1. Module 11: Persuasion (Building Readiness to Change)

2. Objectives To be able to define “ Persuasion” Stage To be able to define motivational interviewing. To be able to describe the key skills involved in MI. To be able to assess readiness to change. To be able to explore ambivalence using decision matrix.

3. Dual Diagnosis Capabilities Demonstrate Empathy: To be able to understand the unique experiences a person with dual diagnosis may have had, and be able to communicate this understanding effectively and empathically to service users, and their carers. Dual Diagnosis Capability 5 level 2 Interpersonal Skills: To be able to demonstrate effective skills such as active listening, reflection, paraphrasing, summarising, utilising open-ended questions, affirming, elaboration. Dual Diagnosis Capability 7 level 2. Delivering Evidence and Values Based Interventions: Be able to utilise knowledge and skills to deliver evidence-based interventions including brief interventions, motivational interviewing, relapse prevention and cognitive behaviour therapy to people with combined mental health problems within own limits and capacity and remit of ones own organisation. To know where else a service use can access appropriate specialist care and facilitate that access. To be able to access support and supervision to perform such interventions. Dual Diagnosis Capability 13 level 2. Evaluate Care: To be able to collaboratively review and evaluate care provided with service user, carers and other professionals. To be flexible in changing plans if they are not meeting the needs of the service user. Dual Diagnosis Capability 14 level 2

4. Transtheoretical ModelOsher and Kofoed’s Four Stages PrecontemplationEngagement ContemplationEarly persuasion PreparationLate persuasion ActionActive Treatment MaintenanceRelapse prevention

5. Persuasion Enters this stage once engaged in a therapeutic alliance. Still not necessarily acknowledging problem with substances Considered behaviourally unmotivated- not showing any signs of reducing substance use (but may be talking about it). Still expect sporadic attendance; be flexible. Worker acknowledges that motivation to change must be generated internally or will fail.

6. Examples of Interventions For Persuasion Individual and family psycho-education. Motivational Interviewing. Peer (“persuasion”) groups. Social skills training. Structured activity. Safe/stable housing. Medication Management.

7. Exercise: Activities for People with Dual Diagnosis Spend a few minutes answering the following questions (in pairs) 1. What activities are available for people with dual diagnosis within your setting? 2. What are the barriers to accessing activities? 3. How could these barriers be overcome? 4. What other activities would you like to see offered?

8. Motivation State of readiness or eagerness to change Fluctuates through time and/or situation-not static trait Motivation to change requires being- –Ready (the time is right) –Willing (want to do it) –Able (has the ability and confidence to do it)

9. What Is MI? Client centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. (Miller and Rollnick, 2002 2 nd ed)

10. Key Ideas Worker style powerful determinant of both resistance and change Ambivalence is normal and to be expected Resolving ambivalence is a key to change Self-efficacy is related to outcome Labelling is not essential empathy, non-judgemental, and genuineness “Spirit”- collaboration, evocation, autonomy Goal:- person generates own reasons for change

11. Four general Principles 1.Express empathy- acceptance facilitates change, skillful reflective listening is fundamental, ambivalence is normal 2.Develop discrepancy- person, not worker presents arguments for change; change is motivated by perceived discrepancy between present behaviour and important goals and values 3.Roll with resistance- avoid arguing for change, resistance is not directly opposed, new perspectives are invited but not imposed, person is primary source of finding answers and solutions, resistance is a signal to respond differently 4.Support self-efficacy- belief in possibility is an important motivator. The person not the therapist is responsible for change. Therapists own belief in change can become a self-fullfilling prophesy

12. Traps (how not to…) Expert/ prescriptive: “ As an experienced nurse, I think you should….” Question-answer: “have you taken your tablets?” “yes I have” Premature focus “I’d like to talk more about your drinking” “but I am really worried about losing my tenancy.” Labelling: “schizophrenic, alcoholic…etc” Blaming: “The reason you end up back in hospital is because you use cannabis” Taking sides “It seems clear to me that you have a serious drink problem” “but a lot of people drink like me”

13. OARS (skills) Open-ended Affirming Reflecting Summarising

14. Some key techniques A “typical day” Readiness to change Timeline-looking back Goals and roadblocks- looking forwards Exploring the good and less good (pros and cons) Evocative questions Raising discrepancies Problem solving Offering choices

15. Examples of evocative questions What worries you about your current situation? How would you like things to be different? What encourages you that you could change if you want to? I can see you are feeling stuck; what is going to have to change? What would be the advantages of making this change?

16. A Typical Day Helps people reflect on processes that are usually automatic Identify maybe some of the less good aspects of the behaviour as well as the good Helps worker get a picture of the behaviour Get a sense of motivational state

17. Adapting MI for Dual Diagnosis (Bellack and Diclemente, 1999) Spend extra time engaging in therapeutic relationship Use of repetition and rehearsal Being concrete and simple in setting tasks and discussions. Being realistic about goals. Small doses (10-20 minutes) Flexibility.

18. Readiness to Change (Rollnick, Mason and Butler, 1999) Readiness to change ruler: NOT READY……......UNSURE…………….READY 0……………………………………………….10 Importance of change: 0----------10 (willing) Confidence in ones own ability to make the change: 0-------------10 (able)

19. Readiness to change Increasing importance A valid reason for change Benefits outweigh costs Information about possible risks Confidence Small achievable goals Reminder of past successes Affirming and empathy

20. Key Questions Can you tell me why you placed yourself there on the scale (readiness to change/importance/confidence) What would have to be different for you to move a bit further forward? Can you tell me a bit more about that…. Is there anything else that’s important that we haven’t discussed yet?

21. Ambivalence- the dilemma of change Natural state to move through during change When we get stuck, problems can persist Decisional balance Cost/benefits of status quo Costs/benefits of change Conflict Approach-approach Avoid-avoid Double approach avoidance

22. Working with Ambivalence Identify and explore the nature of ambivalence about a particular behaviour Always start with the side of “least resistance” List the good and less good aspects in turn Encourage elaboration, and identification of less obvious costs and benefits

23. Example Good things about cannabisLess good things about cannabis It makes me feel goodput on weight (munchies) Relaxedfeel paranoid sometimes Something to doI argue with mates Helps sleepGhosts are bad It’s fun to smoke with friendssmokers cough in the morning Good things about not usingless good things about not using Might lose weightmy friends might think I’m boring Ghosts bother me lessdon’t sleep very well Feel healthiermight get bored