“Because I Said So”:
How to Support Adult Clients
through Change
Louisiana Association of Drug Court Professionals
April 11-13, 2012
Jane E. Pfeifer, MPA
First Question:
Q.: What agency/organization provides
primary case management services for
your Drug Court?
Eight Evidence-Based Principles
for Effective Interventions
1. Assess Actuarial Risk/Needs.
2. Enhance Intrinsic Motivation.
3. Target Interventions.
4. Skill Train with Directed Practice
5. Increase Positive Reinforcement.
6. Engage Ongoing Support in Natural
Communities.
7. Measure Relevant Processes/Practices.
8. Provide Measurement Feedback
NIC, 2004
2. Enhance Intrinsic Motivation
• Use motivational techniques
• Get training
• Develop rapport with the participant
• Avoid arguing!
Engagement
Whose job is it to engage the client?
Engagement
Engagement activities are intended to
identify and fulfill the client's immediate
needs, often with something as tangible
as a pair of socks or a ride to the
doctor.
Center for Substance Abuse Treatment. Comprehensive
Case Management for Substance Abuse Treatment. Rockville (MD):
Substance Abuse and Mental
Health Services Administration; 1998
(Treatment improvement protocol; no. 27).
Increasing Motivation
Whose job is it to assist the client in
increasing his or her motivation?
Increasing Motivation
• Stages of Change
• Motivational Strategies
In a recent study, clients assigned to receive
motivational interviewing techniques at
intake had significantly better retention rates
at the 28-day follow-up than clients who
received the standard intake evaluation.
(Carroll, et al., 2006.)
Stages of Change Readiness
(Prochaska and DiClemente, 1992)
Precontemplation
Maintenance
Contemplation
Action
Preparation
Stages of Change
Contemplation
Preparation
Action
Maintenance
Relapse-Lapse-Change
Pre-contemplation
Stages of Change
Pre-contemplation
•
•
•
•
Not thinking about changing
Happy user
Learned helplessness
Has no intention to take action
within the next 6 months
Stages of Change
Contemplation
•
•
•
•
Thinking about changing
Ambivalence
Chronic contemplators
Intends to take action
within the next 6 months.
Stages of Change
Preparation
•
•
•
•
Decision made
Firm plans
Possibly recent attempts at change
Intends to take action within the next
30 days.
• Has taken some behavioral steps in
this direction.
Stages of Change
Action
•
•
•
•
•
•
•
Overt behavioral change
‘Stopping’ main issue
Grief issues
Counter-conditioning
Stimulus control
Contingency management
Has changed overt behavior for less
than 6 months
Stages of Change
Maintenance
•
•
•
•
Sustained behavior over time
Alternatives established
Later, becomes a non-issue
Has changed overt behavior for
more than 6 months.
What is
MOTIVATIONAL INTERVIEWING?
• Intervention designed to mobilize client’s
internal resources for change by enhancing
intrinsic motivation.
• A style of being with people, not just a set
of techniques
• An important goal is to clarify values and
amplify discrepancies
• Purpose is to move person through the
stages of change
from Morgenstern-”Motivational Interviewing”
Philosophy of Motivational
Interviewing
• MI is a technique in which you
become a helper – not a dictator –
in the change process for your
client.
• In criminal justice we are used to
telling people what to do.
• This is a different style of interview
and counseling.
Goal Of Motivational
Interviewing
The goal of MI is to create a safe
and supportive rapport with a
person, in order to facilitate their
thinking about their behavior and
whether/how they might go about
making changes.
Confrontation:
A Goal Not a Style
AMBIVALENCE
“I want to but I don’t want to”
Important Assumptions in
Motivational Interviewing
• Clients are AMBIVALENT about
changing.
• There are BOTH pros AND cons
to getting off of drugs vs.
continuing to use.
Ambivalence about quitting
• We in criminal justice don’t typically
see that for the client there are at
least some good reasons to
continue to use.
• MI recognizes that ambivalence
about quitting is NORMAL.
Change
Importance of Change
A
B
I
L
I
T
Y
Low importance: Low
confidence
Low importance: High
confidence
These people don’t see the need for
change nor do they believe that could
effectuate the change, if they decided to
change
These people are confident they can
make the change but are not convinced
that change is needed.
T
O
High importance: Low
confidence
High importance: High
confidence
C
H Here the problem is not the willingness
A of the person to change but the person’s
N confidence in their ability to change
G
E
These people see the necessity of change
and believe they can succeed.
Exercise
Share an example with your team of how
you, in your role, can assist with
increasing motivation.
DEVELOPING DISCREPANCY
• Motivation for change is enhanced
when clients perceive the
discrepancies between their
current situations and behaviors,
and their hopes and goals for the
future.
• Let the client present the argument
for change.
• “Tell me the good parts about using.”
• “Tell me the negatives.”
You will often hear about damaged
family relationships, especially with the
client’s children.
• “How do these weigh out to you?”
• “Where do you think you go from
here?”
Have the client state the solution
of what he must do to achieve his
stated goals, desires, wants, and
wishes.
Take Home Message:
• Motivation to change is elicited from
the client, and not imposed from
without.
• It is the client's task, not the
interviewer’s, to articulate and
resolve his or her ambivalence.
Exercise
• Pair up
• Pick a real-life behavior change you want to
make (be sure it’s one you want to share!)
• One is the case manager and one is the drug
court participant—then switch.
• As the case manager, help your partner
develop discrepancy. By the end, and without
asking directly, see if you can determine if
your partner is low importance/low ability; low
importance/high ability; high importance/low
ability; high importance/high ability.
3. Target Interventions
a. Risk Principle: Prioritize supervision and
treatment resources for higher risk
offenders.
b. Need Principle: Target interventions to
criminogenic needs.
c. Responsivity Principle: Be responsive to
temperament, learning style, motivation,
culture, and gender when assigning
programs.
Meeting Client’s Needs
• “client’s” not “clients’”
• What does this client need?
• How do we know?
– Assessment
– Interviewing-ASK HER!
• Comprehensive case management
– Realistic case planning
– Incremental objectives
• Treatment matching
– Gender appropriate
– Culturally relevant
What do Drug Court Participants
need?
What Goals Are Set For
Clients?
• Are there target behaviors that all clients
must achieve?
• Are they different in the beginning of the
program?
• Does your department/agency have
differing goals for clients than the drug
court, or are they consistent?
• How individualized can goals be for each
client?
Exercise
• As a team:
– identify two strengths of your case
management services.
– identify two challenges with your case
management process, and discuss possible
solutions.
Resources
• Motivationalinterview.org
• TIP 35: Enhancing Motivation for Change in
Substance Abuse Treatment.
• Motivational Interviewing, Second Edition,
by William Miller
• Miller and Rollnick, Motivational Interviewing:
Preparing People for Change, (New York:
Guilford Press 2002)