Motivational Interviewing and the Stages of Change

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					   The Stages of Change and
   Motivational Interviewing
Ana Olvera, M.S. Mental Health Therapist
Kern County Mental Health

November 8th, 2011
Stages of Change
  The Transtheoretical Model is a
  description of how people change
  Based on research done by Prochaska
  and Di Clemente in the 1980s that
  sought to identify common elements of
  change
  It then turned to an exploration of
  intentional behavior change
The Five Stages
  Although these stages are sequential, people
  may not move through them in a linear
  fashion, they may move back and forth, or
  re-cycle through them. The five stages are:
     Precontemplation
     Contemplation
     Preparation
     Action
     Maintenance
Stages of Change
Precontemplation
  People in this stage are not thinking about
  change, may not see their behavior as a
  problem, and may not want to change
  In order to move to the next stage, people
  must begin to see that there is a problem,
  get concerned about it and then imagine that
  change is possible
  You may hear: “I don’t have a drinking
  problem”, or “I’m more creative when I
  smoke marijuana”
Contemplation
  People are aware that they have a problem,
  and they are thinking about whether or not
  they want to change
  To move on to the next stage, people must
  weigh the pros and cons and make an
  authentic decision to change
  You may hear: “I don’t want to smoke weed
  all the time, but my friends do, and they’re
  ok”, “Maybe I should stop, but maybe not”
Preparation
  People in this stage are getting ready to
  make a change, and may be planning steps
  to take to achieve change
  To move on to the next stage, people must
  summon the courage to follow through and
  create a realistic plan for change
  You may hear: “I’m ready to start changing,
  but I’m not sure how”, “I’ve looked into
  different treatments, and I need to get
  started”
Action
  People in this stage have obvious behavior
  changes (get rid of sweets in the pantry, pour
  out last bottle of alcohol, etc), and are
  beginning to create new patterns of behavior
  To move on to the next stage, people are to
  establish a plan, put it into practice, and keep
  going when it’s difficult until there is a new
  pattern of behavior
  You may hear: “I’m making changes every
  day, and trying to get used to them”, “I’m
  going to treatment, meetings and not
  spending time where others use”
Maintenance
  People solidify the changes they have made,
  and new behaviors become second-nature
  The goal of this stage is to have the new
  behavior be integrated into his or her total
  life context.
  You may hear: “I like the way my life is and I
  don’t want to go back to using”, “I’m a
  changed person, and I’m planning to stay
  that way”
About the Stages
  It’s important to assess which stage the
  individual is in for a number of
  problems in order to be better able to
  help them move toward change
  Behavior is not the only indicator of
  someone’s stage of change: examine
  thoughts, attitudes to see if they are
  congruent with behavior
Practice
   Now you will have an opportunity to
  identify the 5 Stages of Change!
What is Motivational
Interviewing? (MI)
  “…a method of communication rather
  than a set of techniques. It is not a bag
  of tricks for getting people to do what
  they don’t want to do; rather, it is a
  fundamental way of being with and for
  people—a facilitative approach to
  communication that evokes change”
  (Miller & Rollnick, 2002)
Background
 Developed by Miller and Rollnick, arose
 from treating people with alcohol
 problems
 These clients had a great sense of
 ambivalence
 Motivational Interviewing was created
 so that clients could argue for change
 themselves
Background (cont)
  In the 1970s, in the field of addiction
  treatment, many practitioners were not
  “professionally” trained, and were themselves
  in recovery
  This led to treaters “telling” clients what they
  needed to do in order to change
  This was met with defensiveness and
  resistance
  In some cases, clients were told to “come
  back when you’re ready” (this placed
  responsibility for motivation on clients)
Background (cont)
  The concept of ambivalence (being on the
  fence) indicates that clients have both
  arguments (for change and against) inside of
  them
  If we point out the need for change, they will
  naturally argue for the status quo
  Miller asserts that “it’s part of our job to help
  people to find motivation to change, that’s
  already there inside the person”
Primary Principles of MI
  MI creates a collaborative environment
  where individuals are empowered,
  accepted, supported and understood
  The Primary principles include
     Express Empathy
     Develop Discrepancy
     Roll with Resistance
     Support Self-Efficacy
Expressing Empathy
  Communicating acceptance through skillful
  reflective listening that helps individuals
  resolve confusion without fear of
  embarrassment or shame
  Reflections are used in order to convey
  understanding to the individual about his/her
  experience
  Reflections can be of content, feeling, or
  meaning
More on Reflections
  It’s important to use statements instead
  of questions
  Reflective listening is making a guess
  about what the speaker means—it’s a
  way of checking, rather than assuming
  Understating emotion encourages
  continued exploration
Developing Discrepancy
  This creates doubt about the consistency of
  values and current behavior
  For example, if a person has talked about
  wanting to have a career and be successful in
  the future, ask questions about how current
  behavior may or may not affect this
  Discuss “both sides of the coin”—On one
  hand client wants to change, and on the
  other, he/she may want to stay the same
Rolling with Resistance
  This is harder than it sounds!
  Since we are concerned about others, we
  have the desire to tell them that what they
  are doing may not be in their best interests
  and this leads to advising, teaching,
  persuading, and even arguing
  Resistance usually indicates that we must
  respond differently:
     Use more reflections
     Shift Focus, return to it later
     Emphasize personal control
Supporting Self-Efficacy
  Defined as “a person’s belief in his/her ability
  to carry out and succeed with a specific task”
  This can be done by remaining person-
  centered and instilling hope about being able
  to change
  It’s important to be aware of our beliefs
  regarding others, since they will come
  through when speaking to them
Building Motivation using
OARS
  Open-Ended Questions—these encourage a
  lot of talk from the client (not yes/no
  answers)
  Affirmations—Positive statements that focus
  on clients’ strengths and efforts to change
  Reflective Listening—indicates that we heard
  what the individual said or meant to convey
  Summary—used to bring together
  information, highlight concerns, ambivalence,
  and discrepancies.
Examples of OARS
  Open-ended questions— “What do you
  like about drinking?”, “In the past, how
  have you overcome an important
  obstacle in your life?”
  Affirmations— “Thanks for coming on
  time today”, “I’ve enjoyed talking with
  you today and getting to know you a
  bit”
Examples of OARS
  Reflective listening

  Summary
Change Talk
  Statements that express people’s reasons for
  making a change
  Research indicates that the strength of client
  commitment talk is the strongest predictor of
  change
  Examples include “I want to change”, “I can
  change”, “I should change”, “I will make
  changes”, “I’m taking specific actions to
  change”
How do we elicit change talk?
  Ask for pros and cons of status quo and
  changing
  Ask for examples
  Look back at how things were better
  Look forward at what may happen if
  they continue in status quo, and if they
  are 100% successful in changing
How do we elicit change talk?
(cont)
  Ask about extremes—“What are the
  worst things that may happen if you
  don’t change?”, “What are the best
  things that will happen if you make this
  change?”
How do we elicit change talk?
(cont)
  Use change/confidence rulers—“on a scale from 0-
  10, where 0 is not important at all and 10 is
  extremely important, how important is it to you to
  change?”. Explore rating— “why are you at a __
  instead of a 1?”, “what would need to happen for you
  to go from a __ to a 9?”




     0   1    2   3   4    5    6   7   8   9 10
Integrating MI with the Stages
of Change
  Being aware of individual’s stage of
  change is essential in choosing
  strategies that will be effective at any
  particular time
  Our help may not be well received if we
  use techniques that are “mis-matched”
  to the stage of change that a person is
  currently in
Stage-Matched Techniques
  Precontemplation:
     Task: Increase awareness that there is a
      problem and a need to change
     How: Create an accepting, understanding,
      empathic atmosphere where people can
      explore any slight concern or ambivalence
     Sound familiar? Motivational Interviewing is
      an excellent match for working with clients
      in the early stages
Stage-Matched Techniques
  Precontemplation (cont):
     Elicit clients’ values, not your own
     This can be done by exploring meaning of
      events that led you to the individual
     Provide information and feedback (ask for
      permission and make it personalized)
     Cultivate seeds of doubt—openly discuss
      addictive or problematic behavior and its
      consequences
Stage-Matched Techniques
  Contemplation:
     Task: Consider costs and benefits of changing in
      order to make a decision
     How: Help client deal with ambivalence, and be
      clear about the benefits of keeping behavior vs.
      changing the behavior
     Motivational Interviewing is still used, along with
      Decisional Balance exercises, self-monitoring,
      tying other problems to use
Stage-Matched Techniques
  Preparation:
     Task: Increase commitment and create a change
      plan
     How: Enhance commitment by encouraging
      individual to make it known to others, set a date
      for the change to begin, offer choices and
      increase self-efficacy
     Help create a plan that is specific, workable and
      comprehensive, and that includes supportive
      people, what success will look like, and what could
      go wrong
Stage-Matched Techniques
  Action:
     Task: Implement strategies for change,
      revise plan as needed and sustain
      commitment in the face of difficulty
     How: People need a lot of support as they
      engage in behavioral processes of change
     Explore what is working, and what isn’t;
      practice new responses to old triggers,
      devise rewards to new behaviors
Stage-Matched Techniques
  Maintenance:
     Task: Sustain change over time and across
      a wide variety of situations
     How: Aid in coping with stresses brought
      on by change, cope with infrequent
      triggers, encourage continued involvement
      and support
     Make appropriate referrals, and foster a
      desire for personal growth and self-
      development
Summary
 The five stages of change are a
 process, not an event
 The spirit of Motivational Interviewing is
 to be respectful, empathic and
 empowering to people
 Remember to bring your OARS
 Use stage-matched techniques
Conclusion
  Questions? Comments?

  Contact information
               Ana Olvera
              661 326-6503
         Aolvera@co.kern.ca.us

				
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