Module 11: Persuasion (Building
Readiness to Change)
• To be able to define “ Persuasion” Stage
• To be able to define motivational
• To be able to describe the key skills
involved in MI.
• To be able to assess readiness to change.
• To be able to explore ambivalence using
Dual Diagnosis Capabilities
• Demonstrate Empathy: To be able to understand the unique experiences a person
with dual diagnosis may have had, and be able to communicate this understanding
effectively and empathically to service users, and their carers. Dual Diagnosis
Capability 5 level 2
• Interpersonal Skills: To be able to demonstrate effective skills such as active
listening, reflection, paraphrasing, summarising, utilising open-ended questions,
affirming, elaboration. Dual Diagnosis Capability 7 level 2.
• Delivering Evidence and Values Based Interventions: Be able to utilise
knowledge and skills to deliver evidence-based interventions including brief
interventions, motivational interviewing, relapse prevention and cognitive behaviour
therapy to people with combined mental health problems within own limits and
capacity and remit of ones own organisation. To know where else a service use can
access appropriate specialist care and facilitate that access. To be able to access
support and supervision to perform such interventions. Dual Diagnosis Capability 13
• Evaluate Care: To be able to collaboratively review and evaluate care provided with
service user, carers and other professionals. To be flexible in changing plans if they
are not meeting the needs of the service user. Dual Diagnosis Capability 14 level 2
Transtheoretical Model Osher and Kofoed’s Four
Contemplation Early persuasion
Preparation Late persuasion
Action Active Treatment
Maintenance Relapse prevention
• Enters this stage once engaged in a therapeutic
• Still not necessarily acknowledging problem with
• Considered behaviourally unmotivated- not
showing any signs of reducing substance use
(but may be talking about it).
• Still expect sporadic attendance; be flexible.
• Worker acknowledges that motivation to change
must be generated internally or will fail.
Examples of Interventions For
• Individual and family psycho-education.
• Motivational Interviewing.
• Peer (“persuasion”) groups.
• Social skills training.
• Structured activity.
• Safe/stable housing.
• Medication Management.
Exercise: Activities for People with
Spend a few minutes answering the
following questions (in pairs)
1. What activities are available for people
with dual diagnosis within your setting?
2. What are the barriers to accessing
3. How could these barriers be overcome?
4. What other activities would you like to
• State of readiness or eagerness to change
• Fluctuates through time and/or situation-not
• Motivation to change requires being-
– Ready (the time is right)
– Willing (want to do it)
– Able (has the ability and confidence to do it)
What Is MI?
• Client centred, directive method for
enhancing intrinsic motivation to change
by exploring and resolving ambivalence.
(Miller and Rollnick, 2002 2nd ed)
• Worker style powerful determinant of both
resistance and change
• Ambivalence is normal and to be expected
• Resolving ambivalence is a key to change
• Self-efficacy is related to outcome
• Labelling is not essential
• empathy, non-judgemental, and genuineness
• “Spirit”- collaboration, evocation, autonomy
Goal:- person generates own reasons for change
Four general Principles
1. Express empathy- acceptance facilitates change, skillful reflective
listening is fundamental, ambivalence is normal
2. Develop discrepancy- person, not worker presents arguments for
change; change is motivated by perceived discrepancy between
present behaviour and important goals and values
3. Roll with resistance- avoid arguing for change, resistance is not
directly opposed, new perspectives are invited but not imposed,
person is primary source of finding answers and solutions,
resistance is a signal to respond differently
4. Support self-efficacy- belief in possibility is an important motivator.
The person not the therapist is responsible for change. Therapists
own belief in change can become a self-fullfilling prophesy
Traps (how not to…)
• Expert/ prescriptive: “ As an experienced nurse, I think
• Question-answer: “have you taken your tablets?” “yes I
• Premature focus “I’d like to talk more about your
drinking” “but I am really worried about losing my
• Labelling: “schizophrenic, alcoholic…etc”
• Blaming: “The reason you end up back in hospital is
because you use cannabis”
• Taking sides “It seems clear to me that you have a
serious drink problem” “but a lot of people drink like me”
• O pen-ended
• A ffirming
• R eflecting
• S ummarising
Some key techniques
• A “typical day”
• Readiness to change
• Timeline-looking back
• Goals and roadblocks- looking forwards
• Exploring the good and less good (pros and
• Evocative questions
• Raising discrepancies
• Problem solving
• Offering choices
Examples of evocative questions
• What worries you about your current
• How would you like things to be different?
• What encourages you that you could
change if you want to?
• I can see you are feeling stuck; what is
going to have to change?
• What would be the advantages of making
A Typical Day
• Helps people reflect on processes that are
• Identify maybe some of the less good
aspects of the behaviour as well as the
• Helps worker get a picture of the
• Get a sense of motivational state
Adapting MI for Dual Diagnosis
(Bellack and Diclemente, 1999)
• Spend extra time engaging in therapeutic
• Use of repetition and rehearsal
• Being concrete and simple in setting tasks
• Being realistic about goals.
• Small doses (10-20 minutes)
Readiness to Change
(Rollnick, Mason and Butler, 1999)
Readiness to change ruler:
• Importance of change: 0----------10 (willing)
• Confidence in ones own ability to make the
change: 0-------------10 (able)
Readiness to change
• Increasing importance
• A valid reason for change
• Benefits outweigh costs
• Information about possible risks
• Small achievable goals
• Reminder of past successes
• Affirming and empathy
• Can you tell me why you placed yourself there
on the scale (readiness to
• What would have to be different for you to move
a bit further forward?
• Can you tell me a bit more about that….
• Is there anything else that’s important that we
haven’t discussed yet?
Ambivalence- the dilemma of
• Natural state to move through during
• When we get stuck, problems can persist
• Decisional balance
• Cost/benefits of status quo
• Costs/benefits of change
• Double approach avoidance
Working with Ambivalence
• Identify and explore the nature of
ambivalence about a particular behaviour
• Always start with the side of “least
• List the good and less good aspects in
• Encourage elaboration, and identification
of less obvious costs and benefits
Good things about cannabis Less good things about cannabis
It makes me feel good put on weight (munchies)
Relaxed feel paranoid sometimes
Something to do I argue with mates
Helps sleep Ghosts are bad
It’s fun to smoke with friends smokers cough in the morning
Good things about not using less good things about not using
Might lose weight my friends might think I’m boring
Ghosts bother me less don’t sleep very well
Feel healthier might get bored