1. OBSTACLES AND STRATEGIES FOR A SUCCESSFUL CHANGE. Adopted from Overcoming Obstacles to Change presentation by Dr. Deborah Dobson, Ph.D., R.Psych. For Presentation at Supportive Living Program Team Meeting on April 21, 2011, Marguerite House,.

2. BACKGROUND What is change? Most of us, at one time or another in our lives, reach a point when we know that something in our lives has to change, and that we have to be the ones to change it. The status quo is no longer satisfying our needs, and it’s time to do something about it. However, because the thoughts that have “fed” our behaviors for so long are deeply ingrained in our mind, and the habits of thought are hard to break, it is often a difficult task to make change.

3. OBSTACLES TO CHANGE There are several recurring reasons for resistance to change: The purpose is not made clear. The participants are not involved in the planning. The habit patterns of the work group are ignored. There is poor communication regarding a change. There is fear of failure. Excessive work pressure is involved. The cost is too high, or the reward for making the change is seen as inadequate. The present situation seems satisfactory. There is a lack of respect and trust in the change initiator

4. According to psychologist Dennis O’Grady, the ability to change is related to a combination of five fears that O’Grady says can choke the ability to change : Fear of the Unknown: the unspoken message from society says that when change occurs, you will lose control. Fear of Failure: if I commit myself to goals for change, there is a chance for failure. Fear of Commitment: Commitment to one option is not always fun because it eliminates other options. Fear of Disapproval: If I change, I risk having people say they like me better the way I was. Your own change also forces others to change in relationship to you. Fear of Success: if I change, what other demands will be make of me? Can I sustain this success?

5. Barriers to change for our clients: Consider symptoms Lack of skills and cognitive barriers and internal locus of control Anxiety disorders. GAD, PD, OCD Mood disorders…depression Schizophrenia and psychotic disorders External obstacles-finances, access to resources

6. STAGES OF CHANGE Psychologists Prochaska, Norcross, and others, have developed a theory/model about the process of change, and the process by which Clients can be effective at implementing change in their lives. This model is called the Transtheoretical Model. The model involves a number of steps people go through in the process of change.

7. Transtheoretical Model,

8. Precontemplation. In this stage, a client is unaware that he or she has a problem, or is under-aware of the problem. There is no expressed desire to make any changes, and no real concern or immediacy for anything to be different. If asked, clients might say that things are fine, and that if nothing is different a year from now, it would be okay. RSt, OY, SG Contemplation. In this stage, a client has become aware that there may be a problem, and one has begun considering doing something about it.

9. Commitment: Clients have become more than aware that they have a problem or a situation that demands change. Clients are motivated to do something to change it. Clients go beyond saying “I should” and begin saying “I will.” Interestingly, this is a difficult stage to get to. Clients often enter this stage and commit to change only when the alternative is no longer tolerable. The thought of NOT changing is unbearable. It is in this stage that change—and progress—are born. Preparation: This is a “could” stage. Clients think of every possible alternative and resource. Clients look at options, and they choose the ones that will work for them. Clients devise a plan, and are intent on following it through. Clients are ready.

10. Action. Clients are committed. Clients have prepared. Clients are physically, emotionally, and spiritually ready to embark on a journey by which it will improve their lives.

11. Maintenance. Clients feel proud. Clients hold their head higher. Clients have more self confidence. The danger of this stage, after clients have made some big changes, is that clients might slide into complacency. Clients are no longer so uncomfortable that they MUST change, and Clients are at high risk for relapse into past unhealthy and ineffective behaviors.

12. THE MAIN QUESTION IS HOW DO YOU BRING ABOUT A SUCCESSFUL CHANGE? MOTIVATIONAL INTERVIWING, AN EVIDENCE BASED STRATEGY FOR BRINGING FORTH CHANGE.

13. MOTIVATIONAL INTERVIWING. Motivational Interviewing (MI) is defined as a client-centered counseling style for enhancing intrinsic motivation to change by identifying and resolving ambivalence. Motivational Interviewing (MI) has been developed over the past 25 years by William Miller and Stephen Rollnick (Miller, W.R. & Rollnick S., 2002). The central goal of MI is to examine and resolve ambivalence in order to create an opportunity for self-change. Ambivalence is defined as the conflict between wanting to change a given behavior and maintaining the status quo. Ambivalence is akin to being “stuck” in a situation where certain behaviors lead to negative consequences; this is a normal state for many individuals with addictive behaviors.

14. MI focuses on an individual's interests and concerns, reflecting the work of Carl Rogers on client-centered therapy. Rogers did not view the therapist’s role as one of providing solutions, suggestions or analysis. Instead, the therapist merely needs to offer three critical conditions to prepare his/her client for natural change: empathy, unconditional positive regard and genuineness. The therapist uses reflective listening to clarify and amplify the meaning that the client places on events (rather than the meaning that the therapist places on those events). Clients are also more likely to respond to reflections than to a series of closed-ended questions that block communication. Therefore, reflective listening, which uses statements instead of questions to uncover the meaning of the client’s discourse, is an effective approach to self discovery and, therefore, change.

15. Unconditional positive regard and genuineness are expressed by acknowledging and appreciating a client's thoughts and opinions without judging him/her; this empowers the client to make decisions that match ones personal values, beliefs and goals. How do we practice or apply Motivational Interviewing.

16. A MI SESSION Find the Target Behavior (e.g., using, smoking, and exercising, or moving to the next step in mental health recovery and wellness) Clarify the agenda around a target behavior about which there is ambivalence. Ask about the positive (good things) aspects of the target behavior. This is often an engaging surprise. However, it will only work if you are genuinely interested. What are some of the good things about _______? People usually____ because there is something that has benefited them in some way. How has_______ benefited you? What do you like about the effects of ___? Summarize the positives

17. Ask about the negative (less good things) aspects of the target behavior: – Can you tell me about the down side? – What are some aspects you are not so happy about? – What are some of the things you would not miss? – Summarize the negatives Explore life goals and values. – What sorts of things are important to you? – What sort of person would you like to be? – If things worked out in the best possible way for you, what would you be doing a year from now? – Use affirmations to support “positive” goals and values.

18. Ask for a decision. – Restate their dilemma or ambivalence then ask for a decision. – You were saying that you were trying to decide whether to continue or cut down…? – After this discussion, are you more clear about what you would like to do? – So have you made a decision?

19. MOTIVATIONAL INTERVIEWING: STRATEGIES FOR EVOKING CHANGE 1. Ask Evocative Questions – Use Open-Ended Questions Examples: - Why would you want to make this change? (Desire) - How might you go about it, in order to succeed? (Ability) - What are the three best reasons for you to do it? (Reasons) - How important is it for you to make this change? (Need) - So what do you think you’ll do? (Commitment) 2. Ask for Elaboration When a change talk theme emerges, ask for more detail: - In what ways? - How do you see this happening? - What have you changed in the past that you can relate to this issue?

20. 3. Ask for Examples When a change talk theme emerges, ask for specific examples. - When was the last time that happened? - Describe a specific example of when this happens. - What else? 4. Looking Back Ask about a time before the current concern emerged: - How have things been better in the past? - What past events can you recall when things were different?

21. 5. Look Forward Ask about how the future is viewed: - What may happen if things continue as they are (status quo). - If you were 100% successful in making the changes you want, what would be different? - How would you like your life to be in the future? 6. Query Extremes Ask about the best and worst case scenarios to elicit additional information: - What are the worst things that might happen if you don't make this change? -What are the best things that might happen if you do make this change?

22. 7. Use Change Rulers Ask open questions about where the client sees themselves on a scale from 1 – 10. - On a scale where one is not at all important, and ten is extremely important, how important (need) is it to you to change _______? -Follow up: Explain why you are at a ___ and not (lower number)? - What might happen that could move you from ____ to a _____[higher number]? - How much you want (desire), - How confident you are that you could (ability), - How committed are you to ____ (commitment).

23. 8. Explore Goals and Values Ask what the person's guiding values are. - What do they want in life? - What values are most important to you? (Using a values card sort can be helpful here). - How does this behavior fit into your value system? - What ways does ________ (the behavior) conflict with your value systems 9. Come Alongside Explicitly side with the negative (status quo) side of ambivalence. - Perhaps ____________ is so important to you that you won't give it up, no matter what the cost. - It may not be the main area that you need to focus on in our work together.

24. Strategies for Handling Resistance: 1. Simple Reflection: simple acknowledgement of the client’s disagreement emotion, or perception 2. Double- sided Reflection: acknowledge what the client has said and add to it the other side of the client’s ambivalence 3. Clarification: verify your understanding matches the client’s perspective 4. Shifting Focus: shift the client’s attention away from what seems to be a stumbling block. 5. Emphasizing Personal Choice and Control: assure the person that in the end, it is the client who determines what happens

25. THANK YOU FOR LISTENING VISIT MY BLOG AT: www.mental-health-therapy.org www.mentalhealththerapy.wordpress.org THE END

26. REFERENCES: Addictions Foundation of Manitoba’s website (http://www.afm.mb.ca/) on their home page under “Learn More” and “Tools of AFM”. Miller, W.R. & Rollnick S. (2002) Motivational Interviewing (2nd Edition): Preparing People for Change. New York: Guilford.

30. Barriers to change: Consider symptoms Lack of skills and cognitive barriers and internal locus of control Anxiety disorders Mood disorders Schizophrenia and psychotic disorders External obstacles-finances, acess to resurces