1. “Because I Said So”: How to Support Adult Clients through Change
Louisiana Association of Drug Court Professionals
April 11-13, 2012
Jane E. Pfeifer, MPA

2. First Question:
Q.: What agency/organization provides primary case management services for your Drug Court?
Many drug court programs do not have this issue clearly defined when they begin operation, and it can be difficult, and in some cases it can result in a duplication of services, which wastes resources, or even worse, it can result in a gap in service provision.
Does that mean that no one else participates in case management? No. It is a shared responsibility by all who work the client. That is why the timely exchange of information is so critical. Each of us in our disciplines has a unique relationship with the client, and therefore have important input to share with the rest of the team, that ultimately helps the primary case manager do their job more effectively.

3. Eight Evidence-Based Principles for Effective Interventions
1. Assess Actuarial Risk/Needs.
2. Enhance Intrinsic Motivation.
3. Target Interventions.
4. Skill Train with Directed Practice
5. Increase Positive Reinforcement.
6. Engage Ongoing Support in Natural Communities.
7. Measure Relevant Processes/Practices.
8. Provide Measurement Feedback
NIC, 2004

4. 2. Enhance Intrinsic Motivation
Use motivational techniques
Get training
Develop rapport with the participant
Avoid arguing!

5. Whose job is it to engage the client?
Engagement
Whose job is it to engage the client?

6. Engagement
Engagement activities are intended to identify and fulfill the client's immediate needs, often with something as tangible as a pair of socks or a ride to the doctor.
Center for Substance Abuse Treatment. Comprehensive Case Management for Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration; 1998 (Treatment improvement protocol; no. 27).

7. Increasing Motivation
Whose job is it to assist the client in increasing his or her motivation?

8. Increasing Motivation
Stages of Change
Motivational Strategies
In a recent study, clients assigned to receive motivational interviewing techniques at intake had significantly better retention rates at the 28-day follow-up than clients who received the standard intake evaluation. (Carroll, et al., 2006.)

9. Stages of Change Readiness (Prochaska and DiClemente, 1992)
Precontemplation
Maintenance
Contemplation
Key Points:
Can’t just jump into recruiting your key players (or anyone for that matter)for a change effort. People need to be ready for change.
First step is assessing each key players stage of readiness for change.
Review each of the stages from Prochaska and DiClementi.
Your goal is to move all the key players to action. Your interventions may vary depending on the players stage of readiness for change.
Group Activity:
Break participants into small groups. Ask each group to think of a change they would like to effect in their work site. Then, using the workbook sheet entitled Key Players for Change Efforts, have then list the key players and assess each players stage of readiness for change (columns one and two of the work sheet--don’t have them do column three yet!)
Action
Preparation

10. Relapse-Lapse-Change
Stages of Change
Pre-contemplation
Contemplation
Preparation
Relapse-Lapse-Change
OVERVIEW OF STAGES OF CHANGE
Stages are sequential and according to Prochaska & DiClemente, people do not not skip a stage although they may endorse some aspects of adjacent stages as they move through the process.
Relapse (a break in resolution) can occur at action and maintenance stages with movement to any of the former stages. It is represented in a different colour as it is not considered a stage as such.
Each stage is associated with various processes (discussed later)
Action
Maintenance

11. Stages of Change Pre-contemplation Not thinking about changing
Happy user
Learned helplessness
Has no intention to take action within the next 6 months
COGNITIVE DEFINITION
Cognitive definition “not thinking of changing”
HAPPY USER
Sometimes “happy user” - or positives far outweigh the costs
LEARNED HELPLESSNESS
Sometimes unhappy pre-contemplator - ie. may have unsuccessfully tried change but has given up - eg. battered wife syndrome.
ASSOCIATED PROCESSES
Process of consciousness raising important to aid move to next step
May also be important to look for those areas where the person is contemplating or actioning change.
It’s not that they can’t see the solution, they can’t see the problem.
This stage represents those individuals who have no desire to change their behaviors in the immediate future. The immediate future usually refers to a six month time period. This is used because this is about as far in the future that most people plan a specific behavior change. It is also because most people are concerned with the present and don't plan far in the future so a six month time frame is used. Individuals in this stage usually have a lack of awareness about the specific behavior. Some individuals in this stage are very aware of the consequences of their behavior but may avoid getting involved in behavior change programs because of rationalizing their behavior to make sense to them. Individuals may also be tired of trying and failing at the desired behavior change.
It may be possible for the individual to move from precontemplation to the contemplation stage by increased awareness. Mass media on certain behaviors can influence awareness. Also, by setting goals that can easily be attained can ensure that the individual is successful and increase self-efficacy or the individual's confidence in themselves to make the desired behavior change.

12. Stages of Change Contemplation Thinking about changing Ambivalence
Chronic contemplators
Intends to take action within the next 6 months.
DEFINITION, DECISIONAL BALANCE
Cognitive definition “thinking about it”
The costs of drug use may be outweighing the benefits
The hinders to change may be reduced while the helps (such as helping relationships) may be enhanced
AMBIVALENCE
Ambivalence or “cognitive conflict” as discussed by Jim Orford, is often a major feature of this stage.
MOTIVATIONAL INTERVIEWING
Motivational interviewing is particularly useful to clarify the costs and benefits of the behaviour and may help a move towards preparation and action.
CHRONIC CONTEMPLATORS
Smoking research has shown that many get stuck in this stage known as “chronic contemplators”: There is a danger of therapy allowing people to stay stuck in this stage if all talk & no action….
This stage is where the individual has the intent to change his/her behavior within the next six months. Just as in the precontemplation stage, the six month figure is used because this is about as far in the future that most people plan a specific behavior change. This individual is already aware of the benefits and barriers of the desired behavior and plans change their behavior based on their interpretation of the benefits and barriers.
While the benefits of specific behavior change maybe somewhat obvious, the barriers may be different for each individual. One person may not have the finances to perform a certain behavior change, while another may have family problems that prohibit the behavior change, and yet another may not make the desired behavior change because they don't have access to the neccessary things.
The individual in this stage needs extra attention. Everything needs to be at his/her own pace and he/she doesn't need to be rushed into a behavior change that he/she is not ready for. Encouragement and motivational techniques can be used to persuade this individual to the next stage. This may be done by going beyond the awareness by using mass media but by using things that are "tailor-made" for the individual.

13. Stages of Change Preparation Decision made Firm plans
Possibly recent attempts at change
Intends to take action within the next 30 days.
Has taken some behavioral steps in this direction.
DEFINITION
Initially this stage was called ‘decision making’.
In the cognitive-behavioural model, this stage is the transition point between a movement from more cognitive orientated behaviours to more behavioural orientated behaviours.
Individuals in this stage intend to make a behavior change within the next month (30 days) and have made at least one previous attempt to make a behavior change.
It is in this stage that the individual is most ready for a change. It is the job of the health promotion professional to help manipulate the environment in order to make it conducive to the desired behavior change, therefore promoting the change. This may involve some policy changes.

14. Stages of Change Action Overt behavioral change ‘Stopping’ main issue
Grief issues
Counter-conditioning
Stimulus control
Contingency management
Has changed overt behavior for less than 6 months
DEFINITION
Behavioural defined: “doing it - talk the talk & walk the walk”.
In drug use, as stopping or giving up is the main issue, there can be many grief & loss issues associated with missing the positive aspects of drug use. Towards maintenance, new behaviours replace the changed behaviour.
KEY FACTORS
If drugs are used to manage negative emotional states, the development of new coping strategies are very important at this stage.
Temptation is initially high and confidence to resist urges is often low initially. After some weeks, temptation drops dramatically and confidence to resist rises rapidly. Prior to this high risk.
PROCESSES INCLUDE:
Counter-conditioning - alternative behaviours used to replace changed behaviour
Stimulus control - avoid cues & triggers that prompt the urge to use drugs - eg identify high risk situations...
Contingency management - if certain cues are unavoidable, how to manage them - another aspect of stimulus control. eg. learning refusal skills.
The action stage is a period of time anywhere between 0 and 6 months that involves a sufficient change of behavior. This stage of change reflects a consistent behavior pattern, is usually the most visible, and receives the greatest external recognition. When measuring the pros and cons of the desired behavior change, the individual's perceived cons of the behavior should outweigh the perceived pros of the behavior if it is an attempt to abstain from certain behaviors such as drug abuse or smoking. The individual's perceived pros should outweigh the perceived cons if the individual is making an attempt at a positive behavior change such as exercise adherence. If the individual making the behavior change continues his/her pattern of behavior, he/she will move into the fifth stage, called maintenance.

15. Stages of Change Maintenance Sustained behavior over time
Alternatives established
Later, becomes a non-issue
Has changed overt behavior for more than 6 months.
DEFINITION
Behavioural defined - often with a time frame. eg. maintained over 6 months
ESTABLISHED OTHER BEHAVIOURS
Other behavioural definition could include more established alternative behaviours (counter-conditioning)
Cognitive issues include reduced salience as change becomes more established, experience of success, and new behaviours becoming ‘automatic’.
BEYOND MAINTENANCE?
Maintenance may precede a further stage (not yet defined) called “non-issue”. Difference between someone who as been a smoker being someone who has quit (actioner) a non-smoker (maintainer) or simply a “non-issue”.
Some remain an actioner for years as change continues to be a struggle.
Others remain in maintenance for years (ie. AA or NA) before it becomes a non- issue.
This stage is one that starts six months after the action stage and can last for several years. The behavior being changed is the key factor in determining how long this stage will last. It is in this stage that the self-efficacy ( one's confidence in oneself to make a behavior change) of the individual is at it's highest, especially when compared to the four preceding stages.
Relapse prevention "is a self-control program designed to teach individuals who are trying to change their behavior how to anticipate and cope with the problem of relapse" and is probably the biggest concern of the health promotion professional in this stage. Since the Transtheoretical model is cyclical, the individual may relapse back several stages instead of just one. The individual needs to be prepared for relapse by knowing exactly what to do about it.

16. What is MOTIVATIONAL INTERVIEWING?
Intervention designed to mobilize client’s internal resources for change by enhancing intrinsic motivation.
A style of being with people, not just a set of techniques
An important goal is to clarify values and amplify discrepancies
Purpose is to move person through the stages of change
from Morgenstern-”Motivational Interviewing”
Developed by Miller and Rollnick, this is their definition.
What is unique about this approach is that it relies on the client reaching the point of internally wanting to change, rather than it being forced on them. Criminal justice system is most certainly providing external pressure, but for the client to change, and change for the long term, MI provides the techniques to help the client identify why they haven’t changed, and what their ambivalence is to, say, stop using drugs.
Having clients resolve their own ambivalence toward change.
Be clear: this is not a “therapy technique” to be used only by clinicians. Rather, it is a style that can assist all social service providers.
The Stages of Change were developed by Prochaska and DiClemente, and we’ll talk about them in a minute.

17. Philosophy of Motivational Interviewing
MI is a technique in which you become a helper – not a dictator – in the change process for your client.
In criminal justice we are used to telling people what to do.
This is a different style of interview and counseling.

18. Goal Of Motivational Interviewing
The goal of MI is to create a safe and supportive rapport with a person, in order to facilitate their thinking about their behavior and whether/how they might go about making changes.

19. Confrontation: A Goal Not a Style

20. “I want to but I don’t want to”
AMBIVALENCE
“I want to but I don’t want to”

21. Important Assumptions in Motivational Interviewing
Clients are AMBIVALENT about changing.
There are BOTH pros AND cons to getting off of drugs vs. continuing to use.

22. Ambivalence about quitting
We in criminal justice don’t typically see that for the client there are at least some good reasons to continue to use.
MI recognizes that ambivalence about quitting is NORMAL.

23. Change Importance of Change Low importance: Low confidenceB I L T Y
Low importance: Low confidence
These people don’t see the need for change nor do they believe that could effectuate the change, if they decided to change
Low importance: High confidence
These people are confident they can make the change but are not convinced that change is needed. O C H N G E
High importance: Low confidence
Here the problem is not the willingness of the person to change but the person’s confidence in their ability to change
High importance: High confidence
These people see the necessity of change and believe they can succeed.

24. Exercise
Share an example with your team of how you, in your role, can assist with increasing motivation.

25. DEVELOPING DISCREPANCY
Motivation for change is enhanced when clients perceive the discrepancies between their current situations and behaviors, and their hopes and goals for the future.
Let the client present the argument for change.

26. “Tell me the good parts about using.”
“Tell me the negatives.”
You will often hear about damaged family relationships, especially with the client’s children.
“How do these weigh out to you?”
“Where do you think you go from here?”

27. Have the client state the solution of what he must do to achieve his stated goals, desires, wants, and wishes.

28. Take Home Message:
Motivation to change is elicited from the client, and not imposed from without.
It is the client's task, not the interviewer’s, to articulate and resolve his or her ambivalence.

29. Exercise
Pair up
Pick a real-life behavior change you want to make (be sure it’s one you want to share!)
One is the case manager and one is the drug court participant—then switch.
As the case manager, help your partner develop discrepancy. By the end, and without asking directly, see if you can determine if your partner is low importance/low ability; low importance/high ability; high importance/low ability; high importance/high ability.

30. 3. Target Interventions
a. Risk Principle: Prioritize supervision and treatment resources for higher risk offenders.
b. Need Principle: Target interventions to criminogenic needs.
c. Responsivity Principle: Be responsive to temperament, learning style, motivation, culture, and gender when assigning programs.

31. Meeting Client’s Needs
“client’s” not “clients’”
What does this client need?
How do we know?
Assessment
Interviewing-ASK HER!
Comprehensive case management
Realistic case planning
Incremental objectives
Treatment matching
Gender appropriate
Culturally relevant

32. What do Drug Court Participants need?
Have the trainees talk about what each of the pictures represents: (housing, treatment, education, dental care, parenting skills, transportation, medical care, job skills.) Ask them what’s missing from this list. Then ask how do we make sure participants get what they need? What if we only give them substance abuse treatment? Case management is the answer.

33. What Goals Are Set For Clients?
Are there target behaviors that all clients must achieve?
Are they different in the beginning of the program?
Does your department/agency have differing goals for clients than the drug court, or are they consistent?
How individualized can goals be for each client?
Are there target behaviors that all clients must achieve? What are they? Education? Drug and alcohol abstinence? Are they different for juvenile clients than adult clients? What about those clients who are legally adults but developmentally still adolescents? What about parents vs. non-parents? It is critical to fashion incentives and sanctions with these questions in mind.
It is important to be sure that the goals of your own agency is consistent with the goals being set by the drug court. Important to get them in writing.
How do you balance the individual needs of the client and the need to have consistency in the drug court program?

34. Exercise
As a team:
identify two strengths of your case management services.
identify two challenges with your case management process, and discuss possible solutions.

35. Resources Motivationalinterview.org
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment.
Motivational Interviewing, Second Edition, by William Miller
Miller and Rollnick, Motivational Interviewing: Preparing People for Change, (New York: Guilford Press 2002)