose.  Is the goal realistic, and achievable, in short is it SMART? You may want to ask what the consequences of achieving this goal are and what confidence you have of achieving it.  Goal setting leads naturally to working out how to achieve this.

Considering change options

·         Brainstorm change options
·         Evaluate options and choose best
·         Offer a range of options avoids immediate resistance to any one idea, allow client to choose what would be best for them.

Arriving at a plan

Again elicit the plan with the client:
1.       What do you plan to do
2.       What’s the first step
3.       How do you think you will go about it
A change plan worksheet, or some kind of public commitment can be useful here. There is a change worksheet on p135.

Eliciting commitment

Here you want the client to say their commitment to their plan.  You should note the level of commitment, as low levels still indicate that ambivalence is unresolved.  Again think public commitment and requests for support.

Transition

To get to a committed to change plan completes MI and then enables a movement into action focussed therapy, e.g. CBT.






















Part 3. Learning Motivational Interviewing

Not of current interest to me

Part 4. Applications of Motivational Interviewing

Not of current interest to me

Summary

When a client comes to therapy they need enough intrinsic motivation, i.e. Ready, willing and able to achieve their goals. Either they can come with it, or more likely not or the work of the therapist is to work with the client to develop that intrinsic motivation for their goal and then to implement it.
Of course things don’t happen in a linear fashion, so motivational interviewing is useful any time there isn’t motivation for a goal, or there is ambivalence about something. MI can help in resolving ambivalence.
Willingness: this is when there is a discrepancy between how things are and how you would like them to be, and this difference captures both a lot of your values
Ability: this means you have confidence about the change
Readiness: this is that the change is the highest priority.
Passing through ambivalence is a natural part of change. Indeed if there was no ambivalence you wouldn’t consider it change, you’d just consider it a natural part of yourself. Problems can come, indeed lack of motivation can come, when you are stuck in ambivalence and it’s not moving. Holding true ambivalence would be painful as there is a dissonance there. So generally people aren’t ambivalent but have come to a resolution they aren’t happy with.
So the movement from pre contemplative, through ambivalent to motivated is the path.
At the pre-contemplative stage then you need to generate the ambivalence so that you get dissonance.
At the ambivalence stage then you need to fully elaborate the ambivalence until you can get resolution.
At resolution then you need develop a change plan and then commit to it.

You can work out where someone is using the
1.       How important is it for you to change
2.       How confident are you that you can change

To move from pre contemplation to ambivalence
1.       Develop discrepancy
a.       CBA of staying the same and  changing
b.      Establish beliefs\rules that support each side
c.       Ensure that if you have a big gap, then the importance of change is high, a big gap without importance can be demotivating
To move from ambivalence to resolution
1.       Look at consequences of each side in the future
2.       Look to see how values and goals for life accord with each side of the ambivalence


To move from resolution to committed plan
1.       Develop plan
2.       Commit to it!
The key principles in this process are
1.       Express empathy
2.       Develop discrepancy
3.       Roll with the resistance
4.       Support self-efficacy
The process is to elicit and evoke rather than advocate, you can’t make someone have a lasting change, only they can do that.  Again elicit, evoke don’t advocate, all the time, looking to build on a client’s self-efficacy, what do you think, how can you do it. Again avoid advocacy elicit and evoke!!!
When using MI with a client, then you may hear resistance and you may hear change talk. The former is like a red light the latter a green light. You may hit resistance as you are advocating, going too fast or going the wrong way. Change talk suggests you are going the right way.  Keep an ear out for these types of behaviour from the client, they can be quite subtle, and remember both are relational products.
You can elicit change talk with the importance ruler, i.e. how important is it for you change, why are you x rather than 0 and what would take you to n+1?

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