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Stages of Change Model

Pre-Contemplation

Contemplation

Maintenance

Termination

Relapse and Recycling

Figure 1 – Adapted from Carlo C. DiClemente Addiction and Change 2003

Preparation

Action

Importance and confidence ruler

How important is it for you to change …?

How confident are you?

Why not lower, why not higher?

0Not at all

1 2 3 4 5 6 7 8 9 10Extremely

Readiness

I

C

R

Motivational Interviewing (MI)Developed by Bill Miller & Steve Rollnick in the mid 80s

Motivational Interviewing is a collaborative conversation style for addressing the common problem of ambivalence about change and strengthening a person’s own motivation and commitment to change.

Solution Focused brief Therapy (SFBT)Developed by Steve de Shazer and Insoo Kim Berg in the mid 80s

Focuses on what clients want to achieve rather than on the presenting problem and on what works rather than what’s wrong.

Integrated model main principles

• Collaborative and client centred relationship – the client is the expert and director of their own journey.

• Strengths based - focus on strengths rather than deficits.• Optimism and hope - belief that change is possible. • Empathy - ability to convey an understanding of the perspective

of another• Evocation - Elicit motivation the client needs to present the

arguments for change Elicit solutions; Elicit confidence and skills

• Resist the righting reflex - advocacy for change evokes resistance

How well does each example fit with the model principles?

1. ‘If you’d listened to the advise you were given and done what we suggested, you probably wouldn’t be in this mess now’

2. ‘You just need to stay out of trouble, keep your job, and pay your bills and everything will work out fine’

3. ‘I can see you are making a big effort to manage this tenancy, so what would be the most useful thing to focus on to keep things on the right track?’

4. ‘Why don’t you try joining a few local groups, get involved in the community, get yourself out of the house, it’ll do you good’

Fundamental processes1. Engage – form collaborative

relationship

2. Clarify client’s goals - identify preferred future, set agenda and focus

3. Elicit and highlight client’s motivation and resources

4. Negotiate action plan

5. Identify maintenance and relapse prevention strategiesM

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Fundamental processes - Engage

The relational foundation to build trust and good working alliance

• Person centred style• Listen and understand dilemma (ambivalence),

motivation and values• OARS core skills

Open ended questions

Affirmations

Reflecting

Summarising– Learn this first!

Key open Questions :-‘’What in particular has prompted you to come

here today?’’“What do you think you will do?”“What are you thinking of at this moment?”“What changes, if any, are you thinking about

making at this point?”“What could you do first?” “What are your options?”‘’What has worked for you in the past?’’‘’How might you achieve that?’’

Closed to Open

• Are you going to stick to the plan this time?

• Did you try talking to the teacher?

• So now that you are planning to get pregnant, are you going to try and lose some weight first?

• Have you thought about the effects your drinking is having on your kids?

Forming reflections:

1.) Make an unhelpful reactive response (get it off your chest!!)

2) Form a simple reflection (stick with an aspect of the ‘visible’ content)

3) Form a complex reflection (reflect your hypothesis e.g. the deeper meaning, the unspoken feelings etc)

‘I’ve tried everything you people have suggested, and it’s just not working, if anything things are getting worse’

‘I’ve been to those kind of self help groups before, but nobody there had problems as bad as mine’

‘ I do want to be a good mum and provide the best I can for my daughter, but I’m still young and I want to let my hair down and have some fun too’

Affirmations• Affirmations are neutral to positive complex

reflections containing observations, acknowledgements and validations of clients personal qualities, strengths abilities, efforts etc.

• There is a very subtle, yet highly significant difference between affirming and approving.

“I’ve been getting him to use the alarm on his phone to get up for school ”

“You are really supporting him to take responsibility for himself”

“I try not to smoke around the little ones”

“ You are already taking positive steps to protect your children’s health ”

Summaries

Useful at the start of a session to set the scene from the last session, or to draw a session to a close

Used periodically to provide feedback to the client and to give pace to the interview.

Useful way to collect up and link together the main points that have been discussed

Can illustrate progress

Used strategically to gently move client forward in direction of change.

Fundamental processes-Clarify client’s goals

Open ended questions to identify client’s goalsWhat are your hopes in coming here?How will you know if this is useful?If coming here turns out to be a really good

idea what differences will you notice in your life?

The miracle question – to identify more details“Imagine that when you are asleep a miracle happens

and all the difficulties that you have been having disappear. Because you are asleep you don’t know that a miracle has happened. When you wake up in the morning, what will be the first signs for you that a miracle has happened?”

Clarify client’s goals

The miracle question is expanded with relationship questions:

• Who else would notice that this miracle had happened?

• What would that person notice different about you?• What would you see different about the other person

if this miracle happened?And questions to establish what the person has already

done/is already doing to achieve the desired change• Are there any times that you can remember that bits

of the miracle already occur?

Focusing -Agenda mapping chart....

Where to start?

Relationship ?

?

Housing?

Pregnancy andBaby?

future contraception?

Cannabis?personal safety?

?


Scaling

The aim of scaling questions is to help clients:

1. set small identifiable goals

2. measure progress

3. establish priorities for action.

The client asked to scale from zero to 10,

0------------------------------------------------10

Worse Best


Scaling questions:• Where are you now?• Why not lower? Why not higher?• How motivated are you?• How confident are you?• What would need to happen for you to move up the scale in the

next few days?• What do you need to do to prevent you going down the scale?• What was happening at the time when you were higher/lower?• What is the range to go up and down for it to still be considered

a success?

Evoking Change Talk – ‘DARN CAT’2 different strengths:

Preparatory:

1. DESIRE “I wish, I want”

2. ABILITY “I can, I might, I could”

3. REASONS

4. NEED “I must, I ought, I need, I should”

Mobilising and Implementing:

COMMITMENT “I will, I promise, I plan to

ACTIVATION (ready, willing, able, preparing)

TAKING STEPS (examples of doing in current time)

Responding to change talkUsing EARS

Elaborate

Affirm

Reflect (selective)

Summarise

“I really don’t want to stop smoking, but I know that I should. I have tried before and it’s really hard”

1. You really don’t want to quit

2. It’s pretty clear to you that you ought to quit

3. You don’t think you can quit

Change Talk

Desire

Ability

Reason

Need

Commitment

Taking Steps

ChangeActivating

Preparatory Language

Outcome

Mobilising Language

Elicit motivation and resources

Coping questions:

"I can see that things have been really difficult for you, yet I am struck by the fact that, even so, you manage to get up each morning and do everything necessary to get the kids off to school. How do you do that?"

Exception seeking:

“Tell me about an incident when you managed to deal with your anger better”

Elicit motivation and resources

Open ended questions to elicit confidence:• If you wanted to change how would you do it?• How do you manage to make sure things don’t get

worse?• What are you good at?• What do you like doing?• Confidence ruler – why not lower?• If I asked your

parents/children/teacher/boss/partner/friends etc. What do they like most about you, what would they say?

• What are you already doing?

Fundamental processes-Elicit motivation and resources

Reframing

“My depression was so bad last week I could hardly get out of bed to go to the shop.”

“Even though your depression was particularly bad last week you managed to get out of bed and go to the shop. How did you manage that?”

“I don’t really want to be here. I don’t think you can help”

“Despite your doubts you have decided to give this a go

Externalisation

“When does your anger/ADHD/depression get the best of you? When are you better at keeping it under control”

Providing Information and Advice – using OARS with E-P-E

Elicit – Provide – ElicitMI is not incompatible with giving advice and information.

Two circumstances exist when advice can and probably should be given –

a)When the client requests it - explicit

b)When the client gives permission – implicit

»Ask permission»Offer choices»Talk about what others do

Managing DiscordRolling with resistance skills:

• Reflections: You can’t help me. You don’t know what it is like.

Simple reflection – “You are concerned that I won’t be able to help you”Amplified reflection – “It seems like there is no chance at all that I could help you”

Double sided reflection – “From the one hand you are looking for some help. On the other hand you are not sure I can provide it.”

• Shifting focus• Reframing/affirming• Emphasising personal choice and control

Fundamental processes-managing Resistance

Working with involuntary clientStart with compliment acknowledging the client’s showing up to

session. Followed by the following questions:• Whose idea is it that you come here?• What makes____ think you should come here?• What does____ want you to be doing differently?• Is this something you want? (Goal frame)

– If yes proceed as with a voluntary client– If no, ask: Is there something you would like out of coming

here? (Goal frame) If yes proceed as if voluntary client If no explore the consequences of not coming to

sessions

Fundamental processes-managing resistance

Additional strategies for involuntary clients:• Dyadic questions – questions referring to the client and one

more person– “What do you think your mom thinks of you being excluded?”

• Normalisation - non-judgemental acceptance and understanding – “I understand how difficult this is and I really appreciate your coming here”– “It is often the case when one feels depressed/anxious..”

• Deframing; deconstructing – a strategy that questions client’s interpretation– “How do you know that to be so? What is the evidence?”– Could there be another explanation? For example...”

• Use and tolerate silence

Fundamental processes-Negotiate action plan

• Set SMART goals: Specific, Measurable, Attainable, Realistic, Time oriented

• Identify obstacles and how to overcome them• Discuss what constitutes successBackground reading• Miller W.R. & Rollnick S. 2012, (Third edition) Motivational

Interviewing, Preparing People for Change.• O’Connell B. 2005, (Second edition) Solution-Focused

Therapy.• Milner J.& Bateman J.,2011, Working with Children and

Teenagers using Solution Focused Approaches

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