Article Review: Stages of Change and Motivational Interviewing

The following article can help understand how women who have been rescued recover, and how to help if you come across victims in your own life.

The articles can be found here: A 'Stages of Change' Approach to Helping Patients Change Behavior
and here: Motivational Interviewing

In this write-up, I am going to highlight a few of the facts that jumped out at me. I encourage you to read the full article, as each of us have different perspectives, backgrounds, and passions. Because of these differing viewpoints, some of the facts that I have not mentioned might, in fact, be the most significant facts to you.

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Stages of Change:

One of our roles is to assist patients in understanding and to help them make the changes necessary for health improvement. (I am going to go ahead and make the assumption that health applies to physical, mental, emotional, and spiritual.)

Consistent, life-long behavior changes are difficult. Follow-up calls are critical. Repeatedly education the patient is not always successful. Promising an improved outcome does not guarantee their motivation for long-term change. A feeling of failure may cause patients to give up and avoid contact or avoid treatment altogether.

This is a process of change. One size doesn't fit all.

Brief counseling sessions (lasting 5 to 15 minutes) have been as effective as longer visits.

A change in behavior occurs gradually. Moving from being uninterested, unaware, or unwilling to deciding and preparing. Over time, attempts to maintain the new behavior occur. Relapses are almost inevitable.

Stages of Change:

1. Pre-contemplation: "In Denial." May have tried unsuccessfully so many times that they have simply given up. May be resigned. Feeling of no control. Not thinking about change.
2. Contemplation: Ambivalent. Feel a sense of loss despite perceived gain. Assess barriers as well as benefits.
3. Preparation: Prepare to make a specific change. Experiment with small changes. 
4. Action: If the prior stages have been glossed over, action is not enough. Any action taken by patients should be praised because it demonstrates their desire for change.
5. Maintenance and Relapse: Discouragement over occasional "slips" may halt the change process.

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Motivational Interviewing (MI):

MI focuses on exploring and resolving ambivalence. It does not impose change (that may be inconsistent with the person's own values) but supports change in a manner congruent with the person's own values and concerns. It is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.

Approach MI in a respectful stance with a focus on building rapport. Utilize techniques and strategies that are responsive to the client. It is conversation about change that seeks to call forth the person's own motivation. 

It is used to address the common problem of ambivalence. Interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual's motivation by exploring the person's own arguments for change. 

Collaboration: It is a partnership between the therapist and the person grounded in the experiences of the person. This contrasts with approaches that place the therapist in the "expert" role, confronting the person and imposing their point of view. Collaboration facilitates trust. This does not mean the therapist automatically agrees with the person. It is focused on mutual understanding.

Evocation: The approach draws out the individual's own thoughts rather than imposing their opinion as motivation. Commitment to change is most powerful when it comes from the individual. No matter what reason the therapist might offer to convince the individual of need to change their behavior, lasting change is more likely to occur when the person discovers their own reasons and determination to change. The therapist's job is to draw out the person's own motivations and skills for change, not to tell them what to do or why they should do it. True power for change rests with the individual. This gives them responsibility for their actions. 

See the world through the person's eyes. Victims need to be heard and understood. They are more likely to share their experiences in depth. 

An individual's belief that change is possible is needed to instill hope about making those difficult changes. They often have doubt about their ability to succeed. Highlight skills and strengths that the individual possesses.

De-escalate and avoid a negative interaction. Statements that demonstrate resistance should remain unchallenged early in the relationship. The session should not resemble an argument. Place value on having the individual define the problem and develop their own solutions because ti leaves little for the person to resist. Invite the individual to examine new points of view. Avoid the "righting reflex" to ensure that the individual understands and agrees with the need to change. 

Examine the discrepancies between their current circumstances/behavior and their values and future goals. Do not use strategies to develop discrepancies at the expense of the other principles but gradually help the individual to become aware of how current behaviors may lead them away from their goals. 

OARS:

establishes a therapeutic alliance and elicits discussion about change

• Open ended questions: not easily answered with yes/no, encourage deeper thinking about an issue, create forward momentum
• Affirmations: recognize strengths, build rapport, help the person see themselves in a more positive light, must be congruent and genuine, help the individual feel change is possible even when previous efforts have been unsuccessful, reframe behavior as evidence of positive qualities
• Reflections: reflective listening, express empathy, understand issues from their perspective, guide individual toward change, resolve ambivalence by a focus on the negative aspects of status quo and positives of making change
• Summaries: recaps what has occurred, communicate interest and understanding, call attention to important elements of the discussion, prepare them to move on, promote the development of discrepancy, strategically select what information should be included and excluded

Guide the client to expressions of change talk as the pathway to change. The more someone talks about change, the more likely they are to change.

Darn Cat:

• Desire: I want to change.
• Ability: I can change.
• Reason: It's important to change.
• Need: I should change.
• Commitment: I will make changes.
• Activation: I am ready, prepared, and willing to change.
• Taking steps: I am taking specific actions to change. 

Strategies for evoking change talk:

1. Ask evocative questions: open questions
2. Explore decisional balance: pros and cons of changing and staying the same
3. Good Things/Not so good things: positives and negatives of target behavior
4. Ask for elaboration/examples: When a change talk theme emerges, ask for more details. "In what ways? Tell me more. What does that look like? When was the last time that happened?"
5. Look back: How were things better before the target behavior emerged.
6. Look forward: What might happen if things continue how they are? "If you were 100% successful in making the changes you want, what would be different?"
7. Query extremes: What are the worst things that might happen if you don't change? Best things if you do change?
8. Use change rulers: Scale of 1-10, how important. Why are you at __ and not __?
9. Explore goals and values: Ask what the person's guiding values are. 
10. Come alongside: side with the negative, "Perhaps ___ is so important that you won't give it up no matter what the cost."