 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through AllCEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on Enhancing Motivation Part 2. We will learn about the nature of change. You know, it's great to know how to motivate people, which is what we talked about yesterday, and have some of those techniques under our belt. But we have to understand the change process so we can ebb and flow with that process. So to do that, we'll explore the different stages of readiness for change. We'll learn about goals and interventions for each stage of readiness for change. So somebody who comes in involuntarily, they may be in a stage we call pre-contemplation, we're going to do different things with them. Then somebody who comes in and sits down and says, Doc, I need help. I'm ready to do whatever it takes. So we'll talk about what to do at each stage. We'll identify ways to identify a client's change in readiness for change. How's that for a complicated sentence? Clients may come in and when I first went into substance abuse treatment, you know, I would get really frustrated because clients would come in and they'd be kind of hamming and hauling, but they had to be there. And they would go through treatment and they would seem like they made progress and then they'd be back in detox 30, 60 days later. And I started to get kind of frustrated and I asked my supervisor, I'm like, Mark, what am I doing wrong? It seems like the changes aren't sticking. And he looked at me and he laughed and he was a very socratic supervisor and he said, you know what? They came in, they weren't even thinking about change or they were not thinking they were ready for it. And you got them to the point where they were willing to start working on stuff. What they've been doing, they've been doing for 20 years, getting them to move up one stage in their readiness for change is all you can hope for in 30 days. You know, you're not going to move them from not wanting to be here to just being in all the way 99.9% of the time. So we need to understand how to identify when a client's moving from not being ready at all to thinking about it, but really not ready to take that step where interventions that we offer would be useful to moving to that stage where we can offer interventions and they're like, yeah, that might work or no, but let's try this. We will explore ways to identify barriers to recovery. Sometimes it's not that the client isn't ready and wanting to change but they don't have all their ducks in a row. They have too many barriers that are keeping them from change, whether that's finances or childcare or accessibility. Maybe they live in a rural area and it takes an hour and a half to drive to your office. So we'll look at some of those things. We'll learn how to explore expectations regarding recovery and how to use that to enhance motivation and briefly review how to develop a relapse prevention plan. And remember, when I talk about relapse here, I'm talking about a return to prior functioning, whether it's substance abuse or depression or anxiety, their symptoms are back. So we want to help them figure out how do you prevent this and how do you know what are the signs that you might have another episode starting so you can intervene early instead of having to go into a full-blown major depressive episode before you start taking corrective action. So change is constant, which means of course it occurs all the time in the natural environment. You go outside, the temperature has changed today from when you got up to when you went to work. Hopefully it got warmer. Yesterday it didn't, it got colder throughout the day here. So change occurs. Change occurs among people, the way you interact with people. You can grow closer, you can grow further apart. You can have little hiccups in your relationships. There are a lot of different things that can happen. And as you change, if you've done couples counseling, you know that the two people who met when they were 16 or 18 or whatever, and now they're 40, they are very different. Now they may still be close. Of course, if they're in our office, they're probably not. But we hope they're still close, but they've both changed. And it's a matter of, did they change in a way that was complimentary or did they diverge in some way and we need to help them try to get back together. And change happens in relation to behaviors. You may decide you're going to do something and you go gangbusters and then you kind of get bored with it. You may go gangbusters and figure out, wow, this is really awesome, and keep doing it. Change is going to happen. And it's based in large part on the motivations in our environment. You know, if we're getting, even if it's tough, if we're getting support and encouragement, we may keep doing it. And on rewards, you know, if the rewards are there or if we can see the reward is not too far away, we're probably more likely to change our behaviors. It occurs without professional intervention. So yes, as professionals, we can be awesome catalysts and help people, you know, move along that path, along that process more quickly. But, you know, change eventually would happen when somebody is clinically depressed. They can't stay that way forever. They will reach a crisis point where something's got to give. Relationships, you know, people are in a relationship and it starts getting rocky. Eventually change is going to happen one way or another because people aren't going to keep doing things that make them miserable. So either they're going to come to an understanding, go to counseling, break up, whatever's going to happen without professional intervention. With professional intervention, we can help them identify in an ideal world, what are your goals? Where would you like to see this go? And how can we help you move that way? How can we help you orchestrate your own change? The change process is cyclical. So people are going to move back and forth between the stages and cycle at different rates. So you may start a group with eight people in your group and, you know, two of them just don't seem to get on the bandwagon. They're just not ready to go. And, you know, the other six are doing really well and are progressing really quickly. But we have to look at those other two and say, okay, what's different? And how can we activate their change process a little bit more? And I said they go back and forth. Because like I said yesterday, when the going gets tough, the tough may think about not going anymore. Think about going to the gym and trying to get in shape, trying to start exercising. My mother always used to do this. Bless her heart. She would go out and she would go gangbusters. And when it started getting hard, you know, when she'd wake up in the morning and everything hurt, she's like, I'm not sure I really like this. Or if she went in and she tried to do too much the first day and it was just really unpleasant. The motivation for her to go back the next day was down there. So her readiness for change backed up. She may start thinking, well, you know, maybe this whole fitness thing is a little overblown. You know, I can just watch what I eat to lose weight. You know, I can find a different way to achieve my goal because this fitness thing ain't for me. So we want to help people figure out, you know, if they want to change when it starts to get uncomfortable, how can we either minimize the discomfort and or help them see how the discomfort is worth it. Sometimes it's worth just writing it out in order to get to the other end. It's not uncommon for people to linger in the early stages. So in pre-contemplation or contemplation when they don't really think they've got a problem or they're concerned about it, but not ready to do anything, they may linger there for a while and go, you know, how can I fix this on my own? Can I get a self-help book? What can I read? Not really ready to go to treatment. Recurrence of at least some symptoms or old behaviors is a normal event and many clients cycle through different stages several times before achieving a stable recovery. So think about a client who is dealing with anxiety or depression, you know, they're doing really good. And then something happens, you know, whatever that something is and they start having some negative thoughts and they start worrying a little bit more again and having a little bit more difficulty concentrating and sleeping. Okay, does that mean they've relapsed completely? No, you know, they're not sleeping all day and they haven't fallen back into those behaviors that they had when they came to treatment the first time. So we need to say, all right, how can we intervene now before it becomes a full-blown relapse? The same thing with smoking, for example. Some people, when they stop smoking, they might fall off the wagon and have a cigarette or go places where they can smell secondhand smoke. You know, beggars can't be choosers sometimes. Just to try to, you know, get a little bit of relief. And so we want to help them figure out what's going on when you hit that place where your urges or your cravings or your, you know, behaviors or thoughts start getting bad again. You know, what's different, what changed and what can we do to help you work through that and make that as not unpleasant as possible. There are six basic stages in the process of change and I always liken it to getting into a cold pool. Pre-contemplation, you're sitting out on the pool. You know, you're getting sun, you're fine. It's great. It's wonderful. No problem. You don't have a problem. Contemplation, it's starting to get warm. You've been out there for about an hour. You're starting to bake and you're thinking, oh, that pool looks really good, but it is really freaking cold. And yeah, I'm not that hot yet. We'll just, I'm fine. Preparation, you've sat up and you're like, I'm starting to get uncomfortable. I'm sweating. So you move over to the pool and you start to like dangle your feet in just to see how cold it really is and kind of get a feel for it and see if there are kids that are going to come splash you and stuff. So you're preparing to get in the pool, but you're not there yet. You've decided it's probably what you need to do, but you're not ready to take the plunge. And then action is when you decide, all right, I'm hot. Might as well just get it over with. You jump in the pool. Wonderful. Now at this point in order to warm up and well, cool down and warm up, get comfortable, you probably need to move around and do some things. So if you jump in and it is too unpleasant, you may not stay in until you swim around enough to warm up. You may just get right back out and say, oh, that was too painful. You know what? I really wasn't that hot after all. So somebody who has, who's smoking, who's trying to quit smoking, pre-contemplation, whatever, people blow it out of proportion. Everybody in my family smoked. My grandmother smoked until she was 97 years old and she never had a problem. So they minimize the problems. They're just unwilling to consider the fact that it might be a problem for them. Contemplation, they start to see that, okay, the research says that smoking causes a lot of problems. It's expensive. But I just can't imagine not smoking anymore. It's what I do when I'm stressed. All right. So preparation, the person has decided, you know what? I really need to try to quit smoking. I need to do it for my health, for my family, whatever. Okay, great. But they're not quite ready to do it. They're thinking about what they need to do in order to make this change happen. And then action is when they say, okay, I'm going to go to the doctor. I'm going to see about getting some, you know, nicotine replacement gum or medication. I'm going to look into some of these programs that can help me quit smoking, ready to do it. So then they go and they quit smoking and the first week they have those cravings. And they're used to smoking at certain times of day and doing certain things. So they have certain habits and they encounter those and they're like, I can't smoke. What am I going to do? It's uncomfortable. It's stressful. It's anxiety provoking. And the function that the smoking used to serve for many people, which is calming them, they're stressed out and they don't have anything else to replace it yet. Oftentimes. So what happens? They say, I can't do this. I just can't do this. And they go back to preparation. They're like, yeah, no, maybe I can think about finding another way to quit smoking. That one. That was just too painful. So then you can see how it cycles back and forth. And then we'll stay with smoking. We have the recurrence. They're doing good. They're using their nicotine replacement gum six months down the road. And then all of a sudden one day they just get this craving for whatever reason. We won't go into triggers right now and decide, you know what? I'm just going to have one cigarette. I've been really good for six months. I can just allow myself to have one cigarette. They smoke that cigarette and they're like, oh yeah, I remember what this was. I remember why I like used to like smoking, which can keep them smoking again unless they say, you know what? No, it was good. There were benefits to it, but all the reasons I decided to quit are all the reasons that I'm going to stop smoking again. In pre contemplation, the client is unaware, unable or unwilling to change. So what we want to do is just establish rapport. You got that smoker coming in and he's like, my insurance company said that I had to quit smoking in order to get my rates lower. And my wife said we needed to get our rate rates lower. So I'm here. All right. So we can raise doubts about their patterns of use. If the person says, I don't smoke that much. We can say how much do you smoke on average? We can give information on the risks and pros and cons of use. Now they probably already know the risks and cons of use. So we can ask them what they know if that's helpful. We can give them a handout. You don't want to belabor it because you don't want them to feel like we're lecturing at them, but we want to make sure they have the information. We also need to talk about the pros of use. Why do you do it? What's the benefit? Because if we can't figure out what that is, we can't replace it with anything. If we figure out it's how you deal with stress, if we figure out is what you do instead of when you want to eat instead of eating, what we can help you figure out different behaviors to put in that place. And we want to explore the reasons for unwillingness to change. You know it's a problem. You're here. So obviously part of you thinks that you might be willing to consider making a change. What's stopping you? It could be they've tried before and they failed and they don't want to do that again. It could be they're afraid of the different interventions. They're afraid it's going to be too, they haven't tried before, but they're afraid it's going to be too miserable because they've heard the stories. We want to talk about what are the reasons? Maybe they just can't envision themselves as a non-smoker. Maybe that's something that has always been part of them. They've smoked since they were in high school. So go down those avenues. The client is likely to be wary of the counselor enough treatment. So we want to make sure that we don't want to, that we don't rub the client the wrong way. Don't lecture to them. It always drives me crazy when I used to watch cops. When the police officer would get somebody and they'd have cocaine or something. And the cop would sit there and lecture them about how bad it was and what they're doing to their future. I'm just like, please just hush. Because it was patronizing. The person already knew that they were very clear and the cop didn't know this guy from Adam. So it didn't know what his motivations for use were. So it was just like fingernails down a blackboard. And we want to try to keep it informal. If the client's not wanting to be there and in pre-contemplation, we don't want to be trying to make clinical diagnoses. We want to talk to them and go, what are your concerns? What brings you here today? Try to get that rapport going so he or she doesn't feel pushed or pressured. Ambivalence is common and normal. Whatever we were doing had a benefit, whether it was stress eating or drinking or even self-injury. When you look at what was the function of it and how did it benefit this person? What were the rewards that maintained this behavior? There was a benefit to it. And it wasn't necessarily a healthy benefit, but it served a function. So we want to help people see it's OK to be ambivalent. Change is hard. So if the person starts to argue, challenge or discount what you have to say, just let it go. I can see your point if you can see their point. Or tell them that they're perfectly fine for them to have their own opinion. If they interrupt or try to take over or cut off the conversation, you're going to want to roll with that as much as possible. So you can identify that maybe they're cutting you off because they don't want to hear what you have to say. Or you can paraphrase how you're feeling and go in that direction. Or you can just kind of stop and go, all right, in what way can I help you? Or what do you think is going to be most helpful for you? They may deny that they've got a problem. Blame other people for blowing it out of proportion. Disagree that there's an issue. Minimize how much they use or how much the problem exists. Or ignore, just not responding or not paying attention. Just whatever. If you work with clients who are involuntary, you've probably had at least one of the ignores. During this phase, we want to explore the meaning of the events that brought the client to treatment or the results of previous treatment or both. So why are you here? And what does that mean to you that your wife is saying that you need to come in and figure out how to stop smoking? You know, the person may be really irritated because they feel like they're being pressured into it. But if we can help them change their perspective a little bit or reframe it as their wife cares about them to live longer, not just save money on insurance, then we can maybe help smooth it out and moderate their attitude and their resistance. Because the more somebody feels pushed, the more they're going to dig in. So we don't want to push. We want to pull. We want to join. We want to elicit the client's perceptions of the problem, offer factual information about risks, provide personal feedback about the assessment. So, you know, let them know what your assessment really is. If you're doing a health assessment and somebody is on the obese side, you know, give them feedback, especially if you're using the BMI, the body mass index is what it stands for. That can be kind of deceptive because you can have some people who are really muscular. My husband is one who, you know, he's tall and he's on the overweight side of the BMI. But when you look at his body fat, his body fat is only about 20%. So, you know, we want to help them understand the numbers that we're giving them, understand what their risks are based on, you know, multiple different measurements. But if somebody comes in and they say, you know, I don't really feel I'm overweight, but you can see that their body fat is higher than it should be for health, you can point that out. And point out why having high body fat or why carrying weight around their middle can be a risk factor for a lot of other problems. Explore the pros and cons of, and here I still have just substance use, but explore the pros and cons of their current behaviors. Smoking, eating, you know, if they're overweight, maybe they eat because they like food. I love food. I will not apologize for that at all. That's why I run because I love food. So we want to look at what are the pros of use? Because if the person's afraid that they're not going to be able to eat the foods they love anymore, then they're going to be more resistant. So going back to that decisional balance exercise, what are the drawbacks you see to change? You know, let's see if we can minimize those. Help a significant other intervene. So if you've got a family member who's willing to intervene or willing to be there, help them kind of chime in and provide feedback. Examine discrepancies between the clients and others' perceptions of the behavior. You know, you say that you're fine. You're smoking. You're not smoking that much. You always go out on the porch. It doesn't bother anybody. What are other people's perceptions? What does your wife have to say about that if she were here? And we can ask that even if the wife's not there. If your wife were here because the husband has heard what the wife has to say. He knows what she'd say. And express concern and keep the door open. Say, okay, you know, I hear you're not ready for change yet or you don't think this is a problem. But if you ever decide it is, my door is always open. That way the person doesn't feel like you're trying to sign them up right away and they don't feel as pressured and they have the ability to decide, you know what? I think I might go back and talk to her again. Contemplation, the client is ambivalent or uncertain, still considering the possibility of change. They've recognized that there might be a problem, but they really can't imagine change quite yet. So we want to discuss, continue to weigh the pros and cons, emphasize the client's free choice and responsibility. I can't make you do this. You know, this is on you. And when we embark on a journey together, if you choose to, then you're going to help me because you know what? You've lived in your skin for 30 some odd years. I've known you for 30 minutes. So, you know, you're the expert on you. I know a bunch of techniques and tools. We can put those together and see how I can help you improve your change process. And we want to elicit self-motivational statements. What are the reasons you want to change? Why do you believe you can change? Help them realize that they can and get excited about it. What are the benefits do you see to change? You know, so what did they see as the benefits? What we think is important may not matter to them. Reassure the client that no one's going to force him to change and that he's in charge. I had a client come in one time and she sat down and promptly told me she was not going to go to any of those meetings. Hi, my name's Dr. Snipes. But she was just adamant she was going to get that out there the minute she got into the room. She'd been in the system for a long time and evidently had been put in treatment and pushed into things every time she came into treatment. And I just kind of sat back and I'm like, okay. And I said, I introduced myself and I said, let's just kind of talk about what's going on and then we'll talk about what you will do. What are you willing to do? If you're not going to go to meetings, there's no reason for me to put that on your treatment plan because you're just not going to do it. So let's find something else for you to do instead. And she kind of looked at me and then we went on. And I'm not going to say that the relationship was beautiful henceforth and forevermore. But at least for that session, we had a really good assessment session. Let's see. Help the client acknowledge concern. And help them generate their own intention to change. So help them come up with a statement of, I'm ready to do this. Help them develop optimism about the fact that they can do it. Give them a timeframe. Most people, it takes this amount of time or if you start work soon or when you start work, you should see some appreciable changes in the first three weeks or if you're talking about smoking cessation, the first two weeks are probably going to be the worst for withdrawal and cravings and those sorts of things even if you're on taking some of the medications. But this is what you can do in that period to try to help you through it. Let them know that there's a light at the end of the tunnel. The same thing if you have a client that's taking psychotropic meds for most antidepressants and atypical antipsychotics, the first few days are pretty miserable. So help them realize that. Just say, let them know ahead of time the first couple of days. You may feel like you've got the flu or you may be really groggy. That is totally normal. So if it's too debilitating, obviously you want to call your doctor if it gives you any concerns. But please don't stop just because of that. Call your doctor first. Help clients see a difference in what life might be like if they made this change. Show curiosity about their strengths and explore how skills and competencies may be negated by their current state. So maybe this person was an athlete all through high school and now they've gotten out of shape and they're smoking and they want to get healthy again. But they're not quite ready to give up the smoking thing. So we want to talk about you were this fabulous athlete in high school. How does it feel now when you try to go out and jog or do some sort of physical activity? And they might say, yeah, I am a really good runner, but right now that just ain't happening. So you can help them see connections and reframe negative statements when they start to say those withdrawals are going to be awful. We can reframe them as yes, they are going to be unpleasant, but they will end. And there are things you can do to minimize the withdrawal side effects or, you know, I don't know if I can maintain a healthy diet because that means I can't go out and eat with my friends. No, it just means you may need to make may need to make different choices when you go out to eat. So helping them see how it's not going to stop their life. Help them see how the change can integrate into their life and they're not going to experience great losses. Highlight their reasons for change by summarizing concerns. If they've indicated that they're concerned that they're smoking or their weight might be contribute to a health problem later on in life. Highlight that if they indicate that, you know, it's costing them money and that's a problem because they're financially conscious. Highlight that. So try to highlight any concerns that they have. Explore the pros and cons again. Allow the client to explain the benefits like we already talked about. We need to understand the function of this behavior so we can acknowledge it and go, you know what, that's true. You know, I understand where you might smoke when you get stressed or when you get stressed, you might kind of bury it in a bowl of ice cream. I get that. What else could you do or what else have you done when you felt that way besides smoking or eating or doing whatever? Assure the client conflicting feelings are normal. Continue to review feedback from the assessment. As appropriate, we don't want them to feel lectured. Find out what the client expects from treatment. If they expect it to be a miserable process, then we can allay their fears right there and we might just get them on board. If they expect that they're going to come four times and life is going to be ducky and something they've been doing for 20 years or a lifestyle that they've developed over 20 years is going to completely swap around, they're going to be mistaken and they're going to be irritable after that fourth session when they haven't made as much progress as they'd hoped. So we want to provide information. How long does treatment usually take? How long does it take for people? What are some common hurdles that they experience and how do we get over those? And help them connect core values to committing to treatment. So what is important to you? Which people are important to you in your life? What things are important to you in your life and how does that fit with this behavior change? Strengthen the client's personal choices by nudging the client to make positive choices. They can make small choices, small positive choices. If they're not ready to give up smoking completely, maybe they can cut back to one pack a day. Maybe they can switch to lower nicotine content cigarettes and then one pack a day. So there are things they can do to wean themselves down or start trying it. Or maybe they're willing to say, let me try it for a week. Okay, cool. Let's try it for a week. No commitment. If after a week it's not working for you, you can renegotiate or you can drop back and come back when you're ready. No one can decide this for you. You can choose. And we just need to keep saying that over and over again. Help the client set goals and take small steps. If they go from smoking to cold turkey with no medication, no nicotine patches, no nothing, just nothing, it's going to be really rough. What is their choice then? You know, I'm there to try to support them. If they don't know about the other steps they can take, I want to make sure that they're educated about the options in order to make the transition a little bit easier. If they're trying to change their eating, unless obviously their doctor says you need to do something now. What I usually do with my clients who are trying to make a behavior change is they say pick one aspect. Like if they're trying to eat more healthy, maybe they start drinking more water each day. Do that for a week or so. Once that starts feeling pretty good, then maybe they start walking around the block once a day or whatever. Small steps. Don't go from eating processed foods and meat and fried foods and everything to being a strict vegan overnight unless you really, really want to. But most clients aren't going to want to do that. Remind the client of triggers including negative emotions, social pressures, physical aches, pains and concerns, and any extended withdrawal symptoms. If we're dealing with sugar, if we're dealing with nicotine, if we're dealing with alcohol or drugs, there can be sort of extended withdrawal. And I tell clients that urges, you know, you have a craving. You want to eat, you want to smoke, you want to do something. That's a craving. And then you have the urge to get up there and do it. So that's the behavior of, you have the thought, craving, then the urge is the behavior. Think about having a bumblebee on your arm. A bumblebee's on your arm and you swat it. That's your automatic urge. Get off of me. Probably going to sting you. That's unpleasant. We don't want to do that. And it's going to die, which is sad because they're cute. If it lands on your arm, your immediate thought is going to be get that off of me. But your secondary thought would be, you know what, if I just, if I'm still, it'll fly away in a few minutes. Same thing's true for urges. Just like the bumblebee flies away and doesn't sting you. No harm, no foul. Your urges tend to ebb and flow and they tend to go away after about 10 minutes unless you keep feeding them. Reinforce the client's commitment to change. What do you think has to change in your life, in your situation to make this change possible? What are you going to do to set the stage for this and to start making, taking steps towards your change? What are some of the benefits of making the change? And how would you like it to turn out ideally? So imagine, you know, you've quit smoking or you've lost the weight or you've, you know, whatever the change is, you've gotten rid of your anxiety. What's going to be different in your life? What's life going to look like? You're going to get up in the morning and how are you going to feel? Are you going to feel the same? Are you going to feel different? And have them walk you through a day. So you can see how things are going to be when that change has been implemented. In preparation, the client will start asking questions, indicating they're willing to consider options to make specific changes. So we want to continue to explore treatment expectancies and elicit from the client what's worked in the past, either for him or for other people he knows. So maybe he hasn't tried to quit smoking or to lose weight, but he knows people who have. What's worked for them and what hasn't? And then we'll explore the reasons why. At this stage, the client shifts from thinking about it to planning the first steps, starting to think about how might I do this? The counselor can guide the steps by offering to help, but we don't want to yank the client forward and go, okay, cool, let's develop this treatment plan. No, we're still talking about options here. We're still looking at what could you do? Negotiate the plan is the next step. After you kind of talk about it for a while, maybe the next session you start talking about, just for the heck of it, let's try to put together an action plan and see what that looks like and see if, you know, you think that that'll work for you. Offer a menu of options, develop that behavior contract, identify and lower barriers. So if they have apprehensions, reservations, yes, buts, we need to figure out what those are and get rid of them, lower them, figure out why they're there. They're there for a protective reason of some sort. We want to help eliminate whatever fear that is associated with so we can move on. Encourage them to enlist social support and with advice or with advice, with permission, offer advice. Again, we don't want them to feel lectured at or told what to do, but maybe they don't know all the options that are available for getting rid of cravings or for getting in shape. Maybe they think the only option is to go to the gym to get in shape. Oh, no, there are so many more things you can do. Assist the client in negotiating finances, childcare, work, transportation, or other potential barriers. So I would ask them, what do you see might get in the way of this happening? For example, if people are trying to lose weight and they start on a weight loss plan November 1st, what's the first thing that you see is going to probably try to get in their way? The holidays are coming up. Thanksgiving, Christmas, New Year's, there is unlimited food in front of you, pretty much all the time it seems like. So we want to help them figure out how to negotiate that. They may not lose as much weight as they would otherwise during the holidays, but we can help them learn how to make healthier choices when they go to buffets at Christmas dinner, those sorts of things. So they don't go backwards and they feel like, you know what, I'm making positive changes and choices for myself. The client indicates ready, whoops, and have the client publicly announce plans. The client indicates readiness for change when they stop arguing, interrupting, denying, yes budding, no longer ask questions about the problem, but more about how to change. So they're not going, well, is this really a problem? They're saying, yeah, I know it's a problem. Okay, so how can I get rid of this apprehension I have about the withdrawal symptoms or about never being able to smoke again or whatever. They appear calm and peaceful with their choice and they may state an openness to change. I've got to do something. This is where you hear action. They're ready. They express optimism that they can deal with it. They can beat it. They can achieve it. They talk about how life will be better after the change and they may even experiment between sessions and come in and say, you know what, I tried cutting down to only having one cigarette in the evening and it was pretty rough, but I started feeling a little bit better or, you know, whatever they tried to do, they may try to start experimenting with some of the things you've been talking about between sessions. So we want to seize on those things and go, okay, did it work at all? If so, tell me about that. And what were the problems that may have kept it from being totally successful? And let's see how we can eliminate those things. Tweak this intervention to work for you. We want to ask clients what's gone wrong in the past when they've tried to implement a behavior change so we can address barriers. Provide all necessary information so the clients don't get hit, you know, unawares of some change that may come up. For example, when people are detoxing from benzodiazepines, your anti-anxiety medications, there's something called protracted withdrawal and they could experience withdrawal symptoms 30, 40 days after they quit using. We want to let them know that that's possible. We want to let clients know, again, with substance detox, that they may have dreams about using. For the first month or two after they quit using and it may seem really real and they may wake up and be like, well, did I use or was it a dream? Just let them know so they can develop a plan for how to cope with it. Other barriers can include family relations. Maybe their family's not supportive of whatever this change is. They want to eat unhealthfully. They love their fried foods or they're not willing to get the alcohol out of the house or whatever the case may be. They may have health problems that keep them making all of the changes as quickly as they wanted. They may have depression or other negative feelings that really saps their motivation. They're just like, I'd like to change, but I just don't have the energy to think about it right now. We can address that. We got to address the depression before we can address this change. We've got to help them eliminate or pull down some of those barriers. Bureaucracy, such as waiting lists, paper work or insurance can also get in the way of them either being able to access or afford treatment and finances. So let's look at all those areas, see if there's anything that jumps out that we might be able to help refer them to assistance. In action, the client takes steps towards change, but is still unstable. They've sat down. They've said, I've got to do something. Help me out. I'm willing to do whatever it is. Okay, cool. But that doesn't mean they've got it covered. That means they're willing to try to take steps. It's like when you take your kid out and they want to learn how to ride a two-wheeler. Okay? I took the training wheels off. You push him out. You don't push him out into the road and go, good luck. You know, thinking that he's going to be stable and riding like a pro. You're running behind him kind of half holding the back of the bike so he doesn't fall down the first few hundred feet or whatever. And then you let him go tentatively because you're not sure you see him kind of wibble wobbling. That's action. That's people starting to make a change. People don't just get it and smooth into it. So we want to acknowledge difficulties and support their attempts. Even if they try it and they relapse, okay, let's see what went wrong. Let's adjust this action plan to make it work for you. Let's see what we missed. And I usually use the pronoun we because we're trying to work as a team. Identify risky situations and coping strategies so people can be prepared ahead of time for how to deal with things. Help the client find new reinforcers. So instead of eating when you're stressed or instead of eating when you've had a long day, what can you do to reward yourself? And support perseverance and sticking to that plan. They may come in and go, this was a great week. All right, awesome. Or they come in and go, it was a tough week. Well, let's really give them kudos for sticking to the plan then because sometimes, well, all the time, it's harder to stick to the plan when it's unpleasant than when things are going well. In this stage, clients are receptive to the full range of techniques, but can wax and wane in their motivation. You know, when it gets hard, when it gets uncomfortable, when it's not as rewarding, when they're starting to have those cravings and miss the old behavior, their motivation is going to wane a little bit. So we want to review their decisional balance. We want to review how much progress they've made. We want to review how things are different now, even three weeks into treatment than they were when they started. If relapse occurs, just back up and apply techniques from an earlier stage. So if they go back to pre-contemplation and they're like, you know what, I don't think I need to be here. Okay, so let's talk about that a little bit and then leave the door open. So you're going back and you're reviewing, resetting the stage and opening it up again. In the action stage, we want to engage the client in treatment and reinforce the importance of remaining in recovery. Support a view of change through small steps. Acknowledge difficulties for the client in early stages of change. It's hard. You know, even in the early phases of the action stage, when they start making changes, they've been responding a certain way to stress, for example, for 20 years. So expecting them to turn on a dime and respond a different way, 100% of the time, is unreasonable. So I'll let them know. Let's see if you can just, even if you respond in the old way, okay, acknowledge it, say, oops, I slipped up. What can you do in order to make sure that doesn't happen again? How can you learn from it? And the fact that you noticed in the way that you didn't want to indicates progress. So let's start keeping track of, you know, how many runs, hits, and errors you have, so to speak. Acknowledge difficulties, help the client identify high-risk situations and develop appropriate coping strategies, other reinforcers. Explore past experiences and their hopes and fears regarding confrontation and judgment. Have they had an attempt at change before and whoever they worked with was more like a drill sergeant? Well, okay, that's not me. If they have concerns about costs in money or changed behavior, maybe they're concerned because, you know, I love staying out late. I'm a night owl, but if I stay out late, then I'm groggy all the next day and gets my circadian rhythms out of rack, out of whack, and it triggers my depression. Okay, so let's talk about how you can negotiate that because you want to stay out late, but you also don't want to be depressed. How can we try to compromise here? They may have to give up certain activities, at least temporarily. For me, I'm big into animal rescue, but at a certain point I had to get rid of all of the, most of the rescues that were on my Facebook page because my page was literally filled with urgent, we'll be euthanized today, urgent, we'll be euthanized tomorrow, and I would just see these sad puppy faces and I'm like, oh, you know, it was having, taking a huge toll on me, and, you know, I was just cross-posting my life away. So at least temporarily, I had to stop doing that and just focus on my fostering. Family involvement, shame, and guilt could also be, you know, a hope, or a fear, the shame and guilt part, but they can also hope that their family's going to get involved. So let's talk about what you hope is going to happen and how we can help make sure that happens. How can we get your family involved in a way that's comfortable for you? They may be concerned about medications that they will have to withdraw from or take, reminding them that everything is their choice. So if they don't want to take the medication, you know, obviously there are some exceptions, but they are in charge of their treatment. They may perceive the rules as too strict with no wiggle room. For example, if there's some of the patches for smoking cessation that if you smoke while you're on them could actually be life-threatening. So, yeah, there's no wiggle room there. If you are concerned about that, you know, maybe that person would be more willing to look at a different medication or a different intervention. Or maybe that's an excuse so they have wiggle room. Either way, you know, I'm not going to start going, that's just an excuse. You need to take it. I want to make sure that they're comfortable with the path they're going down. Immunize them against difficulties by role-playing and continuing to talk about their concerns and resolve those barriers to treatment. Increase their motivations by helping them see the value of both internal and external motivating factors. We talked about those last week. Social supports, emotional benefits, cognitive benefits, physical benefits, financial benefits, all of the reasons that they're doing this. Suggest to the client that external coercions may be compatible with their best interest. So if the insurance company says we're going to drop you from our policy unless you quit smoking, yeah, that probably rubs them the wrong way. However, you know, they want to make money because they don't want you to be sick. You know, it may be in your best interest. Examine and interpret non-compliant behavior. Non-compliant behavior is a thinly veiled expression of dissatisfaction with treatment or a therapeutic process. So it's not necessarily them saying no, but it's a dissatisfaction with the way things are going, either because it's uncomfortable, because it's unpleasant, because it's not something they want to do. Well, if they don't want to do it, why not? Why is this other behavior more rewarding? So instead of saying you have to get in their mind and say why wouldn't you want to? It could be you. Maybe you're not forming a good therapeutic alliance. So check that. See what you're missing. Maybe you haven't attended to all the concerns or you haven't considered all the benefits of the behavior. So you may need to dig a little deeper. If the clients in maintenance, they met their initial goals, made changes, and they're now practicing coping and maintenance strategies. So we want to support and affirm their changes. Continue to rehearse those new coping strategies and encourage them to visualize going to a party and making good choices or refusing a cigarette or whatever it is. Review their goals and keep in contact. If your agency has aftercare or support groups on site, it's a great way to keep in contact without having to, I hate to say it, take away from your billable hours. But in some agencies, your billables are really important. In this stage, the clients are keeping on keeping on. We want to remind them about their new tools and reinforce recovery, reminding them about their action plan to be aware of risky situations, have coping strategies for each situation, participate in some sort of non-12-step or support group program. There's overeaters anonymous, there's smokers anonymous, there's schizophrenics anonymous, there's an anonymous for everything. But there are also other non-12-step support groups that are out there and support is essential. Encourage them to pursue hobbies and cultural activities to fill up their time so they don't have as much time on their hands to engage in that other behavior. And maybe encourage them to look at volunteer and give back. If they're teaching smoking cessation techniques, they're going to be more likely to be implementing them. Just like if you're teaching mindfulness, you're going to be more likely to implement it. And vice versa. Help the client identify and sample drug-free sources of pleasure. So they're not drinking, they're not smoking. What else can they do? Support lifestyle changes. Affirm the client's resolve for self-efficacy. Help them practice using coping strategies. So give them some scenarios if you're running an after-care group. Maintain that supportive contact. And develop a fire escape plan if the client feels symptoms returning or return to old ways of thinking. So if you see yourself starting to go down this slippery road, what is the first thing you need to do? That's their fire escape. Call you what is it. What are the long-term goals with the client? Form a plan by identifying their triggers for use or whatever the behavior is. Identify their triggers if you're talking about depression or anxiety. What triggers that for them? Identify the effect or benefits of the old way of responding to the trigger. So if when they get depressed, they tend to crawl into bed and pull the covers over their head for two or three days at a time. What are the benefits of that? But what are the drawbacks? Let's look at both. And identify alternate helpful coping responses. So if they wake up and they feel really depressed that morning, what can they do instead of staying in bed all day long? That might be more helpful. Develop reinforcers. Competing reinforces you can't do them at the same time. So if one of the things you do when you get depressed is sleep all the time, what can you do that's not sleeping? Maybe you force yourself to get up and go to the library. Well, you're not going to sleep at the library, but you're still not having to interact with people. If you cry all the time, maybe when you feel like crying, do something else that can help you feel happy. I don't want them to avoid their emotions, but I also don't want them to get stuck where they're crying for eight hours. If they self-harm, what else can you do? You may start out with snapping a rubber band or something, or you could go to something completely different. One of my clients used to put on there was a band that she really liked and she would put their music on her headphones really loud and she would kind of get into the words of their music and it would serve a similar purpose to her self-injurious behaviors. Create contingent or if then reinforcers. If you respond effectively to a situation, then you can do whatever. Or if you get out of bed by 9 a.m. each day, then at the end of the week you can whatever the reinforcer is. So the reinforcer is contingent upon them using their new skills. And then natural consequences are community reinforcers like friends and family going, that's awesome and giving them positive support, relationships improving, etc. Now if they recur, if there's a relapse, help the client re-enter the change cycle and commend any willingness to reconsider positive change because it's probably a big let down and they feel defeated. They feel deflated. Okay, I can get that. However, you're coming back and you're trying again or you're willing to think about trying again and that tells me that you know you can do this and we just have to figure out what went wrong and fix it so it doesn't happen again. We want to explore the meaning and the reality of the relapse as a learning opportunity. We missed something. You know, it could have been they were going along and they quit being mindful and they had all these relapse warning signs coming up and they weren't taking care of themselves and all of a sudden boom. Because relapses really don't come from out of the blue. So we want to explore what changed that led up to this relapse. Assist the client in finding alternate coping strategies and continue to maintain supportive contact. A lot of times they don't need to re-enter full blown treatment. A couple of sessions to help tune up again is plenty. Motivational interviewing and motivational approaches are a means of rapid engagement in the general medical setting or in our settings because we can't guarantee a client is going to come back. A lot of times they don't put a priority on their mental health. So when we got them we need to try to increase that motivation while they're there. A first session can increase the likelihood that a client will return so we can deliver but we also want to deliver a useful service during this first session in case the client doesn't come back. When they leave that assessment make sure they're walking out with some sort of skill or tool that can help them start feeling better because if they try it and they start feeling better they may go oh maybe she knew something. Let me go back and try that again. An empowering brief consultation when a client is placed on a waiting list can be really helpful. If they come in and it's going to be 30 days before they can get in or two weeks they're like I need help now. Okay so let's sit down and talk about what you want to do. Let's develop this change plan and hear where you're at so they can feel like they're making progress they can stay motivated for entering treatment and it can prepare clients for treatment to increase retention and participation. You get them psyched, you get them jazzed and then they're ready to come in when it's time. It helps clients coerced into treatment, move beyond initial feelings of anger and resentment so they can see what's in it for me. It's a means to overcome client defensiveness and resistance because that tells me that they're scared or apprehensive about something. They're feeling like they're they've lost control and they're being forced into something. So these motivational approaches give them back their power and establishes more of a partnership. You're always still going to have more power but as it establishes more of a partnership. It can be a standalone intervention in settings where there's only a brief contact. So if you're doing a screening or if you're working for an EAP motivational interventions can be really helpful. And it's also a counseling style that can be used throughout the whole process of change because motivation is going to wax and wane. So 12 weeks into the process you may still need to pull out some of those motivational tools because you see the motivation waning to get somebody excited again and get them back on track. So one of the things to remember there's a relatively short period of time to make a beneficial impact. So we want to make sure that we get some change. If we don't make an impact in the first session or two then we may not make an impact at all. So we need to make sure to get clients involved otherwise they may either drop out or just kind of come and go through the motions. So just like when somebody starts at work starts at your job you know goof off and play on Facebook for the first few days that they're there no you expect them to be with the game. And you know because then they're going to keep with the game after that they're not going to be going well I can just coast and get my requirements met. Make the best use of the first conflict contact. It's usually a mistake to start out a session with filling out forms. I know I say this all the time but people do it and just drives me crazy. Talk to the person like they're a human being because guess what they are. Get to know them a little bit. Five minutes will not hurt you at the beginning of the session before you start doing paperwork and walking down the hall talking to the back of their head or turning around and talking to them that doesn't count. Sit down and make sure they know they're a priority. Even one session can make a positive impact. So make use of it. Every single session can have a positive impact. Lasting change takes time and effort but all clients have the ability to make positive choices and changes. We just have to help them figure out what they want and how to get there. Clients will be at different stages of readiness for change between different issues. So they may be ready to change their eating but not their smoking or something else. And that's okay. So let's focus on the eating for now. We'll talk about the smoking later. How do you have some successes and develop some self-confidence? Clients with low motivation may begin arguing, ignoring or becoming apathetic. Just expect it and realize that they may start they may be feeling pushed so back up a little bit. Sometimes enhancing motivation means focusing first on barriers to recovery instead of the problem itself. So help them get their ducks in a row and explore expectations regarding recovery to enhance their motivation. How is this going to benefit you? Finally develop a relapse prevention plant that helps clients identify triggers and vulnerabilities such as not enough sleep, poor nutrition, stressful social environment and ways to prevent and address these things. Alrighty then. Right on the nose at 12 o'clock. Do you have any questions? Alrighty y'all, if that was it like I think I said it was a little bit complicated. We changed our software long story but there was a little glitch in the certificate. I think we've got it fixed. I printed out my certificate just fine today. So that shouldn't be a problem but I apologize for those of you who had difficulty getting your certificate yesterday. I will see y'all hopefully tomorrow when we begin our multicultural series. If you enjoy this podcast please like and subscribe either in your podcast or YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor tool box. This episode has been brought to you in part by allceuse.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. Use coupon code counselor tool box to get a 20% discount off your order this month.