1. Module 12: Resistance

2. Objectives To recognise resistance to change To understand how resistance occurs To be able to use strategies to reduce resistance

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. Acceptance of the Uniqueness of Each Individual : Be able to accept the person as a unique individual and respect their choices and lifestyle. Dual Diagnosis Capability 3 level 2

4. What is resistance? Resistance arises from interpersonal interaction, it is not a trait. Some people come into treatment naturally resistant (expectations, past experience, coercion) Resistant responses are normal; watch out for increases/ escalation Worker may be using strategies inappropriate to stage of change of person. Worker may be using “traps”. Clients way of saying “wait a minute, I’m not with you, I don’t agree…”

5. Exercise 1: Traps Expert/ prescriptive Question-answer Premature focus Labelling Blaming Taking sides In pairs spend 10 minutes discussing your style of working: –are there any of the above traps that you naturally fall into? –Is there anything you could do to change your approach?

6. Categories of resistant behaviour Arguing Challenging, discounting, hostility Interrupting Talking over, cutting off Negating Blaming, disagreeing, excusing, claiming impunity, minimising, pessimism, reluctance, unwillingness to change/intention not to change Ignoring Inattention, non-answer, no response, side- tracking

7. HOW DO WE DEMONSTRATE OUR RESISTANCE?

8. Exercise 2: Your Own Resistance Think of a situation where someone tried to impose a change on you: How did this make you feel/think How did you express your feelings/thoughts to others What did you do to reinforce your position/ maintain your viewpoint What did other(s) do that made you more resistant What did others do that decreased resistance

9. Dealing with Resistance Important goal is to AVOID resistance Resistance is workers problem to solve Receive feedback about success in applying MI by seeing how much resistance is evoked

10. How NOT to: 1.Take control away (“well actually, you don’t have any choice, you have to….”) 2.Misjudge level of importance, confidence or readiness for change (premature focus) (“I think you should go in for a detox now that you have admitted that you have been drinking heavily...”) 3. Meet force with force (argument, challenge, confront) (“Cannabis makes your illness worse, and I know you are still using it, even though you deny it!”)

11. Dealing with resistance- How to:- Emphasising personal responsibility and control. “At the end of the day ultimately the choice to use drugs is yours” Reassess readiness, importance and confidence- you may have assumed that they are more ready for change than they actually are. “Maybe we need to revisit how ready you feel, rather than continue talking about this plan” Back off and come alongside the patient- adapt your approach according to the reassessment of the level of motivation, shift focus of conversation, listen to what they are telling you

12. Specific approaches Reflection Simple reflection-acknowledge feelings and thoughts Amplified reflection- exaggerate what has been said Double sided reflection- reflect two sides of ambivalence Shift focus- diffuse and move on to another topic. Reframe-offer another perspective on what person says. Agreement with a twist- initial agreement but with a slight twist/change of direction

13. Exercise 2 In pairs: As the worker, try to use strategies to increase and then decrease your partners resistance to change. 5 minutes high resistance; 5 minutes decreasing resistance Spend 5 minutes discussing before swapping