Presentation on theme: "Stages of Readiness “Principles”"— Presentation transcript:
1 Stages of Readiness “Principles” Motivation exists along a continuum of readiness;Clients progress through stages in a spiral (not linear);When enhancing motivation, if the clinicians use strategies in a stage other than the one the client is in, the result could be treatment noncompliance;If clinicians push clients at a faster pace than they are ready to take, the therapeutic alliance may break down;Relapse is an event, not a stage.Will describe typical client attitudes and actions at each stage and suggest strategies & techniques clinicians can use to move clients from one stage to the next.Explain the relapse process
2 Stage of Change Model Prochaska & DiClemente (1992) PRECONTEMPLATIONCONTEMPLATIONPREPARATIONACTIONMAINTENANCE
3 Stage 1: Pre-Contemplation Individual is unaware, unable, unwilling to change. No intent to change.Indicators: argue, interrupt, deny, ignore, avoid reading, talking, or thinking about the behavior…Individual is traditionally characterized as resistant, unmotivated.
4 Stage 1: Pre-Contemplation: Clinical Tools Establish rapportDetermine why the client has come to you.Introduce ambivalence about recovery – why it might be a good idea, e.g., “why do you thing other people decide to manage their disorders?”Give information on risks, pros & cons of useAcknowledge the client’s thoughts, feelings, fears, and concerns.Keep the interview informalAsk permissionBuild trustExplore the meaning of events that brought the client to treatment or the results of previous treatmentsElicit client’s perception of the problemProviding personalized feedback about assessment findings (if applicable)Helping significant other interveneExamine discrepancies between the client’s and others’ perceptions of the problem behaviorExpress concernKeep the door open.Effective catalysts for change:Consciousness raisingEnvironmental reevaluationEmotional arousal and dramatic relief.
5 Stage 2: ContemplationIndividual is ambivalent or uncertain regarding behavior change.Indicators: Individual meets clinician “half way,” willing to look at pro and cons of behavior changeIndividual is traditionally characterized as unpredictable, time intensive.
6 Stage 2: Contemplation Clinical Tools Discuss & weigh pros/cons of recoveryEmphasize client’s free choice & responsibilityElicit self-motivational statementsDiscuss the client’s goals in life, how will recovery affect these?Reduce the fear of recovery through example and problem solvingAsk questions that clarify motivation e.g., “what’s most important to you… why?”Normalize ambivalenceHelp the client “tip the decisional balance scales” toward change by:Changing extrinsic to intrinsic motivationExamine the client’s personal values in relation to changeElicit self-motivational statements of intent and commitment from the clientElicit ideas regarding the client’s perceived self-efficacy and expectations regarding treatmentSummarize self-motivational statements.Effective catalysts for change:Self-reevaluationEmotional arousal and dramatic reliefEnvironmental re-evaluation“When you want to keep your motivation for doing something, what are some of the things you say to yourself?”
7 Stage 3: PreparationIndividual shifts from thinking about behavior change to planning first steps.Indicators: Individual asks questions, considers options, demonstrates openness in considering behavior change.Individual is traditionally characterized as compliant, “coming along,”, “good to work with.”
8 Stage 3: Preparation Clinical Tools Support efforts to changeClarify goals & identify successful strategiesStructure plan of action with client based on client’s history and willingness, allowing client to decideEncourage client to commit to actionGive client clear, consistent and unequivocal message about recoveryWith permission, offer expertise and adviceConsider and lower barriers to changeHelp the client enlist social supportExplore treatment expectancies & client’s roleElicit from the client what has worked in the past either for him or others whom s/he knows.Assist client negotiate finances, child care, work, transportation, other potential barriers.Have the client publicly announce plans to change get into treatment..Effective catalysts for change:Self-liberationCounterconditioningHelping relationships
9 Stage 4: ActionIndividual demonstrates steps toward behavior change such as periods of abstinence.Indicators: Individual is receptive to clinical interventions. Treatment compliance is normal. Demonstrated behavior change affects positive outcomes in other areas (i.e., relationships at home and work).Individual is traditionally characterized as “successful,” “working the program.”
10 Stage 4: Action Clinical Tools Seek commitment to specific behavioral change at each sessionAcknowledge difficulties, support even minimal progressIdentify risky situations, triggers & coping strategiesHelp client find new reinforcersSupport perseverance (“Sticking to the plan”)Engage the client in treatmentReinforce the importance of remaining in recoverySupport a realistic view of change through small steps.Help the client assess whether s/he has strong family and social support.Effective catalyst for change:CounterconditioningStimulus controlReinforcement managementHelping relationshipsSelf-liberationAt this stage, clients are receptive to the full range of counselor techniques, but client motivation often wax and wane along a spiral.If relapse occurs, the counselor “backs up” and applies techniques from earlier stage.For example, “Relapse is an event, but not an cat of magic, se let’s look at what was going on just before you resumed using. One we identify some of what you were thinking and feeling, we can devise some ways to choose differently.”
11 Stage 5: Maintenance Individual sustains treatment goals. Indicators: Individual has made behavior changes, practices stable abstinence, met treatment goals, and practices healthy coping strategies.Individual is traditionally characterized as “ready for successful discharge,” “no longer needing treatment,” “ready for aftercare.”
12 Stage 5: Maintenance Clinical Tools Support and affirm changesRehearse new coping strategies and countermeasures to triggersReview personal growth long-term goalsEncourage client to contribute to recovery of othersHelp client identify and sample drug-free sources of pleasure (new reinforcers)Affirm the client’s resolve and self-efficacyHelp the client practice & use new coping strategies to avoid relapseExplain to the client you are available to talk between sessionsTogether develop a “fire escape” plan if client relapsesSuch as:Treatment PlanAwareness of risky situationsCoping strategies for each situationParticipation in 12-Step programsPursuit of hobbies & cultural activitiesVolunteer opportunitiesThe counselor reminds the client of progress.Effective catalysts for change:Helping relationshipsEnvironmental reevaluationSelf-liberationReinforcement management
13 Appropriate Motivational Strategies for Each Stage of Change Client's Stage of ChangeAppropriate Motivational Strategies for the ClinicianStage 1: PrecontemplationThe client is not yet considering change or is unwilling or unable to change.Establish rapport, ask permission, and build trust.Raise doubts or concerns in the client about substance-using patternsExpress concern and keep the door open
14 Client's Stage of Change Appropriate Motivational Strategies for the ClinicianStage 2: ContemplationThe client acknowledges concerns and is considering the possibility of change but is ambivalent and uncertain.Normalize ambivalence.Help the client "tip the decisional balance scales" toward changeElicit and summarize self-motivational statements of intent and commitment from the client.Elicit ideas regarding the client's perceived self-efficacy and expectations regarding treatment.
15 Client's Stage of Change Appropriate Motivational Strategies for the ClinicianStage 3: PreparationThe client is committed to and planning to make a change in the near future but is still considering what to do.Explore treatment expectancies and the client's role.Clarify the client's own goalsNegotiate a change--or treatment--plan and behavior contract.Consider and lower barriers to change.Help the client enlist social support.Offer a menu of options for change or treatment.With permission, offer expertise and advice.Elicit from the client what has worked in the past either for him or others whom he knows.Assist the client to negotiate finances, child care, work, transportation, or other potential barriers.Have the client publicly announce plans to change.
16 Client's Stage of Change Appropriate Motivational Strategies for the ClinicianStage 4: ActionThe client is actively taking steps to change but has not yet reached a stable state.Engage the client in treatment and reinforce the importance of remaining in recovery.Acknowledge difficulties for the client in early stages of change.Help the client identify high-risk situations through a functional analysis and develop appropriate coping strategies to overcome these.Support a realistic view of change through small steps.Assist the client in finding new reinforcers of positive change.Help the client assess whether she has strong family and social support.
17 Client's Stage of Change Appropriate Motivational Strategies for the ClinicianStage 5: MaintenanceThe client has achieved initial goals such as abstinence and is now working to maintain gains.Support lifestyle changes.Affirm the client's resolve and self-efficacy.Help the client practice and use new coping strategies to avoid a return to use.Develop a "fire escape" plan if the client resumes substance use.Review long-term goals with the client.Help the client identify and sample drug-free sources of pleasure (i.e., new reinforcers).Maintain supportive contact (e.g., explain to the client that you are available to talk between sessions).