1 Recovery & Motivational Engagement August 2012

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Recovery & Motivational Engagement

August 2012

Contents

I. What is Recovery?

I. Key concepts

II. The Recovery process

III. Impact of the therapeutic relationship in Recovery

IV. Understanding stigma

II. What is Motivational Engagement and Enhancement?

I. Stages of Change model

II. Barriers to Engagement

III. The F.R.A.M.E.S. Approach

IV. Other Key Elements in Motivational approaches

V. Basic Strategies in Motivational Enhancement

VI. Types of Self-Motivational Statements

VII. Principles of Motivational Interviewing

VIII. Responding to Resistance

IX. Relapse

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The Experience of Recovery

Recovery is an individual’s experience of living successfully with a mental illness.

“ Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing goals

and develop a sense of identify that allows them to grow beyond their mental illness.”

- Pat Deegan,PhD, consumer leader with Schizophrenia

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Key concepts about the Recovery Experience

• Recovery is a personal process of change experienced by each person in a unique way.

• Recovery is characterized by growth beyond the effects of mental illness.

• Recovery is a complex and time-consuming process.

• Recovery is possible when there is hope. • Recovery is a universal human experience.

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What do people Recover from?

• The effects of mental illness, such as physical symptoms, emotional fears, and feelings of being out of control

• The trauma associated with a psychotic break and/or hospitalization

• Negative attitudes from family members, friends, professionals, and towards oneself

• Loss of a role and positive identity in society• Lack of enriching opportunities• Stigma and discrimination

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Traditional versus Recovery Attitude Activity

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The Recovery Process

Phase One: Overwhelmed by the disability and how the person is treated (i.e., initial diagnosis and label of being a person with mental illness)

Phase Two: Struggling with the disability and rebuilding connections to the self, others, the environment, and meaning and purpose

Phase Three: Living with the disability and new connections to the self, others, the environment, and meaningand purpose

Phase Four: Living beyond the disability: Authenticity, Connectedness, and Contribution

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What Patients say Helps the Recovery Process

Internal Conditions

Hope – belief that recovery is possible

Healing – recovery is not synonymous with cure; active participation in self-help activities; locus of control is with consumer

Empowerment – corrects a lack of control, sense of helplessness, and dependency; aim is to have consumer assume increasing responsibility for themselves in making choices and taking risks; full empower requires that consumers live with consequences of their choices

Connection – recovery is a social process; a way of being in the company of others; to find a role to play in the world

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External ConditionsHuman Rights – reducing and eliminating stigma, discrimination

against psychiatric disabilities; equal opportunities in education, employment, housing; access to needed resources

Positive Culture of Healing – a culture of inclusion, caring, cooperation, dreaming, humility, empowerment, hope

Recovery-oriented services – best practices of clinical care, peer and family support, work, community involvement to be implemented by consumers, clinicians, and community (Jacobson & Greenley, 2001).

What Patients say Helps the Recovery Process

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What are our expectations of the people we serve?

- employment- social- educational- housing- self-advocacy

Do we, as providers, underestimate persons with mental illness?

In a 10 year period, Renee Kopache was hospitalized 40 times, was on nearly 40 different medications, survived three suicide attempts, many experiences of self-injury and 23 ECT treatments. Today she has a satisfying personal life and works as Recovery Coordinator of Hamilton County Community Mental Health Board in Cincinnati, Ohio.

Renee’s Recovery Story

Renee’s Recovery Story

“The discharge summary from my last hospitalization stated that my prognosis is “poor,” and recommended that I not live alone in the community. About two years ago, I purchased my first home. Mental illness is devastating. But, through recovery from the illness, I have a career, social and community life in front of me that only I can limit.” (Kopache, 2011)

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Resilience

According to dictionary.com (n.d.) resilience is defined as;

1. the power or ability to return to the original form, position, etc., after being bent, compressed, or stretched; elasticity.

2. ability to recover readily from illness, adversity, or the like; buoyancy.

“The power of the human spirit to sustain grief and loss and to renew itself with hope and courage defies all description.” - Dr. Dan Gottlieb, 1991

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Providers can Facilitate Recovery

• Providers are in a key position to make a difference

• Your (providers’) attitude can either help or hinder the recovery process– What are some traits of providers that hinder the

process? What about those that help?

• Your influence directly impacts the way a person conceptualizes their recovery journey

Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

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The Dilemma

• Paperwork guides the process toward a focus on deficits

• Historically, the provider culture had not encouraged partnership– What is meant by partnership? – What is meant by provider culture?– What is the provider culture at your location?


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Relationship Breakdown

What is the most important treatment tool that you have?

How does the therapeutic relationship impact treatment?


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Providers and the Recovery Process

• Providers may unintentionally interfere with recovery because they are unaware of how to facilitate it

• Providers may feel obligated to take the lead instead of encouraging the person to do so (enabling behavior)

• Providers may focus on the patient’s limitations instead of their potential/strengths


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How it Happens

• Providers usually see people when they are struggling with problems

• Hence, they don’t see their successes • Therefore, they often don’t see the evidence

of recovery• They may come to the conclusion that people

are helpless and hopeless


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This Leads to …

• Not believing that people recover• Not believing they can help people recover• Discouragement and burnout• Poor results and outcomes• Counter-stigma: people receiving services begin

to see providers as irrelevant to their recovery


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What can be done about this

• Provide effective training in recovery facilitation skills

• Develop an integrated workforce that encourages teamwork

• Provide training for professionals by peers • Measure for recovery success so providers can

see how they have helped to promote recovery and eliminate stigma

• Encourage an environment conducive to recovery


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What is stigma?

1. mark of disgrace or infamy; a stain or reproach, as on one's reputation.

2. mental or physical mark that is characteristic of a defect or disease. (Dictionary online, n.d.).

• Stigma is a negative view of a person based on something about them. Many illnesses get stigmatized, not just mental illness.

• Stigmatizing attitudes are held by many, including professionals in the MH field.

Stigma continued…

• One in four people believe people with mood disorders:– are not just like everyone else – should not have children – are easy to identify in the workplace; and they – do not live “normal” lives when treated

• Two-thirds of survey respondents also held the incorrect belief that mood disorder medications are habit forming.

"These misconceptions can do irreparable harm to people with legitimate illnesses who should and can be treated." Herbert Pardes, M.D., President of NARSAD’s Scientific Council

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Our Patients’ Self-stigmatize

• Self-stigma (the belief that you are weak or damaged because of your own illness) can sometimes be the most difficult kind of stigma to fight.

• Self-stigma may cause people to stop their treatment, isolate themselves from loved ones, or give up on things they want to do.

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What can you do to Fight Stigma?

• You can do a lot! Start with the way you act and how you speak – to everyone. You can contribute to an environment that builds on people’s strengths and promotes good mental health.

For example: – Avoid labeling people with words like “crazy” or by their

diagnosis. Instead of saying someone is a “schizophrenic” say “a person with schizophrenia.”

– Learn the facts about mental health and share them with others, especially if you hear

something that is untrue. – Treat people with respect and dignity.

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Motivational Techniques

What is motivational interviewing?

– Motivational Enhancement– Motivational Engagement– Facilitative Partnering– Collaboration

Activity 5

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Motivation

• Define motivation…– A reason or desire to act– That which gives purpose and direction to behavior

What motivates you?

• Motivation is dynamic: Purposeful Intentional Positive Changeable

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So who’s responsible for making the change?

The client ultimately is responsible for change, and this responsibility is shared with the clinician through a therapeutic partnership.

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Motivational Enhancement

Goals and Objectives:• Demonstrate understanding of change theory• Explain the relationship between motivational interventions

and stages of change• Demonstrate basic skills for enhancing client motivation• Identify staff strengths and learning needs• Assess clients’ readiness for change

In this training we will introduce and review some motivational enhancement terms

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Stages-of-Change Model

1. Pre-contemplation - person is not considering or does not want to change a particular behavior

2. Contemplation - person is certainly thinking about changing a behavior

3. Preparation - person is seriously considering and planning to change a behavior and has taken steps toward change

4. Action - person is actively doing things to change or modify behavior

5. Maintenance - person continues to maintain behavioral changes until it becomes permanent

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The Nature of Motivation

Motivation has historically been viewed as an “either-or”:

• Clients were considered motivated if they:– Agreed to participate in treatment– Were compliant to treatment– Accepted the label of their diagnosis

• Clients were considered unmotivated if they:– Resisted a diagnosis– Refused to comply with treatment protocol

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Motivational Enhancement techniques are based on 7 POSITIVE Assumptions:

Motivation is:• A key to change• Multidimensional • Dynamic and fluctuating • Influenced by social interactions• Can be modified• Influenced by the clinician’s style

The clinician’s task is to elicit and enhance motivation.

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People engage when:

1. They can trust

2. They feel respected

3. They are “heard”

4. They are understood

5. They feel safe

6. They are valued

What type of environment helps you to engage?

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Traits of a “Motivator”

• Observant

• Flexible

• Confident

• Fully present

• Consistent

• Empathic listener

• Curious• Humor• Unconditional Positive

Regard• Patient • Open

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Barriers to Engagement

One primary or main barrier is our Assumptions

We assume that because the person has come to us for services, they must: – Have hope that they can change.– Have insight that they need assistance in making the

desired change.– Already accept you as a guide to lead them in the

process of desired change.– Already have most of the resources necessary to make the change.

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Other Important Barriers to Engagement Include

• Beliefs about people• Inability to establish trust• Real or perceived demonstration of

respect• Lack of needed skills• Lack of confidence

Other Barriers?

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The benefits of using Motivational Enhancement techniques

• Inspiring motivation to change• Preparing clients to enter treatment• Engaging and retaining clients in treatment• Increasing participation and involvement• Improving treatment outcomes• Encouraging a rapid return if relapse occurs

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The FRAMES Approach

Researchers have identified six elements of effective intervention and coined the acronym FRAMES to summarize them:

• Feedback is given to the client throughout treatment

• Responsibility for change is placed on the client

• Advice about behavior is given in a non-judgmental manner

• Menus of treatment options are offered

• Empathic Counseling is emphasized by showing warmth, respect and understanding

• Self-efficacy/empowerment is

developed within the client to encourage change

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Other key elements of effective motivational approaches include:

• Decisional Balancing – exploring pros and cons of change

• Discrepancies between personal goals and current behavior

• Flexible pacing – tailor pacing through the stages of change to the client’s need

• Personal contact with clients not in treatment – working to maintain contact with clients not currently in treatment to encourage them to recommit to making a change

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Complete the

Listening: A Self Assessment

Activity 6

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5 Basic Strategies of Motivational Enhancement

1. Open-ended questions (requesting information)

2. Affirming3. Reflective listening (reflecting)

4. Summarizing

5. Eliciting or reinforcing self-motivational statements

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1 - Open-ended questions • Help the clinician understand the client’s point of view• Elicit client’s feelings about a given topic or situation• Facilitate dialog: they cannot be answered with a single

word or phrase and not require a particular response• Solicit additional information in a neutral way• Encourage the client to do most of the talking• Help the clinician avoid making prejudgments • Keep a communication moving forward

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2 - Affirm• Supports and promotes their sense of self-

efficacy

• Acknowledges their difficulties

• Validates their experiences and feelings

• Increases their confidence to take action and change their behavior

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3 - Listen Reflectively

Reflective listening involves the clinician’s making a reasonable guess about what the client means AND rephrasing the client’s statement to reflect what the clinician thinks they heard.

• Provides clients a different way of considering what they have said

• Reduces the likelihood of resistance• Encourages the clients to talk• Communicates respect• Cements the therapeutic alliance• Clarifies exactly what clients mean• Reinforces motivation

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4 - Summarize

Summarizing consists of condensing the elements of what clients have expressed AND communicating it back to them.

• Reinforcing what they said• Demonstrating that the clinician has been listening carefully• Helping clients consider their responses and experiences• Preparing clients to move forward

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5 - Elicit and Reinforce Self-Motivational Statements

When used successfully, motivational interviewing

techniques ensure that clients, not the clinician, identify the changes that are needed to improve their lives.

One signal that clients’ ambivalence and resistance are diminishing is the self-motivational statement.

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Complete the

Basic Strategies of Motivational Enhancement

Exercise

Activity 7

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4 Types of Self-Motivational Statements:

1. Cognitive recognition of the problem2. Affective expression of concern about the perceived problem

(emotional response)3. A direct or implicit intention to change the behavior4. Optimism about one’s ability to change

Clinicians can reinforce a client’s self-motivational statement and encouraging the possibility of change by:

• Reflecting the statement• Nodding or making approving facial expressions• Making affirming statements• Asking for elaboration, explicit examples, or more details about remaining concerns

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5 Principles of Motivational Interviewing

1. Express empathy – key component is reflective listening

2. Develop discrepancy between clients’ goals or values and their current behavior

3. Avoid arguments/power struggles and direct confrontation

4. Support self-efficacy and optimism 5. Roll with resistance

Resistance can be identified by 4 basic behaviors: Arguing Interrupting Denying Ignoring

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Responding to Resistance

• Simple reflection – respond with nonresistance, reflect the client’s statement in a neutral form

• Amplified reflection – reflect in an exaggerated form – stated in an extreme way but without sarcasm

• Double-sided reflection – acknowledge what client has said but also state contrary things they’ve said in the past

• Shifting focus – from obstacles and barriers and affirm clients’ choices regarding the conduct of their lives

• Agreement with a twist – involves agreeing with the client but with a slight twist or change of direction that propels the discussion forward

• Reframing – offers a new and positive interpretation of negative information provided by the client

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Complete the

Resistance Response

Exercise

Activity 8

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Language Use

LANGUAGE PROBLEMS LANGUAGE SOLUTIONS

Can be dehumanizing or offensive

Use “person-first” language, avoid slang, use technically accurate terms.

example: case, schizophrenic,

the mentally ill example: a person who has schizophrenia

Can sound judgmental Use objective and neutral terms

example: non-compliant example: does not take his medication

Can create social distance Use matter of fact, descriptive words

example: victim, suffers from example: has, experiences, diagnosed with

Can connote limitations Describe specifics, emphasize abilities

example: bedridden, wheelchair bound

example: needs assistance to get out of bed, uses a wheelchair

Retrieved from (Psychiatric Rehabilitation: A training curriculum, 2003).

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From Pre-contemplation to Contemplation – Building Readiness

• Those who are not yet concerned about their substance abuse and/or mental illness and are not considering change are in the pre-contemplation stage

• This is true no matter how much and how frequently they use alcohol or drugs or how serious their problems are

• People may remain in the pre-contemplation or early contemplation stage for years, rarely or never considering change

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Engaging the Pre-Contemplation Stage Client

• Establish rapport and trust – the clinician needs to create a safe and supportive environment in which clients can feel comfortable

• Explore events that precipitated treatment entry – the situation that led an individual to treatment can increase or decrease defensiveness about change; making use of the 5 basic strategies of motivation enhancement (ask open-ended questions, reflective listening, summarize, affirm, elicit or reinforce self-motivational statements)

• Commend the client for entering treatment – the clinician needs to affirm clients’ courage in coming for treatment no matter what led them to treatment

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From Contemplation to Preparation – Increasing Commitment

Changing Extrinsic Motivation to Intrinsic Motivation for Change

• Extrinsic motivation – external motivator that may be useful in bringing clients into treatment; i.e. legal issues, pressure from family, friends, employers.

• Intrinsic motivation – internal motivation that often begins when clients recognize discrepancies between where they are and where they want to be.

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Decisional Balancing Strategies

In moving toward any decision, most people weigh the cost of benefits of the action being contemplated, i.e. Decisional Balancing

Benefits of Decisional Balancing:• Accentuate the consequences of the client’s behavior• Lessen the perceived rewards of behaviors• Make the benefits of change apparent• Identify and develop ways to alleviate,

if possible, potential obstacles to

change

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6 Decisional Balancing Strategies

1. Summarize concerns – organize the client’s concerns and present them in a careful summary that: expresses empathy, develops discrepancies and weights the balance toward change.

2. Normalize ambivalence – reassure the client that conflicting feelings, uncertainties, and reservations are common.

3. Reintroduce feedback – by reintroducing objective assessment data, the clinician reminds clients of their earlier insights into the need for change and what may have influenced their decisional considerations.

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6 Decisional Balancing Strategies

4. Examine clients’ understanding of change and expectations of treatment – emphasize that it is important to understand what change means to clients, what their expectations of treatment are, and be prepared to address issues of defensiveness and resistance.

5. Re-explore values in relation to change – helps clients explore and articulate their values and connect these values to positive change.

6. Explore specific benefits and cost – emphasize that weighing benefits and costs of change is at the heart of decisional balance works (continuing

behavior vs. stopping behavior).

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From Preparation to Action – Getting Started

As clients increase their commitment to change through planning and then implementing changes (preparation to action), the clinician must be alert for signs of their readiness to take action.

7 Signs of Readiness to Change1. Decrease resistance – stop arguing, interrupting, denying2. Fewer questions about the problem – have enough info3. Resolve – reached a resolution and are unburdened4. Self-motivational statements5. More questions about change6. Envisioning – talk about life after change, life improvement7. Experimenting – possible change approaches

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Negotiating a Plan for Change

• Creating a specific plan for change is a final step in preparing a client to act

• Nothing is more motivating than being well prepared – no matter what the situation, a well-prepared person usually is eager to get started

• Clients’ change plans can be general or specific, short term or long term

• Some clients may be able to commit only to a limited plan• Specific steps to overcoming anticipated barriers to

success are important components

of many change plans.

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5 Planning Considerations

1. Intensity and amount of help needed

2. Timeframe

3. Available social support

4. Sequence of goals and strategies or steps in the plan

5. How to address multiple problems

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From Action to Maintenance –Stabilizing Change

Clinicians can use motivational approaches in the action stage of change to:

– Help clients plan for stabilization in the recovery– Develop and use behavior reinforcers

There are 2 types of reinforcers:– Natural Competing Reinforcers – any source of satisfaction for

the client that can become an alternative to negative behaviors (replacement behavior)

– External Contingent Reinforcers – temporary or external rewards when the client demonstrates a desired behavior

Examples?

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Motivational Counseling During Maintenance

A motivational approach can be useful in counseling clients during the maintenance stage for situations:– Follow-up– Aftercare– Relapse

Clinical Steps– Rehearse new coping strategies and countermeasures to

triggers– Encourage patient to contribute to recovery of others– Motivational enhancement techniques– Support and affirm positive changes

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Relapse/Recurrence

• Relapse may occur during any stage of change. • Should a relapse occur, clinicians need to support the

client and their continuation of recovery efforts while helping the client learn from the experience.

• Reinforce successes obtained prior to the relapse.• Relapse can be reframed as a partial success. The

clinician needs to help the client build on the skills that helped them maintain their previous stability.

• The clinician’s role is to help the client not get stuck at this point but to move back into preparation and action

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References

Anthony, W. A., Cohen, M., & Farkas, M. (1990). Psychiatric rehabilitation. Boston: Center for Psychiatric Rehabilitation.

Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990’s. Psychosocial Rehabilitation Journal,

Center for Psychiatric Rehabilitation (2003). Psychiatric rehabilitation: A training curriculum. Boston, MA: BCPR.

Deegan, P. (2011). Recovery and the conspiracy of hope. Retrieved July 28, 2011, from http://www.patdeegan.com

Jacobson, N., Greenley, D. (2001). What is recovery? A conceptual model andexplication. Psychiatric Services. Volume 52; No. 4:482-485.

http://www.patdeegan.com/

References

Kopache, R. (2011). Renee Kopache's Recovery Story. Retrieved from http://power2u.org/articles/recovery/recovery_stories/reneek story.html

Resilience. (n.d.). In dictionary online. Retrieved July 26, 2011, from http://dictionary.reference.com/

Stigma. (n.d.). In dictionary online. Retrieved July 26, 2011, from http://dictionary.reference.com/

U.S. Department of Heath and Human Services, Substance Abuse and Mental Health Services Administration Center for Substance Abuse. (2011). Treatment. Retrieved July 26, 2011 from www.samhsa.gov

http://www.samhsa.gov/

Documents

1 Recovery & Motivational Engagement August 2012