1. Motivational Interviewing and the Stages of Change Based on chapter 13 written by Carlo DiClemente From the book Motivational Interviewing

2. PGH Protocol for Resistant Pts Paliwanagan mo. Kulitin mo. Takutin mo. Pagalitan mo. Papirmahin mo.

3. 6 Stages of Change According to Prochaska and DiClemente Pre-Contemplation Contemplation Determination Action Maintenance and relapse prevention Termination

4. The Objective of the Session The goal is not so much to reach the Action stage in one session… …but rather to move the patient from his present stage to the next one. (ideal context--a continuing relationship)

5. Know what stage your patient is in, then plan accordingly.

6. Specific techniques (See if you have tried these already!)

7. Pre-Contemplation Patient is not even thinking about changing his behavior. In fact, they may not see the behavior as a problem at all.

8. Pre-Contemplation The 4 “R”s RELUCTANCE REBELLION RESIGNATION RATIONALIZATION

9. Pre-Contemplation RELUCTANCE They do not want to consider change because of LACK OF KNOWLEDGE or INERTIA. APPROACH: provide feedback and information in a sensitive and empathic manner

10. Pre-Contemplation REBELLION They have a heavy investment in the problem behavior and in making their own decisions. Resistant to being told what to do. Appears hostile. APPROACH: Offer choices Shift some of the energy used to resist into contemplating change

11. Pre-Contemplation RESIGNATION Characterized by lack of energy and investment They have given up on the possibility of change and seem overwhelmed by the problem. APPROACH: Instill hope Explore barriers to change

12. Pre-Contemplation RATIONALIZATION Many reasons why the problem is not a problem or is a problem for others but not for them. Session feels like a debate APPROACH: Empathy and reflective listening; the double-sided reflection (“On the one hand…, but on the other…”)

13. Pre-Contemplation Some important considerations: You have to distinguish between rationalization and informed choice. We cannot assume that “the problem” means the same to the patient as it does to us. It is not true that “more is always better” More education, more intense treatment, and more confrontation does not necessarily produce more change.

14. From Pre-contemplation to Contemplation Building Motivation for Change

15. Eliciting Self-Motivational Statements Goal: To have the client himself present the arguments for change. Counselor’s task: To facilitate the above process--not to do it for him!

16. Types of SMS Problem recognition statement “I guess there’s more of a problem here than I thought.” “I never really realized how much I have been drinking.” “This is serious!”

17. Types of SMS Expression of concern statement “I’m really worried about this.” “How could this happen to me? I can’t believe it!” “I feel pretty hopeless.”

18. Types of SMS Intention to change statement “I think it’s time for me to think about quitting.” “I’ve got to do something about this.” “This isn’t now I want to be. What can I do?”

19. Types of SMS Optimism about change statement “I think I can do it.” “Now that I’ve decided, I’m sure I can change.” “I’m going to overcome this problem.”

20. Evocative Questions to Elicit: Problem recognition statements What things make you think that this is a problem? What difficulties have you had in relation to your drug use? In what ways has this been a problem for you? (the focus is on PRESENT ADVERSE consequences of the behavior to be changed-- you want him to RECOGNIZE the problem)

21. Evocative Questions to Elicit: Expression of concern statements What worries you about your drug use? How do you feel about your gambling? How much does that concern you? What do you think will happen if you don’t make a change? (the focus is on some future adverse consequence of the behavior to be changed-- you want him to WORRY about the problem)

22. Evocative Questions to Elicit: Intention to change statements The fact that you are here means part of you wants to do something. What are your reasons for making a change? If you were 100% successful in changing, what would be different? What would the advantages be if you made a change? (the focus is on a future beneficial effect of changing behavior)

23. Evocative Questions to Elicit: Expression of optimism statements What encourages you that you can change if you want to? What do you think would work for you if you decided to change? What makes you think that if you decided to change, you could do it? (the focus is on available resources that can help to change the behavior)

24. Contemplation Patient is willing to consider the problem and is quite open to information and decisional balance considerations… BUT there is much ambivalence. Remember that contemplation/interest is not the same as commitment.

25. Contemplation APPROACH Provide information and incentives to change… …but make the information palpable and relevant to them personally. Deal equally to the hidden “benefits” of maintaining the behavior (“decisional balance technique”) Deal equally with the pros and cons of CHANGING the behavior

26. Contemplation: The Decisional Balance Technique Prochaska and DiClementi

27. 5 Questions in Series What do you get out of it? What are the disadvantages? What are your goals in life? How does the behavior fit into your goal? If you could change, what would happen?

28. Question 1: What do you get out of it?

29. Question 2: What are the disadvantages?

30. Question 3: What are your goals in life?

31. Question 4: How does the behavior contribute to your goals?

32. Question 5: If you could change, what would happen?

33. Set a quit date. Make a plan that fills legitimate needs and hurdles obstacles.

34. 5 Questions in Series What do you get out of it? What are the disadvantages of your behavior? What are your goals in life? How does your behavior contribute to your goals? If you could change, what would happen?

35. Additional Techniques for the Contemplation Phase

36. Contemplation APPROACH Explore problems with previous attempts to change. Reframe failures into “partial successes”. Emphasize the cyclic nature of change in the stages- of-change model. Anticipate the barriers to change.

37. The Decisional Balance Technique Ask first about the advantages of continuing the behavior. Then ask about the disadvantages of continuing the behavior. Once an SMS is stated, reflect it back and affirm it.

38. Elaboration Used as a follow up to a question to elicit an SMS Ask for more specific examples Ask for details: About the adverse consequences of the behavior About the resources available for change

39. Using Extremes What concerns you the most ? What are your worst fears about what might happen if you don’t make a change? What is the worst that could happen in you continue the way you are now?

40. Looking Back Focus is on the good times before the problem started and compare with the present What were things like before you started drinking heavily? What were you like back then? What are the differences between the Cielo 10 years ago and the Cielo now? How did the two of you meet and what attracted you to each other back then?

41. Looking Forward help the client envision a changed future If you do make a change, what are your hopes for the future? How would you like things to turn out for you? I can see you are really frustrated. How would you like things to be different? What would be the best results you could imagine if you make a change?

42. Exploring Goals Explore the discrepancy between client’s goals and the present What are the things that are most important in your life? How does your behavior (i.e. drinking) fit into this picture? What is it that you want to accomplish in life? How does your behavior fit into this?

43. Using Paradox subtly take a “no-problem” stance You haven’t convinced me yet that you have a problem. Is that all? It’s hard to start if someone isn’t really motivated, and frankly, I’m not sure about you. I’m not really convinced that you are motivated enough. I’m not sure you believe you could change even if you wanted to.

44. Using Paradox: Role Reversal Take the role of the client. Let the client take the role of counselor. As you play the role, repeat the “no- problem” arguments of the client and let him convince you to change.

45. Follow-through Contact Risk of dropping out is highest following the first session. In a study of alcoholics, a single ffup phone call resulted in 52% keeping their next appointment vs. 8% in those without a ffup call (Koumans and Muller 1965)

46. Follow-through Contact Nirenberg, Sobell and Sobell 1980 Phone call after a missed appointment reduced drop out rate from 92% to 60% Panepinto and Higgins 1969 A follow-through letter after the first missed appointment reduced early drop out from 51% to 28%

47. Determination: Commitment to Action

48. Hallmark: deciding to take appropriate steps to stop a negative behavior or start a positive one Assess strength and levels of commitment Anticipate problems and pitfalls Use appropriate techniques. (Enthusiasm is not a cure for ineptness.)

49. Action

50. Provide confirmation of the plan Provide support Provide external monitoring of progress Focus on successful activity (“Progress, not perfection.”) Reaffirm their decision Offer information about successful models Usually lasts 3-6 months

51. Maintenance, Relapse, Recycling New behavior is becoming firmly established Threat of relapse becomes less frequent and intense BUT relapse is always possible APPROACH Provide feedback about length of time needed for change Help patient become aware of “triggers” Help the patient learn from the relapse Remind them of the cycle of change