functional analyses motivational interviewing and the stages of change

Functional AnalysesMotivational Interviewing

and the Stages of Change

-Use motivational interviewing techniques in assessing functional deficits

-Assess the client’s stage of readiness to change specific identified deficits

-Develop appropriate CPRP interventions based on the identified deficit and the client’s stage of change

Learning Objectives

Jamie Smith, MEd, CCDP-D, PLPC

CPRP Supervisor for Pathways CBH, Inc. in Jefferson City, MO

Supervise the IDDT team within the CPRP

Who are we?

Who are you? Where do you work? How long have you worked there? What do you want to get out of this training?

Who are we?

What is CPRP?

Community Psychiatric Rehabilitation Program

2 Criteria for Client AdmissionQualifying DiagnosisDeficit in Functioning

Clients in the CPRP

Qualifying Diagnoses1. Schizophrenia and

other Psychotic Disorders

2. Bipolar Disorders and MDD, Rec

3. Anxiety Disorders4. Borderline PD

Functional Deficit Activities of Daily

Living

Social Role Functioning (Social involvement, social engagement)

Clients in the CPRP

Qualifying diagnosis

A diagnosis is the name of an illness

composed of a constellation of

symptoms that a client expresses.

Constellation of Symptoms

Symptoms are the specific

characteristics of the illness

An Important Distinction

For Example

We say a client’s depression has worsened or improved.

What symptoms of depression indicate a change?


Listed Symptoms of Depression Include:

Depressed FeelingLack of Motivation

Crying SpellsGuilt

Sleep DisturbanceAppetite Disturbance

Deficit in Functioning in Imporant Areas of Life


2 Reasons why understanding the distinction is important:1. Helps us to create specific objectives in

treatment planning:“John will experience an improvement in symptoms of depression.”“John will sleep 8 hours at night 5 of 7 nights in a week.”Understanding specific symptoms can help us

create more measurable objectives.


2 Reasons why understanding the distinction is important:2. The function of symptoms: some symptoms actually are coping mechanisms.

Will discuss later in the presentation


Wise Words“Our clients aren’t just ill, but their illness

interferes with their ability to do things that most people take for granted.”

Marti FrazierCPRP Director

Central Region

Functioning is what sets our clients apart.

Deficits in Functioning

The question is not:“Do they have a deficit in functioning?”

The question is:“Why do they have a deficit in functioning?”

Some Examples:Budgeting Skills

Cognitive deficit caused by MILack of emotional regulation to handle money

Never learned the skill of money management due to social circumstances growing up

Deficits in Functioning:Daily Living Skills

Some Examples: Making a phone call: Client is anxiety driven Client cannot read to look up the

phone number Client was told to never contact that

location again


Some Examples: No Transportation: Physical Disability Off the bus line Anxiety driven Narcissistic Personality Disorder


Encompasses but is not limited to:

Self CarePersonal Hygiene, Chronic Physical Illness

(Diabetes, HBP, COPD), Maintaining sufficient food, housing, clothing

Activities of Daily LivingMaintenance of home cleanliness,

correspondence, mobility, communication skills Finances Access to Community Resources


Deficits in Functioning:

Social Role EngagementThe often forgotten reality of our clients.

Who do you turn to when you need help?

Family Friends

Work Associates Church

Fill in the blank of NATURAL and COMMUNITY SUPPORTS

Deficits in Functioning:Social Roles

We get our clients set up with housing. We show our clients where to access food

pantries and utility assistance. We teach our clients a better way to budget

their finances. And we help them learn some basic anxiety

reduction skills.

Then we leave them, sitting in their apartment alone in “maintenance level of care.”


Many of our clients have isolated themselves from NATURAL SUPPORTS

Family has been overwhelmed by symptomatic behavior

Unable to make or maintain friendships Employment?

Church community..many have had bad experiences


Ability to engage in social activity is limited

Again, the question is not if there is a deficit in social

functioning, but if so, why.


Functional Skills Assessment

Beginning the Process

Functional Skills EvaluationContent vs. Process

Content

The what’s, when’s, how’s, where’s, and

who’s of the client’s life.

Process

This is the treatment that the client receives

or, better,

The rehabilitation that the client experiences

Understanding that treatment is a process of change is immensely important.

It is a process in which we Empathize and Collaborate with and Affirm the client.

The FSE, which occurs at the beginning of treatment (or in the annual review) is not just to gather content, but is the beginning of the

treatment process.

Functional Skills Evaluation

If we’re going to do an “Evaluation” or “Assessment”, we need to get away from asking “yes” and “no” content questions.

Do you answer the phone when someone calls?

Are you able to sort your mail? Have you been evicted or been forced

to move in the last 12 months?


These questions don’t tell us anything about our clients.

Or, what’s worse:

We answer these “yes” and “no” questions for our clients, without ever speaking to

them.

Then all we know is what WE THINK about our clients.


Research indicates that more important than any intervention, strategy, or theory of the

provider

AND

more important than any deficit, characteristic, or illness of the patient is…


THE RELATIONSHIP BETWEEN THE

PROVIDER AND THE CLIENT.


Using the Functional Skills Assessment as a means of building relationship:

The tools of Motivational Interviewing are strategies for building that relationship and

for beginning the process.

OARS with Evoking Change Talk


OARS◦ Open Ended Questions

Makes the client feel you are truly interested Rule of Thumb, never ask 3 open ended questions in a

row◦ Affirmation of the Clients

Every client has something good about them◦ Reflective Listening

Seeing the world with the client’s eyes The client feels as if he/she has been truly understood

◦ Summarizing The white boxes are your friends

Fuctional Skills Evaluation

Evoking Change Talk◦ Ask evocative Questions

Explore disadvantages of status quo, advantages of change, optimism about change, intention to change

◦ Use rating questions with follow up for change “What would it take to move you from a ___ to a ___?”

◦ Elaboration Tell me about the problems you had with ___.”

◦ Query Extremes “What do you think will happen if you don’t do…?”

◦ Explore goals and values Look for discrepancy between client’s core values and

goals and client’s behaviors.


The TRAP of “knowing” our clients:

Building a box to put them inDefining their needs for them

Not doing REHABILITATION work because we’ve decided they’ve reached their highest

potential.


Stages of ChangeAn Essential Element in the Evaluation

Origin

Developed during research with smokers who were trying to quit smoking.

They’ve been found to be universally applicable to processes of change in many

areas of life.

Powerful tool that helps refine our interventions.

Stages of Change

Defined:1. Precontemplative:

Client is not yet considering change

2. Contemplative:Client acknowledges concerns and is

considering the possibility of change, but is ambivalent and uncertain

Stages of Change

Defined cnt’d:3. Preparation:

Client is committed to and planning to make a change in the future, but is still considering what to do.

4. Action: The client is actively taking steps to

change but has not yet reached a stable state in new habits, skills, etc.

Stages of Change

Defined cnt’d:

5. Maintenance: The client has achieved initial goals, is stable in recovery/management habits, and is working to maintain gains.

Stages of Change

Recurrence or Relapse:“The 6th Stage”

Defined as:The client has experienced a recurrence of

symptoms/behaviors and must now cope with consequences and decide what to do next.

Stages of Change

Recurrence/Relapse

1. Is considered part of the process rather than a moral fault of the individual.

2. Can occur at any point once the client has begun to implement change.

Stages of Change

A Person can be in 2 different stages of change at the same time.

1. The person who does not acknowledge that she has schizophrenia but is wanting

to go to work.2. The person who knows he needs to stop

drinking alcohol, but the weed really helps him stay calm.

Stages of Change

Interventions shown appropriate for each stage of change:1. Precontemplative stage:

1. Explore events that led client to treatment2. Eliciting client’s perceptions of the problem3. Offering information about MI4. Personalized feedback of assessments5. Family/Significant Others interventions6. Examining intrapersonal and interpersonal

discrepancies

Stages of Change

2. Contemplation1. Normalize Ambivalence2. Elicit and weigh pros and cons of change3. Examining further values and goals in

relationship to change4. Emphasize client’s free choice,

responsibility, and self-efficacy5. Elicit Change Talk6. Summarize Change Talk

Stages of Change: Interventions

3. Preparation1. Clarify client’s goals/strategies for change2. Offer a menu of options for change or

treatment3. Negotiate a change plan and/or behavior

contract4. Consider and lower client’s perceived

barriers to change5. Increase sense of self-efficacy6. Set a start date for a specific change

Stages of Change:Interventions

4. Action1. Reinforce the importance of the changes using

client’s own words2. Support a realistic view of change through

small steps3. Help the client learn/practice coping strategies4. Develop a relapse/recurrence prevention plan5. Help the client find reinforcers for positive

change6. Help the client find natural and community

based supports


5. Maintenance1. Continue to help client find new

reinforcers for change2. Affirm the client’s resolve and self-efficacy3. Help the client continue to learn new

coping strategies4. Maintain supportive contact5. Renew relapse/recurrence prevention plan6. Review long-term goals with client


In case of Relapse/Recurrence:1. Help the client reenter the change cycle as

quickly as possible2. Explore the meaning and reality of the

relapse as a learning experience3. Help the client learn/practice alternative

coping strategies4. Maintain supportive contact


Stages of ChangeAn Important Concept

to Remember:

Function of Symptoms

What does that mean?

What we call symptoms may be socially learned mechanisms that the person has

learned in order to survive.

Implications?


If we step in with an intervention to remove what we have determined is a symptom,

the client may not want to change because that “symptom” is actually securing

something for them.

We then need to provide a means for them to obtain their goal that is less self-destructive.


Examples:

1. The person who loans all of her money away

1. We see this as a “problem” with boundaries2. The person is actually maintaining friendships

2. The person who refuses to maintain his personal hygiene

1. We see this as a “problem” in self-care2. The person does this to avoid unwelcome guests


3 Questions to Keep in Mind

1. What is causing the deficit?

2. What purpose is the dysfunction serving?

3. What is the person’s readiness or stage of change concerning the specific

dysfunction?

Functional Skills Assessment

1. Divide into groups2. Pick a client with whom you work (or about whom

you’ve heard)3. Pick a section of the FSE, any one you want.4. Interview another person in your group, who will

role play the client he/she has in mind.5. Fill in one page of one section, but make sure it is a

page in which a person has a dysfunction6. Use the questions or make up your own to try to

get to the 3 questions on the previous slide.7. Describe the dysfunction as best you can, and think

of an intervention that would be appropriate.

Let’s Do Some Practice

Answer the questions:1. What is causing the dysfunction?2. What purpose do you think the dysfunction

serves in the person’s life (if any)?3. What is the person’s readiness or stage of

change concerning this dysfunction?4. What intervention strategy would you employ?

Practice

1. Text Boxes are your friends.

2. Don’t spend a lot of time recording areas that are not deficits. It’s important to recognize strengths, but our time is limited, so don’t drive yourself to drink trying “to get it all in there.” Focus on the areas to be integrated into the treatment plan.

Documenting

Some Last ThoughtsPurpose of Treatment

The purpose of treatment is to help our clients

not need treatment anymore.

Client Independence

Fostering Dependence in the Client is Cardinal Sin number 1.

How do we avoid fostering dependence?

Client Independence

Wise Words

“In this line of work, you either figure it out or you burn out.”

Amy BlakeCPRP Supervisor

Camdenton

Client Independence

1. Have our own limitations firmly in place

When I establish my limits with you, I am not telling you what you may or may not do.

I am telling you what my response to your actions will be.

Client Independence

2. Have our own needs met outside of workWhat needs might we have that we would get a client to satisfy?

Ego—I need to be important to somebodyJob security—the best job security is to demonstrate that your clients are progressing toward independence

Others?

Client Independence

3. Knowing that our clients are resilient people.

The client has survived 20, 30, 40, 50 years without me. He’ll make it until our appointment on Friday. And he’ll survive for years after I’m long gone.

If not me, then who (how, what)? “How are you going to get there?”“What would you do if this were Saturday and I weren’t available?”

Client Independence

The Tug of War

Your clients don’t need you

And

They do.

Don’t need them.

Client Independence

“Anybody? Anybody? Anybody? Anybody?”

Closing Thoughts or Questions

functional analyses motivational interviewing and the stages of change

Documents

specific symptoms

function of symptoms

clients depression

functional deficits

specific identified

daily living skillsencompasses

clients arent

specific objectives