Component 1
Enhancing Change

Change Enhancement, incorporates motivational enhancement and the recognition of cognitive capacity. This takes into account the motivational and cognitive capacities that people with chronic and recurring mental disorders, particularly schizophrenia, may experience as barriers to their recovery process.

Motivational Enhancement (ME—originally termed motivational interviewing) is a style of counselling and a set of techniques that aims to engage and motivate the individual towards change (Miller & Rollnick, 1991). The use of ME recognises that change occurs at different rates for different people, and may involve several cycles through the different stages of change before individuals gain some mastery in terms of active self-management of their health and wellbeing. ME involves the clinician helping the individual to identify advantages and disadvantages of specific existing behaviours and planned behaviours.

Corrigan, McCracken, and Holmes (2001) state that when clinicians examine general readiness for change rather than motivation to alter specific behaviours, they make the mistake of presuming that some persons, because of their psychiatric disabilities, may not be able to fully participate in psychosocial treatments.

‘This approach is based on the erroneous assumption that readiness to change is a monolithic phenomenon. More likely is the person motivated to pursue some goals and unwilling to consider others. Hence, the focus of motivational interviews and stages of change are discrete behaviors, not overall willingness to pursue treatment’.

The Transtheoretical Model

The Transtheoretical Model of change basically suggests that regardless of whether behaviour change is externally assisted or the result of the efforts of self-change, people in a change process tend to negotiate a cyclical pathway that traverses a number of recognisable change-stages (DiClemente & Hughes, 1990; Prochaska & DiClemente, 1983). These stages of change reflect the person’s readiness to change and are important landmarks for deciding upon appropriate intervention strategies.

STAGES OF CHANGE

Rogers, et al. (2001) and Addy, et al. (2000) reviewed the stages of change model and described the stages as follows:

Pre-contemplation stage

The individual is either unaware of or has no desire to change specific behaviours, and may feel pressured into treatment by significant others. Pre-contemplators may benefit from information about the potential risks and problems associated poor disorder management, and advice on harm minimisation strategies.

Contemplation stage

The individual is aware of a problem but has not made a significant commitment to change. Contemplators may find it useful to assess the pros and cons of their current decisions and behaviours regarding health management in order to make informed choices about whether to change or whether to maintain specific behaviours.

Preparation/Determination stage

The individual has decided to take action in the near future with regard to a problem, and are making plans and developing motivation to engage in change activities. People in this stage may benefit from validation and reinforcement in respect to their reasons for change, and assistance in planning strategies to bring about change.

Action stage

The individual is attempting to change a specific behaviour and may be seeking help to obtain the desired level of change. People at this stage may benefit from problem solving, goal setting skills and more easily recognisable rehabilitation interventions to assist with implementing and integrating change. They may require orientation to the significant potential of relapse, and mapping of change processes, including adjustment to the impact of change on self-identity.

Maintenance stage

Characterised by a substantial and sustained change of behaviour and by attempts to prevent relapse or consolidate previous gains. These people may require assessment of the strategies that they have found useful in changing and assistance in dealing with any potential problems with sustaining the gains. They may also benefit from reinforcement of relapse prevention strategies, including returning to self-management strategies before full-blown relapse occurs.

Relapse

The return of symptoms or target behaviours is not uncommon in change processes. Relapsers will need to analyse the relapse events including antecedents and post relapse impacts. That is, a relapse should not be wasted, it is an opportunity to refine self-management skills. Relapse is often typified by self-blame which of course only intensifies the impact and possible duration of this setback. Therefore, positive self-talk and reframing skills may be required.

Stages of Change and Therapist Tasks

General Principles Of Motivational Interviewing

Express Empathy

Acceptance facilitates change.
Skilful reflective listening is fundamental.
Ambivalence is normal.

Develop Discrepancy

Awareness of consequences is important.
A discrepancy between present behaviour and important goals will motivate change.
The client should present the arguments for change.

Avoid Argumentation

Arguments are counterproductive.
Defending breeds defensiveness.
Resistance is a signal to change strategies.
Labelling is unnecessary.

Roll with Resistance

Momentum can be used to good advantage.
Perceptions can be shifted.
New perspectives are invited but not imposed.
The client is a valuable resource in finding solutions to problems.

Support Self-Efficacy

Belief in the possibility of change is an important motivator.
The client is responsible for choosing and carrying out personal change.
There is hope in the range of alternative approaches available.
(Adapted from Miller & Rollnick, 1991).

Decisional Balance

Advantages and Disadvantages of Specific Behaviours

Aim is to increase insight into benefits of change over benefits of maintaining the status quo.
(Adapted from Miller & Rollnick, 1991.)

Importance and Confidence

• Assess the consumer’s readiness/motivation to change
• Motivation to change is often influenced by
  • Importance: degree to which the goal/task is aligned with the consumer’s personal values or the change is seen to lead to an improvement in their lives
  • Confidence: perceived mastery of all the associated tasks with goal
• The distinction between confidence and importance is relevant in terms of engagement. For example, a clinician may misjudge the focus of the consumers concerns providing information related to a certain issue (importance) when in fact the consumer lacks confidence to change the behaviour/complete the task.
• Using scaling to ground perceptions of importance and confidence is helpful.

Specific Cognitive Deficits of Schizophrenia

The cognitive deficits experienced by people with chronic and recurring mental disorders, particularly schizophrenia are well documented (Silverstein, Hitzel, & Schenkel, 1998). CRM recognizes the limitations that cognitive capacity place on the identification and pursuit of appropriate recovery-related goals by an individual. Clinicians are encouraged to adapt their practice to optimize communication and collaboration with the consumer, by taking cognitive capacity into account.

The most frequently occurring cognitive problems tend to fall into four categories:

1. Attention: This includes deficits in maintenance of an alert state, orienting toward novel stimuli, selectively filtering relevant information, shifting from one set to another, rapidly discriminating or scanning stimuli.
2. Executive functions: These are believed to be associated with the prefrontal cortex and generally involve integrating functions as discussed earlier. However, it also includes all tasks from executive functions to those sub functions believed to be involved in executive tasks. Functions such as attention, memory, language, planning, starting (initiation), stopping (inhibition), etc.
3. Memory: While memory problems are common, there has been considerable debate over whether memory deficits exist independently in people with schizophrenia, or if the perceived difficulties are secondary to other primary deficits. That is, do they have poor memory because they have attention/executive problems? If a person cannot attend to a task, then it is unlikely that they would be able to store much of the information presented. Also, recall that prefrontal (or executive) problems can result in pervasive deficits that are evident across a wide range of areas. There are also debates as to whether different types of memory (e.g. visual vs verbal) are differentially affected in schizophrenia.
4. Language: The language problems often observed in people with schizophrenia may be associated with disturbances in the language system. That is, they may have difficulty inhibiting irrelevant material, or in using language to facilitate the retrieval of relevant memory units. (Pantelis, et al., 1996)

Ideas to implement

• Visual aids to auditory information
• Visual aids to goal setting
• Non distracting environments
• Structured short sessions with breaks
• Handout summaries of discussions
• Time for client to express ideas
• One task at a time

Media resources

Key references

Library resources