1、Integrating Motivational Interviewing, the Stages of Change Model, and Treatment Planning Kevin Glavin Kent State University kglavinkent.edu Rachel Hoffman Kent State University rhoffmankent.edu All-Ohio Counselors Conference November 2-4, 2005,Agenda,Background & Introduction to the Stages of Chang
2、e Model (Transtheoretical Model) The Stages of Change: Key points Practical Applications Teaching treatment planning and case conceptualization. Educating clients about the stages of change Motivational Interviewing Techniques Moving through the stages: Techniques and Strategies The Processes of Beh
3、avior Change Determining a Clients Stage of Change using SOCRATES,Background Information,During his college years, psychologist James Prochaska, Ph.D., lost his father to alcoholism and depression. Prochaska reported his fathers mistrust in psychotherapy and his refusal to participate in counseling.
4、 This served to fuel Prochaskas research into substance abuse and the stages of change. Prochaska and DiClemente started their research by observing individuals who had over come an addiction to nicotine. They discovered change occurred on a continuum and identified common stages and processes indiv
5、iduals appear to progress through. The model is named the Transtheoretical Model spans so many different theories. This model provides practitioners with a way in which to understand how clients change, as well as what motivates them to change. It can be used to teach case conceptualization, and bui
6、ld appropriate stage related interventions into treatment plans.,The Stages of Change Model: Transtheoretical Model (Prochaska & DiClemente, 1982),The central organizing construct of the model is the Stages of Change The Transtheoretical Model views change as a process involving progress through a s
7、eries of five stages Precontemplation Contemplation Preparation Action Maintenance The goal is to determine which stage of change the client is in and assist the client in progressing through subsequent stages.,The Stages of Change,Source: http:/www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.
8、62561,No intention of changing behavior,Intends to change in the next 6 months, but may procrastinate,Intends to take action soon, for example next month,Has changed behavior for less than 6 months,Has changed behavior for more than 6 months,Change is Dynamic and Cyclical,It is important to note tha
9、t the change process is cyclical, and individuals typically move back and forth between the stages and cycle through the stages at different rates. In one individual, this movement through the stages can vary in relation to different behaviors or objectives. Individuals can move through stages quick
10、ly. Sometimes, they move so rapidly that it is difficult to pinpoint where they are because change is a dynamic process. It is not uncommon, however, for individuals to linger in the early stages.For most substance-using individuals, progress through the stages of change is circular or spiral in nat
11、ure, not linear. In this model, recurrence is a normal event because many clients cycle through the different stages several times before achieving stable change. The five stages and the issue of recurrence are described below.Source: http:/www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.61626
12、,Key Points,Prochaska and DiClemente argue that behavior change cannot be thought of as a specific event occurring at a specific point in time. Rather, change should be thought of as a process that may take months or even years. Many behavioral change programs are characterized as lasting for a pred
13、etermined number of weeks and consisting of structured content. Such programs do not take into account the uniqueness of each client, and the subtle changes that often go unnoticed. Some clients will respond very positively and make significant changes. However, for those who do not, they are said t
14、o lack motivation and/or willpower. We tend to acknowledge change has occurred when we see a change in behavior, e.g. a period of abstinence, leaving an unhealthy relationship. These are seen as successes.,Key Points,The stages of change model suggests that change occurs along a continuum and theref
15、ore cannot be measured by one criteria alone, i.e. a change in a specific problem behavior. If we view change as a process then we can report positive changes each time an individual progresses from one stage to the next. Small steps constitute changes and should therefore be recognized and supporte
16、d.Since clients differ in their readiness to make changes Prochaska and DiClemente suggest matching interventions to the appropriate stage (or readiness). “Success, moreover, is defined not just by changing the behavior but by any movement toward change, such as a shift from one stage of readiness t
17、o another.” There is an emphasis on the maintenance of change. Relapse is common and should not be seen as a sign of failure. Clients are encouraged to learn from their relapse.A great deal of importance is placed on the decision making capability of the individual,Practical Applications,Teaching ca
18、se conceptualization and treatment planning in counselor education and supervision Common concerns of student counselors in supervision: “I dont know what else to do with this client” “I feel like I do not know enough techniques” “I want to be prepared and have a diverse number of tools to draw upon
19、” “The client is stuck, I am stuck, I dont know where to go” “I am exhausted, she or he, wont budge.” Counselors need to become aware of when they are working harder than their clients Counselors may get into difficulties if they rely too heavily on theoretical techniques and attempt to draw from th
20、eir “bag of tricks”. Eventually someone will throw a spanner in the works. Student counselors will benefit from learning about the stages of change because it explains the process of change. More emphasis is placed on the client, which will help alleviate some of the pressure counselors feel. Counse
21、lors can use the model to teach clients about the stages of change, and thus set the tone for future counseling sessions. All of the above can then be used to create a collaborative treatment plan based on the clients current position,Integration of Major Therapy Systems within the Transtheoretical
22、Framework,Motivational Interviewing,A counseling style that is derived from the field of addictions counseling. Brief intervention format. Six critical elements necessary for successful brief interventions (the acronym FRAMES) Feedback emphasizing the clients Responsibility for change offering Advic
23、e provide a Menu of alternative treatment options demonstrate Empathy reinforce clients optimism; Self-Efficacy.,Miller & Sanchez, 1994,Motivational Interviewing,Motivational interviewing is guided by several principles: Avoiding argumentation Rolling with resistance Expressing empathy Developing di
24、screpancies Supporting self-efficacy Counselors avoid harsh confrontations MI counselors emphasize the need for change and increase confidence and hope that change can occur.,Lewis & Osborn, 2004,Stage 1: Precontemplation,Adapted from: The National Center for Biotechnology Information: TIP 35: Enhan
25、cing Motivation for Change in Substance Abuse Treatment: http:/www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.61302,Precontemplation: Strategies,Use self motivational statements with questions such as: “How does this concern you?” “What do you think will happen to you if you do not make any c
26、hanges?” “What has your alcohol use prevented you from doing?” If client is reluctant, try asking “What would have to happen for you to know that this is a problem?“ “What would you consider as warning signs that would let you know that this is a problem?“ Try not to assume client has a substance ab
27、use problem. Instead, start from the viewpoint there is a possibility substance abuse is a problem for you” If subject seems willing, offer feedback from test results, such as the SOCRATES. (but ask, what do these results say to you?) Try not to come from the counselor as expert point of view. If cl
28、ient is willing, explain the concepts behind the stages of change model. Involve them in the process. Ask subject what they would like the next step to be.,Moving from Precontemplation to Contemplation,There is a myth.in dealing with serious health-related addictive.problems, that more is always bet
29、ter. More education, more intense treatment, more confrontation will necessarily produce more change. Nowhere is this less true than with precontemplators. More intensity will often produce fewer results with this group. So it is particularly important to use careful motivational strategies, rather
30、than to mount high-intensity programs.that will be ignored by those uninterested in changing the.problem behavior. We cannot make precontemplators change, but we can help motivate them to move to contemplation. (DiClemente, 1991)Individuals in the precontemplation stage rarely show for treatment by
31、choice. Most are required to attend treatment for one reason or another. They may truly believe their substance use is not a problem. One goal is therefore to create doubt within the client, such that they may question their risky behaviors. When you first meet with client: Establish rapport and tru
32、st Explore events that precipitated treatment entry Commend clients for coming “Why do you think your probation officer believes you have a problem?“ This enables the client to express the problem from the perspective of the referring party. It also provides you with an opportunity to encourage the
33、client to acknowledge any truth in the other partys account (Rollnick et al., 1992a). Source: http:/www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.61822,Moving from Precontemplation to Contemplation,Readiness Ruler: (Source: Rollnick) The simplest way to assess the clients willingness to chan
34、ge is to use a Readiness Ruler or a 1 to 10 scale, on which the lower numbers represent no thoughts about change and the higher numbers represent specific plans or attempts to change. Ask the client to indicate a best answer on the ruler to the question, “How important is it for you to change?“ or,
35、“How confident are you that you could change if you decided to?“ Precontemplators will be at the lower end of the scale, generally between 0 and 3. You can then ask, “What would it take for you to move from an x (lower number) to a y (higher number)?“,Moving from Precontemplation to Contemplation,De
36、scription of a typical day Another, less direct, way to assess readiness for change, as well as to build rapport and encourage clients to talk about substance use patterns in a nonpathological framework, is to ask them to describe a typical day. This approach also helps you understand the context of
37、 the clients substance use. For example, it may reveal how much of each day is spent trying to earn a living and how little is left to spend with loved ones. By eliciting information about both behaviors and feelings, you can learn much about what substance use means to the client and how difficult-
38、or simple-it may be to give it up. Substance use is the most cohesive element in some clients lives, literally providing an identity. For others it is powerful biological and chemical changes in the body that drive continued use. Alcohol and drugs mask deep emotional wounds for some, lubricate frien
39、dships for others, and offer excitement to still others. Start by telling the client, “Lets spend the next few minutes going through a typical day or session of.use, from beginning to end. Lets start at the beginning.“ Clinicians experienced in using this strategy suggest avoiding any reference to “
40、problems“ or “concerns“ as the exercise is introduced. Follow the client through the sequence of events for an entire day, focusing on both behaviors and feelings. Keep asking, “What happens?“ Pace your questions carefully, and do not interject your own hypotheses about problems or why certain event
41、s transpired. Let clients use their own words and ask for clarification only when you do not understand particular jargon or if something is missingSource: (Rollnick et al., 1992a).,Moving from Precontemplation to Contemplation,Provide Information About the Effects and Risks of Substance Use Provide
42、 basic information about substance use early in the treatment process if clients have not been exposed to drug and alcohol education before and seem interested. Tell clients directly, “Let me tell you a little bit about the effects of.“ or ask them to explain what they know about the effects or risk
43、s of the substance of choice. To stay on neutral ground, illustrate what happens to any user of the substance, rather than referring just to the client. Also, state what experts have found, not what you think happens. As you provide information, ask, “What do you make of all this?“ It is sometimes h
44、elpful to describe the addiction process in biological terms to persons who are substance dependent and worried that they are crazy. Understanding facts about addiction can increase hope as well as readiness to change. For example, “When you first start using substances, it provides a pleasurable se
45、nsation. As you keep using substances, your mind begins to believe that you need these substances in the same way you need life-sustaining things like food-that you need them to survive. Youre not stronger than this process, but you can be smarter, and you can regain your independence from substance
46、s.“ Source: (Rollnick et al., 1992a).,Stage 2: Contemplation,Contemplation: Strategies,Contemplation Strategies: Cost Benefit Analysis Scale Source: Davis & Osborn (2000),Costs,Benefits,Stage 3: Preparation,Preparation: Activities,Identify clients needs/wants/desires Emphasis is on outlining and dev
47、eloping plans in order to break the pattern of substance abuse, and find other ways of meeting clients needs. Goal Setting Miracle question Where do you want to be 6 months, 1 year, 5 years from now? What will life look like for you? Encourage client to come up with their own plans, and have them st
48、ate specifically how they will achieve them. Identify alternative ways in which to meet needs. Identify areas of support that can be utilized. Commend client for deciding to change because they always have the option not to. Create an action plan Have client state their next step.,Moving Clients Fro
49、m Contemplation to Preparation,Do not rush your clients into decision making. Emphasize client control: “You are the best judge of what will be best for you.“ Acknowledge and normalize ambivalence. Examine options rather than a single course of action. Describe what other clients have done in a simi
50、lar situation. Present information in a neutral, non personal manner. Remember that inability to reach a decision to change is not a failed consultation. Make sure that your clients understand that resolutions to change often break down; clients should not avoid future contact with you if things go wrong. Expect fluctuations in your clients commitment to change-check commitment regularly and express empathy concerning the clients predicaments. Source: (Rollnick et al., 1992a.),
