Stages of Change: Treatment Needs & Strategies….

In a previous post, I provide an overview of the Stages of Change from a personalized perspective.  “In the transtheoretical model, behavior change is conceptualized as a process that unfolds over time and involves progression through a series of five stages: precontemplation, contemplation, preparation, action, and maintenance” Norcross, Krebs & Prochaska, 2011, p. 143).  The point of this post was to illustrate that change is a process and not a singular event.  In other words, “Just Do It” doesn’t cut it as useful advice for those attempting to institute changes in their lives.

The purpose of this post is to review the stages of change from a pragmatic perspective.  I discuss each stage and review treatment needs and potential strategies.

STAGE #1: Precontemplation

“Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future. Most patients in this stage are unaware or under-aware of their problems. Families, friends, neighbors or employees, however, are often well aware that the pre-contemplators suffer from the problems” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the pre contemplation stage, individuals are not even considering changing and may not even see advice provided to them as applicable to their lives” (Zimmerman, et al, 2000, 1409).  The goal for a therapist with a client in the pre contemplation stage is to increase their concerns for problematic behaviors and/or situations and provide hope that change is possible (Sullivan & Flemming, 1997).   In order to achieve this goal, the primary task is expanding the client’s awareness of their life situation.  At times, this might entail simply providing the client information, such reviewing symptoms of a diagnosis, or the side-effects of a medication.  However, it is also essential that explore the client’s perspective of things.  How do they perceive their situation & what meaning do they live to current life events?  Have they attempted to change before?  These questions can assess what the barriers to change are.  People are rarely liable to change if there is no benefit to doing so.  Therefore, it is critical that we understand the factors the client is struggling with as they weigh their options (i.e. change vs. no change).

Strategies

  1. Establish Rapport & Build Trust
  2. Assess the client rationale for current life-style choices…
  3. Begin to assess barriers to change.
  4. Elicit the client’s current perception of the problem.
  5. Expand the client’s current perspective by providing factual information
  6. Build up the client’s confidence in the idea that change is realistic & possible.
  7. Examine discrepancies between the client’s perception and how others view things.
  8. Provide personal feedback on assessment findings.
  9. Discuss relevant diagnoses, symptoms, and possible treatment.

Interview Approach

The primary goal is to develop rapport and establish trust.  Take time to discuss the client’s understanding of the problem.  Non-judgmentally provide factual information regarding the client’s problematic and/or self-destructive behaviors and express your concern (Sullivan & Flemming, 1997).   Begin establishing an “agree to disagree” standard in order to begin discussing divergent perspectives of the client’s life-situation (Sullivan & Flemming, 1997).  Periodically assess the client’s readiness to change.

STAGE #2: Contemplation

“Contemplation is the stage in which patients are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Contemplators struggle with their positive evaluations of their dysfunctional behavior and the amount of effort, energy, and loss it will cost to overcome it” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain” (Zimmerman, et al, 2000, p1409).  In other words, they are now able to acknowledge that change needs to happen, however remain ambivalent.  The idea of change, is either overwhelming, or highly undesirable.  The therapeutic goal, therefore, is address the client’s feelings of ambivalence.  In other words, what factors weigh in heavily for and/or against the idea of change?  How can this decisional balance tipped in favor of change?  Increasing the client’s understanding of their options can help them make more informed decisions.

Strategies

  1. Acknowledge feelings of ambivalence & normalize this experience as a part of the change process.
  2. Develop a list of factors for & against change.
  3. Provide clear & nonjudgmental messages regarding the client’s need to change.
  4. Examine the client’s personal values in relation to change.
  5. Address intrinsic & extrinsic factors related to the client’s motivation to change.
  6. Assess the client’s feelings of efficacy & expectations regarding process of change.
  7. Ask the client to begin considering small changes and assess their outcome.

Interview Approach

Continue building the therapeutic relationship.  Validate & acknowledge the client’s feelings of ambivalence regarding the idea of change.  Explore the factors underlying feelings of ambivalence.   Discuss positive an negative factors associated with change (Sullivan & Flemming, 1997).  Create a discrepancy between the client’s values and actions (Sullivan & Flemming, 1997).  Consider making small changes in order to address feelings of ambivalence (Sullivan & Flemming, 1997).

STAGE #3: Preparation

“Preparation is the stage in which individuals are intending to take action in the next month and are reporting some small behavioral changes (‘‘baby steps’’). Although they have made some reductions in their problem behaviors, patients in the preparation stage have not yet reached a criterion for effective action” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

During the preparation stage, patients prepare to institute small changes. Sullivan & Flemming, (1997), note that while pre-contemplation and contemplation work well with motivational interviewing techniques, CBT and/or 12-step approaches are useful for the remaining stages.  During this stage, clients work on strengthening their commitment to change.  Therapists should help client’s work though various strategies to institute planned changes.

Strategies

  1. Assist the client in refining their goals & plans for change.
  2. Help the client review the options available & determine a best course of action.
  3. Review previous attempts to institute changes in order to understand what didn’t work.
  4. Elicit the assistant from the clients social support system.
  5. Encourage the client to take action daily to institute change.

Interview Approach

Acknowledge the significance of the client’s decision to institute changes, and reaffirm their ability to successfully achieve their goals.  Help the client develop a plan of action and examine how the road ahead looks.  Reassure the client that progress sometimes involves relapse.

STAGE #4: Action

“Action is the stage in which individuals modify their behavior, experiences, and/or environment to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Individuals are classified in the action stage if they have successfully altered the dysfunctional behavior for a period from 1 day to 6 months” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Helping professionals are really eager to see their clients reach the action stage.  Helping the client implement strategies for change and develop a plan to prevent relapses into old habits.  Therapeutic goals during this stage can center around problem solving, developing a sense of self-efficacy and strengthening your support system.

Strategies

  1. Review the client’s plan for change and revise as necessary.
  2. Develop a relapse plan & prepare the client for this possibility.
  3. Help the client process the difficulties encountered in creating change.

Interview Approach

Be a source of support and encouragement and acknowledge feelings of withdrawal and/or discomfort that tend to accompany efforts to let go of unhealthy habits.  Reinforce the client’s resolve and the importance of remaining in recovery.

STAGE #5: Maintenance

“Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. This stage extends from 6 months to an indeterminate period past the initial action. Remaining free of the problem and/or consistently engaging in a new incompatible behavior for more than 6 months are the criteria for the maintenance stage” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Treatment needs during this stage involve maintaining changes & preventing old habits to crop up again. For example, I’ve tried to lose weight before, but have yet to realistically sustain it over a significant length of time. Life gets in the way, and I end up slipping and gaining a bit.  Recycling through the stages above is common & it is vital to normalize this experience with clients.  This can help clients examine what hasn’t worked out well in order to learn from past mistakes.

Strategies

  1. Help the client develop a support system that can help the client maintain life changes.
  2. Help the client develop new coping strategies in order to let go of old habits.
  3. Help the client examine behavioral & situational issues that can cause relapse.
  4. Help the client work through the beliefs & expectations that guide their progress.

Interview Approach

Help the client anticipate difficulties in creating lasting change and provide opportunities toward through this struggle.  Should relapses occur, help the client work through underlying factors that may have contributed to it.  Help client develop a sense of self-efficacy so that lasting change an be seen as realistic and achievable.

References

All of the information from this post has been adapted and summarized from the following resources below…

  1. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67 (2), 143-154.
  2. Sullivan, E., & Fleming, M. (1997). A guide to substance abuse services for primary care clinicians: Treatment Improvement Protocol (TIP) Series 24. Center for Substance Abuse Treatment, Rockville (MD): DHHS Publication, (1997).
  3. Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A ‘stages of change’ approach to helping patients change behavior. American family physician, 61(5), 1409-1416.

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“Git Er Done!!!” – Motivation & Change

Motivation is Essential for Change….

“clients’ level of motivation for change is often a good predictor of outcome.  Motivation can be influenced by many naturally occurring interpersonal and interpersonal factors and by specific interventions…three are at least three critical components of motivation: readiness, willingness and ability” (Miller & Rollnick, p. 9).  

Willingness to Change

Change happens if an individual feels it is important for them.  Miller & Rollnick, (1991) describe a psychological self-monitoring function that acts like a thermostate.  Any aspects of our reality that are not in sync of our personal values produce a desire for change.  This discrepancy between our current reality and desired goals produces a willingness to change.  It’s polar opposite is resistance.

The Righting Reflex:  “When people perceive a discrepancy between how things are and how they ought to be, they tend to be motivated to reduce that discrepancy if it seems possible to do so.” (Miller & Rollnick, 1991, p. 20)

Ability to Change

Ability to change can be thought of a belief in our level of capability to achieve a specific goal..  When individuals believe they don’t have the ability to change, they are resistant to trying.  Individuals that face a discrepancy between actions and values (as desired above) who are do not feel capable of change can resort to using defense mechanisms.  Defense mechanisms provide an alternative to change via the adjustment of perceptions, beliefs, and thoughts.

Readiness to Change

“One can be willing and able to change, but not ready to do so…this third dimension, readiness, has to do with relative priorities: ‘I want to, but not now'” (Miller &Rollnick, 1991 p. 11).  Motivational Interviewing suggests we do not see low readiness in a pathological manner but as a normal part of the change process.

When Client’s are Not Motivated….

According to Motivational interviewing, human beings are seen as having a “built-in desire to set things right” (Miller & Rollnick, 1991, p. 20).  As stated earlier, change is a byproduct of motivation.  Motivation is a byproduct of any perceived discrepancies between what how things are and how they ought to be. So what happens when we encounter a client who is resistant to change despite clear evidence that it is needed?  Here are just a few examples from Miller & Rollnick (1991).

“You would think that having a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more and take his medication.” (Miller & Rollnick, 1991, p. 3).

“You would think that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking.” (Miller & Rollnick, 1991, p 3).

In the examples, it is often natural to react with frustration and sadness.  We see behavior that appears self-destructive, yet are unable to help the client see this.  Motivational interviewing, suggests not conceiving the client’s resistance in a self-destructive or maladaptive in nature, but instead a part of the process of change.  Consider the following:

What happens when someone with a righting reflex (R) [i.e. motivated]  meets a person who is ambivalent (A) [resistant]?  As A speaks to R about the dilemma of ambivalence, R develops an opinion as to what the right course of action would be for A to take. R then proceeds to advise, teach, persuade, counsel, or argue for this particular resolution to A’s ambivalence….By virtue of ambivalence, A is apt to argue the opposite, or at leastpoint out problems and shortcomings of the proposed solution. It is natural for A to do so, because A feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence.” (Miller & Rollnick, 1991, p. 20-21)

In this above example, we see what happens when the client and the counselor are not on the same page.  So what is the missing piece of the puzzle that the counselor is missing? The client lacks motivation to change.  They are not ready, willing or able…

“Our perspective is that exploring and enhancing motivation for change is itself a proper task, at times even the most important and necessary task, within helping relationships such as counseling, health care, and education.” (Miller & Rollnick, 1991, p. 21)

OUR GOAL:  Developing Discrepancy

Miller & Rollnick, (1991) state that our goal should be to have the client voicing arguments in favor of change.  “When you find yourself in the role of arguing for change while your client (patient, student, child) is voicing arguments against it, you’re in precisely the wrong role” (Miller & Rollnick, 1991, p .22).

So how can we get our clients to begin arguing in favor of change?  In motivational interviewing, arguments in favor of change are called “Change talk”.  The client engages in “change talk when they are motivated.  “The larger the discrepancy, the greater the importance of change” (Miller & Rollnick, 1991, p. 22).  In other words, clients become motivated as feelings of ambivalence are resolved and they gain awareness of discrepancies between their reality and desires.   Change talk falls into one of four categories…

  1. “Disadvantages of the status quo. These statements acknowledge that there is reason for concern or discontent with how things are. This may or may not involve an admission of a ‘problem.’ The language generally reflects a recognition of undesirable aspects of one’s present state or behavior.” (Miller & Rollnick, 1991, p. 24).  
  1. Advantages of change. A second form of change talk implies recognition of the potential advantages of a change. Whereas the first type of change talk focuses on the not-so-good things about one’s current status, this second type emphasizes the good things to be gained through change. Both kinds, of course, are reasons for change.” Miller & Rollnick, 1991, p. 24).  
  1. “Optimism for change. A third kind of talk that favors change is that which expresses confidence and hope about one’s ability to change. It may be stated in hypothetical (I could) or declarative form (I can do it). The common underlying theme is that change is possible” (Miller & Rollnick, 1991, p. 24).  
  1. Intention to change. As the balance tips, people begin to express an intention, desire, willingness, or commitment to change. The level of intention can vary from rather weak to very strong commitment language. Sometimes the intention is expressed indirectly by envisioning how things might be if change did happen” (Miller & Rollnick, 1991, p. 24).  

Images: 1

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press

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Motivational Interviewing & Ambivalence

Misinterpreting Ambivalence

“It is easy to misinterpret ambivalent conflict as pathological — to conclude that there is something wrong with the person’s motivation, judgment, knowledge base, or mental state. A sensible conclusion from this line of reasoning is that the person needs to be educated about and persuaded to take the proper course of action” (Miller & Rollnick, 1991 p. 14)

Ambivalence is a frustrating dilemma that involves feeling two ways about something.   For example, I have been feeling lonely for a while and looking to establish new friendships.  I’m finding the task somewhat daunting with so little free time.  As adults, we establish friendships based on convenience, with those we have an opportunity to interact with regularly. Individuals at my stage in life tend to have quite a bit on their plate.  Between work and home life, where does one find time to establish new friendships?  My ambivalence reflects a conflict between two opposing desires. On the one hand, I feel lonely and desire to establish friendships. On the other hand, I have insecurities stemming from earlier childhood experiences, and am fearful of opening up to others.

When others misinterpret my ambivalence.

There is a coworker I chat with often via text at work.  We are both employed by healthcare float pools and often work at the same facilities, (although rarely on the same floor).  She is a social butterfly who is always urging me to just be more friendly and strike up conversations every so often.  From her perspective I would surmise she is frustrated by my lack of “motivation, judgment, and knowledge base” (Miller & Rollnick, 1991).  In other words, she could easily interpret my ambivalence as an unwillingness to take the initiative and establish friendships.  Alternatively, she might interpret my as a matter of social anxiety or ineptness on my part.  (Mind you, this is just an example, of the sort of consructive criticism I’ve heard before.  Coworkers, friends, and even my sister express advice of this sort from time to time regarding my “shyness & reclusive nature”)

What others miss about my ambivalence…

So what is my perspective? As I stated earlier, I have two conflicting emotional reactions to the idea of establishing friendships.  On the one hand, I feel lonely and wish to cultivate a few meaningful female friends.  Every once in a while, I might have something on that I want to share with somebody…Or mabye I might just simply want to sort things out: (I’m a verbal processor :))  From time to time, I can unknowingly bombard my poor hubby with assorted idle chatter.  As somebody who likes “thinking out loud” to verbally process my thoughts and come to a conclusion, it’s a habit I’ve have had difficulty breaking.   My hubby always tries his best to listen.  However, every once in a while he’ll comment jokingly: “You need to get a few female friends to go out with so you can talk about this at greater length.”  When he says this, I’m aware that he’s done all the listening he can take, and I need to find somebody else to talk to…

At moments such as these, when I need somebody to talk to, I become sad.  As feelings of loneliness arise, so do feelings of fear and anxiety.  I am fearful of opening up to others, primarily because I don’t want to re-experience the rejection and ostracism I dealt with in high school.  I can then berate myself for a lack of experience due to years of self-imposed isolation.  The alternative thought arrises at some point:  Wouldn’t it be much easier to stay home and lounge on the sofa while binge-watching something on Netflix?

…And then there are the pragmatic aspects of developing friendship that produce more frustration… First off, Idespise technology and/or social media as required forms of interaction in today’s social world. However, these things are here to stay and I’ve learned tried to adapt. For example, I might exchange texts occasionally with a coworker or fellow intern.  Every once in a while I might also call to ask a question, discuss a concern, and/or brain-pick.   I stress occasionally about how my text might be interpreted. I also worry about how my own texts are interpreted.   If she doesn’t call, I worry what that might mean.  If I call I worry about being a bother.

So here’s a breakdown of my example of misinterpreted ambivalence.

  1. 1st HAND P.O.V – My social ambivalence reflects unresolved insecurity and hurt stemming from early childhood bullying and ostracism.  In large part, I am anxious and fearful, because I don’t want to get hurt again.
  2. 2nd HAND P.O.V. – Other’s might misinterpret my social ambialence as reflecting the fact that I’m a shy or introverted.  Alternatively, someone could interpret this ambivalence as reflective of social ineptness or simply a lack of motivation to put a little effort into the establishment of friendships.  
  3. THE MAIN POINT – Ambialence is a normal part of the process of change,  it reflects a psychological conflict that needs to be resolved for change to happen.

A Different Perspective on Ambivalence…

“Ambivalence is a common human experience and a stage in the normal process of change. Getting stuck in ambivalence is also common, and approach-avoidance conflicts can be particularly difficult to resolve on one’s own. Resolving ambivalence can be a key to change, and indeed once ambivalence has been resolved, little may be required for change occur. However attempts to force resolution in a particular direction..can lead to a paradoxical response, evening strengthening the very behavior they were trying to diminish” (Miller & Rollnick, 1991, p. 19).

In order to resolve ambivalence, it is vital to understand that stuckness is a normal part of the process of change.  In fact, at the heart of the matter, is resolving one’s own conflicting feelings on an issue. Miller & Rollnick, (1991), suggest conceptualizing one’s dilemma’s as a decisional balance.  “Transactional analysis often regards the experience of ‘ feeling stuck’ as the manifestation of an impasse or an intrapsychic conflict or interpersonal roadblock…Impasses occur each time we encounter a situation in which our current adaptations cannot make sense of or handle meaningfully…(Petriglieri, 2007, pp. 185-187).”  Addressing the issue, from this perspective can be seen as a matter of weight costs and benefits for each course of action.   So how might this explanation apply to my social ambivalence?  

  1. Unresolved insecurities stemming from childhood experiences pollute my thinking today.
  2. My interpretations of others’ opinions becomes a foundational element of how I see myself.  
  3. When I think with my feelings in a knee-jerk manner, my unresolved insecurites turn into self-fuffilling prophecies, by withdrawing and isolating myself.  
  4. Examining how my knee-jerk coping styles perpetuate my insecurity and loneliness can provide the clarity necessary to overcome this ambivalence.
  5. Tipping the decisional balance chart, involves carefully breaking down decisional alternatives in this manner. Which route is the preferable alternative???

In these posts, I share how I’ve worked through ambivalence & feelings of stuckness in my life:

“Getting Unstuck & Why I Started this Blog” 

“An Underdog’s Credo: Choking vs. Panic”

Types of Psychological Conflict…

Miller & Rollnick (1991) describe three types of ambivalent conflict. “In the approach–approach conflict, the person must choose between two similarly attractive alternatives An avoidance–avoidance conflict, in contrast, involves having to choose between two evils—two (or more) possibilities Still more vexing is the approach–avoidance type. This kind of conflict seems to have special potential for keeping people stuck and creating considerable stress. Still more vexing is the approach–avoidance type. This kind of conflict seems to have special potential for keeping people stuck and creating considerable stress” (p. 15).
  1. Here is an example avoidance-avoidance conflict, in which I keep a crappy job because it pays well to support my family.  My choices here: a shitty job or being broke.  

  2. Here is an example of approach-avoidance, described my Miller & Rollnick (1991) as a “fatal attraction..kind of love affair”

Ambivalent Paradoxical Responses…

“The theory of psychological reactance predicts an increase in the rate and attractiveness of a ‘problem’ behavior if a person perceives that his or her personal freedom is being infringed or challenged. Secondary effects of a change within the person’s social environment may also account for detrimental shifts” (Miller & Rollnick, 1991, p. 18)

Miller & Rollnick, (1991) note that  common response to the utilization of deterrents to curb negative behavior is an increase of that behavior.  I like to think of this as a passive-agressive rebelliousness.  As a married mother of two boys, I’m the only source of estrogen.  The males in my family tend to utilize this response to any repetitive requests for them to do/not do something, (i.e. nagging) 🙂 ….  For example, my son hates being late for school, if I keep nagging him to get up earlier he can rebel by dragging his feet in the morning.  The consequence is he gets to school even later and complains about it more.  My youngest complains about being tired at school, yet responds similarly when I tell him to get to bed earlier.  When I  discussed this with my husband, he noted this knee-jerk, response is probably a result of the boy’s picking up on his bad habits 🙂 … These behaviors could be interpreted as an innate desire to challenge the restrictions placed on personal freedom.

A Solution to Ambivalence

So how do you resolve ambivalence?  I’ve spent too many years on a hamster wheel in my own life. Overcoming my own stuckness has been at the heart of my efforts to create forward-motion.  As I mentioned earlier, Miller & Rollnick (1991) discuss a decisional balance chart as a useful tool to overcome ambivalent. When I reflect on my own decision making processes at different points in life, I see flaws in my thinking.  At the heart of the matter, underlying my stuckness, were unresolved hurts and traumas that caused flaws in my thinking.  Addressing these issues head on and allowing healing to occur has been critical for forward progress.

Understanding & Handling Resistance

“My Mental Merry Go Round”

In conclusion Miller & Rollnick, (1991) also suggest the following as a solution to ambivalence:

“Instead of focusing, then, on why a person doesn’t want to make a particular change, it is sensible to explore what the person does want. This is not to ignore the topic of change. Rather, it provides a context for change. Sometimes a behavioral course adjustment does not occur until people perceive that change is relevant to achieving or preserving something that is truly important or dear to them” (Miller& Rollnick, 1991, p. 18).

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Petriglieri, G. (2007). Stuck in a moment: A developmental perspective on impasses. Transactional Analysis Journal. 37(3), 185-194.

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Motivational Interviewing & Resistance

It seems apparent that what a person is doing either isn’t working or is self-destructive; you can see a better way, yet the person persists in the same behavior. In a way, it is captured in the words, “You would think . . . ”

“You would think that having a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more and take his medication.” (Miller & Rollnick, 1991, p. 3).

“You would think that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking.” (Miller & Rollnick, 1991, p 3).

Change vs. Resistance: Two Sides of The Same Coin (Miller & Rollnick, 1991).

In a previous post, we discussed the nature of motivation: Here we consider it’s opposite: Resistance.

The Therapeutic Relationship: Consonance vs. Dissonance

“When things are going well in a motivational interview, there is a sense of moving together smoothly…the feeling is quite different when instead of moving together, the counselor and client seem to be struggling against one another” (Miller & Rollnick, 1991, p. 43).  In fact, conversations between therapist and
client occur along continuum, falling somewhere between understanding and misunderstanding.  Miller & Rollnick, (1991) utilize the terms consonance and dissonance to describe these extremes.  With consonance we have compatibility of perspectives between client and therapist: everybody is on the same page.  In contrast, dissonance involves an inconsistency and contradiction of perspectives: complete misunderstanding.

Miller & Rollnick, (1991) caution against defining dissonant conversations with clients as byproduct of resistance.  Resistance is a term that tends to implicitly apply blame to the therapist.  In reality, dissonant conversations with clients reflects more on the quality of the therapeutic relationship.  “Dissonance in a counseling relationship is not the product…of only one person’s behavior.” (Miller & Rollnick, 1991, p. 43). So what is the solution?  Miller and Rollnick, (1991) state it is the therapist’s job to recognize dissonance, interpret it accurately, and adjust accordingly in order to restore a feeling of consonance between therapist and client.

Client Behavior: Change Talk vs. Resistance

Miller & Rollnick, (1991) also assert that the insights on consonance and dissonance can apply to the understanding of client behavior.  “Resistance is a signal of dissonance in the client relationship…a meaningful signal” (Miller & Rollnick, 1991, p. 46).  The opposite of resistance is change talk, (discussed in a previous post).  Change talk reflects an increase in internal motivation and the resolution of ambivalence.  Resistance, in contrast reflects a high ambivalence, and low internal motivation.  Miller & Rollnick describe four categories of resistant behavior:

  1. ARGUING: The client contests the accuracy, expertise, or integrity of the counselor.”  (Miller & Rollnick, 1991, p. 48).
  2. INTERRUPTING: The client breaks in and interrupts the counselor in a defensive manner.”m(Miller & Rollnick, 1991, p. 48).
  3. NEGATING: The client speaks while the counselor is still talking, without waiting for an appropriate pause or silence.” (Miller & Rollnick, 1991, p. 48).
  4. IGNORING: The client shows evidence of not following the counselor.”  (Miller & Rollnick, 1991, p. 48).

How Should Counselor’s Respond???

“With patients in precontemplation, often the role is like that of a nurturing parent, who joins with a resistant and defensive youngster who is both drawn to and repelled by the prospects of becoming more independent. With clients in contemplation, the role is akin to a Socratic teacher, who encourages clients to achieve their own insights into their condition. With clients who are in the preparation stage, the stance is more like that of an experienced coach, who has been through many crucial matches and can provide a fine game plan or can review the participant’s own plan. With clients who are progressing into action and maintenance, the psychotherapist becomes more of a consultant, who is available to provide expert advice and support when action is not progressing smoothly” (Norcross & Krebs & Prochaska, 2011, p. 145)

Miller & Rollnick (1991) suggest that clients are “understood within the context of the counseling relationship” (p. 51).  Recognizing the fluctuation between dissonance and consonance in the therapeutic relationship is essential, so the therapist can adjust accordingly.  What follows are examples of what not to do:  

  1. “ARGUING FOR CHANGE: The counselor directly takes up the pro-change side of ambivalence on a particular issue and seeks to persuade the client to make change.” (Miller & Rollnick, 1991, p. 50).
  2. ASSUMING THE EXPERT ROLL:  The client structures the conversation in a way that communicates that the counselor ‘has the answers’.” (Miller & Rollnick, 1991, p. 50).
  3. “CRITICIZING, SHAMING, BLAMING, OR LABELING.”  (Miller & Rollnick, 1991, p. 50).
  4. “BEING IN A HURRY: Sometimes the perceived shortness of time causes the counselor to believe that clear, forceful tactics are called for in order to get through…if you act like you only have a few minutes, it can take all day to accomplish a change.”  (Miller & Rollnick, 1991, p. 50)

Misc Techniques…

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67(2), 143-154.

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What is Motivational Interviewing

Everybody knows someone who is making perplexingly unhealthy choices detrimental to their well-being.   It’s quite tough to watch helplessly as a loved one acts self-destructively.  We see their lives heading down a path leading to nowhere.  We are brutally where the end of the road can take them but are helpless to stop them.   All we can do is stand by and watch in horror.  I experience this all-too-often as a student therapist and healthcare worker.

What is motivational interviewing?

Motivational interviewing is a unique client-centered approach that helps the client’s achieve lasting changes in their lives.  It does this by helping the client resolve an feelings of ambivalence to change while clarifying internal motivations to change.  Motivational interviewing is defined by the following characteristics (Miller & Rollnick, 1991).

A Client-Centered Approach

Motivational interviewing has an indebtedness to the work of Carl Rogers in its client-centered approach.   It focuses on developing a concern and understanding of the client’s perspective.  Miller & Rollnick (1991), note that by utilizing a client-centered approach to encourage change, Motivational Interviewing has the following unique characteristics.

  1. It is collaborative in nature and avoids the authoritarian approach (Miller & Rollnick, 1991, p. 22).
  2. This approach focuses in drawing out client insight and develop intrinsic motivation (Miller & Rollnick, 1991).
  3. This method respects individual by asserting that responsibility for change rests upon the client.  (Miller & Rollnick, 1991).

A Consciously Directive Approach

Motivational interviewing, however, diverges from the Rogerian approach, as a consciously directive alternative to instituting change.  This approach is intentionally directed toward resolving any feelings of ambivalence to change.  Getting unstuck, involves working through ambivalence by creating discrepancies between behavior, goals, values, and beliefs.

It is a Method of Communication

“Third, we emphasize that motivational interviewing is a method of communication rather than a set of techniques It is not a bag of tricks for getting people to do what they don’t want to do. It is not something that one does to people; rather, it is fundamentally a way of being with and for people—a facilitative approach to communication that evokes natural change” (Miller & Rollnick, 1991, p. 18).

It Elicits Intrinsic Motivation to Change

“The focus of motivational interviewing is on eliciting the person’s intrinsic motivation for change. It differs from motivational strategies intended to impose change through extrinsic means: by legal sanctions, punishment, social pressure, financial gain and such. Behavioral approaches often seek to rearrange the person’s social environment so that one kind of behavior is reinforced and another discouraged” (Miller & Rollnick, 1991, p. 19).

It Focuses on Resolving Ambivalence

This method focuses on exploring and resolving ambivalence within the client and is based on the idea that change cannot happen unless the client is willing to do so.  Change cannot be imposed upon a client if it conflicts with their beliefs, values, and goals (Miller & Rollnick, 1991).  By addressing the cause of a client’s own “stuck-ness” they develop an internal motivation for change.

Lessons to Learn about Motivational Interviewing…

An article I found titled “Eight Stages in Learning Motivational Learning” provides an overview of skills practitioners must develop in order to utilize Motivational Interviewing successfully (Miller & Moyers, 2006, p. 3).

“practitioners acquire expertise in this method through a sequence of eight stages: (1) openness to collaboration with clients’ own expertise, (2) proficiency in client-centered counseling, including accurate empathy, (3) recognition of key aspects of client speech that guide the practice of MI, (4) eliciting and strengthening client change talk, (5) rolling with resistance, (6) negotiating change plans, (7) consolidating client commitment, and (8) switching flexibly between MI and other intervention styles” (Miller & Moyers, 2006, p. 3).

STAGE #1: THE SPIRIT OF MOTIVATIONAL INTERVIEWING

The first lesson a new therapist must encounter in utilizing motivational interviewing adeptly is to appreciate how it is unique.  What follows are three key descriptive characteristics of motivational interviewing:

  1. COLLABORATION – “Certainly one key component of the spirit of motivational interviewing is its collaborative nature. The counselor avoids an authoritarian one-up stance, instead communicating a partner-like relationship. The method of motivational interviewing involves exploration more than exhortation, and support rather than persuasion or argument” (Miller & Rollnick, 1991, p. 33).
  2. EVOCATIVE – “Consistent with a collaborative role, the interviewer’s tone is not one of imparting things (such as wisdom, insight, reality) but rather of eliciting, of finding these things within and drawing them out from the person…It is not an instilling or installing but, rather, an eliciting, a drawing out of motivation from the person. It requires finding intrinsic motivation for change within the person and evoking it, calling it forth” (Miller & Rollnick, 1991, p. 33).
  3. AUTONOMY – “In motivational interviewing, responsibility for change is left with the client—which, by the way, is where we believe it must lie, no matter how much professionals may debate what people can be ‘made’ or ‘allowed’ or ‘permitted’ to do and choose. Another way to say this is that there is respect for the individual’s autonomy” (Miller & Rollnick, 1991, p. 33).

STAGE #2:  (OARS) CLIENT-CENTERED COUNSELING SKILLS

“The second stage of skill development is not unique to MI. It involves acquiring proficiency in the use of classic client-centered counseling skills…Along with reflective listening, three other counseling micro-skills are particularly emphasized in MI, using the mnemonic acronym OARS: asking open questions (O), affirming (A), reflecting (R), and summarizing” (Miller & Rollnick, 1991, p. 8).

Basic Attending Skills

Active Listening Skills

Questions & Listening Responses

Confrontation, Reflecting, Focusing & Influencing

STAGE #3: RECOGNIZING CHANGE TALK

“MI departs from client-centered counseling in being consciously and strategically goal-directed. Originally developed to help people change addictive behaviors…[it] is directed toward particular behavior change goals. A key process is to help clients resolve ambivalence by evoking their own intrinsic motivations for change. When MI is done well, therefore, it is the client rather than the counselor who voices the arguments for change. Particular attention is given to client “change talk,” verbalizations that signal desire, ability, reasons, need, or commitment to change…If unable to recognize change talk when it occurs, the counselor cannot reinforce and shape it toward commitment” (Miller & Moyers, 2006 p. 7). Another resource for this article notes paradoxically, that it is the reflective, supportive, and client-centered approach that increases a client’s openness to change (Miller & Rollnick, 1991).  In contrast, traditionally confrontational and directional techniques increase resistance (Miller & Rollnick, 1991)

STAGE #4: REINFORCING CHANGE TALK

Once the client recognizes the client’s openness  & desire to change, therapists utilizing MI, must learn to further reinforce it.  This intentional reinforcing can happen through a series of strategies such as the following: “(e.g., ‘In what ways might this change be a good thing?’), and is cautious with questions the answer to which is resistance (e.g., ‘Why haven’t you changed?’)” Miller & Rollnick 1991, p. 8)

STAGE #5: ROLLING WITH RESISTANCE

“The client rather than the counselor should present the arguments for change. Change is motivated by a perceived discrepancy between present behavior and important personal goals or values.” (Miller & Rollnick, 1991, p. 26).  Using this method effectively requires therapists to understand that arguing directly with a client’s resistance to change, only reinforces it.  Rolling with resistance means inviting arguments against change and seeing resistance as a need to change the way you are communicating with the client.  Change can be enabled through a process of active problem solving the includes an acknowledgment the client’s concerns.

STAGE #6: DEVELOPING A CHANGE PLAN

“Miller and Rollnick described therapeutic skillfulness in timing, in knowing when to move on to the development of a change plan. The usual procedure is to offer a transitional summary of change talk (desire, ability, reasons, need) that the client has offered for making a change, and then to ask a key open question, the essence of which is “What next?”… Part of the skill here, then, is knowing when to attempt the transition from Phase 1 to Phase 2…is proficiency in developing a specific change plan (not necessarily treatment plan) without evoking resistance” (Miller & Moyers, 2006, p.10)

STAGE #7: CONSOLIDATING CLIENT COMMITMENT

Once the client has been to acknowledge a need for change, helping them follow through with their plans is the next critical task.  Commitment talk implies that a decision has been made, the client is committing to it and attempting to develop a plan.

STAGE #8: SWITCHING BETWEEN MI AND OTHER COUNSELING METHODS

“MI was never meant to be the only tool in a clinician’s repertoire. It was developed primarily to help clients through motivational obstacles to change. Within the language of the transtheoretical stages of change (Prochaska & DiClemente, 1984), MI was originally conceptualized for helping people move from precontemplation and contemplation, through preparation and on to action” (Miller & Moyers, 2006, p. 21).  Therefore, therapists must learn to utilize it alongside other methods.

What it is & What it Isn’t

Core Strategies

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Miller, W. R., & Moyers, T. B. (2006). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions, 5(1), 3-17.

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