MI & model of change Flashcards
what is the transtheoretical model of change
six specific steps necessary for any type of radical change to occur:
- precontemplation
- contemplation
- preparation
- action
- adaptation/maintenance
-evaluation
explain the pre contemplation stage
- no insight into SUD
- Individual will resist change and typically has no intention of altering behaviour
- Unaware of the impact of behaviour on those around them
role of RPN in pre-contemplation stage
use MI - keep pt engaged
- Build rapport and trust; increase problem awareness; raise the sense of the importance of the change.
explain the contemplation stage
- pts get ready for change
- they become aware that they are stuck in a situation and must decide whether they wish to change or remain where they are
role of RPN in contemplation stage
- the focus is on pros and cons
- Acknowledge ambivalence regarding the difficulties associated with change
- explore the discrepancy between present behaviour and the service user’s personal values and goals
- assist in weighing pros and cons of change, while working to tip the scales towards change
- Discussing reasons for change and risks of not changing important, as is increasing confidence in ability to change
explain preparation stage
- pt considers changing drug-using behaviour and anticipates what this future action will entail
- pt adherent to OATs
- pts more involved, show up for apts
role of RPN in preparation stage
- build pt confidence
- talk about timing of change
- provide information, options
- help pt identify and resolve barriers to success, including friends and family who may still benefit from user’s drug-using behaviour, along with activities associated with drug use
- help pt develop realistic plans that can be easily implemented with minimal risk of failure
- dont rush; work at pt’s pace
describe the action phase
- the work and behavioural change begins; heavy emphasis on problem solving and problem-solving skills
- Entails changing awareness, emotions, self-image, and thinking
- pt is actively involved in the change process
- pt will be abstinent or on OAT
- they may still be using drugs but are involved with tx with harm reduction awareness
role of RPN in action phase
- Support of positive decisions and positive reinforcement
- help develop attainable goals
- monitor progress and assist pt in self-monitoring
- relapse prevention teaching
- helping pt identify and explore times that may lead to use (emotions, urges, cravings, social situations, etc.)
describe maintenance/adaption phase
- pt has made changes and is sticking with it
- e.g., pt on OAT, only seen once every 3 months, taking antidepressants
role of RPN in maintenance phase
- focus on skills training
- focus on supporting and encouraging new behaviour
- provide different counselling approaches to support pt in adapting to not using drugs
- help develop plans to address triggers that can lead to lapse or relapse
describe the evaluation/termination phase
- Sees service user move beyond problem solving, with a focus on preventing reoccurrence and dealing with the reality of sobriety
- Service users assess their strengths and areas that may be problematic in the future as they develop a reoccurrence-prevention plan
role of RPN in evaluation/termination phase
- Reinforce new skills, new knowledge, and the positive changes produced
- review triggers that can lead to lapse
- develop strategies on how to return to the new behaviour if a lapse occurs rather than returning to previous behaviours that led to drug use
consciousness raising
increasing information to service users about themselves and their problem
dramatic relief
experiencing and expressing feelings about one’s problems and solutions grieving losses, partaking in role play to appreciate impact of changed behaviour
Environmental Re-evaluation
assesses habits that affect one’s social and physical environment; increase awareness that one can be a positive or negative role model for others
Self Re-evaluation
users assess how they think and feel about themselves with respect to their substance use; value clarification, healthy role models, imagery used
Self-liberation
choose and commit to change beliefs and actions
Reinforcement Management
providing consequences: punishments or rewards
helping relationships
combining caring, trust, openness, and acceptance and support for healthy behaviour
counter-conditioning
substituting healthier alternatives for problem drug-using behaviours; focus on substituting alternatives for problem behaviours with an emphasis on self-care
stimulus control
removing cues for drug use and replacing them with prompts for healthier alternatives
SOCIAL LIBERATION
increasing engagement in non-drug-related behaviours, considering the needs of others, becoming involved in broader issues; increase is social opportunities or alternatives
what is MI as defined by William miller
An interpersonal and interactional process wherein which there exists the probability of behaviours occurring that are intended to lead to positive outcomes
reasons people resist change
- Nature of necessary change is misunderstood
- Change is forced or mandated
- Hard work required to change what you have been doing for a long time
- New skills and knowledge often required
- Changing threatens one’s competence
- Too many changes are asked for all at once
- Goal is not seen as achievable
Change talk vs Sustain Talk
Change talk is talking about the possibility of changing and sustain talk is talking about remaining in the same situation.
MI tactics
- Encourage the change talk, and acknowledge sustain talk but do not dwell on it.
- Acknowledge difficulties in the process, do not dwell on them.
- Summarize progress and encourage their growth through observations.
- COGNITVE DISSONANCE
what is MI
- Influenced by Carl Rogers; developed by William Miller in 1983
- Brief, person-centred method; uses intrinsic motivation to change
- Explores and resolves client ambivalence
- Uses the ideas of attribution, cognitive dissonance, self-efficacy and empathy
- Interpersonal process that de-emphasizes labelling
- Emphasizes internal attribution for change and individual responsibility
- Strength-based counselling style; counsellor works with user, rather than doing things for or to them
- Focus on locating natural motivating issues within a person’s life
- Non-confrontational in nature; acknowledges that creating conflict is counterproductive
- Seeks to increase user’s awareness of their behaviour as well as unrecognized strengths and opportunities for change
Cognitive Dissonance
- Cognitions include our thoughts and beliefs; our opinions about the environment, ourselves, our actions and behaviours
- Consistency occurs when these cognitions align
- If balance not obtained, individual will experience state of tension or inconsistency between their opinions, attitudes, beliefs, and actions
- Dissonance occurs when this tension motivates individuals to alter their thoughts, bringing their beliefs and perceptions closer
Principles of MI: RULE
- Resist providing suggestions
- Understand the person’s motivation to change
- Listen intently, provide feedback
- Empowerment through encouragement and support
Components of MI: PACE
- Partnership: MI is collaborative work
- Acceptance: Absolute worth; Autonomy and support; Affirmation; Accurate empathy
- Compassion: non-judgemental, non-blaming, non-shaming
- Evocation: draw knowledge and options from service users rather than imparting information or opinions
Attributes of MI
- Express Empathy: sets the stage for acceptance of efforts to facilitate change
- Develop Discrepancies: perceived values versus actual behaviours and outcomes. User must be able to perceive discrepancy between present behaviour and personal goals and values
- Roll with Resistance: resist arguing against resistance; have service user voice arguments for change
- Support Self-Efficacy: service users (and counsellors) must believe change can happen
OARS
- Open-Ended Questions: allow service user to guide conversation
- Affirmations – compliment user on behaviours, strengths, and efforts
- Reflections – 2- 3 reflections after open ended questions
- Summarizing – ensure mutual understanding of discussion
change talk
- Verbalizing arguments for change
- Allows service users to openly discuss new idea
- Think in ways different from when misusing drugs
- Contrasted with “sustain talk”: conversations that favour the status quo and resisting change and “disengagement traps”: approaches that negate value of MI
- Proficient use of MI techniques will increase change talk and decrease sustain talk
disengagement trap: assessment trap
When you begin and focus only on information gathering rather than exploring the service user’s motivation for change.
disengagement trap: question and answer trap
Asking too many questions and not letting the service user lead the discussion.
disengagement trap: expert trap
Assuming and communicating that you have the best answers to resolve the service user’s challenges.
disengagement trap: premature focus trap
Focusing the discussion before fully engaging with the service user.
disengagement trap: labelling trap
Defining the service user through a label.
disengagement trap: blaming trap
When the discussion shifts to blaming or finding faults with others rather than on the change process.
disengagement trap: chat trap
Engaging in access small talk that is not action orientated.
MI PROCESSES
- Engaging: establish a mutually trusting and respectful helping relationship
- Focusing: “what” stage; entails clarifying particular goal or direction for change and exploring ambivalence to change
- Evoking: “why” stage; counsellor assists service users to find, nurture, and implement their own reasons to change
- Planning: “how” stage; counsellor helps the service user develop specific change plan that service user is willing to implement
