Enhancing Motivation: Asking for Change

1
Enhancing Motivation Asking for Change

• EVOKING CHANGE TALK !
• By
• Ladonna Zimmerman, MSW, LCSW
• Fulton State Hospital

2
Biggs Forensic Center
3
Workshop Goals and Objectives

• Preparing Individuals for Change- What Works!
• Introduction to Motivational Interviewing
  Principles and Practice
• Methods for Assessing Motivation

4
Some History

• What works movement in juvenile justice and
  adult corrections- Robert Martinsons
• famous 1974 essay What works?-Questions and
  Answers About Prison Reform.
• He reviewed 230 studies of rehabilitation
  programs in criminal justice settings and
  concluded- nothing works.
• Many questioned the credibility of these
  conclusions and it was found that in fact between
  40-60 of the 230 studies actually showed some
  indication of a recidivism reduction.

5

• Overall, the evaluation research suggests that
  rehabilitation treatment strategies can be
  effective in reducing re-offending.
• Judicial sanctions delivered without treatment
  are ineffective.
• Lipsey (1990) Andrews (1990) developed
• Because of Martisons paper on Nothing Works
  researchers have now identified characteristics
  of programs that are successful
• Principles of Effective Interventions
• Risk Principle- How much-intensity of
  intervention
• Need Principle- What targets, what to focus on
• Responsibility Principle- How
• Principle of Program Integrity- What Works

6
Risk Principle

• Delinquency, acting out, or criminal behaviors
  can be predicted
• Intensity of services should be matched to the
  risk level of the offender. Higher risk offenders
  require more intensive services and might include
  removal from the community. Low risk offenders
  require minimal or no intervention.

7
Need Principle

• Some risk factors are static- i.e. age of 1st
  contact with law enforcement
• Others are dynamic- antisocial attitudes, values,
  behaviors
• Major risk/need factors include behavior
  history, family dynamics, pro-criminal
  associations, personality and temperament,
  antisocial attitudes/values/beliefs, low levels
  of vocational success

8
Responsivity Principle

• All services should be monitored to ensure they
  are effective
• Programs with greatest promise hire and promote
  staff that are professional, experienced, and
  skilled
• To ensure quality services staff require agency
  support in the following areas
• Policies and procedures that include ethical
  guidelines and standards of professional conduct
• Ongoing supervision and technical support
• Training to enhance knowledge, skills,
  commitment
• Adequate resources to sustain program integrity

9
Responsivity Principle

• Services should be delivered in a style and mode
  that is consistent with the ability, willingness,
  and learning style of the client.
• It is from the Responsivity Principle that we
  will consider how to enhance the motivation of
  our clients and ask for change.

10
Research Tells Us

• Change occurs naturally without intervention,
  particularly for clients that are high in
  protective factors and have fewer risk factors.
  (resilience plays a part)
• For clients receiving formal interventions the
  results are mixedsome get worse
• Generally those that do better tend to be medium
  and high risk clients who are exposed to
  effective treatment approaches (cognitive
  behavioral, family base, emphasis on social
  learning theory)

11
2 Primary Factors Contribute to Successful
Outcomes

• Level of motivation. Clients are more likely to
  make changes when they are ready, willing, able
• Style and approach used by treatment provider can
  have a direct influence on outcomes.
• Early 1990s 2 leading practitioners Bill Miller
  and Stephen Rollnick began to systematically
  summarize the literature on client responsiveness
  to intervention.

12
Miller Rollnicks findings

• Are at the heart of the Motivational Interviewing
  approach
• They found that Effective Practitioners use a
  directive approach that encourages client
  responsibility for change.
• See Miller Rollnick (19922002) Prachaska,
  DiClemene Norcross (1992) for detailed
  information

13
Change is a PROCESSNot an event!

• Effective case management is a PROCESS that
  requires the treatment provider to work
  collaboratively with the client in an effort to
  define individual needs and mutually agreed upon
  outcomes.
• An excellent fit with a Strengths Based Case
  Management approach!
• We must begin with the end in mind and allow the
  client to guide the process of change- invite the
  client to dream, continually focusing
  interactions to client strengths and possible
  connections that could support change
• The client should make the argument for change,
  not the worker (evoke change talk)

14
Understanding Change

• Handouts- An Autobiography
• Myths and Facts About Change

15
Whats That Style?

• Ineffective Style
• Confrontational
• Blaming
• Hostile
• Demanding
• Commanding
• Wishy-Washy
• Non-Direct
• Unclear
• Touchy-Feely
• Sympathetic
• Parenting
• Friend

• Effective Style
• Empathic
• Genuine
• Honest
• Supportive
• Trustworthy
• Solution-Focused/Hopeful
• Fair
• Consistent
• Contingency-Based
• Interested
• Non-Argumentative
• Non-Judgmental

16

• People are generally persuaded by reasons which
  they themselves have discovered, than by those
  which have come through the minds of others.
  Pascal-17th Century Philosopher
• Motivational Interviewing was developed by Miller
  Rolnick (1991 2002) and is defined as a
  person-centered, directive method for enhancing
  intrinsic motivation to change by exploring and
  resolving ambivalence p. 25

17
The Spirit of Motivational Interviewing

• It is not a technique, but more a style, a
  facilitative way of being with people, an
  approach
• Concerned with avoiding resistance, resolving
  ambivalence, and inducing change
• Rollnick (1999) uses the metaphor of a delicate
  dance It should feel like a dance NOT an
  altercation

18
Resilience

• Research identifies 3 critical factors in
  building resilience in youth
• A caring supportive adult in their life
• Opportunities for involvement or meaningful
  activities and decisions affecting their
  development
• High expectations for behavior (Bernard, 1991)

19
Motivational Interviewing

• A client-centered, directive method for
  enhancing intrinsic motivation to change by
  exploring and resolving ambivalence. (Miller
  Rollnick, 2002)
• Motivation for change arises in accepting,
  empowering atmosphere that makes it safe for the
  other person to explore the possibly painful
  present in relation to what is wanted and valued.
• The proper question is not, Why isnt this
  person motivated? but RATHER For what is this
  person motivated?

20
4 Principles of Motivational Interviewing

• Express empathy
• Develop discrepancy
• Roll with resistance
• Support self-efficacy (power/confidence to change)

21
Express Empathy

• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Ambivalence is normal (feeling two ways about the
  same thing)
• Seek to understand the clients perspective
  without judging, criticizing or blaming
• Empathy does not mean that you love, like,
  approve of, agree with or sympathize with another
  person. It does mean that you try to understand
  what the other person is telling you by seeing
  the situation through their eyes (Thompson and
  Jenkins, 1993)

22
Develop Discrepancy

• Client rather than case manager should present
  the arguments for change
• Change is motivated by perceived discrepancy
  between present behavior and important
  goals/values.

23
Roll with Resistance

• Avoid arguing for change
• Resistance behavior is not directly opposed
• New perspectives are offered/invited, but not
  imposed
• Client is primary resource for finding answers
  and solutions
• Resistance behavior is a signal to respond
  differently
• Persistent resistance is not a client problem,
  but a case manager skill issue
• Resistance during case management is normal

24
Support Self-Efficacy

• Belief in the possibility of change is an
  important motivator
• Client, not the case manager is responsible for
  choosing and carrying out personal change (never
  do for the client what the client can do for
  themselves)
• Providers own belief in the persons ability to
  change becomes a self-fulfilling prophecy

25
What can I do to persuade you?

• The 2 greatest obstacles to using this approach
• The Righting Reflex- the need to fix things or
  set things right
• The Big Hammer- need to encourage the client to
  take responsibility, if they want our help then
  they have to comply with certain stipulations,
  change is ok, but it will be our way.

26

• Goal of the Motivational Interviewing approach is
  to increase motivation and decrease resistance by
  exploring ambivalence.
• They say you can lead a horse to water, but you
  cant make him drinkbut I say, you can salt the
  oats.
• -Madeline Hunter

27
Ambivalence

• Feeling two ways about the same thing
• When making a change, it is not simply a matter
  of making yes or no decisions because there
  are always pros and cons to change.
• Ambivalence is a NORMAL part of change
• Ambivalence is like a balloon filled with
  water. When you press on one side the other side
  expands.
• It is the same when you tell someone that they
  SHOULD change or argue only one side of
  ambivalence. When you argue in favor of one
  position, the client will often take the other
  position. (lets consider parenting our children
  as one example of how this plays out)

28

• Instead, lets EXPLORE ambivalence and then both
  the client and worker will have a better
  understanding of the pros and cons for change.
  You will know the reasons for change (incentives)
  and the obstacles (barriers) for change.
• YOUR behavior strongly influences resistance,
  which in turn is an excellent predictor of
  outcome.
• How you interact impacts the change process
• What you model impacts the change process
• What you say and do impacts on the change process
• Use resistant behaviors as a signal to try
  something different like traffic signals
• Resistance describes BEHAVIOR and is not an
  underlying character pathology- we can help to
  change those behaviors.
• If you always do what youve always done, youll
  always get what youve always got. Paul Batalden

29
Motivation

• External motivation (courts, etc.)
• Intrinsic motivation ( important goals and
  values)
• Three critical components of Motivation
• Ready- a matter of priorities
• Willing-importance of change
• Able- confidence to change (self-efficacy)

30
Change and Motivation

• People always use their best problem solving
  strategies to get their needs met, even if these
  strategies are dysfunctional.
• We can influence others to change by exploring
  importance and building confidence
• Research consistently shows that people who
  believe they can change (high self
  confidence-self efficacy) are more likely to
  succeed
• Lets look at some ways to Assess Motivation

31
The Transtheoretical Model of Change (James
Prochaska etc.)

• Change is predictable.
• Change is a process that moves through
  well-defined stages. (We will look at those
  stages next)
• People enter the system at different stages of
  readiness.
• People need to go through each stage. They cannot
  skip stages.
• Each stage does not inevitably lead to the next.
• It is possible to become stuck at one stage.
• Relapse is a NORMAL part of the change process.
• You can help to influence movement from one stage
  to next by applying strategies that are effective
  at each stage
• Handout- Stages of Change/ What Stage- Activity?

32
Stages of ChangeProchaska DiClemente

• Precontemplation-client not yet
  ready/unwilling/unable
• Contemplation-client acknowledges concerns and is
  considering change but is ambivalent
• Preparation -client is committed to and planning
  to make change, but is considering what to do
• Action- Client actively taking steps, but not yet
  stable
• Maintenance-has achieved initial goals and is
  working to maintain gains
• Termination has maintained and is able to move
  forard without worker support/ community
  connections-supports in place
• Relapse is viewed as a loss of motivation and
  movement back down the spiral of change (return
  to old behavior)

33
Four types of Precontemplators

• Reluctant
• Rebellious
• Resigned
• Rationalizing

• Motivational Responses
• Raise doubt
• Increase perception of risks and problems with
  current behavior
• Develop discrepancy (painful present in
  relationship to important goals/values)
• Dont
• Nag, push into action
• Give advice
• Cover or make excuses
• Give up

34
Contemplation

• Motivational Responses
• Provide empathy
• Explore ambivalence-why change?...what will
  happen if you dont?
• Evoke clients reasons to change- tip the
  balance/risks of not changing
• Strengthen hope, self-efficacy
• Note client strengths

• Not helpful to
• Take sides
• Create an action plan (premature focus)

35
Preparation

• Motivational Responses
• Help to determine acceptable goals/best course of
  action to take in seeking change
• Develop effective and achievable action steps
  based on clients wants not needs
• Develop SMART Goals- Small, Measurable,
  Attainable, Realistic, Timely
• Focus on what the client believes is possible,
  client strengths

36
Action

• Help build needed skills (coach, do not do for
  the client what the client can do for themselves)
• Help take steps toward change
• Work on barriers to change- the importance of a
  strengths assessment in all life domains cannot
  be overemphasized!
• Assist with accessing resources, building
  connections- interdependence

37
Maintenance

• Motivational Responses
• Facilitate supports for long-term change
• (community connections-interdependence)
• Help to identify and use strategies to prevent
  relapse (Begin with the end in mind!)
• Continue coaching skills and building positive
  experiences-celebrate each success!

38
Resistant Responses

• Argument challenges the accuracy, expertise, or
  integrity of the worker
• (challenging, discounting, hostility)
• Interruption breaks in and interrupts worker in
  defensive manner (talking over, cutting off)
• Denial expresses an unwillingness to recognize
  problems, cooperate, accept responsibility, or
  take advice (blaming, disagreeing, excusing,
  minimizing, justifying, pessimism, reluctance,
  unwillingness to change)
• Ignorning shows evidence of not following or
  ignoring the worker (inattention, non-answer,
  non-response, side-tracking) therapy
  interfering behaviors

39
Responses to Resistance

• Simple reflection-acknowledgement of the clients
  perspective
• Amplified reflection-reflect back what client has
  said exaggerating
• Double sided reflections-reflect back to client
  pros and cons of change that have been discussed
• Shifting focus
• Reframing-acknowledge what client is saying, but
  offer new meaning
• Agreeing with a twist
• Emphasizing personal choice and control
• Coming alongside (playing devils advocate)
• ROLL WITH RESISTANCE!

40
AmbivalenceI want to, but I dont want to

• Normal aspect of human nature, not pathological
• Natural phase in process of change
• Problems persist when people get stuck in
  ambivalence
• Ambivalence is key issue to resolve for change to
  occur
• Emphasize personal choice and control

41
Benefits and Costs
Status Quo
Changing
Benefits of
Costs of
42
Decisional Balance

• Continue status quo
• Benefits vs. Costs

• Change behavior
• Benefits vs. Costs

43
Traps to avoid

• Question-Answer -asking closed questions, or
  confrontational questions
• Taking sides -the client will naturally take up
  other side of argument
• Expert- giving expert advice and assuming
  responsibility for change
• Labeling- worker gives a label or diagnosis for
  the problem and expects the offender to accept
• Premature focus- worker decides agenda and
  prioritizes focus of change without input or too
  early in process
• Blaming-worker implies or directly blames client
  for causing the problem

44
OARS Tools of Motivational Interviewing

• Open Questions -question that requires more than
  simple one word answers- What? How? Tell me
  about?
• Affirmations-statements of recognition of client
  strengths,builds confidence for
  change,supportive,encouraging, acknowlege
  appropriate attempts at change
• Reflective Listening -when in doubt listen more
  and seek to see if you are hearing what you think
  you hear (what has worked and hasnt worked- use
  the 3rd ear)
• Simple-repeating, rephrasing
• Amplified- paraphrasing, double sided
  reflection-testing the meaning/whats going on
  below the surface
• Feelings-emphasizing the emotional aspect of
  communication (Validate, Validate, Validate)
• Summaries- Let me see if I understand thus far

45
Eliciting Change Statements

• Disadvantages of status quo
• Advantages of change
• Optimism about change
• Intention to change
• Change Talk

46
Exploring Importance

• Assess On a scale of 1-10, how important is it
  to you personally to make the changes necessary
  to achieve the want?
• ExploreWhy did you give it a __ and not a ___?
• What would have to happen to raise that score
  from a __ to a __?
• How can I help you with that?
• Would this rating change if the worker picked
  the priority target rather than the client?

47
Strategies to Increase Importance

• Do little more (used for extremely low levels of
  importance) possibly harm reduction
• Scaling and evocative questions
• Explore concerns about problem (evoke)
• Hypothetical look over the fence (lets imagine
  for a moment that you did make change)
• Examine the pros and cons

48
Sample Questions to Increase Importance

• What change would have to happen for it to become
  much more important for you to change?
• What would have to happen before you seriously
  considered changing?
• If you were to change what would it be like?
• What are some good things about current
  behavior? What are some of the worst things?
• What are the things you like about current
  behavior? What are some of the things you
  dislike?

49
Exploring Confidence

• Assess If you decided right now to change,
  how confident do you feel about succeeding with
  this?
• 0Not at all confident, 10 Very confident
• Explore Why did you give it a __ and not a __?
• What would have to happen to raise your
  confidence?
• How can I help you with that?

50
Strategies to Increase Confidence

• Do little more
• Scaling questions (why so high?, how can you go
  higher?)
• Brainstorm solutions
• Looking for exceptions (past efforts- successes
  and failures)
• Reassess confidence

51
Questions to Increase Confidence

• What would make you more confident about making
  these changes?
• Is there anything you have found helpful in
  previous attempts to change?
• What have you learned from the way things went
  wrong the last time that you tried?
• If you were to decide to change what might your
  options be? Are there any ways you know about
  that have worked for other people?
• What are some of the practical things that you
  would need to do to achieve this goal? Do any of
  them sound achievable?
• Is there anything you can think of that would
  help you feel more confident?

52
Strengthening Commitment to Change

• Recognizing signs of readiness
• Asking key questions/using change talk
• Ask permission to discuss concerns
• State concerns non-judgementally
• Affirm decision is clients to make
• Inquire what client thinks
• Help evaluate options
• Provide affirmations and hope, focus on strengths

53
Remember

• This is an intentional approach and the key is
  collaboration and respect. Key principles
  include
• - Empathy, Discrepancies, Rolling with
  Resistance, and Building Self Efficacy
• To decrease resistance- explore ambivalence and
  continually assess motivation
• Evaluations..Thanks for sharing your time with
  me!