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Provoking (non-oppressive) social change
One to one client interchange
STATUS QUO VERSUS CHANGE
• Active listening, open questions, and summarising; being reflective-exploring the client’s current behaviour i.e. pros and cons.
• Subsequently, engaging in the same process in respect of the pros and cons of him/her changing behaviour.
• Remember the approach is non moralising and non confrontational.
• Explicitly change oriented -delineation from Counselling. {Consider}
MI IN PROFILE CONTEXT
• Individual as isolated and ambivalent.
• Your professionalism: His/Her willingness to change {recessed}.
• Eliciting the change potential within the client.
• Risk of temptation to know what’s best for him or her. {relate to issues around values-whose; claiming to know the truth…}.
EXTRINSIC-INTRINSIC DIALECTIC
• Miller and Rollnick {2002} Preparing People for Change.
• Client centred/directive approach.
• “enhancing intrinsic motivation to change.”
• Exploration and resolution of ambivalence.
CYCLE OF CHANGE
Pre-contemplation
Contemplation
DecisionActive Changes
Maintenance
Relapse
STAGES OF CHANGE
• [1] PRE CONTEMPLATION: avoidance/resistance/denial.
• [*] Moving On: the seeds of change?
• [2] CONTEMPLATION: embryonic consideration/midst resistance.
• [*] Moving On: signs of cognitive & affective arousal.
S of C {cont}
• [5] MAINTENANCE: by now process in train/dynamics of personal change.
• [*]Moving On: emphasis on nurturing and enhancing hard won changes; keeping clear of old environments/influences.
• [6] TERMINATION or RECYCLING: ‘the new life’ or recognition of relapse as a manifestation of imperfection. Uncertainty as learning.
S of C {cont}
• [7] CONTINUING TO GROW: the individual as free from….or else relapse. Freedom via painful journey versus relapse as learning.
[8] RELAPSE: one step back two steps forward?
• Learning the lessons of relapse.
• Most people need more than one attempt, and to budget more time, energy and money.
• Being prepared for complications.
• Being aware that small decisions lead to big ones.
• Being aware that distress precipitates relapse.
FOUR GENERAL PRINCIPLES OF PRACTICE • Express Empathy: the capacity of the
facilitator to be as if in the other person’s boots.
• Develop Discrepancy: working assuredly, but without resorting to moralising, with the contradictions in what the client is saying to you, as facilitator.
• Roll with Resistance: clients are likely to resist change; effectiveness in this context is about not getting sucked into providing them with your solutions/knowing what’s good for them.
• Support Self Efficacy: in pursuing the previous 3 stages a practitioner using MI is helping create a safe space for the individual to renew and grow.
CENTRALITY OF AMBIVALENCE
• A seeming yearning to move beyond an addictive behaviour yet retaining an attraction to it {Miller and Rollnick, 2002. Ch1].
• Yet at the same time it can be taken as a normal component of human behaviour [ibid.].
• As the authors contend: “Ambivalence is a reasonable place to visit, but you wouldn’t want to live there.”
•
• Ambivalence is preferred to resistance in order to explore the dynamic interrelationship. [Arkowitz et al, 2008]
• Approach-Avoidance-moving betwixt and between e.g. just one more drink, play on the gaming machine, slab of chocolate……..
• Eclipsed by Double Approach-Avoidance i.e. moving away from option A only for it to become again attractive as B looms closer.
MI HEALTH CONTEXT
• Rollnick, Miller & Butler {2008, p.4.}-twenty first century emphasis on ‘those things that people can do to improve their health.’
• p.5 ‘MI works by activating patients’ own motivation for change and adherence to treatment.’
• P.5. Assumptions can be readily made in relation to a person being unwilling to change i.e. that they are the matter and things are stuck: ‘These assumptions are usually false.’
• p.7. Instead of being prescriptive re client lack MI seeks to activate what they already have. This may include recognition of his right not to change.
SOME DANGEROUS ASSUMPTIONS
• This person ought to change; wants to change.
• This person is essentially motivated by ‘xyz.’
• The intervention is only a success if s/he agrees to change.
• ‘I’m the expert, it’s up to her to follow my advice.’
• ‘S/he needs a tough approach, these people respond best to it.’
In practice
OPENING APPROACHES
• Open Questions
• Reflective Listening
• Summarising
• Affirming
• Eliciting Change Talk
REFLECTION AS CORE
• Repeating
• Re-phrasing
• Paraphrasing
• Reflection of feeling
• Double sided reflection
• Amplified Reflection
AMBIVALENCE
• I don’t want to change………I ought to change
• Don’t want to talk about it…..I want to talk about it
• It’s not necessary……………I could put my mind to it and…
BELIEFS THAT OPEN THE DOOR
• My current behaviour is bad for me {person gives emphasis}.
• I would be better off if I change {again person giving emphasis}.
• If I try to change I can be successful {here person draws on own confidence reserves}.
• This is a good time to do it. {person seizes on the moment/drawing on own confidence}.
RESPONDING TO CHANGE TALK
• Reflect it back to the person.
• Encourage more change talk.
• Encourage person to illustrate with examples.
• Affirm her in efforts, highlighting change oriented values and behaviours.
• Summarise to affirm where ‘she’s at’, to hold clarity.
BUILDING CONFIDENCE
• Key art/skill of brainstorming, using permissive questions.
• Accent on enabling person to develop clarity with review ongoing.
• What has worked/not worked for you in the past/previous attempts?
• Have you been impressed by anything that has worked for someone else?
DEVELOPING DISCREPANCY
• All of us exhibit discrepancies between where we are and where we want to be in our development processes.
• Facilitate the person to affirm her key values.• Identify gaps in consistency in a non
judgemental fashion.• Encourage the person to look at the
consequences.• Remember arguments for change must belong
to the person herself.
READINESS TO CHANGE [signs of]
• Decreasing resistance.
• Less emphasis on the problem.
• Change talk; person gives off increasing resolve.
• S/he is posing her own questions about her own change process.
• Envisioning-how the future might look, could look.
• Genuine experimentation.
References
• Arkowitz, H. Westra, H, Miller, W. & Rollnick, S {Eds} {2008} Motivational Interviewing in the Treatment of Psychological Problems. The Guilford Press: New York.
• Edward L. Deci and Richard M. Ryan. The “What” and “Why” of Goal Pursuits:Human Needs and the Self-Determination of Behavior. Psychological Inquiry 2000, Vol. 11, No. 4, 227–268.
• Fuller, C & Taylor, P {2nd Ed. 2005} A Toolkit of Motivational Skills. John Wiley & Sons Ltd.
• Miller, W. { Second Edition} {2002} Motivational Interviewing: Preparing People for Change. The Guilford Press: New York.
References {Cont}
Prochaska, J. Norcross, J. and Di Clemente, C. {1994} Changing for Good: The Revolutionary Program That Explains the Six Stages of Change and Teaches You How to Free Yourself from Bad Habits . William Morrow and Co.
Rollnick, R. Miller, W. & Butler, C. {2008} Motivational Interviewing in Health Care. Helping Patients Change Behaviour. The Guilford Pres: New York.
Richard M. Ryan and Edward L. Deci. Self-Determination Theory and the Facilitation of Intrinsic Motivation,Social Development, and Well-Being. January 2000 • American Psychologist