Increasing Motivation for Counseling and Change (SAMHSA TIP 35)

Hey there everybody, and welcome to this presentation on enhancing motivation for change. I'm your host, Dr. Donnellice Snipes. This presentation is based in part on SAMHSA TIP 35, which you can find at store.samhsa.gov over the next hour, you're going to learn about the nature of change, explore the different stages of readiness for change, and how to figure out what stage people are in. We'll learn about goals and interventions for each stage of readiness for change and explore ways to identify barriers and expectations regarding recovery or change and how to use that to enhance motivation. Let's first talk a little bit about trauma and change. Though behavior, whatever behaviors the person is currently using often represent the best way they have to survive. Right now, they're using the best tools tool they have in their toolbox. Additionally, change requires stopping the old behavior and starting a new one. So if you have a person who's using this tool in order to survive, and it may not be the best tool, but it's the only one they have, and then you say, well, you got to stop using that, well then what other tool are they going to use instead to help them survive? We just can't take away one without first helping them develop another one. Many people who struggle with emotional distress, stress related health issues, addiction or relationship problems have experienced trauma. Trauma, by its very nature, strips a person of a sense of safety and empowerment. So when we're enhancing motivation, we must pay special attention to, to supporting the person's sense of safety and empowerment. A lot of times when we try to enhance motivation, if we're too aggressive, then we can make the person feel like they're being pushed into doing something which takes away their sense of safety and empowerment. Now, change is constant. It happens constantly in the natural environment. We have plants that grow, plants that age, plants that die. We have it among people. Not only do we change physically, we change psychologically, we change in our relationships, we change our behaviors. There is constantly change going on. Change occurs whether we want it to or not, without professional intervention. Now, professional intervention can help expedite change in the positive direction. But ultimately things are going to change. Nothing is going to stay static. Recurrence of at least some symptoms or old behaviors is a normal event. And many clients cycle through the different stages of change several times before achieving stable recovery. We want to recognize this. So if a person is entering treatment, that often means that they are at least in the contemplation stage of change, if not the action stage, which is great, and we'll talk about those different stages in a minute. So they enter treatment, they're ready to get going. But as they start working through treatment, as they start doing the work that they need to, it can be terrifying, it can be exhausting. Or they can run into barriers that they didn't anticipate, and they may drop back to an earlier level of readiness where they say, you know what? Maybe it wasn't that big of a problem. It's important for us to recognize that that is entirely normal. And part of it, as I mentioned, may be because the person didn't anticipate certain challenges or barriers. And part of it may be that they went too fast or we didn't help them develop the skills and tools they needed to to replace the old behaviors, to move towards that rich and meaningful life. There are six basic stages in the process of pre contemplation. Contemplation, preparation, action maintenance, and sometimes recurrence. Now, I want you to think about this in terms of getting into a pool. In the summer, when you first go out, you're laying on the pool deck, and it's warm, but it doesn't. It's not a problem. You're not sweating, you're not uncomfortable. You don't see a need to get into the pool or to move into the shade. You're perfectly fine. In behaviors like addiction recovery, depression recovery, the person who is in pre contemplation doesn't see a problem. They don't recognize that they could feel better. Contemplation, they start recognizing that there's a problem. So back to that pool deck. And if the person is laying out there sunbathing, they start to move into contemplation. When they start getting hot, they're like, I'm starting to sweat. I might think about maybe moving, but not yet. I'm not prepared to take any steps. I just recognize I'm starting to get uncomfortable. In terms of recovery contemplation, the person recognizes, well, there might be a problem, but they're not ready to do anything yet, because change is scary. Change is hard. Change can be overwhelming. And they may not even see what options they have for change. Preparation is when they're getting prepared to start to do something back to the pool. So the person is hot, they're starting to sweat. They're getting uncomfortable. Now they start thinking, well, do I want to just go over and sit in the shade, or do I want to get into the pool? And so they go over to the side of the pool, but they know that water is really cold, and you Know, it's, it's challenging to get into a cold pool, so maybe they dip their toe in a little bit, they're testing the waters to see is this something I'm really wanting to do right now. In recovery, we see the same thing. In preparation, the person will start talking about how life might be different. They may start trying to do things that are characteristic of a new way of reacting or a new lifestyle. So they're starting to dabble and try a few things. They're exploring what options are out there, but they haven't really started making major changes yet. Action is when the person says, I'm tired of this, I don't like feeling this way anymore and I'm going to do something. So at the pool, the person gets in the water. In recovery, the person enters treatment, starts participating in self help groups, starts reading self help books. They start doing something actively to change their situation, change their behaviors. Whatever's going on that's causing the distress. Maintenance is the next phase and going back to the pool, you know, the person will swim for a while and they'll, then they'll get out and when they start feeling warm again, they may get back in the pool. The goal is to maintain a comfortable body temperature. For the person in recovery, maintenance means maintaining a comfortable and relatively happy lifestyle. This is a lot easier said than done. So maintenance means implementing all of these new strategies and behaviors and everything that's been learned, which is great, but it is exhausting. And people will often start losing some of their motivation to do everything in their new lifestyle plan, which leads them potentially to recurrence. Now, it doesn't mean they will have a full out relapse, but it could mean that they start having negative thinking patterns like they used to have, or they start staying up all night playing video games like they used to do, or doing something else. Things that we know, behaviors that we know are associated with the prior distress. The hope is that the person and or their support systems are able to identify the recurrence of these problematic thoughts, feelings or behaviors early, when it's only one or two things, and address them before the person falls back into the full lifestyle that was causing them distress. People typically vacillate between the stages and cycle through the stages at different rates. And it's important to recognize this people, individuals within themselves will go through some stages faster than others. Additionally, if you've got three people entering treatment, not everybody is going to move through the stages at the same rate. So it's important to recognize when I was Facilitating residential treatment. We would have people come into treatment who were at all different stages, and some would be in action, and then within two or three days it would start to get too uncomfortable and they drop back into contemplation or even pre contemplation or. Whereas others may stay in the action phase for longer. When you're working with different people, you have to regularly assess their level of readiness for change on any given day. And it can change that quickly. Many people are ambivalent about change. It's hard. One of my mentors used to say, change causes crisis and crisis causes change. And that is so true. Ambivalence is expressed in many ways. The person may argue, they may challenge you, or discount your statements. This is the yes, but where you may make suggestions and well, yes, I could do that. But they may interrupt, take over, or cut off the conversation. You are trying to pursue a exploration of something and they just say, I want to go a different direction with this. They may deny, blame, disagree, excuse, or minimize their behavior or the impact of their behavior. Or they may just ignore you altogether. They may not respond or may not pay attention. They may just kind of be sitting there. This is especially true in group therapy. It's a lot harder to ignore an individual in individual therapy. Ignoring and is when the person shows up late or fails to show up for appointments at all. Now, we want to recognize that ambivalence, or sometimes people will call it resistance, is a manifestation of fear for most people. You have people who have been doing the same thing for a long time to try to survive, and they're not sure if how to change. So let's start talking about pre contemplation. In pre contemplation, the client is unaware, unable or unwilling to change. Now, going back to that pool we talked about, they were unaware of the problem. They weren't feeling discomfort at that point in time. That's the unaware part. But pre contemplation can also be unable or unwilling to change. Maybe the person, for whatever reason, could, couldn't get up and get in the pool. Maybe they had an infant they had to watch, and so they couldn't just get up and get in the pool and leave the infant sitting there. Or they were unwilling because, you know, that pool was awful, daggom cold. Either way, in recovery, we see people who are unaware and we can raise their awareness. We also see people who've tried before and they failed or they've relapsed, so they're afraid to try again. We also see people who are aware of the problem, but they are overwhelmed by the thought of change. They just can't imagine doing it. And we see people who can't see how to change. They don't, can't even conceptualize how to make that change. So they feel stuck. So that's kind of where our unaware, unable or unwilling is. People are likely to be wary of counselors and treatment because a lot of times people are sent to a counselor and they're told, or they start seeing a counselor and they believe that the counselor is just going to quote, fix them. And it's important for us to recognize that fixing them can also be scary and disempowering. And if they've experienced trauma, we need to make sure that they feel like they are equal partners in this change relationship. We want to make sure to respect the client, respect their boundaries, respect their goals for treatment, and keep the interview as informal as possible. If we go in there and try to act all super smart and like we're know it alls, which we aren't, that again, can make the client feel disempowered and unsafe because they're afraid you're going to take their power. Establish rapport is one of the first things that we can do with people who are in pre contemplation. Just because they are unaware, unwilling or unable to change doesn't mean that it's all for none. And people who present who are in pre contemplation are often being sent by somebody else. It's not necessarily involuntary, but they're getting external pressure to enter treatment. That's okay. However, external pressure to enter treatment, what is that? That is a removal, if you will, of some of their personal power. They feel like they're being told what to do. So they may be very anxious and they may be very scared about what's going to happen because they're already getting pressure from somebody else over here. So establish rapport. Explore the meaning of the events that brought the person into treatment. What brought you here and why is this important? Maybe your, your significant other told you that you had to see a counselor at least three times in order to start, you know, feeling better. You know, what does that mean to you? That that person wanted you and put this edict down that you had to seek treatment, elicit the client's perceptions of the problem. You know, why is it that you're here? You know, let's say the person's depressed and their significant other said, you're really depressed. I'm scared for your well being, you need to go See a counselor. And so we want to talk to the client. What is your perception of the problem? Are you in danger? Tell me about this depression. Explore the results of previous treatments. There is no sense repeating something that hasn't worked in the past. So let's talk about different things. And it can be formal treatment, self help, informal treatment, or even if they're family members have the same diagnosis treatments that family members have gone through that have either helped or not helped. Let's look at that, because that can help us figure out what might help us. Where can we start? And it will help the person feel heard and not feel like, oh, I'm going to have to go through all this useless stuff all over again before I get to anything that might work. Offer factual information about the risks and pros and cons of current behavior. Now, when we're talking about addiction, there are a lot of risks. When we're talking about mood disorders, for example, we want to talk about the pros and cons of change. We want to talk about what it feels like to feel depressed and any fears about moving towards recovery. And a lot of people who are clinically depressed, they don't want to feel that way anymore. It's overwhelming or. But especially if they've had remissions before, they also may be afraid of a depression relapse. So they may be stuck in this limbo land where they want to get better, but they're also afraid to at the same time provide personalized feedback about the assessment. And it's really important to help them understand, you know, we talked about all these different things in the assessment. We why did I ask you all these questions? What does that tell me might be going on? When I work with people with depression, I do a really comprehensive biopsychosocial assessment, and I talk about any different areas from sleep apnea to poor nutrition, to autoimmune issues, to cognitions to trauma, to, you know, poor, poor sleep that may be contributing to their particular symptoms. And I say, okay, these are the potential causes, and one or more of these things may be contributing to your symptoms. What do you think? Raise doubts about their current behaviors. And this really goes back to saying, basically, what are you doing and how's it working for you? If they are in pre contemplation, they're saying, you know what? I don't need you, even if I'm aware I've got a problem, I may not be willing to change. So we want to start raising doubts about is what you're doing now helping you live the kind of life that you could and that you want. Examine discrepancies between the client's and others perceptions of the problem behavior. We already talked about the client's perception. Then you may start saying, okay, this is your perception of your depression or your addiction, and this is, tell me about what you think your significant other's perception is. And then compare and contrast. Why do you think that they think it's that much more severe than you do? Or what is contributing to their desire for you to enter treatment? Why do you think they think it's so important for you to enter treatment? Explore reasons for unwillingness to change. You know, what is it that you think may or may not happen? And a lot of times when I've worked with people, they've said, I just don't see the point. I don't see how talk therapy can help me. I don't see how what we're going to do here is going to help me. That's where we can educate people about the variety of different interventions that are available and how as clinicians, we are not fixing them, but we may be able to serve as guides or catalysts to help them identify things that would work for them more effectively. And we can help them do that faster than they would their own. Sometimes during the pre contemplation period, a clinician can help a significant other intervene. Regardless, after the session, we want to express concern for the person and keep the door open, not saying, okay, so we've talked for a while. When do you want to schedule your next appointment? In pre contemplation, they're still not necessarily ready or willing to change. So you may say, would you like to schedule another appointment? And if they say no, that's fine. Letting them know that whenever they're ready to start making a change, you're more than happy to help them with it. The next phase is contemplation. The client is ambivalent or uncertain, but considering the possibility of change, they've recognized there's a problem. Now, at this stage, the counselor can discuss and weigh the pros and cons of change. And in tip 35, this is called a decisional balance exercise. And what you look at and it is hard to do sometimes or hard to conceptualize, so I encourage you to write it out. But you want to look at what are the pros and cons of change. Yeah, there are drawbacks to change and we want to help people minimize and any of their anxieties or perceived drawbacks of change because we want to make change as rewarding as possible. And then you want to look at the pros and cons of staying the same. And yeah, they probably have highlighted some of the cons of staying the same, which is why they're there. But the pros really asking them what did this behavior, what did this situation do for you and in what ways might it be benefiting you? Or in one way in what ways might it be protecting you? Emphasize the client's free choice and responsibility. We're not going to make them do anything. Now if you're working with somebody who is court ordered, you know, it's really important to, to navigate that boundary. The court says this has to happen. Let's talk about how we can make that work the best for you and elicit self motivational statements. The I think I can or I'm willing to try. That's all I'm looking for right now. Not the yeah, this is going to work. Just maybe I'd consider doing this. Great. We want to reassure the person that no one can force them to change and that they are in charge now. The court can force them to go to group, the court can force them to do certain things. So if you're working with a court ordered client, they can force them to jump through particular hoops, but the court cannot force them to change. It is up to them. They are individuals with the ability to choose and helping the person see that they're in charge and empower them to define what they want in the future. I used to work in felony probation and parole and a lot of the people were court ordered and they would have to do 10 weeks of group and instead of putting them in this group where we went over the same curriculum every time, I would work with the clients and I'd say what is it? Since you've got to be in group with me, that's part of your probation. What is it that you would like to accomplish and how can we work on that together? What is it that you would like to talk about when we are in session? And instead of just sitting up there spouting at them pharmacology and all that kind of stuff by working on some of their other issues like communication and job skills and self esteem and those things, I was helping them feel safer and more empowered and reduce some of the anxiety and distress that they may have been self medicating with their addiction. Ask questions that prompt motivation. For example, when you want to keep up your motivation for doing something, what are some of the things that you say to yourself if you're out on a run and you want to do two more miles, what do you say to yourself if you are doing something else? How do you keep your motivation up? Help the person recognize problems contributing to the current situation. Help them by acknowledging their concern. You know, they will look at the current situation and they may recognize that, okay, I am experiencing depression. Let's talk about what's contributing to that experience of depression. What's, quote, making me feel depressed and acknowledge concern for the person. You know, it's got to be really difficult to be in that position. Generate intention to change. And by doing this, we are saying, all right, I hear what you've said about the things that are contributing to your depression or your addiction. Let's talk about what are some very specific, concrete behaviors and activities that you can do that will help you change. And let me help you understand why those things can help you change. Help the client develop optimism. Instead of thinking, this will never work or I'm a failure or I'm useless, we want to use positive psychology. We want to help them address that negative inner critic. A lot of people have this inner critic that's telling them they're a failure. They've always been a failure, they'll always be a failure, or they don't deserve to be happy. So we need to address that inner critic and help the person develop optimism. We want to convey feedback and help people see a difference between what life is like when they're symptomatic and what life is like when they're not symptomatic. And a lot of people have a time that they can remember when they were asymptomatic or less symptomatic. So you can compare and contrast and we can say, what was the difference when you had fewer symptoms or no symptoms? What was the difference in how your behaviors, your eating, your sleeping, your relationships, all that stuff? What was different then than what's going on now? So they can start to see the difference not only in how they felt, but what they were doing. Then show curiosity about clients strengths and explore how those skills may be negated by their current state. So if somebody is phenomenally creative or, you know, does great work at their job, or is an amazingly compassionate parent, you know, wonderful. So how are those skills, how are those talents negated because of their oppressive depression or their substance use or whatever their diagnosis is? Help them reframe negative statements in contemplation. They recognize there's a problem, but change is just still way overwhelming. So we want to help them reframe Negative statements like I'll have to change my whole life or there's no way I can make all of the changes necessary, reframe it, break it down, for example, into smaller behaviors. We're not talking about changing everything in your life. Let's talk about addressing this one cognitive distortion. You know, can you do that? You know, can you make this one step this week? And by providing micro goals, micro successes, each week the person comes back and we can say, wow, look at the progress that you've made. Highlight the reasons for change by summarizing not only their concerns, but also their significant others concerns. Explore the specific pros and cons of change. Now, it's important to remember that change is not global. You know, when we say people are going to go into recovery for addiction or go into treatment for depression, that involves a lot of different lifestyle changes, cognitive changes, and their readiness for change. For each one of those things can be very different. They may be more than happy to start talking about and addressing their cognitive distortions, but they may not be ready to start changing their eating habits and their sleeping habits and giving up, staying all night, staying up all night playing video games. Okay, you know, we can cross those bridges later. Any goal contributing factor to your current condition that you're willing to work on, let's highlight and enhance that readiness for change. Encourage the client to explain the benefits of change. Why is it that you are choosing to address these cognitive distortions or to address your sleep habits? Why is it you're choosing to address this behavior now by articulating that, by having to say it themselves, Then they're hearing themselves say it and reinforcing it. Assure the person that conflicting feelings are normal, which goes back to that decisional balance. Exercise. There's pros and cons to everything. There's pros and cons to exercise. There's pros and cons to staying in relationships. There's pros and cons to everything. Review feedback from the assessment if you're still early in the process. Find out what the person expects from treatment. If they're in contemplation, they recognize there's a problem and this is when we can open the door and demystify what may happen when they enter treatment so they can feel more empowered, so they can feel safer. It's not this ambiguous area that they're just blindly walking into. And help the person connect core values to committing to treatment. What are their core values? Compassion, love. Whatever those core values are, how will it improve their relationships? How will it improve their work? How will it improve how they feel about themselves when they move into a place where they feel like they're in recovery? Strengthen the client's personal choices. Nudge them to start making positive choices. Reminding them that nobody can decide what to do for them. Nobody can make them do anything. There can be consequences if they don't do something, but nobody can make them do it. And then encourage them to make those positive choices again. Remembering to break it down into very, very small, manageable goals. Not addressing all your cognitive distortions. Maybe looking at one, not doing 17 things this week. But what's one thing? What is one positive change the person can make this week? Help the person set goals and take steps. One client I worked with was an involuntary client and substance abuser on probation and had was at that point not using. And he had no desire to be clean and sober forever. But he did want to get off probation. He wanted to get off papers. So we looked at it from that perspective. Instead of me trying to convince him why he needed to get sober, we talked about, okay, how can we work together to help you get off papers? Because that was six months down the line. And during that six months, he would be able to work on a lot of things. And then at the end of that, he was able to choose whether he went back to illegal behaviors or whether he stayed the current path. Particular goals. We said, I remember one week, I said, what is an environment or what is a situation in which you know you will not use? And he said, I don't use around my kids. And so he decided that that week after dinner, he was going to start taking the kids out to go play basketball in the evening after dinner. And that would take away several hours by the time they went out, played, came back, got showered, and all that stuff, that would take away several hours where he was tempted to use. So that was one strategy, but that one strategy had multiple effects. When he came back the next week, we started talking about how it worked. And not only did it help with his cravings, but it also started helping with his relationship with his kid. Remind the person of triggers, including negative emotions like anger, anxiety, guilt, social pressures from peers or significant others. Physical concerns like headaches or stomach aches or the need to stay awake when you're exhausted. Extended withdrawal symptoms that may trigger them to either use, if we're talking about addiction, or they may trigger the other symptoms like depression or anxiety. Ask the person, what do you think has to change? What are you going to do? How are you going to do it? What are Some benefits of making the change, and how would you like things to turn out in an ideal situation? You know, those are very practical questions that put the person in the driver's seat. Instead of us telling them what they're going to do, we're asking them, what's your perception? And what are you going to do? How can I support you? In preparation, the person starts asking questions and indicates a willingness to consider options, to make specific changes. They start saying, you know, well, I'm depressed and I'm not sleeping well. I'm wondering, you know, what things could I do that might help me sleep a little bit better? They're not saying, how can I cure my depression? But they're starting to recognize certain symptoms or behaviors or problems, and they're starting to ask questions about, well, how might I start addressing this? Again, we're going to explore the treatment expectancies and the person's role in that. What are you expecting your clinician to do? What are you expecting me as your counselor to do? What is your responsibility in this? And how can we work together? How can I support you? I'm not doing it for you. How can I support you in this process? Elicit from the person what has worked in the past, either for them or. Or for other people that they know. Like I said, some people haven't ever been in treatment before, so they don't know what works. So we want to look around. Has a family member or a friend ever dealt with a similar situation and what worked for them, or what do you think might work for you? During this phase, the person shifts from thinking about it to planning the first steps. It's really important to offer to help, but don't yank the person forward. Person starting to express interest, and they're thinking like, maybe. So say, all right, so let me give you all of these options, and when you're ready, I will help you start taking those steps. You tell me when you're ready. Once they start really showing some interest, towards the end of the preparation phase, we're going to help them get ready by negotiating a plan. What is it that you want to do? Let's look at what the steps might be, what options are out there. Let's develop a contract for making these things happen. What are you going to do each week? Identify and lower barriers, and we're going to talk about barriers a little bit more in a few minutes. Enlist social support with permission. Offer advice. We don't want to just be randomly telling people what they should do because that will shut people down. That's taking their power away and pushing things on them. So we do want to make sure to ask, you know, would you like me to give you some suggestions? Assist the person in negotiating finances, child care workers, work, transportation or other potential barriers. For somebody who works an hourly job or for somebody who doesn't have a lot of leave time, going to treatment may be really difficult to figure out when to do it because they work 8 to 5 and your clinic's open from 8 to 5, so when is it that they can get there? So we want to help, help them figure out how are they going to be able to access services, how are they going to be able to afford services, what are they going to do with their kids while they're in services? If they're seeing the person, you know, when, when the kids aren't in school, or if they are full time caregivers, what are they going to do with the kids? Because child care can get really expensive. When you consider travel time to the appointment, the appointment, travel time home after the appointment, and have the person publicly announce plans to somebody, have them make a commitment not only to you, but to somebody else who can be supportive of them. Outside of the therapy session, the person really starts indicating readiness. When they stop arguing, interrupting, denying, they stop asking questions about how to change, they, they start asking questions, not stops. They start asking questions about how to change. Instead of asking questions about the problem, instead of trying to determine, well, do I really have a problem or how can I get around this? They start asking what can I do to change? How can I start feeling better? They start saying things like I must do something, or expressing optimism with statements like I can beat this, I can do this. They start talking about how life will be better once they start changing. And they may even be willing to experiment between sessions. They may come back and say, hey Doc, last week I tried meditating or I tried yoga and this is how it worked for me. A lot of times people have explored a lot in terms of self help before they come to treatment. And anything that they're trying shows a motivation, a desire to start feeling better. So then we start asking, how did that work for you? That is so awesome that you tried to take a step forward in terms of barriers. We want to ask people what's gone wrong in the past when you've thought about trying to change or you've tried to change, what went wrong. Find out if they currently anticipate problems. For example, if they're recovering from substance abuse and they're living with another substance abuser, that could be a problem. Or if they're working in a job where they're exposed to substances a lot, that could be a problem. So we want to find out what problems they do anticipate. Sources of barriers may include physical health issues. If they have a lot of chronic pain, for example, they may be on certain medications that contribute to fatigue and lethargy, or they may be on certain medications that are addictive in nature, affective dysregulation or dysphoria. So this is guilt, anger, denial, depression. Guilt, anger, depression, grief, all of those things can be. And I guess denial too can be a barrier to treatment, because if people start feeling overwhelmed, they start feeling anxious or angry, then they're in the fight or flight mode. And the urge when people are feeling threatened and they're in that fight or flight mode is to make it stop. And so that can cause people to drop back into old behaviors that have worked before. Depression often represents a feeling of exhaustion or hopelessness and helplessness. And this can really undermine motivation. When doing treatment causes more emotional distress, then it can really inhibit motivation. So we want to look at that. Treatment sometimes will cause emotional distress when people start processing grief or trauma issues or that kind of stuff. So we want to make sure that people have the skills and tools to deal with that before we go there. We also want to make sure that they are aware that if they start to feel overwhelmed or too unhappy, that they can set the pace and we're not going to have them push through it. We want to make sure, again, trauma informed that they know that they're safe and they're empowered, and we will not push them into a situation where they feel too much emotional distress. Cognitively, literacy issues can be barriers, especially if you're dealing with a program that has a lot of worksheets or reading assignments. People's cognitive capacity, are they able to focus when people are significantly grieving? When they're significantly depressed or anxious, it impacts their ability to think clearly, their ability to maintain attention and concentration and make decisions. So we want to recognize that and not expect somebody to be have it be on their a game. If they're presenting with clinical anything. Depression, anxiety, ptsd, addiction, environmentally. Some barriers can include bureaucracy. There may be waiting lists to get into treatment. So what can you do while you wait? There may be paperwork or legal issues that need to be overcome before the person can enter treatment. How can we help them get through those things? They may worry about finances. How are they going to pay for treatment? Or how are they going to pay for their life while they're in treatment? In residential, that's a huge issue. But even an outpatient, the hours that a person misses from work, they may not get paid for. Plus all of the extra expenses of treatment. They may not be sure how they're going to make ends meet if they enter treatment. And dependent care mentioned that before. Who is going to care for the children while you're in treatment, whether that's for an hour a week or for 30 days? Who's going to care for your pets while you're in treatment, if you're going to be in residential treatment? Those are all things that we want to consider. And family relations in families. Families like to maintain homeostasis. And a lot of times when a person enters treatment, they are the identified patient. The family wants to say, you're the problem, not us. Nothing wrong with us. And we know that in most situations that's not true. In most situations, there is some dysfunction within the family and as well as the individual. It's not just this identified patient. So an unsupportive family, maybe they don't think the person needs treatment or they're not supportive of what the person needs to do for treatment, or they don't see their part in it and are not willing to work on their stuff. And sometimes families will flat out sabotage treatment because they are dealing with their own stuff so much that when that person starts to get better, it starts making their stuff show up and they don't like seeing that, so they end up sabotaging the person's recovery. So everything goes back to normal. In the action phase, the client takes steps towards change but is still unstable. We want to negotiate an action plan. What is it that you really want to do now? And action is often when people are entering treatment voluntarily, acknowledge difficulties and risky situations and support their attempts to cope with those things. They're not going to be 100% on target every time, but we want to acknowledge the fact that they tried, then figure out, all right, you tried to do it, but it didn't work 100% of the time. How can we help you strengthen that tool? How can we help you be more successful? Let's look at what we need to develop. Help people find new reinforcers. What is it that makes them happy? What is it that they enjoy doing? Support, perseverance and sticking to the plan, remembering that motivation can wax and wane. So they need to go back and review those decisional balance exercises. The pros and cons of change. The pros and cons of staying the same and figure out what might be waning and how to address that so they can get motivated again if relapse occurs. Now remember, this is emotional or substances. Back up and apply techniques from an earlier stage instead of continuing to push on through and say, well, you'll get back on the horse. We want to back up and say, all right, what did we miss here? And how can we make sure that you have the tools and resources necessary to deal with the distress and the challenges that come with treatment? In the action phase, engage the client in treatment and reinforce the importance of remaining in recovery. Support change through small steps and acknowledge difficulties, especially in the early stages of change. Help people identify high risk situations and develop appropriate coping strategies. So if you're working with somebody who has a lot of anxiety, helping them identify high risk situations and how they can cope. If you're working with somebody who's dealing with depression, what things, what are high risk situations that might trigger their depression or their grief and how can they cope? Help the person assess levels of social support and resolve barriers to treatment. And this is something that is helpful to review at every single session. Ask people what helped you this week, what worked this week, and what challenges did you face, and address those challenges every week. Explore past experiences, hopes and fears regarding confrontation and judgment from peers in the program, from significant others, from work, what interactions with other people and even from other clinicians, what interactions with other people may be causing fears or inspiring hope? In terms of past experiences and treatment, what were the costs in terms of money or behavior? Now money's pretty obvious. How much did it cost you? But also in behaviors, what things did you have to give up that you like doing? And let's talk about alternate ways of, you know, meeting that same need or alternate ways of enjoying life. Talk about hopes and fears regarding family involvement, shame and guilt medications the person may have to withdraw from or take. You know, some people can be very hopeful that medication will help them and very fearful that they may have to withdraw from certain medications. Explore their thoughts about how rigorous and how rigid the treatment program is, recognizing that life changes, and help them understand that there is some wiggle room, so to speak, in treatment and will address things. If things need to be altered a little bit, we can address those on a weekly basis. Help the person see the value of both internal and external motivating factors. Physically, how will this change help you feel better, have more energy, be healthier? Affectively, how will this change help you feel happier? Cognitively, how will this change? How will recovery help you think more clearly? And how are the things that you're getting ready to do what logical to help you achieve your goals? Environmentally, how will this change improve your environment? Improve the tension or the whatever you want to call it, where they live, improve their ability to function at work and how good they feel when they're at work? And how will it improve their relationship not only with others but also with themselves? Suggest to the person that external coercions are compatible with their best interest. So recognizing the significant other that says you need to go to treatment, that's an external coercion. That's a relational motivating factor. But that person may have the client's best interest at heart. They may be concerned about their safety. Remember that non compliant behavior is often a thinly veiled expression of dissatisfaction with treatment or the therapeutic process. It could be you if somebody is being non compliant or resistant, you may be being too pushy, you may be causing them to feel threatened. You may be missing something. Think about what are the benefits to the client's current behavior and why are they not doing what you want them to? In maintenance, the client has met their initial goals, made changes in their lifestyle, and now practices coping strategy. So we want to support and affirm their changes, rehearse new coping strategies, review their goals, and keep in contact. In this stage, we want people to keep on keeping on. We want to remind them about new tools to maintain and reinforce recovery, such as a detailed review of their action plan, mindfulness of risky situations, coping strategies for each situation, participation in support groups, and pursuit of activities that promote relaxation and happiness. Motivational approaches can be very useful for for people, it's a means of rapid engagement in the general medical setting to facilitate referral to treatment. It can be a first session to increase the likelihood that a client will return and to deliver useful service if the person doesn't return. It can be an empowering brief consultation. When a person is put on a waiting list, rather than just telling them to wait for treatment, we can help them start getting excited about the potential for change and the potential for feeling better. There's often a relatively short period of time to make a beneficial impact on the client. The average length of stay in substance abuse treatment is very short. If clinicians do not make an impact in the first session or two with people, they may not be able to make an impact at all. Make the best use of your first contact. It's usually a big mistake. And to start out by filling out forms, establish rapport, then move on to the administrative Even one session can make a positive impact on a person. Lasting change takes time and effort. All people have the ability to make positive choices and positive changes. People will be at different stages of readiness for change for different issues and symptoms may vacillate between conflicting goals. People with low motivation may begin arguing, ignoring, or becoming apathetic. Sometimes enhancing motivation means focusing first on barriers to recovery instead of the problem itself. Let's clear the way so then when you're ready, you can just move on through. Explore expectations regarding recovery to enhance motivation and develop a relapse prevention plan that helps people identify triggers and vulnerabilities and ways to prevent and address them.