Motivation Expert Reveals Best Techniques to Boost Engagement

I'd like to welcome everybody to today's presentation on enhancing motivation and increasing engagement. I'm your host, Dr. Donnelly Snipes. Today we're going to learn about the nature of change, explore the different stages of readiness for change, and how to identify what stage a person is in. We'll learn about goals and interventions for each stage and explore ways to identify barriers and expectations regarding recovery and and how to use that to enhance motivation. Let's start out by talking about trauma, though. When people experience trauma, that trauma causes them to feel unsafe and powerless. In the future, when they experience situations in which they feel like they are unsafe or powerless, or feel like somebody's taking their power away, it's very likely that they will. It will trigger some of those feelings from the past of anxiety and dread behavior, even resistant behavior, represents the person's best way to survive at that point in time. Change requires stopping the old behavior and starting a new one. One of the things that a mentor of mine once said, and to this day I have it in a lot of my videos. Change causes crisis, and crisis causes change. Think about times when you've had to change something. You were going to change the way you ate, you were going to start working out. It doesn't have to be a big change, but it required something to prompt you, some crisis of some level, to prompt you to say, you know what, I probably need to make this change. And then when you made that change, it was hard. And there were probably times when you thought, you know, is this really worth it? So that crisis that caused the change led to a change that caused a crisis. And we need to recognize that. And in both places where there's crisis, we need to help people feel empowered and supported. Many people who struggle with emotional distress, stress related health issues, addiction or relationship problems have a trauma history. Most people that we work with have a trauma history. Honestly, most people that exist have some level of trauma history. Now, a lot of people have resolved that trauma and they once again feel safe and empowered. But there's a big proportion of people who haven't and they still feel on some level unsafe and powerless. When enhancing motivation, the clinician must pay special, special attention to supporting a sense of safety and personal control. Change, as I said, can cause crisis, but it's constant. Everything changes in the natural environment. You look outside, the light level is constantly changing. As the clouds move by, your heart rate is constantly changing. Things are constantly changing in your world. Change is constant among people. As you get to know somebody better, you may like them more you may want to distance yourself as they change. You will either change with them or you'll grow apart. But it's change. And change is constant in relation to behaviors, things that we want to do. Change occurs without professional intervention. It may not occur the way we want it to, but things are going to morph. And, you know, if I decide that I'm not going to work out anymore, I don't want to work out, then the change might be my health starts to deteriorate. Recurrence of at least some symptoms or old behaviors is a normal event when we try to change. And many people cycle through the different stages of readiness for change several times before achieving stable recovery. So you're going to vacillate between being gung ho and ready to do it and just conquer the world and thinking, you know, maybe it really wasn't that big of a problem after all. There are six basic stages in the process of change, and this was posited by Prochaska and Diclemente decades ago. Pre contemplation, contemplation preparation, action maintenance, and sometimes recurrence. People typically vacillate between the stages and cycle through the stages at different rates. And as I explain each of these stages, I'm going to use what I call the pool metaphor. The first stage of pre contemplation involves ambivalence. Many people are ambivalent about change. When you're thinking about changing your diet or starting to exercise or stopping smoking or whatever your change is going to be, you may be going, okay, you know, yeah, that's probably good. But if I do that, what do I lose? If I do that, what are the negative consequences? Change is hard. Ambivalence is expressed in several ways. People will argue with you, they will challenge you. They will discount your statements. They'll say you don't understand. They may interrupt you, cutting off conversations or taking them over. They may deny, blame, disagree, excuse, minimize, justify. All of those are in the toolbox of the person who is not ready, willing, and able to change. Or they may just ignore what you have to say. They may not respond to you, not pay attention, just whatever. All of these behaviors may be a way a person is trying to reclaim their power. They feel. Or they may feel like you're trying to take their power. You're trying to tell them that they have to change. Well, that takes their power, takes the choice out of their hands. So to regain their power, they're going to use a more aggressive stance, or in the case of ignoring a more passive stance. But remembering behavior is communication. What is the motivation for the person to argue with you? What are they getting out of that? They're getting a sense of control or they're getting a sense that they're trying to protect themselves. Resistance. We have yet a new mnemonic. FOBs know. Think about key fobs that we have. And I know it only has one S, but in this mnemonic we've got two. And we want to look at the keys to understanding resistance. The first one is failure. People are often resistant to change because they're afraid they will fail. So conversing with them, what is if you try this and you fail, what does it mean about you? And helping people separate themselves from failure at a change is very important. Just because you failed doesn't mean you are a failure. It means you failed at doing this at this time. What are the consequences of change for you, and how can we buffer those consequences? If I'm going to the gym, you know, some of the consequences, I'm not going to have as much TV time. I'm going to be sore. There are some other, you know, excuses, reasons I can come up with that I'm like, you know, I don't know that I'll be able to do it because I'm going to be too sore, and then I'll give in and then it'll just be a whole failure. What are the consequences of not trying to change, not trying to make this move in your life? What parts of this do you believe do you think you're going to fail at? Let's break it down. What is it that specifically that you're afraid you won't be able to do? What can you learn from past failures, including what worked? And I know you're scratching your head going, failures. What worked? When people, for example, in addiction treatment, when they go into relapse, okay, so they failed at that recovery attempt. But during that recovery attempt, there were periods where they were sober. So what worked during that period? And let's build on that, because every time you do something, there are things that worked. There are things you can learn. So let's build on those. And, you know, we can learn from our past experiences what we probably shouldn't do again or need to account for. Okay, so failure is the F. Overwhelmed is the O. Some people have so much going on in their life or going into treatment means it's going to take so much of their time and they've got too much other stuff going on that they just can't possibly see how to even begin right now. They don't have another second, another iota of energy. Okay, let's look at how you're spending your energy and your time and figure out how we can take some of that load off. And it's a brainstorming session. It doesn't mean that they're going to have to change, but it means you're helping them see that there are options. There are ways that they can modify the situation so they could engage in the change if they wanted to. B stands for belief. They don't believe that whatever they're going to do is going to work. They've seen other people try to do it and fail. They've tried before themselves and failed. So they don't believe that this is going to work this time. Let's examine evidence for and against that belief. Yeah, no matter what the change is out there, there's somebody that's failed at making that change. I also believe that no matter what the change is, there's somebody out there that has succeeded at making that change. And helping people get a more balanced picture of some successes and failures is important. Yeah, this person, it didn't work for them. My grandmother, God bless her, she was a heavy woman, and she kept going to Weight Watchers and she would take off £50, take off £100, and then she'd put it right back on and then some. And she felt so defeated. And ultimately, you know, if I would have been her therapist, I probably would have started digging deeper and saying, oh, this, this strategy works well for a time, but then it stops working for you. So what needs to change? What else is motivating the eating behavior? But we need to help people see that no one strategy can be packaged and work for everybody. All right, this program didn't work for you. I've had people come into me and sit down and before they even, like, tell me their name, they're like, I'm not going to those AA meetings. Okie dokie, let's figure out what you're going to do instead. What will work for you? They don't know where to start. That's the first S is starting. It can feel overwhelming to try to make a change, especially a big change. I've been depressed for 15 years. Where do I start trying to heal that depression? I have had PTSD for, you know, however long. Where do I start trying to address it? I just don't even know where to start. Okay. That's where we as clinicians are skilled. We can say, well, there are a lot of different places we can start. Let's look at some of them, and you can figure out what place you want to start at. And the final S is the skills. If people don't have the skills to make the change, guess what? It won't work for them, and they will fail. And it's important that we help them identify. What tasks or aspects of this do you feel unprepared to manage? What skills do you think you need? Resistance is communication. It's saying, I'm afraid. I'm afraid of losing power. I'm afraid of failure, but I'm afraid. And so we need to explore what things are you afraid of? Tips from the trenches. It can be hard to go through the fobs and really increase motivation. But as you start learning about motivational enhancement, practice it. Practice convincing yourself or someone else to do something they may not want to do, like clean their room. If it's a child, eat their spinach. Heck, if it's my husband, eat his spinach. Work out, cut back on caffeine or do your homework. Or for those of us who are clinicians, do your progress notes. These are things that most of us don't love doing. How do we motivate ourself to do it? What are the fobs that are standing in our way, and how can we address those? So the first stage of readiness for change is pre contemplation. The person is unaware, unable, or unwilling to change. There's a lot of UN's there. The person is likely to be wary of the counselor and of treatment because it makes them feel like they're not in control. They're coming in here. And if somebody's coming in for an assessment and they're in pre contemplation, they're being forced. Somebody told them they had to come in. Whether it was the court or their boss or their spouse or somebody. All right, they're coming in. They're already feeling disempowered. They're already feeling like they're being forced into something. So we want to help them feel comfortable. They're going to walk in and say something to the effect of, I don't have a problem. Let's just get this over with so I can get out of here. Okay, Pre contemplation with this pool metaphor. You're laying out on the side of the pool, you're sunbathing, whatever, and somebody says, you look like you're getting awful hot. Pre contemplation, you're like, I'm not hot. I'M fine, I don't have a problem. Now back in the back of your mind, you may start to know that, you know, maybe I am getting a little hot. But you're not acknowledging that. You just say, nope, not hot. So what do we do in pre contemplation? Somebody's coming in you, as the therapist can see, yep, there's a problem. But the person says, nope, not a problem. All right, you're at an impass. Part of this goes back to creating a win win creating mutually agreeable goals if you need to. When I worked with people who were in involved in the criminal justice system on probation and parole, they were basically court ordered to group. And instead of sitting there and just hounding them about how bad drugs are and blah, blah, blah, I said, okay, you're here, you're stuck with me for at least 10 weeks. How can we make use of this time? The county is paying for you to be here for 10 weeks and have access to therapy. So what is it that I can help you with? And instead of pushing that narrative now, I knew deep down underneath that continuing to use drugs was probably negatively impacting every area of their life. So I was able to tie it back to that a lot of times. But the first thing was recognizing them as human beings and saying you have the right to control how much or how little you change. So establishing rapport. I know a lot of stuff from books. You know, I have book learning, I have experiential learning, but I haven't lived in your skin for 40 years. And you have. You are the expert on you and you are going to control the flow. Validate how the person is feeling. You know, if they seem like they're uneasy, if they feel like they're being forced, if they're angry. Okay, let's validate it. I can see how it would really tick you off to have to come in here and waste three hours of your day. Keep the interview informal as possible. If you start getting formal, then people start feeling more forced. If you start getting all technical and jargony, people are going to feel like you are trying to convince them that they need to change and that's when they're going to start putting those defenses up. Explore with the person why other people think they have a problem. Whoever referred you here, what is it that makes them think you've got a problem? Explore if they think they have a problem. And why do you think you don't have a problem and they do. What's help me understand the difference here about what's going on. If they think they may have a problem, you know, and they're like, yeah, I might have a problem, but, you know, it. It's fine. I got it. Okay, well, then go back to exploring FOBs. Their fear of failure if they're overwhelmed, their belief that it won't work. They don't know where to start, or they don't have the skills to. Or they don't think they have the skills to get the job done. Explore the results of previous treatments, if they've had any. Consider offering facts about the risks of continuing along this path. A lot of times they've already heard that and that this is one that SAMSA suggests. But in clinical practice, I haven't found to be overly useful most of the time because they already know these things. And as soon as I start talking about the risks, they tune me out. Um, just like I would tune out my parents when they started, you know, lecturing me. They feel like they're being lectured. Okay, we can help them identify what's important in their rich and meaningful life and look at how that jibes with their current behaviors and look at how their current behaviors may be keeping them from their rich and meaningful life. But I try to avoid just this litany of these are the risks of continuing to use. Explore the pros and the cons of the current behavior. They're pretty aware of the cons already, and very rarely has a person said, okay, you know, behavior has meaning. We all do the. The things we do, we do because there's reinforcing in some way. So help me understand what the benefits are to this behavior. What are the benefits to you of using? What are the benefits to you of not doing your homework? Provide personal feedback about what you're observing and, you know, just own it. Say, okay, let me just step back and from a thousand foot view, tell you what I'm seeing is going on here. And it may be on point, it may not be, but this is what I'm observing. Tell me what's right or wrong. I always throw it out there. Correct me, Correct me where I'm wrong. That puts the power back in their place. I'm saying this is what I'm seeing, but am I seeing what's actually there? And I allow them to help me see more clearly. Raise doubts about current behaviors. Again, challenging it, comparing it to what they want in their rich and meaningful life and whether these behaviors are helping them get there or keeping away. Consider helping a significant other intervene. Sometimes it can be helpful for a family Member to. Or a friend to come in with the person with releases and blah, blah, blah. Of course. And say, john, I'm really worried about you because this is what I've seen. Focusing on objective behaviors and facts, owning their own feelings, just putting it out there. Express concern and keep the door open. All right, you've heard what I've had to say. I've heard what you have to say. This is what I think is going on. And if at some point you decide you think you have a problem or you, you're ready for treatment, I'm here. I'm not forcing it. I'm not saying, all right, so when are you coming back for the. For your first appointment? Because that's not empowering them and that's can feel manipulative if you just try to slide that in at the end. Contemplation. Just like it sounds. The person is ambivalent or uncertain, but contemplating but considering the possibility of change. So the person may be saying, I, I may drink too much sometimes and maybe I need to cut down, but I can do it on my own. I got this. I still don't need your help. Thank you very much. I'm going to keep my own power. When it comes to the pool metaphor. The person's laying there, they're really starting to sweat. They're like, well, I may be getting a bit hot and yeah, I want to cool down, but the pool is so cold and I, I know if I go over there, I'm going to be splashed and it's going to be miserable and blah, blah, blah. I've. I've got it. I'm going to, you know, wait for the fan to come by or I'm going to start fanning myself. The counselor can discuss and weigh the pros and cons of change. The decisional balance exercises that we've talked about so many times look at the pros and cons of staying the same and the pros and cons of. Of change. Now, when we were in pre contemplation, we were looking at pros and cons, but we were looking at pros and cons of the behavior. So now we're going to put it all together and say, all right, we've looked at the pros and cons of continuing the behavior. Now let's look at the pros and cons of change. And in each situation, you want to minimize the drawbacks to change and try to highlight the drawbacks to staying the same. We want to continue to emphasize the person's free choice and responsibility and elicit self motivational statements. What is it that you can do this week to start moving toward your rich and meaningful life? Reassure the person that no one can force them to change and they are in charge. And obviously if there is, if there are court orders, if there's something else going on, there can be consequences for their behavior, but nobody can force them to change. It's kind of semantics there. But if they're willing to experience the consequences, then they can keep doing whatever they want to do. Ask questions that prompt motivation, such as when you want to keep up your motivation for doing something. What are some things you say to yourself? And highlight things that are non threatening. When you want to keep up your motivation. For washing your car, for cleaning the garage, for going to the gym, anything that they do. You may even start out by asking them what are some things you have to do regularly that you really don't like doing? We all have them. Okay, when you've got to do those things, how do you get motivated to do them and stay motivated to complete them? What are the benefits of proving to so and so that you don't have a problem? A lot of people that I've worked with in pre contemplation who have addictions say I don't have a problem, I can quit anytime I want. And, and so I say all right, well if you quit for a month, then that would prove that you don't have a problem. So what are the benefits of proving that? So you know, would it, do you think it would help get them off your back? You are here because someone thinks you have a problem. What are the benefits of a two week change to prove to them that you don't have a problem? Help the person recognize the problems contributing to the current situation, which is being here and contributing to the problem behavior. So there's two different sets of issues we're looking at. What is it that caused you to be here? My drinking. Okay. And what is it that's causing you to drink? What is, what is the underlying reason for the problem behavior? People are not going to continue to do something unless it is more rewarding than the alternative. Help the person acknowledge concern you. Does that bother you at all? What are your concerns about this current situation? Help them generate intention to change. You're here on the scale of 1 to 10. Or you can ask them on a scale of 1 to 10. From 1 your life is a mess to 10 things are perfect. Where are you at? If they say a three, great. What do you need to do? To move to a 4. What needs to happen? Help the person develop optimism about the change process. Reflecting on times that they've been able to change in the past. Maybe not this particular issue, but what other successes have they had? Help them identify the things that are going well in their life so that they don't feel just completely defeated, like their whole life's a dumpster fire. Optimism can help. It can encourage dopamine release and can encourage a person to want to try. Continue to convey feedback. If you see that they're become starting to make optimistic statements, wow, it sounds like you're starting to really consider change. Just seize on that. Highlight self motivational statements. Highlight positive talk. Highlight positive behaviors that they've done. Help them see a positive change in themselves as they experiment with change. You know, John, you said you weren't, you were going to not used last week and you didn't tell me what changed for the good and for the bad over the week when you were trying that experiment. Show curiosity about the person's strengths and how those skills may be negated by their current state. Tell me about what things, what characteristics, what strengths you have that are important to you and then tell me about how this current situation may be kind of making that all go away. Give you the example with progress notes. So we're not always staying on addiction for a therapist. You can have a wonderful therapist who does great work, but if they don't do their progress notes, they're not going to stay in business and they're not going to be able to pay the bills and then they won't be able to see patients and they won't be able to help people. So the act of not doing documentation negates most of their skills because they're not going to be able to do their job most of the time. There are very few people that are independently wealthy that would be able to continue to do it and not worry about getting paid. Reframe negative statements if they say, oh, I was so stupid when I did that. All right, let's look back at what happened and what motivated that behavior and then figure out what you can do differently the next time and recognizing again that our behaviors represent the best way we feel like we can respond given the tools we have at the time. And that means the tools that we have accessible to us. You may have a library full of cognitive, behavioral, you know, recovery type tools in your head, but when you are in a stressed state, when you're in fight or flight, all that's locked up in a Vault back here somewhere, and your prefrontal cortex is completely disengaged. So the only tools that you have available to you may be those unhelpful behaviors that you engage in when you're on autopilot. Okay, so what we need to do is help a person figure out what they need to do in order to down regulate, get in their wise mind so they can make choices and act in ways that are more consistent with how they feel and who they want to be. Summarize concerns, explore specific pros and cons. I had one patient that I worked with that, you know, just loved his kids to death, to the moon and back, and his relationship with his kids was the most important thing in his life. And so we would explore specific pros and cons about him continuing to smoke weed and the impact that that would have on the kids if he went back to prison, if they saw him smoking what, smoking weed, how that would impact them. You know, there are a lot of things, and we, we talked about that. Again, allow the person to continue to explain the benefits, and we need to help them figure out a way to achieve similar benefits, not the same, but similar benefits with the new behavior. If they smoke in order to relax, okay, that's a tool they have. We need to help them identify other tools that can help them relax so they don't feel the need to smoke. Assure the person conflicting feelings are normal. You know, change is hard, and sometimes you think, you know, I'd just love to go back to the way it used to be. It was a lot easier. That's, that's true. But is the way that it used to be helping you move toward a life that you want or just kind of tread water? Find out what the person expects from change and from treatment. Some people think that treatment is going to be like the old movies, like One Flew Over a Cuckoo's Nest, where they're all sitting around in, in a group, in a group room and everybody's over medicated and blah, blah, blah, that's not how it is. What do you expect is going to happen in treatment? What do you need to happen in treatment and how can I help you facilitate that when you become ready for treatment? Provide information about the recovery process, about the biopsychosocial implications of their current behavior, whatever it is, and help the person connect their core values to committing to treatment. What core values do you have that say I really need to change this behavior? Strengthen the person's personal choices, Nudge them to make those positive choices, reminding them that you Know what? Nobody can decide for you what to do. You can choose. And I'm wondering now that you're faced with this choice, let's make a pro and con list and figure out what is going to work best for you. Help the person set goals and take steps. Most people set really crappy goals. They're either too big or too vague or they're expecting too much too soon. So it's important that we help people set smart, specific, measurable, achievable, time limited goals to help them move toward where they want to be and to ensure that they have successes. Every time they set us a goal, a small goal, and they have a success, it increases their self efficacy. It gives them a little hit of dopamine. It helps motivate them to take the next step. Help the person identify triggers and vulnerabilities in each piece of their life. What's going on that may be contributing to this behavior? If you feel overwhelmed and exhausted and you just can't do this stuff you need to do, or if you feel stressed out and because of that, you try to numb that pain or numb that stress by using whatever is going on. Let's look at what's going on that is causing you unnecessary distress. Physically, interpersonally, emotionally, cognitively and environmentally. And then tie that back and help them see when you are over tired or you're sick or you're in pain or your relationship is, you know, on the rocks, that takes a lot of energy. That's exhausting and that is your brain registers that as a threat. So it takes a lot of your time and energy every day just to maintain, keep the lid on that. Which means if you think of yourself like a pressure cooker, you've already got the pressure up to about a six before you even start the day. Which means you're more vulnerable to hitting that high and blowing the top off the pressure cooker. When anything happens, you're more vulnerable. You're more reactive to things that happen during the day because you're starting out stressed. Reinforce their commitment to change. What do you think needs to change in this situation? Not only your behavior, but what needs to change in your environment, in your relationships, in your health in order to support this change. If you're trying to stop smoking and your significant other that lives in your house smokes in the house, well that's probably not going to be super supportive. So that may need to change in order for you to have an environment that supports your desire to change. What are you going to do to try to Institute those changes. How are you going to do it? Review again some of the benefits of making a change. And ideally, how would you like things to turn out? You know, maybe staying with smoking, maybe you want your significant other to stop smoking too. You realize it's not good for you and you realize it's not good for them. You want them to stop, you can't force them to stop. But ideally you'd like to have a smoke free household. All right, that's the ideal. What are some compromises? Maybe they start smoking outside or not around the house, only when they're at work or something. There are more tips and tools. In tip 35 from the SAMSA publication on motivational enhancement preparation. The person realized they have a problem and they're preparing, go figure, to make a change. They are not quite ready to turn desire into action though. They're making the list, they're checking it twice, they're getting everything packed and ready, but they're not quite there. The person with the problem may say, I know I need some help making a change, but I need to get things in order first and try a few things. I need to pick out a treatment center. I need to get somebody to cover my shifts at work. I need to, you know, these are the things that I need to do to prepare to go to treatment. The pool metaphor. The person realizes they're hot and they really need to cool off. That, you know, just sitting here, fanning myself, ain't cutting it anymore. I'll just go put my feet in the water. I'm preparing to get in the pool and cool off, but I'm not ready to take the plunge yet. Signs of preparation. The person starts asking questions indicating a willingness to change and considers options to make specific changes. They start saying, okay, well, I'm having a hard time doing this. I'm wondering, you know, is there something besides residential that I could do? Because I just don't think I can swing 90 days and not being at home and not working. Cool. Let's talk about it. Explore treatment expectancies and the person's role in creating those expectancies. What can they expect from treatment and what is treatment going to expect from them? Elicit from the person what has worked in the past for them or for others whom they know. When somebody you know has tried to make a similar change, what's worked, what's helped? For some people it may be support groups. For other people, it, you know, maybe behavior modification just kind of depends on what kind of change you're talking about. You Notice the person shifts from thinking about it to planning first step steps. So I'm thinking about treatment. You know, I'm considering my options. Then one day they come in and they say, all right, I'm ready to get on a waiting list and I need to. These are the six things I need to do before I can enter treatment. Hallelujah. The person has moved into the planning stage. We need to offer help but not yank the person forward. How is it that I can support you in taking these first steps? What is it that I can do for you? How can I support this process and let them tell you what they want you or don't want you to do? Revisit FOBs their fear of failure. If they're overwhelmed, assist them in negotiating finances, child care, work, transportation, etc. Help them identify and lower barriers to entering treatment. Maybe they think they can't afford it or they don't have anybody to watch their kids while they go into treatment. There's a lot of things. Enlist social support and publicly announce plans to one other person. Now, SAMSA says publicly announced plans and just kind of leaves it open. But that doesn't mean you've got to go and tell everybody that you work with, hey, I'm going to make this change. I'm going to start working out. I'm going to change my, my diet. I'm going to go to treatment. You know, we don't need to involve everybody in that. But it's good to have an accountability partner, somebody that says, I am glad you're making that change and I'm here to support you. I am going to be your biggest cheerleader. Revisit their belief that it won't work. What concerns do you have that this won't work or this isn't working? If they're already in treatment or trying to make that change and they feel stuck, what is it that you think is not working or you're afraid it's not working if they start, if they don't know where they're going to start? Again, we negotiate a plan. We write down all the things they need to get in order before they go into treatment, and then they have a list. They can start anywhere they want to on the list and then they just start marking it off. Develop a behavior contract, and this one's not necessary, but it helps some people where they say, within the next 30 days, I commit to going to treatment, or within the next 30 days, I commit to going to the gym three times a week for at least 30 minutes. Something where they are putting it down on paper, what they're going to do and by when they're going to do it. If they believe their skills to succeed are lacking. Provide a menu of options. All right, you're afraid that you won't be able to do this. Let's talk about some strategies you can use to manage the discomfort as you're detoxing, to manage the pain in your in your arm from the carpal tunnel when you're writing your notes. Whatever, whatever they think they're worried about. Help them identify skills that they have or could develop that will help them succeed. Sources of barriers may include physical health issues and post acute withdrawal symptoms. If we're talking about addiction for pause. But physical health issues can always be a barrier. If some medications contribute to depression, for example, and if people are feeling tired and sluggish and depressed and some of their whatever they're being medicated for may be contributing to that, it may not just be cognitive depression encouraging them to get a physical. You know, like I always say, get a physical. Full blood panel, check their sleep, etc interpersonal relations may be a barrier if their significant others are unsupportive or even worse if their significant other is sabotaging them. Low self esteem or self efficacy if the person doesn't feel like they deserve to be happy or they deserve to heal. Emotional disregulation or dysphoria is another barrier to long standing recovery and we and long standing change. We need to help people develop those downregulating, downregulation and distress tolerance skills cognitively help them identify their unhelpful beliefs about themselves, about others, about the process. Increase their literacy about the problem as well as the solutions to the problem. Help them work on their cognitive capacity. Some people, when they're depressed, when they are anxious, when they're grieving, when they're recovering from being intoxicated, their cognitive capacity is not going to be what it could be. And okay, you're having difficulty remembering thinking clearly, you have brain fog. All right, how are we going to deal with that? That's a barrier to making progress. It's going to slow progress. So let's figure out what you can do to mitigate that. Environmentally, bureaucracy can be a huge environmental barrier to change. For treatment. Waiting lists can be a big deal. Paperwork, legal issues can be a barrier. If somebody really wants to get clean and sober and they're in jail, that's not the ideal situation to try to get get clean and sober. If you're wanting to make other changes, there May be. May be bureaucracy that is holding that up. Finances and employment. It may be hard to make a change in your life because you're like, when. What time am I really going to find to go to the gym every single day when I'm working two jobs? You've. You've lost your mind. That's just not going to happen. I need to work in order to keep a roof over my head. So, you know, try again with the ideas. Dependent care and home and work triggers things that trigger anxiety and anger in the person. Set them into fight or flight, which basically unhooks our, our wise mind. And it's harder for people to make purposeful choices and decisions. So we need to, again, help people recognize those triggers and, and eliminate as many of the distress triggers as possible. In action, the person's ready to take active steps to change and do the work. Sign me up. Where do. Where do I go in terms of the pool metaphor? They've been dipping their toe in for a little while. They're like, all right, you know, I'm just too hot. I'm going in. And, yeah, it's cold for a minute. It's a little bit uncomfortable. And you think about getting out in the pool. The same thing is true in treatment. A lot of times people are in action, they start treatment, they're like, oh, this is uncomfortable. And they start thinking, well, maybe it wasn't that big of a deal. Maybe I should leave. Maybe I should, you know, abandon this goal. Helping people stop and think about all of the reasons they got to the action stage is important. When people are ready to take action, they stop arguing, interrupting, denying. They start asking questions about how to change instead of about the problem. And they appear calm and peaceful. They often are open to change, saying, yeah, you know, this has gone on too long. I need to do something about my weight. I need to do something about this behavior. I need to do something. They may express optimism that with some new tools and some assistance that they can make that change. They talk about how life or work or whatever else will be better after the change, and they experiment. Between sessions, they try doing something a little bit different. I had one employee who really struggled getting his notes done, and at the end of the week, he hadn't done any of his progress notes. It just inevitably, I'd walk into his office on Friday evening, none of the notes had even been started yet, and I'm like, okay, this isn't working. You know, the consequences are, I'm going to have to put you on a pip. And I really don't want to do that. So let's talk about what is preventing you from getting these done and what might help you. One of the things that was preventing them from getting them done was he loved to talk, he loved to counsel, he loved to help people. He hated to do paperwork. I'm with you. However, we created a system in the residential wing where all of the therapists had a period of time, a period of two hours every day that they shut their doors and the residents were supposed to interact with other staff during that period of time. We obviously had one therapist that was on call for an emergency, but that was the time every day that people had to get their. Get their notes done and without interruption. And that helped tremendously. So experimenting with things. And that particular employee would talk about how much less stressful work would be if he didn't have these notes hanging over his head all the time. Okay, well, let's try a few things. And I worked with him on writing more concise notes. So he was getting down what needed to be down for billing, but he wasn't spending 40 minutes writing one note. Motivation will wax and wane in. In any of these stages, but especially in action, you're doing the hard work and it can get uncomfortable. And remember I said people do whatever choice is most rewarding or least painful is what they're generally going to choose. So staying in treatment is often fighting against our natural or continuing with change is often fighting against our natural desire to take the path of least resistance. Motivation will wax and wane. The person takes steps towards change, but is still unstable. When change feels more painful than staying the same, they will regress. You're going to see it. They may not drop out of treatment, but you may see them become more ambivalent. Again, negotiate an action plan with the person from the beginning, and then when you see their motivation starting to, you know, slide back a little bit, identify that it seems like your motivation is backsliding. This is what I've seen. Now, am I. Am I on point? And if so, let's talk about how to increase your motivation. Again, Acknowledge difficulties and risky situations and support attempts to cope. Help the person find new reinforcers, new ways to reinforce doing something they don't want to do, and new ways to reinforce positive behaviors that may not be, you know, the ones they'd rather be doing. Support sticking to the plan. And if motivational relapse occurs, back up and apply techniques from an earlier stage. If they drop out of action and they're in pre Contemplation, help them or if they're in contemplation, help them figure out why. You know, now that they've started the process, it might be worth continuing it on. Engage the person in treatment and reinforce the importance of remaining in recovery. This is for depression, for anxiety, for anger, and even other behavior changes. Like I said, getting our documentation done. Support change through small steps. Don't expect a person to turn their life upside down like that. Obviously, if you go into residential treatment, your life changes kind of like that. But for a lot of people, if they're going to change their nutrition, they're going to make a small change and then another small change. If they are going to stop smoking there, they may go to cutting down and then go to using the nicotine patch and then eventually stop altogether. But they're making small changes. We don't want to. For a lot of people, sudden extreme changes are just too painful and too overwhelming. Acknowledge difficulties in this says in early stages of change, but I would say throughout the process, if you, if you're working with somebody who's been sober for 25 years, that's great, but, but they're still doing it one day at a time and there are challenges that arise. Help the person identify high risk situations and develop appropriate coping strategies. When we're talking about mood issues or addiction issues, high risk is pretty obvious. When we're talking about behavioral issues such as overeating or not getting your notes done or what, what things are make you more likely to fall back into that old behavior. Help the person assess and improve their social support and resolve barriers to treatment. That was another thing that I found worked well on my unit was having people support each other in getting their notes done. They were two to an office. So encouraging people to, you know, misery loves company, so to speak. Explore expectations. Continuing to explore past experiences, hopes and fears and make a plan to manage confrontation and judgment. Whether they're confronting and judging themselves or they feel like other people are confronting and judging them for their success or for their failure, how are they going to handle that? So they don't say, well, screw it, you expect me to fail anyway. Help them make a plan to manage costs in money or behavior. Maybe they're trying to get better sleep so they can be healthier. Well, that means they can't stay out late anymore. All right, well, how can you manage the cost? You don't get to do that anymore. But what do you get to do? They may have to give up certain activities, at least temporarily. Okay. You know, if you have to give these up. What are you going to replace them with? The expense of treatment or change can also be problematic for some people. Family involvement in their process. Now if this is a work thing, then you know, coworker involvement. But how supported or unsupported do they expect to feel by their family or by their co workers? And what do they have that they're dealing with in terms of shame or guilt about their behaviors that they're still carrying with them? Identify medications the person will have to withdraw from or take if they're going to address the issue. Now not, not all issues require medications. Address any perceptions they may have of not having any wiggle room in the process. If I go into this treatment program, I have to follow everything step by step and I've got no wiggle room. Well, that's not realistic. Humans are all slightly different, so there's always wiggle room. Help the person see the value of both internal and external motivating factors. How will this change in your behavior help you feel better physically? Help you have more energy, sleep better, whatever? How will it help you interpersonally with others, your relationship with others, and intrapersonally your relationship with yourself? How will it improve your mood? How will it help you think more clearly? And how might it impact your environment? So what motivating factors or what benefits are you going to get out of making this change? Suggest to the person that maybe external coercions are compatible with their ultimate goals. Yeah, I know you don't want to go to treatment, but I'm also hearing that you love your kids and you love your wife and you want to be able to, you know, stay in your house. You don't want a divorce and you don't want shared custody. So maybe being forced by the court to go into treatment is actually going to help nude you to make the changes you need for the life that you want. Non compliant or resistant behavior is a thinly veiled expression of dissatisfaction with treatment or the therapeutic process. I'll tell you a little secret. Sometimes it is you. A lot of times we want to blame the patient, but sometimes it's us. So we need to step back and go, are we listening? Are we hearing? What are we missing? What are the benefits to the behavior? And again, go back over the fobs to see if there is something in there that is contributing to their resistance or their non compliance. Once they get to maintenance, they've met their initial goals, made changes in lifestyle and are now practicing this new behavior. We want to support and affirm Those changes with my employee, you know, I continue to recognize, you know, you got all your notes done. That was great. Thank you so much. And it helped him, you know, Number one, no, I was keeping an eye on it. But number two, understand that I valued the effort he was putting in. Remain aware of lingering post acute withdrawal syndromes. If you're dealing with a drug or alcohol addiction, rehearse new coping strategies. Review their goals for their life in general, not just the behavior change. Recognize changes in any piece of the person's life that may require alteration of the plan and help them adapt. Maybe they're in treatment and they're doing great, but one of their vulnerabilities is sleep loss. And then lo and behold, they have a new baby in the house. Oh, you know, with a new baby you ain't going to be sleeping very much. So okay, you can still stay, keep with this behavior change. You can still keep succeeding, but we may have to put in some, make some adjustments to adapt to this new change and keep in contact through aftercare and support groups. In the maintenance stage, the person keeps on keeping on. Remind the person about new tools to maintain and reinforce their change, such as a daily review of their goals and their action plan. Mindfulness of risky situations or situations that make them more likely to regress to those old behaviors. Coping strategies for each situation and pursuit of activities that promote relaxation and happiness. Really providing energy or using energy to nurture multiple aspects of their rich and meaningful life. You know that whole work life balance thing that they say define and maintain focus on the rich and meaningful life as the person defines it, their long term goals. How is this helping you work towards those? Identify and sample and new and old sources of healthy enjoyment. Support lifestyle changes. Affirm the person's resolve and self efficacy. Help the person practice and use coping strategies and develop a fire escape plan. If the person feels symptoms returning or feels like their motivation is just shot for this new behavior, okay, what are we going to do? What is the fire escape plan that you have so you don't backslide into that behavior even if your motivation has waned? Identify triggers, identify the effect or the benefit of the old way of responding to the trigger and alternate helpful coping responses. Develop reinforcers for this new behavior. Competing reinforcers. If the person's trying to stop smoking, for example, maybe they're going to spend time with their kids and they know they won't smoke in front of their kids. If they're trying to stop eating junk, maybe they're going to chew gum. Contingent reinforcers If I do this, then I can reward myself with and community reinforcers or natural consequences helping them identify, you know, my my spouse is so much happier with me when I do this new behavior. In terms of recurrence, help the person re enter the change cycle and commend any willingness to reconsider positive change. Explore the meaning and reality of the recurrence as a learning opportunity. What did we miss and how can we prevent it from happening again? Assist them in finding alternate coping strategies and maintain supportive contact. In terms of why we use motivational approaches, it's a means of rapid engagement in the general medical setting or mental health setting to facilitate a referral to treatment. A first session increases the likelihood the person will return. But if they don't, you're delivering a useful service that they can start using to build on the idea of change. It's an empowering brief consultation. When a person on a waiting list When a person is on a waiting list, rather than just telling them, you know, wait for treatment. And it's a preparation for treatment to increase retention and participation. It helps people coerced into treatment to move beyond initial feelings of anger and resentment. Serves as a means to overcome defensiveness and resistance. It can be a standalone intervention in settings where there's only a brief contact. And for some it's a counseling style used throughout the process of change. Other things to remember and I promise we're almost done There's a relatively short period of time to make a beneficial impact on the person. We need to kind of hook them where they start believing in the process. The average length of stay in addiction treatment or any kind of treatment honestly is very short unless the person believes that it's working. If clinicians do not make an impact in the first session or two, they may not be able to make an impact at all. So make the best use of your first contact or two. Really focus on hearing the client and minimizing as much as you can. The paperwork, even one session can make a positive impact. Lasting change takes time and effort and all people have the ability to make positive choices and changes in their life. People will be at different stages of readiness for change for different issues and symptoms and may vacillate between conflicting goals. Maybe the person really wants to work on their marriage, but they're not ready to quit drinking. So you've got two different problems. They're pre contemplative on one and the action stage of another. And you're going to need to figure out how to balance those people with low motivation and high fear. Begin arguing, ignoring, or just becoming apathetic. Sometimes enhancing motivation means focusing first on barriers to recovery instead of the problem itself. Explore expectations regarding recovery to enhance motivation and develop a relapse prevention plan. And that's for anything. Relapse means going back to a prior way of being. This is not just an addiction thing. Develop a relapse prevention plan that helps people identify triggers and vulnerabilities and ways to prevent and address them. Alrighty, everybody. Thank you for sticking with me. I know a few people had to leave to go see a patient or what have you. Totally get that. Are there any questions about motivation and retention and all that kind of happy stuff? You are quite welcome. Mark, Janine, Paula, Christina, Bob, Lori, Alana, Jim, Welcome. Hello, Michael. Always good to see you. Oh, hello, Dr. Darlene. I'm sorry I missed seeing you come in. You are quite welcome, Maggie Moon. You're quite welcome, Allison. No problem, Bo. Thank you all for being here. Please remember to like and share and I will see you next Wednesday for our next live CEU presentation.