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Enhancing Motivation for Change
1. Enhancing Motivation for
Change in Substance Abuse
Treatment Part 2
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
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2. Objectives
Learn about the nature of change
Explore the different stages of readiness for change
Learn about goals and interventions for each stage for
readiness for change
Identify ways to identify a clients change in readiness for
change
Explore ways to identify barriers to recovery
Learn how to explore expectations regarding recovery and
how to use that to enhance motivation
Briefly review how to develop a relapse prevention plan
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3. Change
Is Constant
Occurs all the time
In the natural environment
Among people
In relation to behaviors
Occurs without professional intervention
The change process is cyclical, and people typically move back
and forth between the stages and cycle through the stages at
different rates.
It is not uncommon for people to linger in the early stages.
Recurrence of at least some symptoms or old behaviors is a
normal event, and many clients cycle through the different
stages several times before achieving stable recovery.
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4. Nature of Change
6 basic stages in the process of change:
Precontemplation
Contemplation
Preparation
Action
Maintenance
Recurrence
People typically vacillate between the stages and cycle
through the stages at different rates. (Pool)
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5. Precontemplation
The client is unaware, unable, or unwilling to change.
Establish rapport
Raise doubts about patterns of use
Give info on risks, pros and cons of use
Explore reasons for unwillingness to change (.i.e fear of failure)
The client is likely to be wary of the counselor and of
treatment.
Should not rub the client the wrong way
Should try to keep the interview informal.
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6. Ambivalence
Many clients are ambivalent about change.
Change is hard
Ambivalence is expressed in several ways.
Argue: Challenge or discount statements
Interrupt: Take over or cut off conversation
Deny: Blame, disagree, excuse, minimize
Ignore: Not responding, not paying attention
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7. Goals/Actions
Explore the meaning of events that brought the client to
treatment or the results of previous treatments.
Elicit the client's perceptions of the problem.
Offer factual information about the risks
Provide personalized feedback about assessment
Explore the pros and cons of substance use.
Help a significant other intervene.
Examine discrepancies between the client's and others’
perceptions of the problem behavior.
Express concern and keep the door open.
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8. Contemplation
The client is ambivalent or uncertain, considering the
possibility of change.
◦ Counselor can
Discuss and weigh pros/cons of change (Decisional Balance)
Emphasize client's free choice and responsibility
Elicit self-motivational statements
Reassure the client that no one can force him to
change and he is in charge.
Ask questions that prompt motivation.
◦ For example, "When you want to keep up your motivation for
doing something, what are some of the things you say to
yourself?"
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9. Goals/Actions
Help the client recognize the problem(s) contributing to
the current situation
Help the client acknowledge concern
Help the client generate intention to change
Help the client develop optimism
Convey feedback
Help clients see a difference
Show curiosity about client strengths. Explore how those
skills and competencies may be negated by their current
state
Reframe negative statements.
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10. Highlight Reasons for Change
Summarize concerns
Explore specific pros and cons
Allow client to explain benefits
Assure client conflicting feelings are normal
Review feedback from assessment
Find out what client expects from treatment
Provide info
Help client connect core values to committing to
treatment
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11. Strengthen the Client's Personal Choices
Nudge the client to make positive choices.
"No one can decide this for you. You can choose."
Help the client set goals and take steps.
Provide feedback.
Remind client of "triggers," including negative emotions
(anger), social pressures (peers), physical concerns
(headache) and extended withdrawal symptoms (craving).
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12. Reinforce the Client's Commitment
What do you think has to change?
What are you going to do?
How are you going to do it?
What are some benefits of making a change?
How would you like things to turn out, ideally?
For more detailed information, see TIP 35, pp. 54–92.
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13. Preparation
The client asks questions, indicates willingness and
considers options to make specific changes.
Explore treatment expectancies and the client's role.
Elicit from the client what has worked in the past
either for him or others whom he knows.
At this stage, the client shifts from "thinking about it"
to "planning first steps."
Counselor guides the steps by offering help but not
yanking the client forward.
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14. Help The Client Get Ready
Negotiate a plan
Offer a menu of options
Develop a behavior contract
Identify and lower barriers
Enlist social support
With permission offer advice
Assist the client in negotiating finances, child care,
work, transportation, or other potential barriers.
Have the client publicly announce plans
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15. Client Indicates Readiness
Stops arguing, interrupting, denying
No longer asks questions about the problem, but more
about how to change
Appears calm, peaceful
States openness to change ("I have to do something")
Expresses optimism ("I can beat this")
Talks about how life will be after the change
Experiments between sessions
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16. Barriers
Ask what has gone wrong in the past
Find out if clients anticipate problems
Provide all necessary information
Sources of barriers may include
Family relations
Health problems
Depression or other negative feelings
Bureaucracy: Waiting lists, paperwork, legal
Finances
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17. Action
The client takes steps toward change, but is still unstable.
Negotiate an action plan
Acknowledge difficulties and support attempts
Identify risky situations and coping strategies
Help client find new reinforcers
Support perseverance ("Sticking to the plan")
In this stage, clients are receptive to the full range of
counselor techniques, but motivation can wax and wane
If relapse occurs, "back up" and apply techniques from an
earlier stage.
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18. Goals/Actions
Engage the client in treatment and reinforce the
importance of remaining in recovery.
Support a view of change through small steps.
Acknowledge difficulties for the client in early stages of
change.
Help the client identify high-risk situations and develop
appropriate coping strategies
Assist the client in finding reinforcers
Help the client assess levels of social support.
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19. Explore Expectations
Explore past experiences, hopes, and fears regarding
Confrontation, judgment
Costs in money or changed behavior
Can’t stay out late anymore because it triggers depression
Have to give up certain activities (at least temporarily) like cross
posting
Family involvement, shame, guilt
Medications the client will have to withdraw from or take
Perception of rules too strict, no "wiggle room."
Understanding
Immunize against difficulties
Resolve barriers to treatment
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20. Increase Motivations
Help the client to see the value of both internal and
external motivating factors
Suggest to the client that external coercions are
compatible with the client's best interests
Support signs of internal motivation
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21. Examine & Interpret Noncompliant Behavior
Noncompliant behavior is a thinly veiled expression of
dissatisfaction with treatment or the therapeutic
process.
It may be you
You may be missing something
What are the benefits to the behavior
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22. Maintenance
Client has met initial goals, made changes in lifestyle and
now practices coping strategies.
Support and affirm changes
Rehearse new coping strategies
Review goals
Keep in contact (aftercare, support groups)
In this stage, clients "keep on keeping on."
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23. Cont…
Remind the client about new tools to maintain and
reinforce recovery, such as
Action plan
Awareness of risky situations
Coping strategies for each situation
Participation in 12-Step programs or support groups
Pursuit of hobbies and cultural activities
Volunteer opportunities
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24. Goals/Actions
Help the client identify and sample drug-free sources of
pleasure (i.e., new reinforcers).
Support lifestyle changes.
Affirm the client's resolve and self-efficacy.
Help the client practice/use coping strategies
Maintain supportive contact
Develop a "fire escape" plan if the client feels symptoms
returning or notices a return to old ways of thinking
Review long-term goals with the client.
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25. Form a Plan.
Identify triggers
Identify effect/benefits of the old way of responding to
the trigger
Identify alternate, helpful coping responses
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26. Developing Reinforcers
Competing
Sleeping
Crying
Self-Harm
Contingent (If/Then)
If you respond effectively then you can…
If you get out of bed by 9am each day then…
Community (natural consequences)
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27. Recurrence
Help the client reenter the change cycle and commend any
willingness to reconsider positive change.
Explore the meaning and reality of the recurrence as a
learning opportunity.
Assist the client in finding alternative coping strategies.
Maintain supportive contact.
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28. Applications of Motivational Approaches
A means of rapid engagement in the general medical
setting to facilitate referral to treatment
A first session to increase the likelihood that a client will
return and to deliver a useful service if the client does
not return
An empowering brief consultation when a client is placed
on a waiting list, rather than telling a client just to wait
for treatment
A preparation for treatment to increase retention and
participation
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29. Applications cont…
A help to clients coerced into treatment to move beyond
initial feelings of anger and resentment
A means to overcome client defensiveness and resistance
A stand-alone intervention in settings where there is only
brief contact
A counseling style used through the process of change
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30. Other Things to Remember
Often there is a relatively short period of time to make a
beneficial impact on the client
The average length of stay in substance abuse treatment is
very short
If clinicians do not make an impact in the first session or
two with clients, they may not be able to make an impact
at all
Make the best use of the first contact
It is usually a mistake to start a session with filling out
forms
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31. Summary
Even one session can make a positive impact on a client
Lasting change takes time and effort
All clients have the ability to make positive choices and changes
Clients will be at different stages of readiness for change for
different issues and symptoms and may vacillate between
conflicting goals
Clients with low motivation begin arguing, ignoring or becoming
apathetic
Sometimes enhancing motivation means focusing first on barriers to
recovery instead of the problem itself.
Explore expectations regarding recovery to enhance motivation
Develop a relapse prevention plan that helps clients identify
triggers and vulnerabilities and ways to prevent and address them
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31