1. PRACTICAL USE OF STAGES OF CHANGE MOTIVATIONAL INTERVIEWING & STAGED INTERVENTIONS NIKI MILLER MS CPS RSAT TECHNICAL ASSISTANCE CENTER

2. COURSE OBJECTIVES Upon completion of this course participants will able to: Identify each Stage of Change Demonstrate approaches matched to each stage Find out where clients are in the process through open-ended questions Explain how the model can be applied to a variety of behavioral changes

3. STAGES OF CHANGE MODEL (SCM) developed by James PROCHASKA and Carlo DICLEMENTE Originally developed in late ‘70s and early ‘80s at University of Rhode Island to study how smokers quit. Since then, the model has been applied to substances, weight loss, contraception and other behavioral changes. Also known as the Transtheoretical Model of Change, since the original research built on elements of 18 difference theories of change.

4. SCM VALIDITY HAS BEEN WIDELY STUDIED Prochascka and DiClemente’s research used acceptable scientific and academic standards to verify the validity of the method. (cluster, analytical methods in retrospective, prospective and cross-sectional studies). The model has been validated and applied to the behavioral components of many health conditions and to changing high risk behaviors.

5. SCM ESSENTIAL ELEMENTS Change is rarely a single, discrete event. Change has come to be understood as a process of identifiable stages through which clients pass. Treatment providers once viewed a change in alcohol and drug use as a single event that occurred during treatment. It is now understood that clients enter treatment in various stages of readiness to change.

6. SCM IS A UNIQUE TREATMENT APPROACH SCM offers simple staged approaches to changing alcohol and drug use behaviors based on the following: Lasting change must be internally motivated- the client must decide for themselves to change a behavior. This is true even if external factors such as revocation of parole influence this decision. Motivation is dynamic and the opportunity for change can increase when the client and counselor work to resolve ambivalence. Direct confrontation, unsolicited advice or authoritative instruction are not part of this model.

7. SCM- May be adapted to any Behavioral Change Can be applied to any target behavior--re-cycling, exercise or decreased substance use.

8. SCM AND TARGET BEHAVIOR Brief counseling sessions using Motivational Interviewing and (lasting 5- 15 minutes) have been shown to be as effective as longer sessions. Brief sessions in Community Corrections settings will be adequate if the correct approach is used. Like anyone else, parolees are who trying to eliminate substance use upon re-entry, may be unlikely to maintain the target behavior right away.

9. THE STAGES OF CHANGE MODEL - PROCHASKA & DICLEMENTE, 1986 Permanent Exit? Pre- contemplation MI Contemplation MI MI Preparation (Determination) MI /CBT MI /CBT Action CBT CBT Maintenance Relapse? MI MI

10. DETERMINING THE BEST APPROACH The chart on the previous page shows: Motivational Enhancement approaches that make use of MI are best for clients who are still ambivalent about change Cognitive behavioral approaches are used once a client has reach the determination/ preparation stage

11. RESEARCH ON CONFRONTATION “Research suggests that the more frequently clinicians use adversarial confrontational techniques with substance-using clients, the less likely clients will change (Miller et al., 1993), and controlled clinical trials place confrontational approaches among the least effective treatment methods (Miller et al., 1998 ).”(Miller et al., 1993),(Miller et al., 1998 ). -CSAT Treatment Improvement Protocol 34

12. THE USE OF SCM REQUIRES INTERVENTIONS TO MATCH INDIVIDUAL STAGES If a counselor provides instructions on how to quit using when a client thinks he or she doesn’t have a problem…. Then the counselor has not matched the intervention to the client’s stage of change and client resistance may increase rather than decrease. The SCM model says the correct intervention for a client that says or thinks “I have no problem” is... See next slide

13. OK. Tell me the reasons you that you have decided you can safely use drugs and alcohol. Tell me about someone you know who does have a problem with drugs and alcohol? What types of change in you drug and alcohol use would prompt you to wonder if you had a problem? How would you like your substance use to be 3 mos. from now? THOUGHT PROVOKING/OPEN ENDED QUESTIONS, SUCH AS:

14. STAGES OF CHANGE APPROACHES FOR PRE-CONTEMPLATION IF Client is not considering change. Begin MI:  Build rapport  Elicit reasons for not wanting to change  Let the client know that you support positive change  With permission, provide nonjudgmental, accurate information about effects of substances  Review assessment & feedback w/permission Then………..

15. GOAL IS TO Develop DISCREPANCIES Creating Doubt  What warning signs would let you know this is a problem?  What kinds of changes have you considered/made in the past?  What might your life look like in 3 months if you were to make a change? (or not)  Use the readiness ruler

16. READINESS RULER This will be covered in detail in during MI training.  Scale is set from one to ten; one is low, ten is high  “On a scale of 1-10 how ready are you to change your drug use?”  If the answer is a two or three ask “What will it take to get you to a four or five?”  If the answer is a five or six ask “Why is it a five and not a two?”

17. DESIRED RESULT The client is presenting his or reasons for changing to the counselor This is one goal of motivational sessions. Client resistance decreases. If you, the counselor, are presenting the reasons for change to the client…………… then ……

18. USE MI TO GET THE CLIENTS TO TALK …… then stop talking and begin open ended questions: When the client is talking the counselor can use supportive listening skills and other MI tools.

19. STAGES OF CHANGE APPROACHES FOR CONTEMPLATION Client is aware of a problem, knows they should change, may want to change but have not yet changed:  Client recognizes cause for concern and reasons to change  Is considering possibilities of stopping behavior  May seek information  May plan on making a change in the future Since ambivalence is still present ……

20. MOVING AT THE CLIENT’S PACE PREVENTS RESISTANCE Continue with MI  Give client control  Normalize ambivalence- change is difficult and motivation shifts  Help tip the scale by eliciting the costs and benefits of continued use  Help client determine the options that are available  Support Client Cost benefit and decisional balance tools are available as handouts and can be used as worksheet in sessions with the client.

21. STAGES OF CHANGE CONTEMPLATION Other MI tools:  Specifically praise any step or willingness client shows towards change. “ It is great that you made it here tonight. I know your car is in the shop.”  The more you personalize positive reinforcement and make it specific to the client’s current situation the more effective it is.

22. BUILDING SELF EFFICACY THOUGH MI When a client is discouraged by past attempts to change, help them look for strengths and past and current successes: “Sounds like you have survived many difficult situations. Tell me how you managed to cope?” “Tell me a difficult change that you have been able to make in the past….” “ Tell me about some things you have achieved since you began considering recovery …”

23. IDENTIFY BARRIERS Use open ended questions and supportive listening to elicit client’s barriers they must overcome in order to change.  “Tell me what would you need in order to do this?”  Elicit from client resources/ supports they might use  Arrive at a realistic commitment  Ask what they would need to succeed  Contingency statements: “So if this then…….”  Normalize fears and doubts about life w/out substances MI/CBT (Delivered w/MI Style and Spirit)

24. STAGES OF CHANGE DETERMINATION/PREPARATION Moving from MI to CBT (Delivered w/MI Style and Spirit)  Negotiate change  Help client enlist additional social support  Explore TX expectations/options what worked & what didn’t  Guide client to begin to negotiate barriers  Role play  Encourage public announcement of commitment (group)

25. STAGES OF CHANGE ACTION Client is ready to attempt target behavior  Continue to explore tools to change behavior  Build steps toward further change  Work with client on environment  If possible encourage client to limit other attempts at major changes  Help client plan for high risk situations; role play

26. STAGES OF CHANGE ACTION  Reevaluate self-image from user to person in recovery  Build and reinforce recovery identity  Enjoy the honeymoon and help memorialize feelings of relief  Remind them of this relief as they face more daunting and longstanding challenges (relationships, employment, co-occurring)  Recognize in public overt changes (in session, group, w/ family and support and referral networks) CBT tools are available as handouts

27. STAGES OF CHANGE MAINTENANCE The client has experienced the target behaviors  Elicit recognition of prolonged behavior changes and benefits  Encourage efforts made to sustain the gains achieved  Visit precautions to keep from reverting to old behaviors  Teach client to guard against high-risk situations and to identify triggers; role play  Continued support, education, skill building through role plays  Re-evaluate plan and progress Continue CBT (Delivered w/MI Style and Spirit)

28. STAGES OF CHANGE RELAPSE Client may cycle through SCM many times before the change is permanently established. Some change may take effect in as little time as one hour; for some change may never occur.

29. STAGES OF CHANGE RELAPSE  Client acknowledgement of relapse is a great thing  Normalizing without giving permission- “This happens to many people.”  “Tell me what has worked for you (or others) to get back on track?”  Elicit self-motivational statements  Elicit reasons to get back on track and recounting of benefits  Reflective Listening-open ended questions

30. STAGES OF CHANGE RELAPSE Crisis or opportunity?  Opportunity to identify barriers to recovery  Opportunity to identify function of using  Expand different skills and abilities that lead to success  Explore values, hopes and goals  Help client develop a new plan

31. MANUALIZED TREATMENT AND SCM Remember –manualized sessions are based on individual needs relative to the stage of change the client is experiencing. Individualized treatment is guaranteed if MI is used to listen to the client and respond to what, you, the counselor have just heard. One Size Does Not Fit All