This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at ALLCEUs.com/CounselorToolbox. I'd like to welcome everybody to today's
presentation on enhancing motivation part two. We will learn about the nature
of change. You know it's great to know how to motivate people which is what we
talked about yesterday and have those some of those techniques under our belt
but we have to understand the change process so we can AB and flow with that
process so to do that we'll explore the different stages of readiness for change
will learn about goals and interventions for each stage of readiness for change
so somebody who comes in involuntarily they may be in a stage we call pre
contemplation we're going to do different things with them then somebody
who comes in and sits down and says doc I need help I'm ready to do whatever it
takes so we'll talk about what to do at each stage we'll identify ways to
identify a client's change in readiness for change how's that for a complicated
sentence clients who may come in and and when I first went into substance abuse
treatment you know I would get really frustrated because clients would come in
and they'd be kind of hemming and hawing but they had to be there and they would
go through treatment and they would seem like they made progress and then they'd
be back in detox 30 60 days later and I started to get kind of frustrated and I
asked my supervisor I'm like mark what am I doing wrong it seems like the
changes aren't sticking and he looked at me and he laughed and he was a very
Socratic supervisor and he said you know what they came in they weren't even
thinking about change or they were not thinking they were ready for it and you
got to them to the point where they were willing to start working on stuff what
they've been doing they've been doing for 20 years
getting them to move up one stage in their readiness for change is all you
can hope for in in 30 days you know you're not going to move them from not
wanting to be here to just being in all the way 99.9 percent of the time so we
need to understand how to identify when a client's moving from not being ready
at all to thinking about it but really not ready to take that step where
interventions that we four would be useful to moving to that
stage where we can offer interventions and they're like yeah that might work or
no but let's try this we will explore ways to identify barriers to recovery
sometimes it's not that the client isn't ready and wanting to change but they
don't have all their ducks in a row they have too many barriers that are keeping
them from change whether that's finances or childcare or accessibility you know
maybe they live in a rural area and it takes an hour and a half to drive to
your office so look at some of those things well learn how to explore
expectations regarding recovery and how to use that to enhance motivation and
briefly review how to develop a relapse prevention plan and remember when I talk
about relapse here I'm talking about a return to prior functioning whether it's
substance abuse or depression or anxiety their symptoms are back so we want to
help them figure out how do you prevent this and how do you know how do you what
are the signs that you might have another episode starting so you can
intervene early instead of having to go into a full-blown major depressive
episode before you start taking corrective action so change is constant
which means of course it occurs all the time in the natural environment you know
you go outside the temperature temperature has changed today from when
you got up to when you went to work hopefully it got warmer yesterday it
didn't it got colder throughout the day here so you know change occurs change
occurs among people the way you interact with people you can grow closer you can
grow further apart you can have little hiccups in your relationships you know
there are a lot of different things that can happen and as you change you know if
you've done couples counseling you know that the two people who met
when they were 16 or 18 or whatever and now they're 40 they are very different
now they may still be close of course if they're and they're in our office
they're probably not but you know we hope they're still close but they've
both changed and it's a matter of did they change in a way that was you know
complimentary or do they diverge in some way and we
need to help them try to get back together and change happens in relation
to behaviors you may decide you're going to do something and you go gangbusters
and then you kind of get bored with it you may go gangbusters and figure out
wow this is really awesome and keep doing it so change is going to happen
and it's based in large part on the motivations in our environment you know
if we're getting even if it's tough if we're getting support and encouragement
we may keep doing it and unrewarded see the reward is not too
far away we're probably more likely to change our behaviors it occurs without
professional intervention so yes as professionals we can be awesome
catalysts and help people you know move along that path along that process more
quickly but you know change eventually what happened when somebody is
clinically depressed they can't stay that way forever they will reach a
crisis point where something's got to give relationships you know if people
are in a relationship and it starts getting rocky eventually change is going
to happen one way or another because people aren't going to keep doing things
that make them miserable so either they're going to come to an
understanding go to counseling break up whatever is going to happen without
professional intervention with professional intervention we can help
them identify in an ideal world what are your goals where would you like to see
this go and how can we help you move that way how can we help you orchestrate
your own change the change process is cyclical so people are going to move
back and forth between the stages and cycle at different rates so you may
start a group with eight people in your group and you know two of them just
don't seem to get on the bandwagon they're just not ready to go and you
know the other six are doing really well and are progressing really quickly but
we have to look at those other two and say okay what's different and how can we
activate their change process a little bit more and I said they go
back and forth because like I said yesterday when the going gets tough the
tough may think about not going anymore think about going to the gym and trying
to get get in shape trying to start exercising my mother always used to do
this bless her heart she would go out and she would go gangbusters and when it
started getting hard you know when she'd wake up in the morning and everything
hurt she's like I'm not sure I really like this or if she went in and she
tried to do too much the first day and it was just really unpleasant the
motivation for her to go back the next day was yeah down there so her readiness
for change backed up she may start thinking well you know maybe this whole
fitness thing is a little overblown you know I can just watch what I eat to lose
weight you know I can find a different way to achieve my goal because this
fitness thing ain't for me so we want to help people figure out you
know if they want to change when it starts to get uncomfortable how can we
either minimize the discomfort and or help them see how the discomfort is
worth it sometimes it's worth just writing it out in order to get to the
other end it's not uncommon for people to linger in the early stages so in pre
contemplation or contemplation when they don't really think they've got a problem
or they're concerned about it but not ready to do anything they may linger
there for a while and go you know how can I fix this on my own can I get a
self-help book what could I read not really ready to go to treatment
recurrence of at least some symptoms or old behaviors is a normal event and many
clients cycle through different stages several times before achieving a stable
recovery so think about a client who is dealing with anxiety or depression you
know they're doing really good and then something happens you know whatever that
something is and they start having some negative thoughts and they start
worrying a little bit more again and having a little bit more difficulty
concentrating and sleeping okay does that mean they've relapsed completely No
you know they're not sleeping all day and they haven't fallen back into those
behaviors that they have when they came to treatment the first
time so we need to say all right how can we intervene now before it becomes a
full-blown relapse the same thing with with smoking for
example some people when they when they stop smoking they might fall off the
wagon and have a cigarette or go places where they can smell secondhand smoke
you know beggars can't be choosers sometimes just to try to you know get a
little bit of relief and so we want to help them figure out what's going on
when you hit that place where your urges or your cravings or your you know
behaviors or thoughts start getting bad again you know what's different what
changed and what can we do to help you work through that and make that as not
unpleasant as possible there are six basic stages in the process of change
and I always liken it to getting into a cold pool pre contemplation you're
sitting out on the pool you know you're getting Sun you're fine it's great it's
wonderful no problem you don't have a problem contemplation
it's starting to get warm you've been out there for about an hour you're
starting to bake and you're thinking oh that pool looks really good but it is
really freaking cold and yeah I'm not that I'm not that hot yet we'll just I'm
fine preparation you've sat up and you're like it's starting to I'm
starting to get uncomfortable I'm sweating so you move over to the pool
and you start to like dangle your feet in just to see how cold it really is and
kind of get a feel for it and see if there are kids that are gonna come
splash you and stuff so you're preparing to get in the pool but you're not there
yet you've decided it's probably what you need to do but you're not ready to
take the plunge and then action is when you decide alright I'm hot might as well
just get it over with you jump in the pool wonderful now at this point in
order to warm up and well cool down and warm up get comfortable you probably
need to move around and do some things so if if you jump in and it is too
unpleasant you may not stay in until you swim
around enough to warm up you may just get right back out and say oh that
was too painful you know what I really wasn't that hot after all so somebody
who has who's smoking who's trying to quit smoking
you know pre contemplation whatever people blow it out of proportion
everybody in my family family smoked my grandmother smoked until she was you
know 97 years old and she never had a problem so they minimize the problems
they're just unwilling to consider the fact that it might be a problem for them
contemplation they start to see that okay the research says that smoking
causes a lot of problems it's expensive but I just can't imagine not smoking
anymore it's what I do when I'm stressed all right so preparation the person has
decided you know what I really need to try to quit smoking it's I need to do it
from from my health for my family or whatever okay great but they're not
quite ready to do it they're thinking about what they need to do in order to
make this change happen and then action is when they say okay I'm gonna go to
the doctor I'm gonna see about getting some you know nicotine replacement gum
or medication I'm going to look into some of these programs that help can
help me quit smoking ready to do it so then they go and they quit smoking and
the first week they have those cravings and they're used to smoking at certain
times a day and doing certain things so they have certain habits and they
encounter those they're like crap I can't smoke what am I gonna do it's
uncomfortable it's stressful it's anxiety provoking and the function that
the smoking used to serve for many people which is calming them they're
stressed out and they don't have anything else to replace it yet
oftentimes so what happens they say I can't do this I just can't do this and
they go back to preparation they're like ya know maybe I can think about finding
another way to quit smoking but that one that was just too painful so then you
can see how it cycles back and forth and then we'll stay with smoking we have the
recurrence they're doing good they're using their nicotine
placement calm six months down the road and then all of a sudden one day they
just get this craving for whatever reason we won't go into triggers right
now and decide you know what I'm just gonna have one cigarette I've been
really good for six months I can just allow myself to have one cigarette they
smoke that cigarette and they're like oh yeah I remember what this was I remember
why I like used to like smoking which can keep them smoking again unless they
say you know what no it was good there were benefits to it but all the reasons
I decided to quit are all the reasons that I'm gonna stop smoking again in pre
contemplation the client is unaware unable or unwilling to change so what we
want to do is just establish rapport you got that smoker coming in and he's like
my insurance company said that I had to quit smoking in order to get my rates
lower and my wife said we needed to get our rates lower so I'm here alright so
we can raise doubts about their patterns of use if the person says I don't smoke
that much we could say how much do you smoke
on average we can give information on the risks and pros and cons of use now
they probably already know the risks and cons of use so we can ask them what they
know if that's helpful we can give them a handout you don't want to belabor it
because you don't want it to feel like we're lecturing at them but we want to
make sure they have the information we also need to talk about the pros of use
why do you do it what's the benefit because if we can't figure out what that
is we can't replace it with anything if we figure out it's how you deal with
stress if we figure out is what you do instead of when you want to eat instead
of eating what we can help you figure out different behaviors to put in that
place and we want to explore the reasons for unwillingness to change you know you
know it's a problem you're here so obviously part of you thinks that you
might be willing to consider making a change what's stopping you
it could be they've tried before and they failed and they don't want to do
that again it could be they're afraid of the
different interventions they're afraid it's going to be too they haven't tried
before but they're afraid it's gonna be too miserable because they've heard the
stories we want to talk about what are the reasons maybe they just can't
envision themselves as a nonsmoker maybe that's something that has always been
part of them they've smoked since they were in high school so go down those
avenues the client is likely to be wary of the counselor enough treatment so we
want to make sure that we don't want that we don't rub the client the wrong
way don't lecture to them it always drives me crazy when I used to watch
cops when the police officer would get somebody and they'd have cocaine or
something and the cop would sit there and lecture them about how bad it was
and what they're doing to their future and I'm just like please just hush
because it was patronizing the person already knew that they were very clear
and the cop didn't know this guy from Adam so didn't know what his motivations
for use were so it was just like fingernails down a blackboard and we
want to try to keep it informal if the clients not wanting to be there and in
pre contemplation we don't want to be trying to make clinical diagnosis we
want to talk to him and go what are your concerns what brings you here today try
to get that rapport going so he or she doesn't feel pushed or pressured
ambivalence is common and normal whatever we were doing had a benefit
whether it was stress eating or drinking or you know even self-injury when you
look at what was the function of it and how did it benefit this person what were
the rewards that maintained this behavior there was a benefit to it and
it wasn't necessarily a healthy benefit but it served a function so we want to
help people see it's okay to be in bivolo chase is hard so if the person
starts to argue challenge or discount what you have to say just let it go
I can see your point if you can see their point or tell them that they're
perfectly fine have it's perfectly fine for them to have their own opinion if
they interrupt or try to take over or cut off the conversation
you know you're gonna want to roll with that as much as possible
so you can identify that maybe they're cutting you off because they don't want
to hear what you have to say or you know you can paraphrase how you're feeling
and go in that direction or you can just kind of stop and go alright what in what
way can I help you or what do you think is going to be most helpful for you they
may deny that they've got a problem blame other people for blowing it out of
proportion disagree that there's an issue minimize how much they use or how
much the problem exists or ignore just not responding or not paying attention
just whatever we've probably if you work with clients
who are involuntary you've probably had at least one of the ignores during this
phase we want to explore the meaning of the events that brought the client to
treatment or the results of previous treatment or both so why are you here
and what does that mean to you that your wife is saying that you need to come in
and figure out how to stop smoking you know the person may be really irritated
because they feel like they're being pressured into it but if we can help
them change their perspective a little bit or reframe it as their wife cares
about them and wants them to live longer not just save money on insurance then we
can maybe help smooth it out and moderate their attitude and their
resistance because the more somebody feels pushed the more they're going to
dig in so we don't want to push we want to pull they want to join we want to
elicit the clients perceptions of the problem offer factual information about
risks provide personal feedback about the assessment so you know let them know
what your assessment really is if you're doing a health assessment and somebody
is on the obese side you know give them feedback especially if you're using the
BMI the body mass index is what it stands for that can be kind of deceptive
because you can have some people who are really
skilar my husband is one who you know he's tall and he's on the overweight
side of the BMI but when you look at his body fat his body fat is only about 20%
so you know we want to help them understand the numbers that we're giving
them understand what their risks are based on you know multiple different
measurements but if somebody comes in and they say you know I don't really
feel I'm overweight but you can see that their body fat is higher than it should
be for health you can point that out and point out why having high body fat or
why carrying weight around their middle can be a risk factor for a lot of other
problems explore the pros and cons of and here I still have just substance use
but explore the pros and cons of their current behaviors smoking eating you
know if they're overweight maybe they eat because they like food I love food I
will not apologize for that at all that's why I run because I love food so
we want to look at what are the pros of use because if the person's afraid that
they're not going to be able to eat the foods they love anymore then they're
gonna be more resistant so going back to that decisional balance exercise what
are the drawbacks you see to change you know let's see if we can minimize those
helped a significant other intervene so if you've got a family member who's
willing to intervene or willing to be there help them kind of chime in and
provide feedback examine discrepancies between the clients and others
perceptions of the behavior you know you say that you're fine you're smoking
you're not smoking that much you always go out on the porch it doesn't bother
anybody what are other people's perceptions what does your wife have to
say about that if she were here and we can ask that even if the wife's not
there if your wife were here because the husband is heard what the wife has to
say he knows what she'd say and express
concern and keep the door open say okay you know I hear you're not ready for
change yet or you don't think this is a problem but if you ever decide it is my
door is always open way the person doesn't feel like you're
trying to sign them up right away and they don't feel as pressured and they
have the ability to decide you know what I think I might go back and talk to her
again contemplation the client is ambivalent or uncertain still
considering the possibility of change they've recognized that there might be a
problem but they really can't imagine change quite yet so we want to discuss
continued away the pros and cons emphasize the client's free choice and
responsibility I can't make you do this you know this is on you and when we
embark on a journey together if you choose to then you're gonna help me
because you know what you've lived in your skin for 30-some odd years I've
known you for 30 minutes so you know you're the expert on you I know a bunch
of techniques and tools we can put those together and see how I can help you
improve your change process and we want to elicit self motivational statements
what are the reasons you want to change why do you believe you can change help
them realize that they can and get excited about it what are the benefits
to do you see to change you know so what did they see as the benefits what we
think is important may not matter to them reassure the client that no one's
gonna force him to change and that he's in charge um I had a client come in one
time and she sat down and promptly told me she was not gonna go to any of those
meetings hi my name is dr.
Snipes but she was just adamant she was gonna get
that out there the minute she got into the room she'd been in the system for a
long time and evidently had been put in treatment and pushed into things every
time she came into treatment and I just kind of sat back and I'm like okay and I
said I introduced myself and I said let's just kind of talk about what's
going on and then we'll talk about what you will do what are you willing to do
if you're not going to go to meetings there's no reason for me to put that on
your treatment plan because you're just not going to do it so let's find
something else for you to do instead and she kind of looked at me and then
went on and I'm not gonna say that the relationship was beautiful henceforth
and forevermore but at least for that session we had a really good assessment
session let's see help the client acknowledge concern and help them
generate their own intention to change so help them come up with a statement of
you know I'm ready to do this help them develop optimism about the fact that
they can do it you know give them a time frame you know most people it takes this
amount of time or if you start work soon or when you start work you should see
some appreciable changes in the first three weeks or if you're talking about
smoking cessation you know the first two weeks are probably going to be the worst
for you know withdrawal and cravings and those sorts of things even if you're on
taking some of the medications but you know this is what you can do in that
period to try to help you through it let them know that there's a light at the
end of the tunnel the same thing if you have a client that's taking psychotropic
meds for most antidepressants and atypical antipsychotics the first few
days are pretty miserable so help them realize that just say let them know
ahead of time the first couple of days you may feel like you've got the flu or
you may be really crog II that is totally normal so if if it's too
debilitating obviously you want to call your doctor if it has gives you any
concerns but please don't stop just because of that
call your doctor first help clients see a difference in what life might be like
if they made this change show curiosity about their strengths and explore how
skills and competencies may be negated by their current state so maybe this
person is was it was an athlete all through high school and now they've
gotten out of shape and they're smoking and they want to get healthy again but
they're not quite ready to give up the smoking thing so we want to talk about
you know you are this fabulous athlete in in high school how is it how does it
feel now when you try to go out and jog or you know do something some sort
of physical activity and they might say you know yeah you know I am a really
good runner but right now that just ain't happening so you can help them see
connections and reframe negative statements when they start to say you
know those withdrawals are gonna be awful we can reframe them as yes they
are going to be unpleasant but they will end and there are things you can do to
minimize the withdrawal side-effects or you know I don't know if I can maintain
a healthy diet because that means I can't go out and eat with my friends no
it just means you may need to make meth may need to make different choices when
you go out to eat so helping them see how it's not gonna stop their life help
them see how the change can integrate into their life and they're not going to
experience great losses highlight their reasons for change by summarizing
concerns if they've indicated that they're concerned that they're smoking
or their weight might be contribute to a health problem later on in life
highlight that if they indicate that you know it's costing them money and that's
a problem because they're financially conscious highlight that so try to
highlight any concerns that they have explore the pros and cons again allow
the client to explain the benefits like we already talked about we need to
understand the function of this behavior so we can acknowledge it and go you know
what what that's true you know I understand where you might smoke when
you get stressed or when you get stressed you might kind of bury it in a
bowl of ice cream I get that what else could you do or what else have you done
when you felt that way besides smoking or eating or doing whatever assure the
client conflicting feelings are normal continue to review feedback from the
assessment as appropriate we don't want them to feel lectured find out what the
client expects from treatment if they expect it to be a miserable process then
we can allay their fears right there we might just get them on board if they
expect that they're gonna come four times and life is going to be ducky and
something they've been doing for twenty years or a lifestyle that they've
developed over 20 years is going to completely swap around they're going to
be mistaken and they're going to be irritable after that fourth session when
they haven't made as much progress as they'd hoped so we want to provide
information how long does treatment usually take what does it look like for
people what are some common hurdles that they experience and how do we get over
those and help them connect core values to committing to treatment so what is
important to you which people are important to you in your life what
things are important to you in your life and how does that fit with this behavior
change strengthen the clients personal choices by nudging the client to make
positive choices they can make small choices small positive choices if
they're not ready to give up smoking completely maybe they can cut back back
to one pack a day maybe they can switch to lower nicotine content cigarettes and
then one pack a day so there are things they can do to wean themselves down or
start trying it or maybe they're willing to say let me try it for a week okay
cool let's try it for a week you know no commitment if after a week it's not
working for you you know we can renegotiate or you can you know drop
back and come back when you're ready no one can decide this for you you can
choose and we just need to keep saying that over and over again help the
clients set goals and take small steps you know if they go from smoking to cold
turkey with no medication no nicotine patches no nothing just nothing it's
going to be really rough now if that is their choice then you know I'm there to
try to support them if they don't know about the other steps they can take I
want to make sure that they're educated about the options in order to make the
transition a little bit easier if they're trying to change their eating
unless obviously their doctor says you need to do
and now what I usually do with my clients who are trying to make a
behavior change as I say pick one aspect like if they're trying to eat more
healthy maybe they start drinking more water each day do that for a week or so
once that starts feeling pretty good then maybe they start walking around the
block once once a day or whatever small steps don't go from eating processed
foods and meat and fried foods and everything to being a strict vegan
overnight unless you really really want to but most clients aren't going to want
to do that remind the client of triggers including negative emotions social
pressures physical aches pains and concerns and any extended withdrawal
symptoms if we're dealing with sugar if we're dealing with nicotine if we're
dealing with alcohol or drugs there can be sort of extended withdrawal and I
tell clients that urges you know you have a craving you want to eat you want
to smoke you want to do something that's a creep um that's a craving and then you
have the urge to get up there and do it so that's the behavior of you have the
thought craving then the urge is the behavior think about having a bumblebee
on your arm but bumblebees on your arm and you swat
it that's your automatic urge get off of me probably gonna sting you that's
unpleasant we don't want to do that and it's gonna die which is sad because
they're cute it lands on your arm your immediate thought is gonna be get that
off of me but your secondary thought would be you know what if I just if I'm
still it'll fly away in a few minutes same things true for urges just like the
bumblebee flies away and doesn't sting you no harm no foul your urges tend to
ebb and flow and they tend to go away after about 10 minutes unless you keep
feeding them reinforce the clients commitment to change ask them what did
what do you think has to change in your life in your situation to make this
change possible what are you going to do to set the stage for this and to start
making taking steps towards your change what are some of the benefits of making
the change and how would you like it to turn out ideally so imagine you know
you've quit smoking or you've lost the weight or you've you know whatever the
change is you've gotten rid of your anxiety what's gonna be different in
your life what's life gonna look like you're gonna get up in the morning and
how are you gonna feel I can feel the same you can feel different and have
them walk you through a day so you can see how things are going to be when that
change has been implemented in preparation the client will start asking
questions indicating they're willing to consider options to make specific
changes so we want to continue to explore treatment expectancies and
elicit from the client what's worked in the past either for him or for other
people he knows so maybe he hasn't tried just quit smoking or to lose weight but
he knows people who have what's worked for them and what hasn't and then we'll
explore the reasons why at this stage to the client shifts from thinking about it
to planning the first steps starting to think about how might I do this the
counselor can guide the steps by offering to help but we don't want to
yank the client forward and go okay cool let's develop this treatment plan no
we're still talking about options here we're still looking at what could you do negotiate the plan is the next step
after you kind of talk about it for a while maybe the next session you start
talking about just for the heck of it let's try to put together an action plan
and see what that looks like and see if you know you think that that'll work for
you offer a menu of options develop that behavior contract identify and lower
barriers so if they have apprehensions reservations yes but we need to figure
out what those are and get rid of them lower them figure out why they're there
they're there for a protective reason of some sort we want to help eliminate
whatever fear that is associated with so we can move on encourage them to a lit
in list social support and with advice work with advice with permission
offer advice again we don't want them to feel lectured at or told what to do but
maybe they don't know all the options that are available for getting rid of
cravings or forgetting in shape maybe they think the only option is to go to
the gym to get in shape oh no there are so many more things you
can do assist the client in negotiating finances childcare work transportation
or other potential barriers so I would ask them what do you see might get in
the way of this happening for example if people are trying to lose weight and
they start on a weight-loss plan November 1st what's the first thing that
you see is going to probably try to get in their way the holidays are coming up
Thanksgiving Christmas New Year's there is unlimited food in front of you pretty
much all the time it seems like so we want to help them figure out how to
negotiate that they may not lose as much weight as they would otherwise during
the holidays but we can help them learn how to make healthier choices when they
go to buffets at Christmas dinner those sorts of things so they don't go
backwards and they feel like you know what I'm making positive changes and
choices for myself the client indicates reading whoops
and have the client publicly announced plans the client indicates readiness for
change when they stop arguing interrupting denying yes budding no
longer ask questions about the problem but more about how to change so they're
not going well is this really a problem they're saying yeah I know it's a
problem okay so how can I get rid of this apprehension I have about the
withdrawal symptoms or about never being able to smoke again or whatever they
appear calm and peaceful with their choice and they may state an openness to
change I've got to do something this is where you hear action they're ready they
express optimism that they can deal with it they can beat it they can achieve it
they talk about how life will be better after the change and they may even
experiment between sessions and come in and say you know what I tried cutting
down to only having one cigarette in the evening and it was pretty rough but I
started feeling a little bit better or you know whatever they try to do they
may try to start experimenting with some of the things you've been talking about
between sessions so we want to seize on those things and go okay did it work at
all if so tell me about that and what were the problems that may have kept it
from being totally successful and let's see how we can eliminate those things
tweak this intervention to work for you we want to ask clients what's going
wrong in the past when they've tried to implement a behavior change so we can
address barriers provide all necessary information so the clients don't get hit
you know unawares of some change that may come up for example when people are
detoxing from benzodiazepines you're anti-anxiety medications there's
something called protracted withdrawal and they could experience withdrawal
symptoms 3040 days after they quit using we want to let them know that that's
possible we want to let clients know again with substance detox that they may
have dreams about using for the first month or two after they after they quit
using and it may seem really and they may wake up and be like well
did I use or was it a dream just let them know so they can develop a plan for
how to cope with it other barriers can include family relations maybe their
family's not supportive of whatever this changes they want to eat unhealthily
they love their fried foods or they're not willing to get the alcohol out of
the house or whatever the case may be they may have health problems that keep
them from making all of the changes as quickly as they wanted they may have
depression or other negative feelings that really saps their motivation
they're just like I'd like to change but I just don't have the energy to think
about it right now we can address that we got to address the depression before
we can address this change we've got to help them eliminate or pull down some of
those barriers bureaucracy such as waiting lists paperwork or insurance can
also get in the way of them either being able to access or afford treatment and
finances so let's look at all those areas see if there's anything that jumps
out that we might be able to help refer them to assistance in action the client
takes steps towards change but it's still unstable they've sat down they've
said I got to do something help me out I'm willing to do whatever it is okay
cool but that doesn't mean they've got it
covered that means they're willing to try to take steps it's like when you
take your kid out and they want to learn how to ride a two-wheeler okay I took
the training wheels off you push him out you don't push him out into the road and
go good luck you know thinking that he's gonna be stable and riding like a pro
you're running behind him kind of half holding the back of the bike so he
doesn't fall down the first first few hundred feet or whatever and then you
let him go tentatively because you're not sure you see them kind of
wibblewobble in that's action that's people starting to make a change people
don't just get it and smooth into it so we want to acknowledge difficulties and
support their attempts even if they try it and they relapse okay let's see what
went wrong let's adjust this action plan to make it work for you let's see what
we meant and I usually use the pronoun we because
we're trying to work as a team identify risky situations and coping strategies
so people can be prepared ahead of time for how to deal with things help the
client find new reinforcers so instead of eating when you're stressed or
instead of eating when you've had a long day what can you do to reward yourself
and support perseverance and sticking to that plan they may come in and go this
was a great week all right awesome or they come in and go it was a tough week
well let's really give them kudos for sticking to the plan then because
sometimes well all the time it's harder to stick to the plan when it's
unpleasant than when things are going well in this stage clients are receptive
to the full range of techniques but can wax and wane and their motivation you
know when it gets hard when it's uncomfortable when it's not as rewarding
when they're starting to have those cravings and miss the old behavior their
motivation is going to wane a little bit so we want to review their decisional
balance we want to review how much progress they've made we want to review
how things are different now even three weeks into treatment than they were when
they started if relapse occurs just back up and apply
techniques from an earlier stage so if they go back to pre contemplation and
they're like you know what I don't think I need to be here okay
so let's talk about that a little bit and then leave the door open so you're
going back and you're reviewing resetting the stage and opening it up
again in the action stage we want to engage the client in treatment and
reinforce the importance of remaining in recovery support of view of change
through small steps acknowledge difficulties for the client in early
stages of change it's hard you know even in the early phases of the action stage
when they start making changes they've been responding a certain way to stress
for example for 20 years so expecting them to turn on a dime and respond a
different way a hundred percent at a time is unreasonable
so I'll let them know let's see if you can just even if you respond in the old
way okay acknowledge it say oops I slipped up what can you do in order to
make sure that doesn't happen again how can you learn from it and the fact that
you noticed that you responded in the way that you didn't want to indicates
progress so let's start keeping track of you know how many runs hits and errors
you have so to speak acknowledge difficulties help the client
identify high-risk situations and develop appropriate coping strategies
other reinforcers explore past experiences and their hopes and fears
regarding confrontation and judgment you know have they had an attempt at change
before and whoever they worked with was more like a drill sergeant well okay
that's not me if they have concerns about costs in money or changed behavior
maybe they're concerned because you know I love staying out late I'm a night owl
but if I stay out late then I'm groggy on the next day and gets my circadian
rhythms out of rack out of whack and it triggers my depression okay so let's
talk about how you can negotiate that because you want to stay out late but
you also don't want to be depressed how can we try to compromise here they may
have to give up certain activities at least temporarily for me I'm big into
animal rescue but at a certain point I had to get rid of all of the most of the
rescues that were on my facebook page because my page was literally filled
with urgent will be euthanized today urgent will be euthanized tomorrow and I
would just see these sad puppy faces and I'm like oh you know it was it was
having it's taking a huge toll on me and you know I was just cross posting my
life away so at least temporarily I had to stop doing that and just focus on my
fostering family involvement shame and guilt could also be you know a hope or a
fear the shame and guilt part but they can also hope that their family's going
to get involved so let's talk about what you hope is going to happen and
how we can help make sure that happens how can we get your family involved in a
way that's comfortable for you they may be concerned about medications that they
will have to withdraw from or take reminding them that everything is their
choice so if they don't want to take the medication you know obviously there are
some exceptions but they are in charge of their treatment they may perceive the
rules is too strict with no wiggle room for example if there's some of the
patches for smoking cessation that if you smoke while you're on them could
actually be life-threatening so yeah there's no wiggle room there if
you are concerned about that you know maybe that person would be more willing
to look at a different medication or a different intervention or maybe that's
an excuse so they have wiggle room either way you know I'm not going to
start going well that's just an excuse you need to take it I want to make sure
that they're comfortable with the path they're going down immunize them against
difficulties by role-playing and continuing to talk about their concerns
and resolve those barriers to treatment increase their motivations by helping
them see the value of both internal and external motivating factors we talked
about those last week social supports emotional benefits cognitive benefits
physical benefits financial benefits all of the reasons that they're doing this
suggest to the client that external coercion
may be compatible with their best interest so if the insurance company
says we're going to drop you from our policy unless you quit smoking yeah that
probably rubs them the wrong way however you know they want to make money because
they don't want you to be sick so you know it may be in your best
interest examine interpret non-compliant behavior non-compliant behavior is a
thinly veiled expression of dissatisfaction with treatment or a
therapeutic process so it's not necessarily them saying no but it's a
dissatisfaction with the way things are going either because it's uncomfortable
because it's unpleasant because it's not something they want to do
you well if they don't want to do it why not why is this other behavior more
rewarding so instead of saying you have to get in their mind and say why
wouldn't you want to it could be you you know maybe you're not forming a good
therapeutic alliance so check that see what you're missing
maybe you haven't attended to all the concerns or the you haven't considered
all the benefits of the behavior so you may need to dig a little deeper if the
clients in maintenance they met their initial goals made changes and they're
now practicing coping and maintenance strategies so we want to support and
affirm their changes continue to rehearse those new coping strategies and
encourage them to visualize and you know going to a party and making good choices
or refusing a cigarette or whatever it is review their goals and keep in
contact if your agency has aftercare or support groups on-site it's a great way
to keep in contact without having to I hate to say it take away from your
buildable hours but in some agencies your billables are really important in
this stage the clients are keeping on keeping on we want to remind them about
their new tools and reinforce recovery reminding them about their action plan
to be aware of risky situations have coping strategies for each situation
participate in some sort of 12-step or support group program
there's Overeaters Anonymous they're smokers Anonymous there's schizophrenic
synonomous there's there's an anonymous for everything but there are also other
non 12-step support groups that are out there and support is essential encourage
them to pursue hobbies and cultural activities to fill up their time so
they're not don't have time as much time on their hands to engage in that other
behavior and maybe encourage them to look at volunteer opportunities to give
back if they're teaching smoking cessation techniques they're going to be
more likely to be implementing them just like if you're teaching mindfulness
you're going to be more likely to implement it and vice versa
help the client identify I and sample drug free sources of
pleasure so they're not drinking they're not smoking what else can they do
support lifestyle changes affirm the client's resolve and self-efficacy help
them practice using cope coping strategies so give them some scenarios
if you're running an aftercare group maintain that supportive calm contact
and develop a fire escape plan if the client feels symptoms returning or
return to old ways of thinking so if you see yourself starting to go down this
slippery road what is the first thing you need to do that's their fire escape
and call you what is it and review the long term goals with the client form a
plan by identifying their triggers for use or whatever the behavior is identify
their triggers if you're talking about depression or anxiety what triggers that
for them identify the effect or benefits of the old way of responding to the
trigger so if when they get depressed they tend to crawl into bed and pull the
covers over their head for two or three days at a time what are the benefits of
that but what are the drawbacks you know let's look at both and identify
alternate helpful coping responses so if they wake up and they feel really
depressed that morning you know what can they do instead of staying in bed all
day long that might be more helpful develop reinforcers competing reinforces
you can't do them at the same time so if one of the things you do when you get
depressed is sleep all the time what can you do that's not sleeping you know
maybe you force yourself to get up and go to the library well you're not gonna
sleep at the library but you're still not having to interact with people
if you cry all the time maybe when you feel like crying you know do something
else that can help you feel happy and you know I don't want them to avoid
their emotions but I also don't want them to get stuck where they're crying
for eight hours if they self-harm you know what else can you do and you know
you may start out with snapping a rubber band or something or you could go to
something completely different one of my clients used to put on there was a band
that she really liked and she would put their music on on her
headphones really loud and she would kind of get into the words of their
music and it would SAW serve a similar purpose to her self-injurious behaviors
create contingent or if-then reinforcers if you respond effectively to a
situation then you can do whatever or if you get out of bed by 9:00 8:00 9:00
a.m.
Each day then at the end of the week you can whatever the reinforcer is
so the reinforcer is contingent upon them using their new skills and then
natural consequences our community reinforcers like friends and family
going that's awesome and giving them positive support relationships improving
etc now if they recur if there's a relapse help the client re-enter the
change cycle and commend any willingness to reconsider positive change because
it's probably a big letdown and they feel defeated they feel deflated okay I
can I can get that however you're coming back and you're trying again or you're
willing to think about trying again and that tells me that you know you can do
this and we just have to figure out what went wrong and fix it so it doesn't
happen again we want to explore the meaning and the reality of the relapse
as a learning opportunity we missed something you know it could have been
they were going along and they quit being mindful and they had all these
relapse warning signs coming up and they weren't taking care of themselves then
all of a sudden boom because relapses really don't come from out of the blue
so we want to explore what change that led up to this relapse assist the client
and finding alternate coping strategies and continue to maintain supportive
contact a lot of times they don't need to re-enter full-blown treatment a
couple of sessions to help tune up again is plenty motivational interviewing and
motivational approaches are a means of rapid engagement in the general medical
setting or in our settings because we can't guarantee a client is going to
come back a lot of times they don't put a priority on their
mental health so you know what we got them we need to try to increase that
motivation while they're there a first session can increase the
likelihood that a client will return so we can deliver but we also want to
deliver a useful service during this first session in case the client doesn't
come back when they leave that assessment make sure they're walking out
with some sort of skill or tool that can help them start feeling better because
if they try it they start feeling better they may go oh maybe she knew something
let me go back and try that again an empowering brief consultation when a
client is placed on a waiting list can be really helpful if they come in and
it's gonna be 30 days before they can get in or two weeks they're like I need
help now okay so let's sit down and talk about what
you want to do let's develop this change plan and hear where you're at so they
can feel like they're making progress they can stay motivated for entering
treatment and it can prepare clients for treatment to increase retention and
participation you get them psyched you get them jazz and then they're ready to
come in when it's time it helps clients coerced into treatment move beyond an
initial feelings of anger and resentment so they can see what's in it for me it's
a means to overcome client defensiveness and resistance because that tells me
that they're scared or apprehensive about something they're feeling like
they're they've lost control and they're being forced into something so these
motivational approaches give them back their power and establishes more of a
partnership you're always still going to have more power but it establishes more
of a partnership it can be a standalone intervention in settings where there's
only a brief contact so if you're doing a screening or if you're working for an
EAP motivational interventions can be really helpful and it's also a
counseling style that can be used throughout the whole process of change
because motivation is going to wax and wane so you know 12 weeks into the
process you may still need to pull out some of those motivational tools because
you see the motivation waning to get somebody excite
and get them back on track other things to remember there's a relatively short
period of time to make a beneficial impact so we want to make sure that we
get some change if we don't make an impact in the first session or two then
we may not make an impact at all so we need to make sure to get clients
involved otherwise they may either drop out or just kind of come and go through
the motions so just like when somebody starts at work starts at your job you
don't let them you know goof off and play on Facebook for the first few days
that they're there know you expect them to be with the game and you know because
then they're gonna keep with the game after that they're not going to be going
well I can just coast and get my requirements met make the best use to
the first conflict contact it's usually a mistake to start out a session with
filling out forms I know I say this all the time but people do it and just it
drives me crazy talk to the person like they're a human being because guess what
they are get to know them a little bit five minutes will not hurt you at the
beginning of the session before you start doing paperwork and walking down
the hall talking to the back of their head or turning around and talking to
them that doesn't count sit down and make sure they know they're
a priority even one session can make a positive impact so make use of it every
single session can have a positive impact lasting change takes time and
effort but all clients have the ability to make positive choices and changes we
just have to help them figure out what they want and how to get there clients
will be at different stages of readiness for change between different issues so
they may be ready to change there they're eating but not they're smoking
or something else and that's okay so let's focus on the eating for now we'll
talk about the smoking later you know let's have you have some successes and
develop some self-confidence clients with low motivation may begin arguing
ignoring or becoming apathetic just expect it and realize that they may
start they may be feeling pushed so back up a little bit sometimes enhancing
motivation means focusing first barriers to recovery instead of the
problem itself so help them get their ducks in a row and explore expectations
regarding recovery to enhance motivation how is this going to benefit you finally
develop a relapse prevention plan that helps clients identify triggers and
vulnerabilities such as not enough sleep poor nutrition stressful social
environment and ways to prevent and address these things alrighty then right
on the nose at twelve o'clock do you have any questions you all righty y'all if that was it like I
think I said when I was still muted we changed our software long story but
there was a little glitch in the certificate I think we've got it fixed I
printed out my certificate just fine today so that shouldn't be a problem but
I apologize for those of you who had difficulty getting your certificate
yesterday I will see y'all hopefully tomorrow when we begin our multicultural
series if you enjoy this podcast please like and subscribe
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Snipes by subscribing at all CEUs comm slash
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