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?
