1. Enhancing Motivation
to Change
Heather Durdle, PhD, R. Psych
Karen Pellerin, MSW, RSW

2. Stages of Change (Prochaska, DiClemente, & Norcross)
Precontemplation
Contemplation
Preparation
Action
Maintenance

3. Stages of Change
 Successful changers use different tools
depending on their stage of change
 A series of tasks need to be completed
before moving on to the next stage
 The tasks must be matched to the stage of
change
 NOT A LINEAR PROGRESSION

5. Precontemplation
“Everyone else needs to change”
 Typically deny having a problem
 Usually present to treatment under pressure
from others
 Usually feel demoralized and hopeless so
they avoid wanting to think, talk, read about
their problem
 Free of failure and guilt
 Traditionally labeled as “resistant”

6. Contemplation
“I want to stop feeling so stuck”
 Acknowledge they have a problem and begin
to start thinking about how to address it
 May be stuck in this stage for a long time
(e.g., two years for smokers)
 At transition to Preparation:
 Begin to focus on solution rather than problem
 Begin to think about future rather than the past

7. Preparation
“I will stop drinking on Monday”
 May be committed but might not have
resolved their ambivalence
 Awareness is high
 A short preparation stage may not lead to
success

8. Action
“No thanks, I don’t smoke anymore”
 Make the move for which they have been
preparing
 Changes are visible to others, tend to get the
most support during this time
 This has been the focus of traditional
interventions

9. Maintenance
“I’m in recovery”
 Long, ongoing process
 People may “test” themselves during this
stage
 Often return to precontemplation or
contemplation stages
 Relapse is the rule rather than the exception

10. Assessing Stage of Change
I don’t think I smoke too much (P)
I am trying to smoke less than I used to (A)
I enjoy smoking but sometimes I smoke too much (C)
Sometimes I think I should cut down on my smoking (C)
It’s a waste of time thinking about my smoking (P)
I have just recently changed my smoking habits (A)

11. Assessing Stage of Change
I am at the stage where I should think about smoking less (C)
My smoking is a problem sometimes (C)
There is no need for me to think about changing (P)
I am actually changing my smoking habits right
now (A)

12. Helping Precontemplators
 Defensive Thinking Styles:
 Denial and minimization (“Maybe I do drink too
much but I can handle it”)
 Rationalization/Intellectualization (“I need one
vice, it may as well be cigarettes”)
 Projection and displacement (“I drink because my
wife nags me”)

13. Helping Precontemplators
1) Address defenses
2) Consciousness raising
• Amount spent on cigarettes/drugs/alcohol, etc.
• Normative data on peers’ use
• Biological data
• Number of risk factors/Negative consequences

14. DANGER!!

15. Helping Precontemplators
What not to do:
• Don’t push someone into action
• Don’t nag
• Don’t give up (apathy looks like approval to
the precontemplator)
• Don’t enable

16. Helping Contemplators
 Define the goal
 Understand the purpose of the target
behaviour (Functional analysis: Antecedent
Behaviour Conseqence)
 Resolve ambivalence

17. Decisional Balance
Benefits/Pros Costs/Cons
Making a
change
Not changing

18. Decisional Balance
Benefits/Pros Costs/Cons
• I’d be healthier • I’d lose my friends
• People would stop nagging me • People would make fun of me
• I’d fight less with my parents • I’d be bored
Making a
• I’d have more money
change
• My grades would get better
• I’d get to keep my friends • I’ll get kicked off the chess
• I’d be able to cope team
• I won’t get all my credits this
Not changing year
• My parents might kick me out
• I’d have to keep coming to
CHOICES

19. Helping those in Preparation
 Focus on the future
 Normalize and address anxiety
 Set a date (realistic but ASAP)
 Create a detailed, well thought out,
multidimensional plan

20. Change Plan Worksheet
The changes I want to make (or continue making) are:
The reasons why I want to make these changes are:
The steps I plan to take in changing are:
The ways other people can help me are:
I will know that my plan is working if:
Some things that could interfere with my plan are:
What I will do if the plan isn’t working:

21. Helping those in Action
 Create a healthy substitute
 Relaxation techniques
 Address irrational self-statements (e.g., “I
can’t resist the urge to drink”; “I can’t control
my anger”)
 Address cues and triggers
 Build in rewards

22. Helping those in Maintenance
 Relapse Prevention
 Address overconfidence
 Educate that a lapse is not a relapse

23. Motivational Interviewing

24. Motivational Interviewing (MI)
(Miller & Rollnick)
 Empirically-based, client-centered, directive
method for enhancing intrinsic motivation to
change by exploring and resolving
ambivalence
 Intrinsic motivation: within the self

25. MI and Stages of Change
 Motivation is what provides the impetus for
moving through the stages of change
 MI is an excellent counseling style to use
particularly for individuals in the early stages
 “Natural fit” with each other

26. The Push and Pull
 The more a client argues against change
during a session, the less likely change will
occur
 One year later: The more a counselor
confronted during treatment, the more a
person drank

27. Three Critical Conditions
1) Accurate empathy
2) Warmth
3) Genuineness

28. Three Critical Conditions
1) Accurate empathy
2) Warmth
3) Genuineness
Why isn’t this person motivated?

29. Three Critical Conditions
1) Accurate empathy
2) Warmth
3) Genuineness
Why isn’t this person motivated?
For what is this person motivated?

30. Ambivalence
 Approach- avoidance conflict is normal
 Passing through ambivalence is a normal
phase in the process of change
 Brief interventions may work to get them
unstuck
 Ambivalent people are not always logical

32. The Righting Reflex
 We all want to set things right
 Especially in the helping professions, the
desire is to put people back on the right path
 People develop an opinion on the “right”
course of action
 The ambivalent person argues against this
 The two act out the ambivalence
 This strengthens the commitment to not
changing

33. The Wrong Questions
 “Why don’t you want to change?”
 “How can you tell me you don’t have a
problem?”
 “What makes you think you’re not at risk?”
 “Why don’t you just…?”
 “Why can’t you…?”

34. How do your sessions feel?
vs.

35. Motivational “Inter-viewing”
 Clinician elicits and selectively reinforces
change talk
 Directive method
 Not about teaching new skills; it is a way of
being with people
 Not incompatible with other methods
 Should be offered as a prelude to other
services

36. Spirit of MI
Fundamental approach of MI Mirror Image Opposite
Collaboration Confrontation
Evocation Education
Autonomy Authority
From Miller and Rollnick (2002)

37. Four General Principles
1) Express empathy
2) Develop discrepancy
3) Roll with resistance
4) Support self-efficacy

38. Express Empathy
 Fundamental
 Attitude of acceptance (not agreement or
approval)
 Desire to understand the client’s perspective

39. The Use of Reflection
 Unlikely to provoke resistance
 Encourages talking/exploration
 Communicates respect, builds alliance
 Clarifies what the client means
 Can be used to reinforce ideas expressed by
the client

40. Examples of Reflection
Client: “My parents are always telling me I’m an
alcoholic”
a) What’s wrong with that? They probably
have some good reasons.
b) Why do they think that?
c) And that really annoys you.

41. Examples of Reflection
Client: “My parents are always telling me I’m an
alcoholic”
a) What’s wrong with that? They probably
have some good reasons. (JUDGING)
b) Why do they think that? (QUESTION)
c) And that really annoys you. (REFLECTION)

42. Examples of Reflection
Client: “If I quit using, what am I supposed to do for
friends?”
a) I guess you’ll have to get some new ones.
b) Well, you could just tell your friends you don’t drink
any more.
c) It’s hard for you to imagine living without drugs

43. Examples of Reflection
Client: “If I quit using, what am I supposed to do for
friends?”
a) I guess you’ll have to get some new ones.
(ADVICE)
b) Well, you could just tell your friends you don’t drink
any more. (SUGGESTION)
c) It’s hard for you to imagine living without drugs
(REFLECTION)

44. Develop Discrepancy
 Create and amplify a discrepancy between
present behaviour and the client’s goals and
values
 Coercion: Discrepant with someone else’s
goals and values
 Client presents arguments for change

45. Roll with Resistance
 Resistant behaviours are a reminder to shift
approaches
 Turn a question or problem back to the client
 Assume the client is a capable and
autonomous individual

46. Support Self-Efficacy
 Good predictor of treatment outcome
 Goal is to enhance the client’s confidence in
their abilities to cope with obstacles and deal
with change

47. Traps to Avoid
 Question-Answer Trap
 Can be the result of anxiety
 Elaboration is needed in motivational interviewing
 Subtlety implies an expert role
 Open-ended questions…with reflective listening

48. Traps to Avoid
 Trap of Taking Sides
 Natural and predictable response
 The “opening moves” can set the direction of the
outcome
 Expert Trap
 Shift into problem solving, answers, solutions
 Encourages passivity
 Should be a collaboration

49. Traps to Avoid
 Labeling Trap
 Recommend de-emphasizing labels and
diagnoses in motivational interviewing
 Premature Focus Trap
 Pressing concern for the client may not be their
“problem”
 Blame Trap
 Make blame irrelevant

50. Signs of Readiness to Change
 Decreased resistance
 Decreased discussion about the problem
 Resolve
 Change talk
 Questions about change
 Envisioning
 Experimenting

51. Effectiveness of MI
 Effective across a wide variety of behaviours
 Often works as well as longer interventions
 Most effective when used as an
enhancement to other treatments
 May be most effective with individuals who
are most angry/resistant to change
 May be contraindicated for individuals who
have already changed
 Effective for minority samples

52. MI and Adolescents
 Adolescents push against authority
 Often face a great deal of ambivalence
 Often curious and open to philosophical
questions
 MI can also be consistent with harm
reduction goals
 Effective way to engage youth in services
 May help transition external internal
motivation

53. Take Home Messages
 It is important to recognize your client’s stage
of change and tailor your interventions
appropriately
 Help the client develop discrepancy and
voice their own reasons for changing
 Avoid the “Righting Reflex”
 This strengthens the commitment to not changing

54. Useful Resources
www.motivationalinterview.org
National Institute on Alcohol Abuse and Alcoholism.
(1995). Motivational Enhancement Therapy Manual.
Available at www.niaaa.nih.gov
Miller, W.R., & Rollnick, S. (2002). Motivational
Interviewing (2nd ed.). The Guilford Press: New
York.
Prochaska, J.O., Norcross, J.C., & DiClemente, C.C.
(1994). Changing for Good. HarperCollins: New
York.