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Overview
• Introduction
• ‘FRAMES' and Other Approaches
• Stages of Change
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Integrating Motivational Approaches
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Motivation
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Why enhance motivation?
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Desirable attributes for the counselor
• Nonpossessive warmth
• Friendliness
• Genuineness
• Respect
• Affirmation
• Empathy
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Help Increase Motivation
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Elements Of Current Motivational
Approaches
• The FRAMES approach
• Decisional balance exercises
• Discrepancies between personal goals and
current behavior
• Flexible pacing
• Personal contact with clients in treatment
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FRAMES
• Feedback regarding personal risk or impairment
• Responsibility for change is placed squarely and
explicitly on the client
• Advice is clearly given to the client by the
clinician in a nonjudgmental manner.
• Menus of self-directed change options and
treatment alternatives are offered to the client.
• Emphatic counseling
• Self-efficacy is engendered in the client to
encourage change.
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Decisional Balance
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Discrepancies Between Goals and Current
Behavior
• Help clients recognize a discrepancy or gap
between their future goals and their current
behavior.
• The clinician might clarify this discrepancy by
asking, "How does drinking fit in with having a
family and a stable job?"
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Flexible Pacing and Personal Contact
• Pacing
– meet clients at their levels
– use as much time as necessary with the essential
tasks of each stage of change.
• Personal Contact: letters or telephone calls
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Precontemplation
• The client is unaware, unable, or unwilling to
change.
– Counselor can
• Establish rapport
• Raise doubts about patterns of use
• Give info on risks, pros and cons of use
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Goals/Actions
• Explore the meaning of events that brought the
client to treatment or the results of previous
treatments.
• Elicit the client's perceptions of the problem.
• Offer factual information about the risks
• Provide personalized feedback about assessment
• Explore the pros and cons of substance use.
• Help a significant other intervene.
• Examine discrepancies between the client's and
others‘ perceptions of the problem behavior.
• Express concern and keep the door open.
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• Many clients are ambivalent about change.
• Ambivalence is expressed in several ways.
– Argue: challenge or discount statements
– Interrupt: take over or cut off conversation
– Deny: blame, disagree, excuse, minimize
– Ignore: not respond, not pay attention
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Ways to Respond
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Contemplation
• The client is ambivalent or uncertain, considering
the possibility of change.
– Counselor can
• Discuss and weigh pros/cons of using
• Emphasize client's free choice and responsibility
• Elicit self-motivational statements
• At this stage, the client usually meets the counselor
halfway, and is willing to look at the "cons" of using.
• Reassure the client that no one can force him to
change.
• Ask questions that prompt motivation.
– For example, "When you want to keep up your motivation
for doing something, what are some of the things you say
to yourself?"
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Goals/Actions
• Help the client recognize the problem
• Help the client acknowledge concern
• Help the client generate intention to change:
• Help the client develop optimism
• Convey feedback
• Help clients see a difference
• Show curiosity about client strengths. Explore how
those skills and competencies may be negated by
drinking
• Reframe negative statements.
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Highlight Reasons for Change
• Summarize concerns
• Explore specific pros and cons
• Allow client to explain benefits
• Assure client conflicting feelings are normal
• Review feedback from assessment
• Find out what client expects from treatment
• Provide info
• Help client connect core values to committing to
treatment
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Strengthen the client's personal
choices.
• Nudge the client to make positive choices.
• "No one can decide this for you. You can
choose."
• Help the client set goals and take steps.
• Provide feedback.
• Remind client of "triggers," including negative
emotions (anger), social pressures (peers),
physical concerns (headache) and extended
withdrawal symptoms (craving).
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Reinforce the client's commitment
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Preparation
• The client asks questions, indicates willingness
and considers options to make specific changes.
• Explore treatment expectancies and the client's
role.
• Elicit from the client what has worked in the past
either for him or others whom he knows.
• At this stage, the client shifts from "thinking
about it" to "planning first steps."
• Counselor guides the steps by offering help but
not yanking the client forward.
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Helps The Client To Get Ready
• Negotiating a plan
• Offering a menu of options
• Developing a behavior contract
• Identifying and lowering barriers
• Enlisting social support
• With permission offer advice
• Assist the client to negotiate finances, child care,
work, transportation, or other potential barriers.
• Have the client publicly announce plans
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Client Indicates Readiness
• Stops arguing, interrupting, denying
• No longer asks questions about the problem,
• but more about how to change
• Appears calm, peaceful
• States openness to change ("I have to do
something")
• Expresses optimism ("I can beat this")
• Talks about how life will be after the change
• Experiments between sessions
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Barriers
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Examine and interpret noncompliant
behavior
• Noncompliant behavior is a thinly veiled
expression of dissatisfaction with treatment or
the therapeutic process.
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Maintenance
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Cont…
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Goals/Actions
• Help the client identify and sample drug-free
sources of pleasure (i.e., new reinforcers).
• Support lifestyle changes.
• Affirm the client's resolve and self-efficacy.
• Help the client practice/use coping strategies
• Maintain supportive contact
• Develop a "fire escape" plan if the client
resumes substance use.
• Review long-term goals with the client.
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Form a Plan.
• Identify triggers
• Identify effect/benefits of using in response to
the trigger
• Identify appropriate coping response
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Developing Reinforcers
• Competing
• Contingent (If/Then)
• Community (natural consequences)
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Recurrence
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Other Tools
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Applications of Motivational Approaches
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Other Things to Remember
• Often there is a relatively short period of time to
make a beneficial impact on the client
• The average length of stay in substance abuse
treatment is very short
• If clinicians do not make an impact in the first
session or two with clients, they may not be able
to make an impact at all
• Make the best use of the first contact
• It is usually a mistake to start a session with
filling out forms
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Summary
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