Stop Being Miserable. Enhance Motivation and Readiness for Change

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox. I'd like to welcome everybody to today's presentation. What it is and how to keep it. Over the next hour we're going to define motivation, identify the five principles of motivational enhancement, review the concepts of motivation and identify the types of motivation and ways to enhance them. Now, generally, when we think about motivation, we just think about this general concept of do I want to do it or not? But what you'll learn in this presentation is there actual facets to motivation that we can work on enhancing in order to ensure that people are as motivated as we can possibly get them? So thinking about it, why do people change? You know, you wake up in the morning and you drink your coffee, you eat your breakfast, you go to work, you do whatever, you come home, you go to sleep and you repeat what would make you want to change? And the answer to that, we'll talk about a little bit more, is generally because you either want something you're not getting, so you're feeling a deprivation, if you will, or you're getting something that you don't want and you want to get rid of it. So there is some sort of discomfort associated with it. I had a mentor when I was in graduate school who said change causes crisis and crisis causes change. And he may have gotten that from somebody else, but it stuck with me for many, many years. Change causes crisis. Once you upset the apple cart and you start trying to do something new, it is going to cause a little bit of upheaval and you can generally term that crisis. Is it going to be debilitating? No. If it's debilitating, people aren't going to keep doing it, but it is going to be uncomfortable. So we have to figure out a way to keep people motivated. Even when things are uncomfortable, even when the going gets tough. Crisis causes change. The other half of that we know that when people feel some sort of a crisis, feel some sort of discomfort, they want to make it stop. So they're motivated at that point to change. Which leads you into what is motivation? It's the desire to change. And there are a lot of different types of motivators that we'll look at. Can individuals motivation to change their behavior be modified? Yes, but they have to want to do it. It has to be more uncomfortable for them to stay the same. When I work with people who are in recovery or people who are addicted to something and maybe not ready to stop using, maybe they're not ready to stop smoking. Can I change their behavior? No. I can put a lot of things in their way of little obstacles. I can make it more unpleasant for them to stay the same. For example, increased in cigarette taxes, not being able to smoke in the office, not being able to smoke in restaurants. There were a lot of things that the government did to make things more unpleasant in order to keep smoking. So that did motivate some people to change. But basically the person themselves has to decide this is just not worth it anymore. Do clinicians have a role in enhancing clients motivation recovery? Oh yeah, mainly because a lot of our clients are not aware of the motivational process. Once they understand it, a lot of times they can do it themselves. But there's also that other motivation out there. If they don't want to be coming to counseling, they're involuntary clients, then they're probably going to be motivated to not see you anymore. So they're going to change their behavior at least temporarily in order to get released from treatment. The other thing that we're looking at is even people who want to change their behavior when they come to see you, they have to shell out money. And a lot of people don't like to part with their money. It's uncomfortable. So they're motivated to get better or make the change quicker. And that doesn't even begin to touch on the reasons that they're uncomfortable and the reasons they're wanting to make the change. So there's a lot of stuff here. Motivation is a combination of desire, willingness and ability to do something. You got to want to, but even if you want to, like I can sit in, in the living room and I can look outside at my garden and I can go, I would really like to get started on my garden. But I may not be willing to get off the couch or I may not have the ability to do so, because at least in Tennessee, the ground is still not ready to be worked for the spring. So desire, willingness and ability. We've got to make sure we're taking into account all three effectively. Enhancing motivation requires empathy and understanding. And if you're trying to motivate yourself or someone else, you have to have empathy and understanding, why is it that I want to do this and why is it that I don't want to? What are the reasons that I might be hemming and hauling and not just like jump into it? Understanding that and working with what you've got, identifying discrepancies between your desired situation and your current situation. So, you know, if you want to, you know, I want to have a beautiful garden in the summer. Well, that's great. The ground hasn't even been worked yet, so I can't even begin to start planting. And there's a whole process in getting a garden to grow and produce food and all that kind of stuff. So there's a discrepancy between what I've got and where I want to be. When we're talking about people who are engaging in unhealthy behaviors, where is it that you see your life in a year or two years or five years? Or what is it that you pride yourself on and pointing out how they may not be able to be as available to their kids if they keep smoking and they develop emphysema, or pointing out some of the facts that may be there. Now, we're not going to go off to the extreme and say you're going to get cancer and you're going to die. That's a possibility. But we've got to look at probabilities, because as soon as you start making mountains out of molehills and they go and they find out, well, the chances of this happening are like 3%, you know, no worries. Then you lose some credibility. So we want to make sure that we present information that's factual, that's credible, but it also highlights the difference between what they're doing and where they want to be. Overcoming resistance to change means more rewarding behaviors or fears about change. So resistance, and I don't like this word, and thankfully we've really stopped using it over the past few years, means that somebody's choosing more rewarding behaviors. You know, if they are choosing to use instead of stay clean, then using is more rewarding, and we need to figure out why. What is it that makes using more rewarding? And generally it comes down to it's helping them escape the page pain from the depression and the anxiety and yada, yada, yada. But why is it they choose this? Because it looks awful. I mean, they're. They're stressed out, they're homeless, they're this, they're that, or, you know, whatever the case may be. But generally, when people are in active addiction, it looks to an outsider very painful. But we've got to understand that being clean and change in and of itself is even more terrifying and more painful. And, you know, going with those fears about change, Anytime you take on something new, there's a bunch of ambiguity. So you don't know if you can do it. And if you've tried before and you failed, then you already have a couple strikes against you and you're going, well, you know, it hasn't worked before. What's the likelihood of success? All of these fears can add up to go, you know, you've tried three times, you've relapsed three times. Just never mind. We need to help people understand why did they relapse those three times? Why did returning to use become more rewarding than staying clean? What did we miss? And it's all about, I look at it like a detective. I want to get in there with my clients and I want to say, what did we miss? It's not what did you do wrong? And it's not necessarily what did I do wrong, but what did we overlook? What triggers what happened? And let's figure out a way to tighten up your relapse prevention plan. And then supporting self efficacy, helping people take that step, making sure they get frequent rewards, doing something and then getting a reward in six months, not real rewarding. So we want to make sure that they have small successes and they can build on those successes. For example, if somebody is trying to stop smoking, what is something that a lot of people try to do? Suck on sugar free candy or get a drink. And so you're still having that same kind of hand to mouth oral behavior, if you will. And it's not solving the problem, it's not addressing whatever was stressing the person out that made them want to smoke, but it is a healthier behavior. Okay, so let's start there. Let's start with a healthier behavior. And then we, while we're addressing these underlying issues that you're trying to deal with, with whatever your dysfunctional coping mechanisms are, stay with that one. And then once you start feeling less stressed, then maybe we can start looking for alternate, less similar behaviors to replace it. Change involves recognizing that something needs to be done. My garden needs to be planted, the house needs to be cleaned, something needs to be done. And then we've got to increase motivation to do it. We've got to realize there's a problem and get the desire and the willingness to get up off the couch and do it. So in defining the problem, we want to create crisis. We want to say, where do you want to be? All right, now, how is this situation? How are your behaviors? How is your current situation different than where you want to be? Or how is this current behavior negatively affecting you? Create that crisis. When they do commercials on television and I talk about them A lot, because they just stab me in the heart. The ASPCA commercials can't even watch them. Their whole goal, in that minute and a half commercial or something, they are eternally long, is to tug at your heartstrings and create crisis. So when they get down to asking you for money, you're like, sure, you know, I just. I want to make the puppy stop hurting. Create crisis, and then identify the solution. You don't want to create crisis. And go, okay, this is the problem. So over the next 12 weeks or so, we'll work on it. We want them to know what their end goal is and be motivated to start taking the first step and have a success and say, okay, you know, that first step wasn't so hard. Identify the benefits to doing what you need to to reach your goal if you want to. We'll stick with the smoking analogy or example. Right now, if you want to stop smoking, you know, eventually you need to be out here. And there are a lot of different ways to stop smoking. You can do it cold turkey, you can wean off. We're going to say, this person decided to go cold turkey. So what are the benefits to stopping smoking cold turkey? And what are the drawbacks to stopping smoking cold turkey? And then we've got to figure out how to enhance the benefits and minimize the drawbacks, which is why a lot of people end up talking to their physician about getting some sort of a nicotine replacement. Some people are looking at E cigarettes. You know, there's a lot of different theories and a lot of different debate about what the right way is. And my answer is, the right way is, what's going to keep you motivated and going to help you keep moving forward. If you get stuck, then we need to look at, why are we stalling out? Where did the motivation go? So they know what the problem is. They know where they want to be, they know why the problem's a problem, and they're motivated. You know, they're feeling uncomfortable. They want to change. So we create a plan. But that plan has got to be individualized, and it's got to provide small, reasonable goals. Again, we want to have them receive some sort of reinforcement or reward or have the success at least once a week. That way they keep going, okay, I can do this. They need to implement the plan and then adjust the plan as needed to ensure that working toward this goal is more rewarding than staying the same. So like I said, if they hit a plateau, if they stall out, we need to look at it and say, okay, what needs to be adjusted. You seem to be losing interest or losing momentum here. Maybe something else just totally changed in their life and they're dealing with that and their stress has gone through the roof. Okay, totally understandable. We need to address that though, so you can keep with your momentum and we can address the plan as it is. Maybe we need to slow down the progress so you can get a hold of all the other stuff that's going on in your world right now and then pick it up again. A lot of times treatment needs to be somewhat episodic because people need to solidify their gains, if you will. Motivation is often doing something to get a reward. We do it because we want to achieve a goal, we want to feel better, we want something. So what do we know about motivation? And this can be found in tip 35 on the SAMHSA website. So you can go and you can read in depth about it, but we're going to hit the highlights here. It's a key to change. If you're not motivated, you're not going to change. It's multidimensional. This is the part we're really going to spend a lot of time on. It's dynamic and fluctuating. When the going gets tough, when it gets uncomfortable to keep making this change. A lot of times people go, you know what, nevermind, it's just not worth it. Think about New Year's resolutions you've made. Maybe you decided that you were going to get healthy, maybe you decided you were going to start working out. So you go to the gym and the first day you are really motivated, you are stoked, you learn about all the machines, you have an easy workout, nothing too hard, and you come home, you go back the next day and you decide to push it a little bit harder. You come home and you wake up the next morning and you're starting to feel sore and you're like, oh yeah, this isn't so nice. Well, anyway, you keep doing this for a little while. Eventually you may get to the point where either you wake up in the morning, you're stiff and you're sore and you just don't want to get out of bed that morning. And your bed is more rewarding than the gym. I know. Surprise, surprise. So we've got to say, what is going to keep this person going on those days? That they've got a lot to do at work or that their bed is way more rewarding than going to the gym? What's going to help them keep going? Motivation can be modified. So when People's motivation starts to wane. All we've got to do is go, okay, how can we increase your motivation? How can we remind you, or how can you remind yourself of what you're doing and why you're doing it? And then again, really look and adjust the plan as necessary. If the person is going to the gym and getting sore, maybe they need to back off and not increase so quickly. That way it's not punishing to go to the gym. If they are stopping smoking, There are going to be times when maybe they're around a lot of people who do smoke. They smoke outside, but they come in and they smell like smoke and it's a trigger for them. Okay, so that's something we need right there. How do we address triggers? When you're around somebody that smells like smoke, or when you walk past the tobacco aisle or whatever your triggers are, we identify those, address those, so the person doesn't have that stress. We can make motivation increase again. It's the key to change. We've talked about that. When we're not motivated, we're not going to do it. And that means doing your homework. That means coming to this class. That means doing your progress notes. Anything you do, you've got to be motivated. Even fun things like going to sleep or cooking dinner or whatever it is that you really like to do, you have to be motivated. But if you like it, you're motivated. That's your motivator. It's rewarding, it's reinforcing, it's fun. Resistance is often a lack of a motivation for the new behavior or more motivation for the old behavior. So we've got to say, what is more rewarding about the person who wants to stop smoking? What does smoking do for you? What were the benefits to it? And how can we achieve those benefits without smoking? How can we help you figure out how to deal with stress? How can we help you figure out how to break those habits? Because sometimes you smoke just out of habit. You wake up. My mother was a chain smoker the entire time I was growing up. She would wake up in the morning, and before she even had her first cup of coffee, she was smoking her first cigarette. Whether she was that stressed that early in the morning, I don't know, but I think a lot of times it was just more habit. Wake up, turn off the alarm, light up. We need to help people figure out how to address those. One of the first steps in developing motivation for change is to create a crisis such. So help them identify what are the problems with the current situation, you want to stop smoking, okay. You don't want to have to go out and smoke outside when it's cold and rainy. And okay, that's one. You want to save money because it's getting expensive to smoke. You want to be healthier, great. You want to be around for your kids, great. You are finding it more difficult to breathe since you've been smoking so much. Okay? Those are all reasonable problems. So in what ways will the change be worth the effort? What are you going to get out of this? Because stopping smoking is hard. So I want to know, aside from being there for your kids, which is a motivator, don't get me wrong. But what else makes the change worth the effort in the short term to get you through today or this week? So you're not going. You know what, I can have a little slip here. Motivation is multidimensional, and this is one of my favorite parts. Emotional motivation. Whatever you're doing makes the person happy or it makes they make themselves happy by doing it. So if you're stopping smoking, how can the person feel happy about doing that? They may need to find rewards to put in if they get through an entire day without smoking. Or what could they do at the end of the day to make themselves happy? Because stopping smoking itself is not necessarily happy. What could they do instead when they're stressed that they might enjoy besides smoking? And you know, my fallback is always cat videos on YouTube. But whatever works for a certain person mentally help them really ferret out what the logical choice is based on their goals. Is this the logical choice? And how is it the logical choice? How does it make sense that this is what they need to do? So emotional is. It's what they want to do either for the reward itself or because they're going to get a reward for making it through the day. Physical motivations. It improves your physical health, it may reduce pain, it may increase energy. What are the physical motivations for doing this? In what ways is it going to help you feel better in your body? Socially Social motivations, look at how will this improve relationships with yourself or others? And I emphasize with yourself because a lot of times we overlook that. We say, how is it going to help you in your relationships? And, and we sort of hint or indicate that relationships with others, but we're also talking about our relationship with ourself, doing things for ourselves in order to make ourselves healthier, happier, yada, yada yada, and in order to help you embody what you envision as your self esteem Social motivation could also come in the form of eliciting positive feedback again from self and others. You got to pat yourself on the back and go, you know what? Today was a really crappy day. But I didn't light up. I thought about it, but I didn't do it. Have other people around you that are willing to provide positive feedback. When you have a good day or a good week or achieve a goal, get a buddy. One of the best ways to maintain motivation is if you're both doing it together. So maybe the two of you are stopping smoking together so you can give each other positive feedback, support and reinforcement. And then environmental motivation. Anything that makes the environment more comfortable. If you stop smoking, what will be better about your environment? If back to my mother when, and you know, it was the time when everybody smoked, but there was always nicotine on the walls and nicotine in the drapes and there was always kind of a, you know, nicotine smell. And when she quit smoking, that all went away. So you didn't have to wash the walls as much and wash the drapes as much. So that helps in the environment. What else might stopping smoking change about the environment? Well, hey, you don't have to get up from the meal or leave work four times during the day to go out and smoke. You can go out to lunch with your friends instead of having to grab lunch. So you can eat in your car and smoke. There are a lot of different motivators. This is a good activity to do in group. If you've got 612 people that all have a similar goal, put each type of motivation on a flip chart page, tape it around the room, break them into groups, and have them identify what they see as the emotional motivations. Mental, physical, social, environmental. You see what I mean? And then you'll have a whole list and people can go through each one and go, yeah, I hadn't even thought about that benefit. It helps gets people stoked and reminds them of all the various, even sort of tangential reasons they're doing this. Interventions creating the crisis. If you have someone who is in pre contemplation or contemplation, they're not quite ready yet to make the change we need to kind of create a crisis. So we want to examine the ways that the mood issue or addictive behaviors are impacting each area of wellness. And so we want to look at how is this problem that you're presenting with impacting you emotionally? How is it making you sad, angry, stressed, depressed, guilty, any of those dysphoric emotions? How is it impacting you cognitively? Is it stressing you out? Are you thinking about it a lot? Are you worrying about it? Are you whatever, physically, how is it impacting you socially and environmentally? We want to recognize that each negative impact is likely the result of energy shortages. So when somebody is smoking and they decide, you know, I really want to stop smoking, so we want to say, why do you want to stop smoking? What is motivating you to stop smoking? And they may say, you know, I'm worried that I'm going to get cancer or I'm not going to be there for my kids. So worry is down here. So they're spending a lot of energy worry. And we want them to understand that one of the ways they're coping with this worry, one of these ways that they're stopping spend spending so much energy on worrying is smoking. It distracts them. Identify individualized interventions. Identify ways to reduce stress and improve each area of wellness. So we know that whatever you're trying to change is making you uncomfortable. So how can we make you more comfortable, reduce stress, make you more uncomfortable, more comfortable, however you want to put it. And then on top of that, instead of just focusing on this one issue, like stopping smoking, let's look at all these other areas that will help you be healthy in your mind and body. So emotionally, what can you do to be happy each day? Because you know what, you can't be stressed out and happy at the same time. So even if it's for 10 minutes, it may not be forever, but even if it's for 10 minutes, what can you do? What can you do to help yourself stay focused, think better, improve your memory? That's usually not a big motivator for people, but you know, you can look at it physically, what can you do to improve your health? And you know, I'm going to go back to looking at those vulnerabilities. Sleep, nutrition and pain. What can you do to give your body the tools it needs to recover, rebalance, and support you in this change? And socially, how can you improve your relationships right now? How can you improve your relationship with yourself so you feel like you deserve the very best and you deserve all the effort that you're putting into it? Highlight motivations for change in as many areas as possible and define and identify motivations to change in each dimension. That's kind of what we talked about on the last slide with emotional, mental, physical, social, and environmental motivations. Sorry, I'm losing my voice. Motivation is dynamic and fluctuating. When the going gets tough, motivation gets Going, I have had many, many, many, many clients over the years come into treatment. They get out of detox, they come into residential. They are motivated. I mean, the detox process was not pleasant. So they've been pretty uncomfortable. They're ready to change. They are in an environment where it's really pretty comfortable. You know, they've. They've got a roof over their head, they've got food. There are some, you know, they may be packed in like sardines, depending on what facility that you're at, but they start going to group and they start feeling not so bad. You know, they're getting further and further away from that detox period. So they're not physically feeling as bad. They're making friends. There's not a whole lot of stress going on. So they forget about all the stuff that's out there, not in the treatment center. And then you hit a hot button. It starts getting uncomfortable. You start hitting some of their issues, and they're like, you know what? I feel pretty good. I think I've got this licked. I'm out of here. And they discharge ama. And that's when it's really important for a clinician to be able to step up and say, so let's talk. Give me, you know, sometimes I would say, can you give me an hour? Can you stay for at least another hour? And let's talk about what's going on. And then if you decide you're ready after that, you know, I can help you with your discharge paperwork. If you think you can get until the next day, think it over, because you're not going to be able to get back in right away. Before you went into detox and when you were in detox, what. What were your motivations for recovery? Yeah, you're feeling a little bit better now, and that's good because that means you're making progress. But what is the likelihood that you're going to be able to maintain this when you go back out there and start dealing with all this stuff? So it's up to us to really create that crisis again, which kind of seems mean when they were feeling pretty good. But if you know or you suspect that the reason they want to leave is because it started getting more uncomfortable, they say, you know, dealing with my past trauma is worse than anything I had to deal with on the street. Then it's time to talk and maybe time to put the brakes on some of the interventions that you're doing in treatment, because maybe you're going a little bit too fast for them at that point, motivation is also a combination of commitment, your willingness to do something, and these are the three aspects of hardiness. If you want to look back into the 1970s, I believe is when the concept of hardiness came about. Commitment, control and challenge. You have to be committed to making the change and ready to stay the course even when it gets uncomfortable. Control. You have to believe that you actually can affect change in your own life. You have to have some self efficacy. Because if you don't believe that you be able to do it, then why try? If you've gone through treatment before and you've relapsed two, three, four times, or even just once, then the next time you go through, you may be questioning your self efficacy. So as clinicians, it's up to us to highlight what they did do and when they were working their recovery program. Whether it's for addiction or depression or mood disorders. When they were working their recovery program, how were things going? What triggered the relapse? Was there a major change? Was there a major crisis? Or did they just quit working their program and fall back into old behaviors? So what we want them to understand is when they're doing the next right thing, when they're using these new behaviors, things are pretty good. It's when they start getting slack that a lot of times they'll fall back into old behaviors. Emphasize how well they did during that period they were doing the right things. You were clean for three months. It's the longest you've been clean in five years. So that's really awesome. Let's build on that. We need to make sure there's a little bit of a challenge. If they think that there's nothing to recovery, then there's not going to be a whole lot of investment in it. We want to challenge them to figure out how they can make it last for themselves. Reasons motivation wanes no effective plan. You want to stop smoking? Okay, today is the last day I'm going to smoke. Henceforth and forevermore. I'm just not going to buy any more cigarettes and I'll white knuckle it through the cravings. In my personal opinion, for most people, that's not going to be an effective plan because the smoking was more than just a habit for most people. It was helping them deal with stress. So if they're not also learning new coping skills for stress and or reducing the stress in their life, they're going to have a real hard time not returning to the one thing they were using to cope with stress. Distractions. You're wanting to. And this isn't quite as appropriate with smoking. We'll talk about addiction recovery in general. In addiction recovery, you need to go to meetings, or you need to go to support groups, or you need to go to church. There are a lot of different places you can receive support and work your program. There's a lot of different ways to work a program. But if you start getting too busy at work and getting distracted by things on TV and getting distracted because the car broke down, if there's always an excuse and you're not engaging in your recovery plan, then motivation is going to wane, and you're likely not going to keep doing those new behaviors that may not have kind of solidified yet as just part of what you do. Drawbacks. If we don't take into consideration the benefits of the old behavior, what did it do for the person, and how can we help them meet that need, and the drawbacks of the new behavior, what are the potential reasons you might not want to do this? When I talk with people who are trying to live a healthier lifestyle, and part of that being nutrition, and they're like, you know, I can do a lot of it, but I just can't eat rabbit food all the time. I'm like, you can eat a healthy diet without confining yourself exclusively to rabbit food. So we want to make sure that whatever you're putting out there for this new behavior is something that they're willing and able to continue for the duration, not just for three weeks or three months. Negative motivation in behavior modification, one of the principles we have is you always want to add three behaviors for any behavior you eliminate. And why is that? Well, think about if you have, we'll say a dog, and the dog barks, and you. And you scold it, you punish it. The dog eventually learns not to bark, and he starts making noise, running around the house because he wants to play. And everything he does that makes noise to indicate that there's either a problem or he needs to go out. You scold because it's disruptive. Well, then he pees on the floor, and you look at him, and you're like, fido, why did you pee on the floor? Why didn't you tell me you needed to go outside? And the dog's just sitting there looking at you, going, I couldn't bark. I couldn't run around. I couldn't bring you my leash. Everything I tried to do, I got punished for. And I had no other behaviors to do. So if you take away a behavior that is serving a Function, you've got to replace it with something in order to increase the chances of effective change. So negative motivation means when you're setting goals. Yes, we're probably trying to eliminate something, get rid of depression, stop smoking. That's your initial problem. But what is your goal? Your goal is to add something, to get healthier, to feel happier. That's what you want to add. That's the reward that you're going towards. Extrinsic motivation means depending on the outside world, waiting for somebody else to go, good job. You've got to be able to pat yourself on the back. You've got to do make these changes for you. A lot of times people make changes in order to try to save a relationship or in order to try to save a relationship, get a promotion, do something that involves someone else validating it. And it's important to make sure that the person is doing this for themselves. That way, if whoever it is doesn't pat them on the back, they don't go, well, that was a waste of effort and yes, a lot of motivation. You can work in the decisional balance exercise, where you look at the benefits and drawbacks to both staying the same and change. Oh, and hey, here we are on our decisional balance. Enhance the benefits to change and the drawbacks to staying the same. So I hated the color clash, but I had to do it. Green means go. We want to enhance these things. Red means we want to stop or remove them. We want to remove the benefits to staying the same. You know, if you got social rewards for doing this, how can we make sure that you're getting social rewards in your new behavior? And we want to eliminate the drawbacks to change. This is probably my favorite example when we talk about readiness for change, because you've got to motivate people. And my first supervisor, when I was doing my practicum, I talked to him one day because I was getting really frustrated that our clients were coming back, they were relapsing. And his point to me was, and it's another one that stuck with me, if somebody's been doing something for five, 10, 20 years, and they come into treatment for 28 days, if you can move them from one stage of readiness for change to the next, you have done more than your job. You have done a great job. You're not going to get them from pre contemplation all the way to maintenance in 28 days. So start with where they are and look for small episodes of care. You have to be motivated to move forward. And when someone Is in pre contemplation, they're not motivated because they don't see a problem, or they do and they're not ready. There are three types of precontemplators. These are the people that go, you know what? I'm okay staying. The same is better than whatever this change is you're offering me. Reluctant precontemplators often don't have the information they need to understand that this is a problem. So we want to increase their knowledge or awareness about the problem and the personal impact it's having on the problem. Rebellious precontemplators, they fear that somebody's trying to force them into treatment or make them do something, and they fear loss of control. So we want to take that and go, you know what? It's okay. With my clients who are on felony parole, we would do this group, and none of them wanted to be there. They were all pre contemplative, and, you know, that was okay. So instead of lecturing on drug addiction and pharmacology every night, I would turn it around and I'd go, what is it that you want to get out of this 10 weeks that you're stuck with me? The state's paying for it, so you might as well benefit. What is it that you want to get from it? So shift the energy from fear of losing to control to what can I get out of it? Because most of the time, the goals are going to be overlapping. They're not mutually exclusive. So if they want to get off probation and not have to do deal with their PO anymore, not have to deal with you anymore, that's great. But that means they've got to stay clean. My goal is for them to stay clean. But by helping them work on their goal, I also achieve my goal. Resigned. Pre contemplators have tried before and they failed. So they feel like it's hopeless. And we want to rekindle that hope and optimism by highlighting their successes, strengths, and supports. Okay, you relapsed, but you were clean for a month. You weren't. You were not depressed for six months before this episode came along again. So that's good. And each time that you recover from a depressive episode, you stay happy or not depressed, depending on how the person presents it, for a little bit longer. Let's look at how you're doing that, and let's build on that for the person again, going back to smoking. Maybe you've tried and failed before, and you've tried and failed before. Let's look at what caused those failures and tighten that up. We're just learning about you as an individual and what you need in order to recover. Now, I use the analogy of a pool. Precontemplators. It is 95 degrees in the shade. You are hot, but you're looking at the pool going, it is really cold in there. Pre contemplators either have tried to get in the pool before, and it's been uncomfortable, and they're like, no, I don't do pools. Or maybe they just. They don't even realize how hot they are yet. They're sitting there and they're like, no, I'm fine. It's not really a problem yet. Contemplators. It's getting a little hot, but I'm still okay. You know, they're fanning themselves. They're putting their lemonade up to their face, but they're not ready to get in that cold pool because they know it's going to be uncomfortable for a little bit. As clinicians, we can address the ambivalence by tipping the decisional balance scales. Have them do one of those decisional balance exercises. We want to address their anxiety about change. What are you afraid of with change? Are you afraid of failing? Are you afraid of losing friends? What are your anxieties and apprehensions? And also their grief, letting go of something, not being able to smoke anymore. There could be some grief in it. So let's talk about. What does it mean to you to not be a smoker anymore or to not be able to turn to cigarettes when you get stressed? Help them visualize change. Help them see what it's going to be like when they start reaching their goal, when they start changing. So you can do this through either just talking about it, through. What's the word I'm looking for? Collages. There are a lot of different ways to help them visualize change. If they've had clean times in the past or happy times or, you know, not asymptomatic times. What did life look like? How was it? Awesome. Help them remember that that's where they want to be. So they're getting that, and they're like, okay, yeah, I'd really like to be back there again. So they move into preparation. They realize they've got to do something. It's getting too hot and they've got to do something. So they stick their toe in. They start trying to think about change, what they might do, what they might need to do differently. They're not into making action yet. They're still in the thinking stage in terms of the Pool. They're sticking their toe in to see how it feels and then they're going to make a decision. If it's too uncomfortable on their toe, then they may not be ready yet. Increase self efficacy by increasing that commitment, control and challenge. What is one thing that you can control that you want to change? Let's start working on that. You know, it may not have anything to do with this other problem over here. Let's start working on that. Generally, we find that positive changes in any one area have reciprocal positive changes on whatever other issue is over here. Encourage the person to begin learning about the issues. If it's depression, learn about what causes it and what interventions are out there. Addiction, smoking, whatever their issue is, point them in the right direction so they're not just drowning in a sea of Google. Identify motivations in each area and create small successes for components of the goal. If somebody's dealing with depression, you know, maybe they are not sleeping well, they're not eating well and they're having difficulty concentrating and they have no energy. Okay, that's four different components of that goal. To be happier, to not be depressed. We want to address all four of those. So where do you want to start? You want to start with sleep, nutrition, energy, foggy headedness, and then create the goal from there. Clarify goals and strategies by identifying and addressing barriers to change. What has tripped you up in the past? What might trip you up in the future? Or is there something coming up that you know is going to cause you a problem? I'm based just out of Nashville and some of the clients that I work with are musicians and they tour. And so I'll have clients come in and they're like, well, I've got seven weeks and then I'm going to be okay for the next three months. Okay, you're ready to change. I want to keep your momentum going. So let's see what we can do in the time that you're here now. What are we going to do when you're overseas? How are we going to handle that barrier to change? And there are ways. There's Skype, there's email, There's a variety of different things they can get. If they're working on addiction, there are online meetings that they can go to. There are a variety of things, but you need to plan them out. Highlight strengths and past successful strategies. Garner social support, get a cheering section going, get a battle buddy, get ready and make sure that you've got some support for it. Maybe not necessarily. Even if you don't have somebody making that same change. Maybe people who are willing to help you so you have more energy to focus on making this change instead of doing laundry and dishes and carpool and whatever else. And envision change if you've never been there or you don't know what it's going to look like, or somebody's sort of ambivalent here. Find motivating stories about others who have changed. Who has struggled with depression, succeeded to come out the other end and be happy. You know, it doesn't mean you're not going to have another depressive episode, but it means you can cope with it. Who's quit smoking, who has gotten into recovery from addiction? Find stories, whether it's celebrities, people in their church, people that they know. Encourage them to build off those. So they're dipping their toe in now, okay, they're tired of being hot. They're going to take the plunge. They're going to jump in. We want to make sure that motivation is maintained. So when they get in and it's really cold, there's some discomfort there. We want to make sure that they remember how uncomfortable it was being hot in order to make sure they're maintaining motivation. Mindfulness activities are wonderful. I encourage my clients to do mindfulness activities every morning and every evening for the first three months after they get out of residential. How are you feeling? And just go through the list emotionally, mentally, physically. In my program, we talk about spiritually. What is going on? Are there any particular stressors? Just check in with yourself and then proceed from there, knowing what your vulnerabilities or your strengths are for that day. At the end of the day, you go through the same thing to identify where you're ending the day. So you're not hopefully ending the day just stewing on a bunch of stuff. You can identify it, deal with it, and then rest comfortably. Identify triggers, how they could cause relapse and how to deal with them. So, you know, one of the triggers for the pool is cold. It could cause you to want to get out of the pool. So how do you deal with that cold? You can tread water, you can swim, you can dive. There are a bunch of things you can do with our clients. Help them identify what's triggered you in the past. What is it that you think? What are the things that could happen that would make you go, screw it? We need to address those right now. Let's make a plan. Maintenance. This is the time to enjoy your successes. Step back and look how far you've come and go. You know, six months ago, I was Feeling pretty bad and look where I am. Or six months ago I was smoking three packs a day and now I'm a non smoker. Awesome. Good for me. Stay mindful of continuing to work your program and remain vigilant for relapse triggers. We have that behavior in the back of our head as sort of a drop back and punt coping skill. So if our new coping skills and our new strategies fail to work, we always have that one that we could potentially go back to. We need to be aware of that and be vigilant for it. If we're talking about depression, you know, there are relapse triggers like holidays or three weeks of no sunshine, all rain. If that's a relapse trigger, how do you prevent that from triggering a relapse and make minor adjustments as needed? Relapse so the person got in, it was too cold and they jumped out. Relapse means falling back into old ways of thinking and acting. Relapse is not a requirement for recovery. Some people have one depressive episode and that's it. Some people, when they're trying to stop smoking, do it the first time, stop drinking, do it the first time. It is possible, but it requires a whole bunch of diligence and mindfulness to be aware of all those triggers and things that come up and sort of trip you. I'm a trail runner and when I'm out running, I'm always having to look for routes and things. And I'm not the most graceful thing in the world. It never fails. At the end of the run, I'm always trying to beat my partner because I'm a little competitive and I will start running and I'm tired and I'm not paying attention and I'm trying to, you know, go fast and really just push through to the end. And 8, 8 out of 10 times I trip over a tree root and I fall and just bust my butt. So this is sort of something that people need to be aware of with recovery. They need to pay attention when they're getting tired, be aware of vulnerabilities, not try to rush through and be cognizant of what's going on. So they can adjust, they can dodge those tree roots and not trip and relapse. The earlier you catch a relapse, the better. So if they do use, okay, you used what caused you to use. Let's look at what happened and how can we prevent it from happening again? We found that shaming people does no good. They've already shamed themselves, they already feel guilty, they Already feel disempowered. So it's up to us to empower them and go, all right, you were already clean for three weeks or three years, whatever it was, you'd stop smoking and you hadn't smoked for eight months. What was it that. What changed? Let's look at that and address it. What things need to be addressed to keep recovery the most rewarding choice? The pies approach proximity. When you put in motivational enhancement. The best way to do it, the best way to encourage behavior change is to provide the intervention in the natural environment. So not wait till somebody's in your office. It's going to be much more effective if they try to practice it out there. Immediacy. Intervene as soon as the problem or loss of motivation is noticed. Not wait until their next appointment a week from today. What can they do? What can they do to build up their motivation? Encourage clients to make sure with when they're creating their relapse prevention plan and they're creating their plan for treatment, they know how to increase their motivation if they start waning. And what are the emergency steps if they're just like, I'm really going to relapse here? Expectancy. Expect the intervention to be successful and emphasize self efficacy. Make sure they know that you believe in them. If they think that you're going to, yeah, let's see how long he stays clean this time. Then that just kills self efficacy. And keep things simple. Don't make these complicated treatment plans. Keep it really simple. When we talk about nutrition, you can total macros and micros and vitamins and all kinds of stuff. Or you can, say, have three colors on your plate at each meal. A lot simpler. Most people can do the second one, whereas the first one is just overwhelming. The more types of motivation involved, the stronger the motivational force. So if it's emotional, social and environmental motivation, that's a whole lot better than just somebody going, yeah, I think I might like to change. Signs of decreasing motivation include failure to attempt change. What we called resistance back in the day, Boy. But basically a lot of yes buts, excuses and yes buts and lack of enthusiasm. People not coming to appointments or when they come, they're just kind of half there. They're like, all right, I'm here. What are we going to talk about, doc? Let's talk about why you're here. Then. Have clients rate their motivation on each target behavior. Not each goal, but each target behavior each day. So if somebody's trying to lose 15 pounds, maybe they need to go to the gym Maybe they need to start drinking eight glasses of water each day and start eating healthier. So you want to rate their motivation on each one of those target behaviors because they may be more motivated to eat healthier, but that water is hard to get down. Okay, let's talk about how we can increase your motivation and make that more pleasant. Motivation is behavior specific. So you want to make sure that you're addressing all of the behaviors that need to change, but you're also looking at the motivation for each one of those behaviors. Emotional motivation are things that make things happy. So we want to increase things that make the person happy. And we want to help them see how the old behavior adds distress. We want to decrease the ways the old behavior makes a person happy. Like smoking helps them calm down. Okay, well, what else can you do instead? And we want to decrease the ways the new behavior adds distress. This particular emotional motivation is more powerful with people who have more of a feeling temperament. Mental motivation, things that people see as logical. So if you've got somebody who tends to be more logic oriented, this will help increase their motivation. So again, looking at that decisional balance activity, you want to increase the green and decrease the red. Social motivation increases the person's self esteem and self acceptance, as well as social approval and acceptance from those people that are important to them. So we want to identify all of the reasons that this new behavior will increase their self acceptance and self approval. Environmental motivation identifies the new way the behavior will allow the person to improve their environment. Maybe they'll be around people who are kindred spirits. Maybe they will get to go on vacation. It will allow them to do that, or move to a different house, change their environment, or maybe it'll allow them to get things that they want. It's, you know, a perfectly individual choice. So we want to help them identify environmental motivators. Motivation is essential to behavior change. It involves choosing the behavior that provides the greatest rewards for the effort. Increasing motivation means enhancing rewards and reducing punishment. So we got to enhance the rewards, not just reduce the pain. Motivation is behavior not goal specific. There are five phases of readiness, or steps to change, which clients will bounce between pre contemplation, contemplation, preparation, action, and maintenance. So making sure they're aware of where they are in the stages of change. Waning motivation is one of the most overlooked components to relapse. Too often as clinicians, we don't pay attention to waning motivation. And then all of a sudden, a client relapses from out of the blue, and you and I Both know that stuff generally doesn't happen from out of the blue. So let's look at when did their motivation start to wane, to do the things they needed to do to stay happy and healthy. But remember that relapse is not necessarily a component of recovery. And I got in a minute and a half under the wire. So there are a couple questions that came up. If you're working with a family for family therapy with a parent and child, the child is in the action stage and the parent is in reluctant pre contemplation stage, how do you proceed? Well, the first thing I would say is, you know, looking at who's the identified patient in that particular case and what is it that the family. What goal does the family hope to achieve if the child's in action? You know, I want to support that motivation for change. So anything that I can give the child to do to start feeling happier and you know, whatever solving this problem going to be good. So maybe, you know, thinking of addicted families that I've worked with, the child really wants this addiction problem to go away that's in the household and the parent is the one who is the identified patient and addicted. They're not quite ready to change yet. So how do we help the child? Well, the child can't change the parent and that's the first thing that I would stay with with that in this particular scenario. But help them look at what is it that they expect to get out of the addiction, going away from the family and how can I help you achieve that now and then work with the parent, the addicted parent, the identified patient, whatever we want to call them on increasing motivation. If they're reluctant, helping them identify ways that they might help Junior because they're probably there to help Junior. And so if stopping using is one of those, then that may come up eventually. But this will help give them some control back. What are some of your goals? What are some of the things that you want to see happen? Most likely it will overlap with the family goals and hopefully the child's goals. Okay, everybody, thank you very much for being here today. If you have any questions, comments, concerns, whatever, you can always email me@supportlce.com and I will get back to you. You usually within 24 hours. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing@Allce.com Counselortoolbox this episode has been brought to you in part by allce.com providing 24.7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.