Using Motivational Techniques to Create Readiness for Change

1
Using Motivational Techniques to Create Readiness
for Change Build Therapeutic Alliance

• Paul OHalloran
• Director
• Training, Education Development
• National Institute for Mental Health England
• (East of England Development Centre)

2
AUSTRALIA
3
(No Transcript)
4
(No Transcript)
5
Aims Objectives of the WorkshopThese Sessions
will better enable participants to

• Explore Motivational Techniques Concordance
• Examine various models of Motivation
• Identify how motivation is best understood as a
  dynamic and cyclical process
• Understand the obstacles ambivalence facing
  users in the change process
• Explore techniques to enhance motivation
  concordance
• Consider Motivational Interviewing as an
  enhancement to other approaches to treatment
  care.

6
Creating Readiness for ChangeMotivational
Interviewing

• What is Motivation'?
• A personality trait?
• Will power?
• Does the person's environment play a role? or
• Is motivation' entirely a personal attribute?

7
What is concordance ?

• Concordance can be defined as
• Optimal adherence through active collaboration
  with an effective programme of Recovery,
  including treatment
• as negotiated and agreed between service user and
  practitioner
• That is achieving Common purpose
• Not the same as compliance. In many
  dictionaries this is defined as acquiescing or
  yielding.

8
Why is optimal adherence important ?

• The impact of non-concordance includes
• Increased rates of relapse re-hospitalization
• Increased length of stay in hospital
• Decreased rates of positive recovery (increase in
  poor outcome)
• ( Gaebel Pietzcker 1985, Green 1988, Verghese
  et al 1989, Helgason 1990, Haywood 1995, Kemp et
  al 1996)

9
Why is optimal adherence important ?

• The impact of non-concordance includes
• Increased risk of violent behaviour for users
  with psychosis (Fuller-Torrey 1994)
• Increased costs of health care
• up to 100 million p.a in UK (Bebbington 1995)

10
Factors which influence concordance..through
building new relations between these domains
The person social environment personality,
insight, family/social network, culture, values,
life experience
The Illness Symptoms (psychosis, depression,
grandiosity), cognitive impairment
The Treatment Relationship, treatment setting,
effectiveness, side effects, stigma, complexity
11
Motivation'can be conceptualised as

• a dynamic and cyclical process characterised by
• a state of readiness
• often characterised by ambivalence
• where levels of readiness often change

12
Motivation'can be conceptualised as

• where relapse is an important part of the cycle
  of learning
• most effective if it takes place in the context
  of a therapeutic alliance (can be part of
  engaging and building on relationship).

13
Definition Motivational Interviewing

• "Motivational interviewing is a collaborative,
  directive,
• client-centred counselling style for eliciting
  behaviour change by
• helping clients to explore resolve ambivalence"
• Rollnick Miller (1995) p326.

14
(No Transcript)
15
Ladder of Participation( adapted from O Hagan
1986)

• Citizen
• Partner
• Tokenism
• Patient
• Inmate

(From Helen Glover 2006)
16
Motivation - The Wheel of Change
Permanent Exit-in Recovery
BEGINS WITH
Resolution I made it!!
Relapse ..oh oh !!
Pre-contemplation what problem??
Action Im doing something about it !!
Contemplation maybe there is a problem
Determination Im going to do something about
it!!
17
Motivation The Wheel of ChangeStage 1
PRE-CONTEMPLATION

• Characteristics
• Lack of recognition of problem or of need to
  change
• Not motivated to act
• Problem awareness is often by others
• Rarely self-present for counselling

18
Motivation The Wheel of ChangeStage 1 PRE -
CONTEMPLATION

• Practitioner tasks
• Raise awareness - newsworthy interviewing
• provide information
• don't give prescriptions

19
Motivation The Wheel of ChangeStage 1 PRE -
CONTEMPLATION

• Practitioner tasks
• Explore impact of current behaviour
• on self on others
• On before now
• i.e. draw out contrasts

20
Motivation The Wheel of ChangeStage 1 PRE -
CONTEMPLATION

• Practitioner tasks
• Move towards Developing an acceptable and
  resolvable definition of the problem
• Be empathic
• non confrontational
• neutral'
• engaging

21
Motivation The Wheel of Change Stage 2
CONTEMPLATION

• Characteristics
• Increasing awareness of the problem
• Ambivalence
• To change or not to change'

22
Motivation The Wheel of Change Stage 2
CONTEMPLATION

• Practitioner tasks
• Assure of normality of ambivalence
• Try and tip the balance in favour of change
• Evoke (rather than prescribe) reasons for change
• Strengthen clients sense of self efficacy

23
Motivation The Wheel of Change Stage 2
CONTEMPLATION

• Practitioner tasks
• Elicit exceptions / draw contrasts
• Collapse time Career counselling
• Raise a dilemma
• Assess what the client needs in order to overcome
  the obstacles to change

24
Contemplation StageBalancing the Cost-Benefit
equation
Costs of no change - - -
Costs of change - - -
Benefits of no change
Benefits of Change
25
Motivation The Wheel of Change Stage 3
DETERMINATION

• Characteristics
• Increase in awareness of problem
• And conviction of need to change

26
Motivation The Wheel of Change Stage 3
DETERMINATION

• Practitioner tasks
• Assist in developing a change strategy that is
• acceptable
• accessible
• appropriate
• effective

27
Motivation The Wheel of Change Stage 4 ACTION

• Characteristics
• Less resistance
• More talk of solutions and less of problem
• Imagining life with the problem under control

28
Motivation The Wheel of Change Stage 4 ACTION

• Practitioner tasks
• Set goals
• short-term
• long-term
• Co-develop specific achievement strategies

29
Motivation The Wheel of ChangeStage
5 RESOLUTION

• Characteristics
• Goals being achieved
• Increased sense of self efficacy

30
Motivation The Wheel of ChangeStage
5 RESOLUTION

• Practitioner tasks
• Sustain change
• Build "life support" system
• Relapse Prevention
• Contingency planning
• Predict setbacks and plan.

31
Internal External Supports
External
Internal
Self Direction Care
Hobbies and Interests
I am mentally Ill
Humor
Self Determination
Mental Health Care support
Stubbornness
I have to face reality that I am sick
I am not capable of doing that
Resilience
Natural supports
Physical Health care
Motivation
Courage
Future
Sense of Self
Personal Responsibility
Spirituality
Ill have to ask the doctor first
Sense of meaning and purpose
Meaningful occupation
Housing Financial Supports
(From Helen Glover 2006)
32
Motivation The Wheel of Change Stage 6 RELAPSE

• Characteristics
• Drop in sense of self efficacy
• Hopelessness and helplessness
• Blaming
• Guilt

33
Motivation The Wheel of Change Stage 6 RELAPSE

• Practitioner tasks
• Need to "keep the wheel rolling" and avoid being
  stuck at this stage
• Valorise honour the struggle
• Plan for comeback
• Extract lessons from the experience
• Re-evaluate

34
Active Recovery Space Opportunity Learning
environment Possible Turning point Honouring the
initiative Honour the previous Honouring the
ordinary
Crisis Relapse Episode Psychotic Back
again Chronic Frequent Flyer Revolving Door
Sense of Failure
Recovery
(From Helen Glover 2006)
Time
35
Danger
Chinese symbol for Crisis
Opportunity
(From Helen Glover 2006)
36
Motivation The Wheel of Change Some further
Roles for the Practitioner

• Therapeutic Neutrality
• but with feeling empathy
• ... No pushing please !!
• Newsworthy interviewing
• crossing the Threshold
• Creating front page news

37
Motivation The Wheel of Change Some Roles for
the Practitioner

• Developing an alliance with the client against
  the problem
• Mapping Relative Influence
• Whos in the driving seat ???

38
(No Transcript)
39
Motivation The Wheel of Change Some Roles for
the Practitioner

• Externalisation
• ME IT

40
Construction of Chronicity
Construction of Wellness
(From Helen Glover 2006)
IT
ME
ME
IT
Micro Disablers
Micro Enhancers
41
General Tactics to develop motivation to shift
from Pre-contemplation to the Determination stage

• Developing a new relationship between the
  illness/problem and the persons sense of
  self/identity

Construction of illness
Construction of wellness
IT
ME
ME
IT
Micro enablers
Micro disablers
42
CONSTRUCTION OF WELLNES ILLNESS

• MICRO DISABLERS
• Relating to the person thru. the IT
• Manages treats the IT
• Provides more knowledge about the IT, while
  minimising the active role of SELF (ME)
• As IT grows, ME shrinks
• Promotes an internalised identity with
  illness/chronicity
• Uses language associated with IT dominance
  permanence
• Reduces the knowledge expertise of the person

• MICRO ENABLERS
• Relates to the person thru. the ME
• Relates to the ME to enquire about the
  relationship a person has with their IT
• Seeks to make visible a persons Active Self
  amplifies the selfs mastery of the IT
• Seeks to support a person so they can establish a
  different relationship with IT
• Looks for exceptions and amplifies occasions when
  Me masters IT
• Uses language which relays HOPE, resists
  labelling and
• is respectful of and amplifies knowledge and
  power of LIVED EXPERTISE

43
Motivation The Wheel of Change Some Roles for
the Practitioner

• Drawing distinctions
• The Way we were
• The Way it is
• The Way it could be
• are we there yet ?? have we even moved ??
• How can we tell when weve arrived ???

44
Motivation The Wheel of Change Some Roles for
the Practitioner

• Career counselling
• The long winding road.
• at the Cross Roads
• Collapsing time
• back to the future
• Using the future . now !!

45
Motivation The Wheel of Change Some Roles for
the Practitioner

• Raising a dilemma creating the tension
• Ideas to action overcoming inertia keeping
  the wheel rolling

46
(From Helen Glover 2006)
47
(From Helen Glover 2006)
48
Motivation to change and enter change cycle is
difficult for some because of

• Restraining ideas
• Lack of understanding information, myths,
  styles of thinking and cognitive set or self
  concepts about what is possible
• High threshold for receiving new information

49
Motivation to change and enter change cycle is
difficult for some because of

• Lack of new information to draw distinctions or
  notice change.
• individuals are not so much influenced by events
  as by their perceptions of events
• perceptions' are bits of information
• meaningful information involves news of
  difference' or Contrast
• otherwise information can be camouflaged and not
  perceived.

50
General Tactics to develop motivation to shift
from Pre-contemplation to the Determination stage

• Creating News of Difference
• crossing thresholds
• information needs to be formulated in terms of
  HEADLINES not small print

51
General Tactics to develop motivation to shift
from Pre-contemplation to the Determination stage

• Drawing distinctions - establish benchmarks about
  how things - were in the past - are now -
  might be in the future - are changing or not.
• Removing Restraints'

52
Motivational InterviewingKey Concepts

• Ambivalence is normal not a pathological part of
  the change process
• Practitioner style is a powerful determinant of
  client resistance and willingness to change.

53
Motivational InterviewingKey Concepts

• Motivation is best' conceptualised as a cycle of
  different stages rather than an absolute state of
  being
• Facilitating readiness to change and overcoming
  ambivalence should be a key focus for
  intervention
• not merely an artefact

54

• THANK YOU

55
(No Transcript)