Module 11: Persuasion (Building Readiness to Change)

Objectives

• To be able to define “ Persuasion” Stage

• To be able to define motivational interviewing.

• To be able to describe the key skills involved in MI.

• To be able to assess readiness to change.

• To be able to explore ambivalence using decision matrix.

Dual Diagnosis Capabilities• Demonstrate Empathy: To be able to understand the unique experiences a person

with dual diagnosis may have had, and be able to communicate this understanding effectively and empathically to service users, and their carers. Dual Diagnosis Capability 5 level 2

• Interpersonal Skills: To be able to demonstrate effective skills such as active listening, reflection, paraphrasing, summarising, utilising open-ended questions, affirming, elaboration. Dual Diagnosis Capability 7 level 2.

• Delivering Evidence and Values Based Interventions: Be able to utilise knowledge and skills to deliver evidence-based interventions including brief interventions, motivational interviewing, relapse prevention and cognitive behaviour therapy to people with combined mental health problems within own limits and capacity and remit of ones own organisation. To know where else a service use can access appropriate specialist care and facilitate that access. To be able to access support and supervision to perform such interventions. Dual Diagnosis Capability 13 level 2.

• Evaluate Care: To be able to collaboratively review and evaluate care provided with service user, carers and other professionals. To be flexible in changing plans if they are not meeting the needs of the service user. Dual Diagnosis Capability 14 level 2

Transtheoretical Model Osher and Kofoed’s Four Stages

Precontemplation Engagement

Contemplation Early persuasion

Preparation Late persuasion

Action Active Treatment

Maintenance Relapse prevention

Persuasion• Enters this stage once engaged in a therapeutic

alliance.• Still not necessarily acknowledging problem with

substances• Considered behaviourally unmotivated- not

showing any signs of reducing substance use (but may be talking about it).

• Still expect sporadic attendance; be flexible.• Worker acknowledges that motivation to change

must be generated internally or will fail.

Examples of Interventions For Persuasion

• Individual and family psycho-education.

• Motivational Interviewing.

• Peer (“persuasion”) groups.

• Social skills training.

• Structured activity.

• Safe/stable housing.

• Medication Management.

Exercise: Activities for People with Dual Diagnosis

Spend a few minutes answering the following questions (in pairs)

1. What activities are available for people with dual diagnosis within your setting?

2. What are the barriers to accessing activities?

3. How could these barriers be overcome?4. What other activities would you like to

see offered?

Motivation

• State of readiness or eagerness to change

• Fluctuates through time and/or situation-not static trait

• Motivation to change requires being- – Ready (the time is right)– Willing (want to do it)– Able (has the ability and confidence to do it)

What Is MI?

• Client centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

(Miller and Rollnick, 2002 2nd ed)

Key Ideas

• Worker style powerful determinant of both resistance and change

• Ambivalence is normal and to be expected • Resolving ambivalence is a key to change• Self-efficacy is related to outcome• Labelling is not essential• empathy, non-judgemental, and genuineness• “Spirit”- collaboration, evocation, autonomy

Goal:- person generates own reasons for change

Four general Principles

1. Express empathy- acceptance facilitates change, skillful reflective listening is fundamental, ambivalence is normal

2. Develop discrepancy- person, not worker presents arguments for change; change is motivated by perceived discrepancy between present behaviour and important goals and values

3. Roll with resistance- avoid arguing for change, resistance is not directly opposed, new perspectives are invited but not imposed, person is primary source of finding answers and solutions, resistance is a signal to respond differently

4. Support self-efficacy- belief in possibility is an important motivator. The person not the therapist is responsible for change. Therapists own belief in change can become a self-fullfilling prophesy

Traps (how not to…)

• Expert/ prescriptive: “ As an experienced nurse, I think you should….”

• Question-answer: “have you taken your tablets?” “yes I have”

• Premature focus “I’d like to talk more about your drinking” “but I am really worried about losing my tenancy.”

• Labelling: “schizophrenic, alcoholic…etc”• Blaming: “The reason you end up back in hospital is

because you use cannabis”• Taking sides “It seems clear to me that you have a

serious drink problem” “but a lot of people drink like me”

OARS (skills)

• O pen-ended

• A ffirming

• R eflecting

• S ummarising

Some key techniques

• A “typical day”• Readiness to change• Timeline-looking back• Goals and roadblocks- looking forwards• Exploring the good and less good (pros and

cons)• Evocative questions• Raising discrepancies• Problem solving• Offering choices

Examples of evocative questions

• What worries you about your current situation?

• How would you like things to be different?• What encourages you that you could

change if you want to?• I can see you are feeling stuck; what is

going to have to change?• What would be the advantages of making

this change?

A Typical Day

• Helps people reflect on processes that are usually automatic

• Identify maybe some of the less good aspects of the behaviour as well as the good

• Helps worker get a picture of the behaviour

• Get a sense of motivational state

Adapting MI for Dual Diagnosis(Bellack and Diclemente, 1999)

• Spend extra time engaging in therapeutic relationship

• Use of repetition and rehearsal• Being concrete and simple in setting tasks

and discussions.• Being realistic about goals.• Small doses (10-20 minutes)• Flexibility.

Readiness to Change(Rollnick, Mason and Butler, 1999)

Readiness to change ruler:

NOT READY……......UNSURE…………….READY

0……………………………………………….10

• Importance of change: 0----------10 (willing)

• Confidence in ones own ability to make the change: 0-------------10 (able)

Readiness to change

• Increasing importance• A valid reason for change• Benefits outweigh costs• Information about possible risks

• Confidence• Small achievable goals• Reminder of past successes• Affirming and empathy

Key Questions

• Can you tell me why you placed yourself there on the scale (readiness to change/importance/confidence)

• What would have to be different for you to move a bit further forward?

• Can you tell me a bit more about that….• Is there anything else that’s important that we

haven’t discussed yet?

Ambivalence- the dilemma of change

• Natural state to move through during change

• When we get stuck, problems can persist• Decisional balance

• Cost/benefits of status quo• Costs/benefits of change

• Conflict• Approach-approach• Avoid-avoid• Double approach avoidance

Working with Ambivalence

• Identify and explore the nature of ambivalence about a particular behaviour

• Always start with the side of “least resistance”

• List the good and less good aspects in turn

• Encourage elaboration, and identification of less obvious costs and benefits

Example

Good things about cannabis Less good things about cannabisIt makes me feel good put on weight (munchies)

Relaxed feel paranoid sometimesSomething to do I argue with mates

Helps sleep Ghosts are badIt’s fun to smoke with friends smokers cough in the morning

Good things about not using less good things about not usingMight lose weight my friends might think

I’m boringGhosts bother me less don’t sleep very well

Feel healthier might get bored