Module 10
Motivating Patient Change

Major Sections

Time

Purpose

Objectives

1. Describe three indicators of a patient's readiness for treatment.
2. Identify three strategies for assisting patients in addressing their ATOD problems.
3. In a simulated patient interview, apply the strategies for motivating patients to address their ATOD-related problem.

Training Aids, Materials, and Equipment

Overhead projector

Filled in 3x5 or 5x7 cards for exercise III

Prepared newsprint:

• PN-10.1: Objectives
• PN-10.2: Phases in the Change Process
• PN-10.3: Strategies for Motivating
• PN-10.4: Instructions - Phases of Change Exercise
• PN-10.5: Instructions - Role Play

(NOTE: Any one of the prepared newsprint items above can be used as a transparency, if desired. The PN hard copy is appropriate for the development of transparencies. It is best to leave in newsprint form those things you may want to leave posted, such as the objectives and the exercise instructions.)

Handouts

• HO-10.1: Role Play - Patient
• HO-10.2: Role Play - Clinician

I. INTRODUCTION (10 minutes)

A. Purpose of module

1. One of the most difficult things in working with patients with ATOD problems is in convincing them to begin to confront and work on their problems.
2. This module focuses on motivating patients to change. It addresses such issues as understanding patient's readiness level for change and guidelines for encouraging change.
3. An exercise helps participants identify appropriate clinician behavior for each phase in the change process.
4. Participants will also have an opportunity to build skills in motivating patients to address their problems through the use of simulated patient interviews.

B. Objectives (PN-10.1)

II. LECTURE: MOTIVATING PATIENTS TO CHANGE (20 minutes)

A. Phases of change for patients (PN-10.2)

(NOTE: You can pause after the description of each phase to get participant suggestions for interventions, and then add the interventions listed below if they haven't been mentioned.)

1. Precontemplation phase:
• The individual perceives no need to change. Problems with alcohol, tobacco, and other drugs are apparent to others.
• Intervention: Increase the individual's awareness of his/her present behavior and its consequences for self and others.
2. Contemplation phase:
• The individual is ambivalent.
• Intervention: Help the individual compare the negative effects of continued use with the positive benefits of changes.
3. Determination phase:
• The individual acknowledges a situation warranting change and begins to make a commitment.
• Intervention: Assist in selecting an optimal strategy for change and provide support.
4. Action phase:
• The individual makes an active attempt to change.
• Intervention: Assist in implementing the plan for change. (Most treatment programs are geared for the action phase.)
5. Maintenance phase:
• The individual attempts to continue the results achieved in the action phase.
• Intervention: Continue support and apply relapse prevention measures.

B. Denial

1. Denial mechanisms
• Denial is present in nearly all who are actively abusing alcohol, tobacco, or drugs.
• It can take the form of denying there is any problem at all to minimizing the problem and effects of the problem.
• Denial may be due to one or more of the following mechanisms:
• Lying (least common)
• Class denial - a copy response to avoid a problem
• Memory blackout
• Euphoric recall - remembering only the good times
• Wishful thinking
• Denial on part of family or other close person
• Ignorance of the nature of addictive disease
• Toxic effect on information processing or memory
• Stigma related to such terms as "alcoholic" and "addict"
• Fear of the unknown
• Complex thinking quandary (genuine confusion - does not know problems are connected to ATOD).
• Overcoming denial
• It is important to be certain that a denial mechanism is in place. What might get incorrectly labeled denial may be a defensive response on part of the patient to disgust or negative judgement exhibited by the clinician.
• Depending on where the person is in the change process and the mechanism supporting the denial, various methods can be used to overcome it.
2. Examples of interventions to help overcome denial include:
• Increasing the awareness of the present behavior and its effect on self and others.
• Education on the disease process or the effects of alcohol, tobacco, or other drug abuse.
• Pointing out negative consequences of ATOD abuse.
• Working with families and significant others.
• Discuss the participants' experience with denial and solicit other ideas for overcoming it.

C. Guidelines for motivating patients to address their ATOD problem:

1. Patients may be more willing to address their ATOD problems if they receive assistance in overcoming their conflicts and uncertainties about their problems and the need for change. It is important to determine the phase that the patient is in and to motivate the patient in that and all subsequent phases in the change process.
2. There are numerous ways to motivate patients, and what works with one may not work with another. Understanding the patient's attitude toward change and his/her denial mechanisms will aid in selecting the best strategy for motivation.
3. Some strategies are:
• Giving information and creating options---suggesting a change in behavior related to alcohol, tobacco, and other drugs can lead to a decrease in consumption for those still in early phases.
• Providing feedback---providing objective feedback on the nature and severity of the patient's ATOD problems can clarify the discrepancy between the patient's present and desired state.
• Setting goals---setting specific goals toward a desired state or toward alleviation of a problem may, in itself, be a motivating factor.
• Plan for maintaining contact---follow-up calls and letters expressing concern and inviting further consultation. Phone calls or letters after missed appointments support and motivate the client.
• Manipulating external consequences---arrange, where possible, for random drug tests, close surveillance, or the threat of job loss to emphasize to the client the negative consequences of continued use.
• Providing choices---making certain that you have provided the patient with a variety of alternatives for dealing with ATOD problems gives him/her a sense of involvement and hope.

III. EXERCISE: PHASES OF CHANGE (25 minutes)

A. Divide the participants into five small groups.

B. Post the names of each phase of change on a separate piece of newsprint and post these in front of the room.

C. Distribute the five description cards and five intervention cards randomly-one of each for each small group.

D. Post the instructions for the exercise (PN-10.4) and review them with the participants.

1. 1st round:
• read your description card
• as a group, decide which phase it describes
• tape the card on the appropriate newsprint
• discuss in large group
2. 2nd round:
• read your intervention card
• as a group, decide which phase it addresses
• tape the card on the appropriate newsprint
• discuss in large group

E. After each round, lead a discussion on the placement of the cards giving the rationale for correcting any misplaced cards.

F. Lead a general discussion on the Change Process with personal or other examples from the participants.

IV. TAG-TEAM ROLE PLAYS: MOTIVATING PATIENTS (35 minutes)

A. Divide into two groups.

B. Distribute role play instructions for "patient" to one group and for "clinician" to other group (HO-10.1 and HO-10.2).

C. Post role play instructions and review (PN-10.5)

1. Each group reads the role play handout for their role.
2. Be prepared to take over from someone in your group as the role play continues.
3. Decide who will go first in the "fish-bowl."

D. Manage role plays: In fish-bowl format (two chairs in the center of the room with other chairs in a circle around them), have participants from each group take turns acting out the roles. Roles change as members of each group tap the shoulder of the player to take his/her place. Spontaneity and improvisation should be encouraged. If group members are not taking turns, the trainer can call for a change.

E. Allow players to talk about their experience, and lead a discussion on the effectiveness or ineffectiveness of the "clinician's" comments in motivating the patient.

V. SUMMARY (5 minutes)

1. Review of objectives (PN-10.1)
2. Review newsprint with objectives as a way of reinforcing learning and summarizing the module.
3. Preview of upcoming modules
4. Relate this module to other modules that will be presented to this group.