Integrating Motivational Interviewing, the Stages of Change Model, and Treatment Planning Kevin Glavin

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Integrating Motivational Interviewing, the
Stages of Change Model, and Treatment Planning
Kevin Glavin Kent State Universitykglavin_at_ken
t.eduRachel Hoffman Kent State
Universityrhoffman_at_kent.edu All-Ohio
Counselors Conference November 2-4, 2005
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Agenda

• Background Introduction to the Stages of Change
  Model (Transtheoretical Model)
• The Stages of Change Key points
• Practical Applications
• Teaching treatment planning and case
  conceptualization.
• Educating clients about the stages of change
• Motivational Interviewing Techniques
• Moving through the stages Techniques and
  Strategies
• The Processes of Behavior Change
• Determining a Clients Stage of Change using
  SOCRATES

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Background Information

• During his college years, psychologist James
  Prochaska, Ph.D., lost his father to alcoholism
  and depression. Prochaska reported his fathers
  mistrust in psychotherapy and his refusal to
  participate in counseling. This served to fuel
  Prochaskas research into substance abuse and the
  stages of change.
• Prochaska and DiClemente started their research
  by observing individuals who had over come an
  addiction to nicotine. They discovered change
  occurred on a continuum and identified common
  stages and processes individuals appear to
  progress through. The model is named the
  Transtheoretical Model spans so many different
  theories.
• This model provides practitioners with a way in
  which to understand how clients change, as well
  as what motivates them to change. It can be used
  to teach case conceptualization, and build
  appropriate stage related interventions into
  treatment plans.

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The Stages of Change Model Transtheoretical
Model (Prochaska DiClemente, 1982)

• The central organizing construct of the model is
  the Stages of Change
• The Transtheoretical Model views change as a
  process involving progress through a series of
  five stages
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• The goal is to determine which stage of change
  the client is in and assist the client in
  progressing through subsequent stages.

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The Stages of Change
No intention of changing behavior
Has changed behavior for more than 6 months
Has changed behavior for less than 6 months
Intends to change in the next 6 months, but may
procrastinate
Intends to take action soon, for example next
month
Source http//www.ncbi.nlm.nih.gov/books/bv.fcgi?
ridhstat5.section.62561
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Change is Dynamic and Cyclical

• It is important to note that the change process
  is cyclical, and individuals typically move back
  and forth between the stages and cycle through
  the stages at different rates. In one individual,
  this movement through the stages can vary in
  relation to different behaviors or objectives.
  Individuals can move through stages quickly.
  Sometimes, they move so rapidly that it is
  difficult to pinpoint where they are because
  change is a dynamic process. It is not uncommon,
  however, for individuals to linger in the early
  stages.
• For most substance-using individuals, progress
  through the stages of change is circular or
  spiral in nature, not linear. In this model,
  recurrence is a normal event because many clients
  cycle through the different stages several times
  before achieving stable change. The five stages
  and the issue of recurrence are described below.
• Source http//www.ncbi.nlm.nih.gov/books/bv.fcgi?
  ridhstat5.section.61626

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Key Points

1. Prochaska and DiClemente argue that behavior
   change cannot be thought of as a specific event
   occurring at a specific point in time. Rather,
   change should be thought of as a process that may
   take months or even years.
2. Many behavioral change programs are
   characterized as lasting for a predetermined
   number of weeks and consisting of structured
   content.Such programs do not take into account
   the uniqueness of each client, and the subtle
   changes that often go unnoticed. Some clients
   will respond very positively and make significant
   changes. However, for those who do not, they are
   said to lack motivation and/or willpower.
3. We tend to acknowledge change has occurred when
   we see a change in behavior, e.g. a period of
   abstinence, leaving an unhealthy relationship.
   These are seen as successes.

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Key Points

• The stages of change model suggests that change
  occurs along a continuum and therefore cannot be
  measured by one criteria alone, i.e. a change in
  a specific problem behavior. If we view change as
  a process then we can report positive changes
  each time an individual progresses from one stage
  to the next. Small steps constitute changes and
  should therefore be recognized and supported.
• Since clients differ in their readiness to make
  changes Prochaska and DiClemente suggest matching
  interventions to the appropriate stage (or
  readiness).
• Success, moreover, is defined not just by
  changing the behavior but by any movement toward
  change, such as a shift from one stage of
  readiness to another.
• There is an emphasis on the maintenance of
  change. Relapse is common and should not be seen
  as a sign of failure. Clients are encouraged to
  learn from their relapse.
• A great deal of importance is placed on the
  decision making capability of the individual

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Practical Applications

• Teaching case conceptualization and treatment
  planning in counselor education and supervision
• Common concerns of student counselors in
  supervision
• I dont know what else to do with this client
• I feel like I do not know enough techniques
• I want to be prepared and have a diverse number
  of tools to draw upon
• The client is stuck, I am stuck, I dont know
  where to go
• I am exhausted, she or he, wont budge.
• Counselors need to become aware of when they are
  working harder than their clients
• Counselors may get into difficulties if they rely
  too heavily on theoretical techniques and attempt
  to draw from their bag of tricks. Eventually
  someone will throw a spanner in the works.
• Student counselors will benefit from learning
  about the stages of change because it explains
  the process of change.
• More emphasis is placed on the client, which will
  help alleviate some of the pressure counselors
  feel.
• Counselors can use the model to teach clients
  about the stages of change, and thus set the tone
  for future counseling sessions.
• All of the above can then be used to create a
  collaborative treatment plan based on the clients
  current position

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Integration of Major Therapy Systems within the
Transtheoretical Framework
Levels Pre-contemplation Contemplation Preparation Action Maintenance
Symptom/ Situational Behavioral
Maladaptive cognitions Alderian Rational Emotive Cognitive Behavioral Rational Emotive Cognitive Behavioral
Interpersonal Conflicts Sullivanian Therapy Couples Communication Transactional analysis Couples Communication Transactional analysis
Family System Conflicts Strategic Bowenian Bowenian Structural Structural
Intrapersonal Conflicts Psychoanalytic Existential Existential Gestalt Gestalt
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Motivational Interviewing

• A counseling style that is derived from the field
  of addictions counseling.
• Brief intervention format.
• Six critical elements necessary for successful
  brief interventions (the acronym FRAMES)
• Feedback
• emphasizing the clients Responsibility for change
  
• offering Advice
• provide a Menu of alternative treatment options
• demonstrate Empathy
• reinforce clients optimism Self-Efficacy.

Miller Sanchez, 1994
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Motivational Interviewing

• Motivational interviewing is guided by several
  principles
• Avoiding argumentation
• Rolling with resistance
• Expressing empathy
• Developing discrepancies
• Supporting self-efficacy
• Counselors avoid harsh confrontations
• MI counselors emphasize the need for change and
  increase confidence and hope that change can
  occur.

Lewis Osborn, 2004
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Stage 1 Precontemplation
Description Techniques Questions to ask
Individuals in the precontemplation stage are often viewed as unmotivated clients who are not ready for change. They may not believe they have a problem and state they do not intend on making any changes in the near future (not within the next 6 months). Their lack of motivation to change may be as a result of failed prior attempts to change their high risk behaviors. It is also possible these individuals may not fully realize the negative consequences of their behavior. The goal of the precontemplation stage is to move the client into contemplation, i.e. to help client begin to think about negative consequences of their behavior and consider change as a possibility Validate clients feelings and thoughts regarding lack of readiness Make client aware it is her/his decision whether or not to change. Encourage re-evaluation of current behavior Self exploration, not action, should be the goal Raise awareness and doubt Explain and personalize the risk "What would have to happen for you to know that this is a problem? "What would you consider as warning signs that would let you know that this is a problem?" What things have you tried in the past to change?
Adapted from The National Center for
Biotechnology Information TIP 35 Enhancing
Motivation for Change in Substance Abuse
Treatment http//www.ncbi.nlm.nih.gov/books/bv.fc
gi?ridhstat5.chapter.61302
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Precontemplation Strategies

• Use self motivational statements with questions
  such as
• How does this concern you?
• What do you think will happen to you if you do
  not make any changes?
• What has your alcohol use prevented you from
  doing?
• If client is reluctant, try asking
• "What would have to happen for you to know that
  this is a problem?
• "What would you consider as warning signs that
  would let you know that this is a problem?
• Try not to assume client has a substance abuse
  problem. Instead, start from the viewpoint there
  is a possibility substance abuse is a problem for
  you
• If subject seems willing, offer feedback from
  test results, such as the SOCRATES. (but ask,
  what do these results say to you?)
• Try not to come from the counselor as expert
  point of view.
• If client is willing, explain the concepts behind
  the stages of change model. Involve them in the
  process.
• Ask subject what they would like the next step to
  be.

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Moving from Precontemplationto Contemplation

• There is a myth...in dealing with serious
  health-related addictive...problems, that more is
  always better. More education, more intense
  treatment, more confrontation will necessarily
  produce more change. Nowhere is this less true
  than with precontemplators. More intensity will
  often produce fewer results with this group. So
  it is particularly important to use careful
  motivational strategies, rather than to mount
  high-intensity programs...that will be ignored by
  those uninterested in changing the...problem
  behavior... We cannot make precontemplators
  change, but we can help motivate them to move to
  contemplation. (DiClemente, 1991)
• Individuals in the precontemplation stage rarely
  show for treatment by choice. Most are required
  to attend treatment for one reason or another.
  They may truly believe their substance use is not
  a problem. One goal is therefore to create doubt
  within the client, such that they may question
  their risky behaviors.
• When you first meet with client
• Establish rapport and trust
• Explore events that precipitated treatment entry
• Commend clients for coming
• "Why do you think your probation officer believes
  you have a problem?" This enables the client to
  express the problem from the perspective of the
  referring party. It also provides you with an
  opportunity to encourage the client to
  acknowledge any truth in the other party's
  account (Rollnick et al., 1992a).
• Source http//www.ncbi.nlm.nih.gov/books/bv.fcgi?
  ridhstat5.section.61822

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Moving from Precontemplationto Contemplation
Readiness Ruler (Source Rollnick) The simplest
way to assess the client's willingness to change
is to use a Readiness Ruler or a 1 to 10 scale,
on which the lower numbers represent no thoughts
about change and the higher numbers represent
specific plans or attempts to change. Ask the
client to indicate a best answer on the ruler to
the question, "How important is it for you to
change?" or, "How confident are you that you
could change if you decided to?" Precontemplators
will be at the lower end of the scale, generally
between 0 and 3. You can then ask, "What would it
take for you to move from an x (lower number) to
a y (higher number)?"
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Moving from Precontemplationto Contemplation

• Description of a typical day Another, less
  direct, way to assess readiness for change, as
  well as to build rapport and encourage clients to
  talk about substance use patterns in a
  nonpathological framework, is to ask them to
  describe a typical day. This approach also helps
  you understand the context of the client's
  substance use. For example, it may reveal how
  much of each day is spent trying to earn a living
  and how little is left to spend with loved ones.
  By eliciting information about both behaviors and
  feelings, you can learn much about what substance
  use means to the client and how difficult--or
  simple--it may be to give it up. Substance use is
  the most cohesive element in some clients' lives,
  literally providing an identity. For others it is
  powerful biological and chemical changes in the
  body that drive continued use. Alcohol and drugs
  mask deep emotional wounds for some, lubricate
  friendships for others, and offer excitement to
  still others.
• Start by telling the client, "Let's spend the
  next few minutes going through a typical day or
  session of...use, from beginning to end. Let's
  start at the beginning." Clinicians experienced
  in using this strategy suggest avoiding any
  reference to "problems" or "concerns" as the
  exercise is introduced. Follow the client through
  the sequence of events for an entire day,
  focusing on both behaviors and feelings. Keep
  asking, "What happens?" Pace your questions
  carefully, and do not interject your own
  hypotheses about problems or why certain events
  transpired. Let clients use their own words and
  ask for clarification only when you do not
  understand particular jargon or if something is
  missing
• Source (Rollnick et al., 1992a).

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Moving from Precontemplation to Contemplation

• Provide Information About the Effects and Risks
  of Substance Use Provide basic information about
  substance use early in the treatment process if
  clients have not been exposed to drug and alcohol
  education before and seem interested. Tell
  clients directly, "Let me tell you a little bit
  about the effects of..." or ask them to explain
  what they know about the effects or risks of the
  substance of choice. To stay on neutral ground,
  illustrate what happens to any user of the
  substance, rather than referring just to the
  client. Also, state what experts have found, not
  what you think happens. As you provide
  information, ask, "What do you make of all this?"
  
• It is sometimes helpful to describe the addiction
  process in biological terms to persons who are
  substance dependent and worried that they are
  crazy. Understanding facts about addiction can
  increase hope as well as readiness to change. For
  example, "When you first start using substances,
  it provides a pleasurable sensation. As you keep
  using substances, your mind begins to believe
  that you need these substances in the same way
  you need life-sustaining things like food--that
  you need them to survive. You're not stronger
  than this process, but you can be smarter, and
  you can regain your independence from
  substances.Source (Rollnick et al., 1992a).

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Stage 2 Contemplation
Description Techniques Questions to ask
During the contemplation stage, individuals are ambivalent about changing. They are aware their behavior is resulting in negative consequences and may be considering making a change. However, no commitment has been made to take action. One could say these individuals are sitting on the fence. Contemplation is characterized by ambivalence and feelings of being stuck. Make client aware it is her/his decision whether or not to change. Encourage evaluation of pros and cons of behavior change with the goal of helping tip the balance toward change. Identify and promote new, positive outcome expectations Have client state their next step "What are the pros and cons for not changing? What are the pros and cons (costs/benefits) for changing? Why do you want to change at this time?" "What would keep you from changing at this time?" "What are the barriers today that prevent you from changing?" "What things (people, programs and behaviors) have helped in the past?" "What would help you at this time?"
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Contemplation Strategies

Figure 8-3Deciding To Change Use decisional balance techniques. Figure 8-3Deciding To Change Use decisional balance techniques.

Changing Not Changing
Benefits Increased control over my life Support from family and friends Decreased job problems Financial gain Improved health Benefits More relaxed More fun at parties Don't have to think about my problems
Costs Increased stress/anxiety Feel more depressed Increased boredom Sleeping problems Costs Disapproval from friends and family Money problems Could lose my job Damage to close relationships Increased health risks
Source Sobell et al., 1996b. http//www.ncbi.nlm.nih.gov/books/bv.fcgi?ridhstat5.table.62797 Source Sobell et al., 1996b. http//www.ncbi.nlm.nih.gov/books/bv.fcgi?ridhstat5.table.62797
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Contemplation Strategies Cost Benefit Analysis
Scale Source Davis Osborn (2000)
Costs of Use




Benefits of Use




Costs of Sobriety





Benefits of Sobriety





Costs
Benefits
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Stage 3 Preparation
Description Techniques Questions to ask
Individuals in the preparation stage intend to take action (within the next month) and may already have had previous failed attempts at trying to change. Some may have already tested the waters by engaging in small changes, e.g. going without a drink for a night. Client may have an initial plan. Identify and assist in problem solving, e.g. identify barriers and brainstorm solutions Help identify client resources such as social supports Encourage and support small initial steps What barriers do see ahead, and how can you minimize or eliminate them? Who can you turn to for support? What kind of support do you feel you need the most, and where can you get this support?
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Preparation Activities

• Identify clients needs/wants/desires
• Emphasis is on outlining and developing plans in
  order to break the pattern of substance abuse,
  and find other ways of meeting clients needs.
• Goal Setting
• Miracle question
• Where do you want to be 6 months, 1 year, 5 years
  from now? What will life look like for you?
• Encourage client to come up with their own plans,
  and have them state specifically how they will
  achieve them.
• Identify alternative ways in which to meet needs.
  Identify areas of support that can be utilized.
• Commend client for deciding to change because
  they always have the option not to.
• Create an action plan
• Have client state their next step.

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Moving Clients From Contemplation to Preparation

• Do not rush your clients into decision making.
• Emphasize client control "You are the best judge
  of what will be best for you."
• Acknowledge and normalize ambivalence.
• Examine options rather than a single course of
  action.
• Describe what other clients have done in a
  similar situation.
• Present information in a neutral, non personal
  manner.
• Remember that inability to reach a decision to
  change is not a failed consultation.
• Make sure that your clients understand that
  resolutions to change often break down clients
  should not avoid future contact with you if
  things go wrong.
• Expect fluctuations in your client's commitment
  to change--check commitment regularly and express
  empathy concerning the client's predicaments.
• Source (Rollnick et al., 1992a.)

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Stage 4 Action
Description Techniques Questions to ask
Individuals are actively changing their behavior and/or environment in a positive manner in order to address their problem(s). Client has changed behavior for less than 6 months. Focus on restructuring cues and social support Bolster self-efficacy for dealing with obstacles Combat feelings of loss and reiterate long-term benefits Use strategies listed for Preparation Stage if necessary. Continue consolidating clients motivation for change What actions have you taken? What has helped/not helped? What might you do to replace things that have not helped?
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Action Strategies

• Elicit clients sources of support
• Understand client is trying to fill a void having
  given up their substance of choice.
• How can this void be filled with healthier
  behaviors so that they client can meet their needs

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Stage 5 Maintenance
Description Techniques
Maintenance involves the individual proactively working to prevent relapse. Change is continuous, it does not end at Maintenance. Conducting a Functional Analysis Developing a Coping Plan Plan for follow-up support
In addition to handling problems that can
interrupt treatment prematurely, work to
stabilize actual change in the problem behavior.
This requires considerable interactive planning,
including conducting a functional analysis,
developing a coping plan, and ensuring family and
social support. Start with identifying Triggers
and Effects
Triggers Effects

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Maintenance Strategies Functional Analysis

• Conducting a Functional Analysis
• Although a functional analysis can be used at
  various points in treatment, it can be
  particularly informative in preparing for
  maintenance. A functional analysis is an
  assessment of the common antecedents and
  consequences of substance use. Through functional
  analysis, you help clients understand what has
  "triggered" them to drink or use drugs in the
  past and the effects they experienced from using
  alcohol or drugs. With this information, you and
  your clients can then work on developing coping
  strategies to maintain abstinence.
• "Tell me about situations in which you have been
  most likely to drink or use drugs in the past, or
  times when you have tended to drink or use more.
  These might be when you were with specific
  people, in specific places, or at certain times
  of day, or perhaps when you were feeling a
  particular way." Make sure to use the past tense
  because the present or future tense may unsettle
  currently abstinent clients.
• As your client responds, listen reflectively to
  make sure that you understand. Under the Triggers
  column, write down each antecedent. Then ask,
  "When else in the past have you felt like
  drinking or using drugs?" and record each
  response
• After the client seems to have exhausted the
  antecedents of substance use, ask about what the
  client liked about drinking or using drugs. Here
  you are trying to elicit the client's own
  perceptions or expectations from substance use,
  not necessarily the actual effects.
• Miller and Pechacek, 1987

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Maintenance Strategies Functional Analysis

• Once the client has finished giving antecedents
  and consequences, you can point out how a certain
  trigger can lead to a certain effect. First, pick
  out one item from the Triggers column and one
  from the Effects column that clearly seem to go
  together. Then ask the client to identify pairs,
  letting the client draw connecting lines on the
  paper or blackboard.
• For trigger items that have not been paired, ask
  the client to tell you what alcohol or drug use
  might have done for her in that situation, and
  draw a line to the appropriate item in the
  Effects column. Sometimes there is no
  corresponding item in the Effects column, which
  suggests that something has to be added. Then do
  the same thing for the Effects column. It is not
  necessary, however, to pair all entries.
• With this information, you can develop
  maintenance strategies. Point out that some of
  the pairs your client identified are common among
  most users. Next, you can say that if the only
  way a client can go from the Triggers column to
  the Effects column is through substance use, then
  the client is psychologically dependent on it.
  Then make clear that freedom of choice is about
  having options--different ways--of moving from
  the Triggers to the Effects column. You can then
  review the pairs, beginning with those the client
  finds most important, and develop a coping plan
  that will enable the client to achieve the
  desired effects without using substances
• Miller and Pechacek, 1987

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Maintenance Strategies Coping Plans

• Coping Strategies Coping strategies are not
  mutually exclusive (i.e., different ones can be
  used at different times) and not all are equally
  good (i.e., some more than others involve getting
  close to trigger situations). The point is to
  brainstorm, involve the client, reinforce
  successful application of coping strategies, and
  consider it as a learning experience if a
  particular strategy fails.Example 1 Client X
  typically uses cocaine whenever his cousin, who
  is a regular user, drops by the house. Coping
  strategies to consider would include (1) call the
  cousin and ask him not to come by anymore, (2)
  call the cousin and ask him not to bring cocaine
  anymore when he visits, (3) if there is a pattern
  to when the cousin comes, plan to be out of the
  house at that time, or (4) if someone else lives
  in the house, ask them to be present during the
  cousin's visit.Example 2 Client Y typically
  uses cocaine when she goes out for the evening
  with a particular group of friends, one of whom
  often brings drugs along. She is particularly
  vulnerable when they all drink alcohol. Coping
  strategies to consider might include (1) go out
  with a different set of friends, (2) go along
  with this group only for activities that do not
  involve drinking, (3)leave the group as soon as
  drinking seems imminent, (4) tell the supplier
  that she is trying to stay off cocaine and would
  appreciate not being offered any, (5)ask all her
  friends, or one especially close friend, to help
  her out by not using when she is around or by
  telling the supplier to stop offering it to her,
  or (6)take disulfiram Antabuse to prevent
  drinking.Example 3 Client Z typically uses
  cocaine when feeling tired or stressed. Coping
  strategies might include (1) scheduling
  activities so as to get more sleep at night,
  (2)scheduling activities so as to have 1 hour per
  day of relaxation time, (3)learning and
  practicing specific stress relaxation techniques,
  or (4)learning problem-solving techniques that
  can reduce stressful circumstances.

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The Processes of Behavior Change How clients
can move from one stage to the next
The processes of change are the activities
clients engage in to progress through the stages
of change. (Prochaska, 1997)

1. Consciousness-raising finding and learning new
   facts and suggestions supporting the change
   (e.g., reading a book watching a TV show
   talking with a friend, teacher, or doctor)
2. Dramatic Relief experiencing and expressing
   negative feelings about one's problems such as
   worry or fear (e.g., communicating with a friend,
   partner, counselor writing in a journal)
3. Self Re-evaluation realizing that the
   behavioral change is part of one's identity
   (e.g., seeing yourself as a non-smoker or a fit
   person)
4. Environmental Re-evaluation assessing how one's
   problem affects the physical environment (e.g.,
   realizing that second-hand smoke may affect
   non-smoking children and partners or even pets)
5. Self Liberation choosing and committing to act
   on a belief that change is possible (e.g., making
   a New Year's resolution) accepting
   responsibility for changing.

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The Processes of Behavior Change How clients
can move from one stage to the next(Prochaska,
1997)

1. Counter-conditioning substituting healthier
   alternatives for problem behaviors (e.g., using
   relaxation or meditation techniques instead of
   eating to deal with stress)
2. Stimulus Control avoiding triggers and cues
   (e.g., avoiding bars, friends who still smoke,
   dessert parties)
3. Contingency Management increasing the rewards
   of positive behavioral change and decreasing the
   rewards of the unhealthy behavior (e.g., buying
   new clothes after losing weight instead of eating
   dessert)
4. Social Liberation societal support for
   healthier behaviors (e.g., smoke-free workplaces
   discussions about safer sex in school and
   communities)
5. Helping Relationships seeking and using a
   strong support system of family, friends, and
   co-workers.1

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Stages of Change in Which Change Processes are
Most Emphasized
Individual treatment plans can be designed by
identifying the stage of change a client is
currently experiencing, and making use of the
processes of change associated with that stage.
(Prochaska, 1997)
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Determining a Clients Stage of Change using
SOCRATES
The Stages of Change Readiness and Treatment
Eagerness Scale(Miller Tonigan)
The Stages of Change Readiness and Treatment
Eagerness Scale was originally developed as a
parallel measure of the stages of change
describedby Prochaska and DiClemente with item
content specifically focused on problem
drinking. Miller, Tonigan (1996) p. 82

• Contains 19 items
• Client responds based on a lickert scale from
  (1 - NO! Strongly Disagree) to (5 - YES! Strongly
  Agree)
• 10 minutes to complete
• Reports on 3 factors
• Recognition
• Ambivalence
• Taking Steps
• SOCRATES in pdf format
• SOCRATES in Excel Format
• Source http//www.ncbi.nlm.nih.gov/books/bv.fcgi
  ?ridhstat5.section.6220362297

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Solution-Focused Goal Setting

• When determining goals, a solution-focused frame
  can create measurable, achievable goals for each
  stage that the client is in
• State the goal POSITIVELY
• State the goal in PROCESS form (how will it be
  done)
• State the goal in the HERE and NOW
• State the goal as SPECIFICALLY as possible
• State the goal as the client having CONTROL
• State the goal in the clients LANGUAGE

From Walter Peller, 1992
36
Determine the stage of change
37
References

• Davis, T. E. Osborn, C. J. (2000) The solution
  focused school counselor Shaping professional
  practice. Philadelphia, PA Accelerated
  Development.
• DiClemente, C.C. (1991). Motivational
  interviewing and the stages of change. In W.R.
  Miller S. Rollnick (Eds.) Motivational
  interviewing Preparing people to change
  addictive behavior (pp. 191-202). New York
  Guilford Press.
• Lewis, T.F., Osborn, C.J. (2004).
  Solution-focused counseling and motivational
  interviewing A consideration of confluence.
  Journal of Counseling Development, 82, 38-48.
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