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Motivational Counseling Strategies
Reviewing a Typical Day
Here, the counselor builds rapport while gathering information. The
counselor avoids a focus on "problem behaviors," focusing
instead on how substance use fits in to the person's life. Rollnick
et al. (1992) suggest starting with, "Can we spend the next
5-10 minutes going through a day from beginning to end. What happened,
how did you feel, and where did your use of xxx fit in? Let's start
at the beginning." (P. 30). Proceed to help the client tell
a story of the day, focusing on feelings and behaviors. If the client
is receptive, summarize, then move to the next strategy.
Looking Back
This strategy simply involves engaging in a conversation with the client
about what life was like "before." Before substance use problems,
before legal, work or relationship difficulties, etc. What does the
client remember? What good memories, hopes, dreams or plans did the
person once have? What successes, achievements did the person have?
If the person's history is very negative, it may still be useful to
explore "what it was like," not necessarily in an attempt
to process or resolve issues from that time, but primarily to establish
the situation that existed before substance problems.
These techniques can be spurred by a client comment such as, "I
used to have it all" or "I wasn't always this way." This
is a natural segue for a therapist comment and question, "So things
have really changed. Tell me a little bit about what life was like back
then." Then the therapist uses OARS
to keep momentum going and to elicit how the problem behavior fit into
this circumstance and/or how it changed over time. For example, if drinking
is the client issue, then, "So I'm wondering how your drinking fit
in back then." Then later, the therapist might ask, "It sounds like
your drinking changed over time. Tell me about that."
Then, you can explore how the client's path went from those previous
dreams, plans successes or stressors into occasional, regular or chronic
substance use. Again, the goal is not "insight" into deep
psychological processes, just an establishment of some history to help
"ground" the client as those with substance problems often
seem caught in the "here and now" and sometimes seem to have
lost a deep sense of self, of who they feel they are. The goal is for
the client to obtain some perspective from the immediacy of his or her
circumstance and to observe either how things have changed over time.
Good Things and Less Good Things
This strategy is simply to review what is "good" about substance
use alongside a review of what is "not-so-good" about the
use of substances. Steve Rollnick developed this phrasing for a particular
purpose; namely, he wanted to avoid labeling a behavior as a problem
when the client was not using that language. Failure to do this may
lead to arguments with clients where they state adamantly the behavior
is not a problem. Conversely, clients are often willing to acknowledge
that there are less good things about a behavior. behavior. The technique
also provides the therapist an opportunity to explore what "positives"
may be sustaining a behavior. This is often a very fruitful inquiry
and typically quite surprising to clients. They are often confronted
with why they need to change a behavior, but only rarely asked what
benefits they are receiving. This often serves to reduce resistance
and allows inquiry into the Less Good things to be more acceptable to
the client. We start this technique with a prefacing comment, then follow
with a question about the Good Things. We follow up until all the Good
Things have been exhausted. We summarize, then ask about the Less Good
Things. These are then explored in more detail with requests made for
examples of Less Good behavior. For example, "You said that your
use had affected your children. Tell me about a time that happened."
Once this area is fully explored, we summarize, emphasize any change
talk that emerged, and then ask the client what their take on this material
might be. The most important part of this strategy is to avoid labeling
things as a problem.
Some counselors have begun using an alternate focus for the exploration
of "good things and not-so-good things" - asking clients to
talk about their experiences at AA or NA meetings and considering both
"pros" of attending as well as "cons." The goal
is to engage the client in sharing both likes and dislikes with the
intention of reducing resistance or unhappiness about attending these
meetings by "getting things out in the air." Often, people
are more willing to accept the "good things" about meetings
if their counselor explores and gives respect to what clients see as
the "not-so-good" things.
Discussing the Stages of Change
Below is an example of how a counselor might talk with a client about
the stages of change. After an explanation such as the one below (or
something briefer!), the counselor might ask the client to react to
the explanation just given about the stages of change. The counselor
might ask the client to think about things they have changed in the
past, and examples of when they were in the various stages of change
during this process. If a client previously got stuck in a stage, ask
the person to think about what methods they were using during that stage,
if he or she can identify any. Write these down as well. Spend some
time discussing the client's experiences with change, and consider focusing
more on "less threatening" changes such as diet, adhering
to medical advice, cigarette smoking, work habits, exercise, rather
than on drug and alcohol abuse. This can reduce defensiveness about
drug and alcohol in later sessions and help to teach how changing addictive
behaviors is similar to making other changes.
One way a counselor might introduce the topic:
In or out of treatment, people seem to pass through similar stages
as they work on making changes. This goes for many kinds of changes.
The same stages seem to apply to people who want to lose weight as
they do to people who want to cut down or stop their drinking or drugging.
The first stage of change is called the "Pre-contemplation
Stage". During this stage people are not thinking about making
a change. This may be because they have never thought much about their
situation or they have already thought things through and decided
not to change their behavior. Sometimes people may want to change,
but not feel as if they could successfully make the change they desire.
People in this stage might find it useful to get more information
about their situation.
When people start thinking about their situation, they begin
the second stage called the "Contemplation Stage." During
this stage, people are "unsure" about what to do. There
are both good and not-so-good things about their present situation.
People in this stage also struggles with the good and not-so-good
things that might come with change. During this stage people often
both want change and yet want to stay the same at the same time. This
can be a bit confusing for people as they feel torn between these
options.
At some point, when people have been thinking through whether
or not to change, they may come to feel that the reasons for change
outweigh the reasons not to change. As this weight increases on the
side of change, the person becomes more determined to do something.
This is the beginning of the next stage, called the "Preparation
Stage." During this stage, poeple begin thinking about how they
can go about making the change they desire, making plans, and then
taking some action toward stopping old behaviors and/or starting new,
more productive behaviors. People often become more and more "ready"
and committed to making changes.
During the next stage of change called the "Action Stage"
people begin to implement their "change plans" and trying
out new ways of being. Often, during this stage people let others
know what's happening and look for support from them in making these
changes.
Once people have succeeded in making and keeping some changes
over a period of time they enter the "Maintenance Stage."
During this stage, people try to sustain the changes that have been
made and to prevent returning to their old ways. This is why this
stage is also known as the "Holding Stage." Many times the
person is able to keep up the changes made and then makes a permanent
exit from the wheel (or spiral) of change. During this stage it is
also common for people to have some "slips" or "lapses"
where old habits return for a short time.
Sometimes people also have "relapses" which may last
a longer period of time. When a person has a relapse, he or she typically
returns to the precontemplation or contemplation stages. the person's
task is to start around the wheel of change again rather than getting
stuck. Keep in mind that relapses, slips, and lapses are normal as
a person tries to change any long-standing habit. Often times people
go around the wheel of change 3 or 4 (or more) times before permanent
change takes hold.
There is some pretty good evidence that people shouldn't skip stages.
Someone that jumps right into the action stage may not spend enough
time preparing for change. The result is they have trouble in keeping
the changes they've made. For this reason, it is important for you
to know which stage you're in and what things you need to do to move
to the next stage.
Assessment Feedback
Another strategy involves providing feedback to the client about
their behavior. This can be formalized, as in the Drinker's Check-up
discussed below, or informal based on information elicited during the
course of the intervention. Normative feedback can include information
about levels of use, consequences of use or comparison to others. Standardized
instruments like the ASI, SASSI, AUDIT or DrInC or InDUC provide ready
resources for this type of feedback. The comparison can be to others
or within themselves on scales. For example, a therapist could use the
DrInC scales to convey where the client acknowledges experiencing problems
and where they seem to be doing fine. An informal feedback opportunity
that frequent arises is tolerance. Clients often point to their ability
to "hold" alcohol as a sign there is not a problem. This statement allows
the therapist to offer information about how tolerance operates, including
the potential detrimental effects of circumventing this early warning
system. Feedback can also be from locally used instruments or information
gathered in the session. For example, in exploring HIV risk behavior,
on emight elicit information about values, goals and sexual practices
and then review with clients the information they shared, including
any inconsistencies observed. They then explore together these inconsistencies.
The most important point here is the therapist acts simply as a conduit
for information. The client is given the job of ascribing meaning. An
example of informal feedback might go like this:
Mary, would it be okay if I offered a little information to you
based on what we've talked about so far? Correct me if I'm wrong about
anything. To begin, it sounds like you've noticed an escalating pattern
in your cocaine use. This is a source of some concern to you both
because of your parents' history of substance misuse and because you've
begun to drop away from your old friends. You're spending a lot more
time recovering from the use and the financial drain has begun to
create some issues with your husband. You've also noticed the high
has changed and your using more to get to that place you want. Finally,
you are concerned about your relationship with your kids. You swore
that you were going to be a better mom to your kids than your mom
was to you, but now your not so sure how you've done with that. I'm
wondering what you make of all this?
Values Exploration
A values focus can help a person define his or her "ideal self"
by exploring those behavioral ideals to which the person resonates.
Sometimes, individuals have forgotten about these values or have rejected
them as naive or unachievable. Simply focusing on these ideals can help
open a person detect actual behaviors inconsistent with the ideal.
A focus on values may stimulate motivation for change. Focusing on
discrepancies between ideal life conditions and actual conditions may
induce a desire to "recalibrate" daily behaviors to be more
congruent with deeply held beliefs. Awakened to a deeper sense of self
and values, the person may become increasingly aware that the problematic
behaviors meet certain short-term needs but do not lead to fulfillment
of higher values or long-term satisfaction. Focusing on ideals can help
decrease clients' defensiveness and increase desire for change by shifting
the focus away from consideration of "bad" behaviors or lifestyle,
toward a focus on a more deeply satisfying lifestyle that can be pursued
and enjoyed. Clients may come to perceive that they do not necessarily
have to purge valued aspects of their current self; instead they need
to restrain certain tendencies in order to develop a deeper, more aware
self and live with a greater sense of purpose (importance) and power
(confidence).
Ambivalence about various possibilities can be viewed in part as the
experiential result of multiple conflicting values. While ambivalence
may be resolved from concluding that longer-term values (for example,
stable job, good family and friend relationships, ownership of property)
take precedence over short-term values (for example, fun, relief from
stress or anxiety, excitement), there are other paths to its resolution.
Sometimes, it is not so much a conflict between the long- and short-term
values themselves but an issue that the strategies for fulfilling short-term
values are precisely those strategies that prevent fulfilling the longer-term
values. There are other ways to gain excitement other than using cocaine
and living a fast lifestyle. By seeking with the client the positive
motivations behind the problem behaviors, we can open the door to consideration
of alternative behaviors that address short-term needs without unduly
interfering with the pursuit of long-term goals.
In addition to a general discussion of the client's values, counselors
can use a set of values cards and have the client sort through the cards
and order them in accordance with his or her priorities. Topics discussed
may include the meaning of the various values statements, evaluation
of current consistency between values and behavior, perceived barriers
to and opportunities for increasing value-behavior consistency, and
personal evaluation of the extent to which the use of substances plays
a role in achieving or preventing consistency. Counselors sometimes
report that this technique increased the ease of practice as well as
client engagement.
One study of individuals who have made "quantum" changes
shows the dramatic shifts in values that individuals can undergo in
a very brief timeframe. See the table in this link
for an example of the types of value changes individuals can undergo.
Looking Forward
Looking Forward has a similar focus to Looking Back. It has the client
envision two futures. The first is if they continue on the same path
without any changes where they might be five or ten years from now.
The second future is if - and the emphasis is on if - they decided to
make a change in their behavior, what that future might look like. The
therapist's job is not argue one position or another, but rather just
elicit the information and then ask the client to comment on these imaginings.
Exploring Importance and Confidence
A recent strategy developed by Rollnick and colleagues (Rollnick,
Mason, & Butler, 1999) involves the dimensions of importance and confidence.
This strategy essentially explores the client's impressions of how important
is to make a change and how confident he or she is that he or she can
succeed in changing. The therapist explores the client's impressions
of what it is that makes the change important, how this change fits
in with other aspects of his or her life, and what events may transpire
to make this change seem more important than it currently does. The
issues around a person's confidence in changing are explored in a similar
way, and the therapist may guide the client to review past change attempts
and determine how the therapist and significant others could help the
person succeed in making a change.
Decisional Balance
The decisional balance exercise is a values exercise similar to
good things/less good things, except with a focus on future behavior.
Counselors ask clients to identify the anticipated "pros"
and "cons" of changing a behavior, then compare this with
the pros and cons of not changing the behavior. Once the pros and cons
have been identified, counselors may ask clients to consider which of
these options best meet clients' ideals while also tending to their
preferences for experiences. Counselors may reflect that clients have
the opportunity to create different lifestyles and to choose in part
who they will become in the future through the course of action they
choose.
As with a number of these strategies, this one can be done on paper
as preparation for or a supplement to a conversational approach. See
a Decisional Balance worksheet here
(PDF file).
Change Planning
A change plan is a technique that can be quite helpful with clients
that are ready to do this type of work. To avoid a premature focus on
action plans, some have taken to calling these forms, "The Next 90 days."
This form can then be used to record any number of actions including
simply thinking more about an issue. This form typically includes just
a few simple questions (Fill in), which the therapist and client fill
in conjointly.
See a Change Plan worksheet form and completed sample here
(PDF file)
Do it All in a Moment or Two
One counselor, Chris Dunn, has offered what he calls the 20-second MI
intervention. Apparently, there are also colleagues at Kaiser-Permanente
in Portland who are doing similar work. The basic premise is you have
a very brief amount of time and a potentially thorny issue to solve.
Chris simply clicks through an acronym-based model called FRAMES and
leaves the client with the responsibility for making a choice. For example:
So, Bill you are in your third week of treatment and your feeling
like you've accomplished everything you need to (FEEDBACK). My sense
is you've begun exploring what's led to your drinking (FEEDBACK).
I am concerned that you've not spent much time thinking about how
you'll handle your homelife (FEEDBACK). If you asked for my advice,
I would recommend you stick with treatment a little longer and work
on this area (ADVICE). However, there may be other ways to do this
(MENU OF OPTIONS) and the choice is really yours to make (RESPONSIBILITY).
I know you've been feeling antsy (EMPATHY) and I have faith that you
can make a good decision (SELF-EFFICACY). What do you think?
Monitoring the effectiveness of your use of MI Strategies
Although formal research methods for client outcomes are a worthwhile
goal, this is unlikely to be available for many clinicians. A much more
practical method is available for practitioners: observe your clients.
If during the session they are constantly arguing, disagreeing or ignoring
you, then what you are doing is not working. It's a signal that you
should shift methods. Even if you convince them of the folly of their
ways, change is unlikely to be sustained under these circumstances.
If clients agree to do something between sessions, then fail to do it,
this does not necessarily mean there is a problem. It may simply be
ambivalence. However, if it happens consistently, then you may be arguing
for change and the client is simply acquiescing. It is time to focus
on listening to your client. Finally, if your client's don't return
for sessions, it may be a sign that they are giving up you rather than
the problem behavior. You may have pressed too hard for a change the
client was not ready to make. Our advice: pay attention to your clients,
they tell you one way or another how you are doing.
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