CEP Workshop Series 2013

Module 3: Engagement & Motivation

Fraser Todd and Michelle Fowler
2013
Workshop Introduction
Workshop Agenda
Mihi, Introductions, Housekeeping & Workshop overview
Introduction to the Workshop & Exercise 1
Strategies to enhance engagement
Exercise 2
Motivation
Models of Motivation
Motivation Tools
Session Structure and the Motivational Framework
The Spirit of MI
Change Talk
Exercise 3
Implementation Intention and Mental Contrasting
Exercise 4
Action Planning Take Home
Homework
Three Dimensions of CEP Practice
Spirit Principles - Techniques:
SpiriL
7 Key Principles
Techniques
1. Cultural Considerations
2. Recovery & Well-being
3. Engagement
4. Motivation
5. Assessment
6. Management
7. Integrated Care
Person-focused care
Well-being orientated care Integrated care
Walk the Talk
Engagement
Principle 3: Engagement
The Importance of Engagement:
35 - 50% of all CEP patients drop out of treatment
50% of MH patients do not comply with treatment
Factors Associated wit Poor Engagement
o Lack of belief that treatment is effective
o Low sense of psychological safety in treatment
(stigma, MH environment)
o Single mode treatment (psychotherapy OR
pharmacotherapy
o Young age
o Lack of social pro-treatment support
o Male gender
o Drug dependence
o High levels of daily stress
Principle 3: Engagement
What is Engagement? :
!"#$#%&%"'
WlLh cllnlclan WlLh servlce WlLh managemenL plan
1o be acuvely lnvolved
resence
1
C C
1 1
Exercise 1: Presence
See age 9 of Lhe Workbook
Principle 3: Engagement
A Structure for Thinking About Engagement :
!"#$#%&%"'
LxLernal
hyslcal - LransporL, chlld
care
SupporL for LreaLmenL
e.g. famlly, peers
Coerclon e.g. courLs
rogramme conslsLency
Soclal norms
re-LreaLmenL &
LnLry lnLo 1reaLmenL
SympLoms severlLy
Mouvauon for change
8eadlness for LreaLmenL
asL LreaLmenL experlence
AnxleLy & hosullLy
Lmouon dysregulauon
1 1
WlLhln 1reaLmenL &
8eLenuon
1herapeuuc relauonshlp
Asseruve follow-up
Cognluve funcuonlong
CuLcome expecLancles
SLrucLured sesslons
Cognluve funcuonlng
1
Principle 3: Engagement
Factors Influencing Engagement:
Principle 3: Engagement
Strategies to Enhance Engagement 1:
Values, vision of well-being
Cognitive mapping
MI Engagement Interview
Autonomy-supportive environment
(3-5 choices)
Treat hostility, emotional dysregn early
Clearly structured sessions
Adapt to coping style
Remove barriers
Consistency of approach
Peer Support to engage
Assertive follow-up
Adapt for cultural needs
Principle 3: Engagement
Cognitive Mapping:
Cognluve Mapplng
lncreases engagemenL
by 1.7x
resenL lnformauon
as a dlagram
CllenL or cllnlclan
may compleLe lL
1wo dlsuncL channels for
Laklng ln lnformauon:
1. verbal
2. vlsual
Lach has llmlLed capaclLy
uslng boLh doubles lnpuL
C
C
C
C
C
Principle 3: Engagement
Cognitive Mapping:
Cognluve Mapplng
lncreases engagemenL
by 1.7x
resenL lnformauon
as a dlagram
CllenL or cllnlclan
may compleLe lL
1wo dlsuncL channels for
Laklng ln lnformauon:
1. verbal
2. vlsual
l = lnuences
L = leads Lo
n = nexL
C = CharacLerlsuc
= arL
1 = 1ype
A = Analogy
Co = CommenL
Lx = Lxample
Lach has llmlLed capaclLy
uslng boLh doubles lnpuL
C
C
C
C
C

Principle 3: Engagement
Cognitive Mapping:
Cognluve Mapplng
lncreases engagemenL
by 1.7x
resenL lnformauon
as a dlagram
CllenL or cllnlclan
may compleLe lL
1wo dlsuncL channels for
Laklng ln lnformauon:
1. verbal
2. vlsual
l = lnuences
L = leads Lo
n = nexL
C = CharacLerlsuc
= arL
1 = 1ype
A = Analogy
Co = CommenL
Lx = Lxample
Lach has llmlLed capaclLy
uslng boLh doubles lnpuL
C
C
C
C
C

Principle 3: Engagement
Cognitive Mapping:
Cognluve Mapplng
lncreases engagemenL
by 1.7x
resenL lnformauon
as a dlagram
CllenL or cllnlclan
may compleLe lL
1wo dlsuncL channels for
Laklng ln lnformauon:
1. verbal
2. vlsual
l = lnuences
L = leads Lo
n = nexL
C = CharacLerlsuc
= arL
1 = 1ype
A = Analogy
Co = CommenL
Lx = Lxample
Lach has llmlLed capaclLy
uslng boLh doubles lnpuL
C
C
C
C
C

use arrow Lo lndlcaLe sLrengLh
v
v
Principle 3: Engagement
Rachel Cognitive Map of Formulation:
ulagnoses roblems
Aeuologlcal lacLors
SLrengLhs values
Well-belng
8ape
Sexual Abuse
Muluple prlmary schools
SLu
LxLernallslng
behavlours
AvoldanL coplng
Principle 3: Engagement
Autonomy-Supportive Environment:
AuLonomy-Supporuve LnvlronmenL
Cpumally 3-3 cholces
Shape dlrecuon by oerlng cholce
CllenL encouraged Lo make declslons
Principle 3: Engagement
The Engagement Intervention:
Exercise 2: Rachel Engagement
See age 12 of Lhe Workbook
Motivation
Model of Motivated Behaviour:
Principle 4: Motivation
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-
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/"'%*$21,"
321," 40'2,&% 5,"+%60%"2%+
lnLenuon
lormauon
lnLenuon
lnluauon
lnLenuon
ueacuvauon
uellberauon lannlng Acuon Lvaluauon
erson:
needs
mouves
goals
SlLuauon:
opporLunlues
lncenuves
Principle 4: Motivation
Key Principles of General Motivation:
1. AccesslblllLy rlnclple
Mouvauonal consLrucLs are acuvaLed from memory
Worklng memory has llmlLed capaclLy
Muluple goals = 'spreads' Lhe avallable resources across Lhem, weakenlng each of Lhem
2. lnLerconnecLedness rlnclple
1here are several alLernauve paLhways Lo aualnlng each goal.
When one paLhway ls problemauc, lL ls posslble Lo subsuLuLe oLher paLhways
3. Coal Shleldlng rlnclple
1he power of a goal ls relaLed Lo Lhe deslrablllLy of Lhe ouLcome
Muluple goals = hlgh value goals wlll be proLecLed, low value goals lnhlblLed
4. rlnclple of Lmouonal 1ransfer
1he emouon auached Lo a goal can be Lransferred Lo Lhe means of aualnlng Lhe goal
Principle 4: Motivation
Implications of the Key Principles of General Motivation:
LlmlL Lhe number of goals belng acuvely worked on
C8
lncrease compeung goals for unwanLed behavlours.
LsLabllsh a persons mouvauon for subsLance use. llnd alLernauve
paLhways Lo provlde Lhls emouonal sLaLe.
AlLer Lhe deslrablllLy and value of a goal by auachlng lL Lo hlgher value
goals e.g. auach Lhe goal of noL uslng subsLances Lo hlgh value llfe goals
1he emouons auached Lo pursulng a goal may be re-Lralned
e.g. auach avoldanL acuons and emouons Lo drug seeklng behavlour
- go/no go, [oysuck Lechnlque
Principle 4: Motivation
Stages of Change (Prochaska & DiClemente):
re-
conLemplauon
ConLemplauon
reparauon Acuon
MalnLenance
Non-autonomous Autonomous
Amotivation Extrinsic Motivation Internal
Motivation
External
Regulation
Introjected
Regulation
Indentified
Regulation
Integrated
Regulation
Intrinsic
Regulation
! CompeLence, auLonomy & relaLedness
- greaLer mouvauon for LreaLmenL
- LreaLmenL belng more valued
- less amblvalence abouL LreaLmenL
- hlgher levels of self-emcacy & self-esLeem
- beuer engagemenL ln LreaLmenL
- beuer LreaLmenL ouLcomes
- lncreased ablllLy Lo overcome barrlers Lo change
Principle 4: Motivation
Self-determination Theory (Ryan &Deci):
Principle 4: Motivation
Theory of Planned Behaviour Change (Azjen):
7%8$9/,0* lnLenuon Lo AcL
AmLude Lowards behavlour
Sub[ecuve norms
(felL soclal pressure Lo acL)
ercelved 8ehavloural ConLrol
8ehavloural bellefs
CuLcome evaluauon
normauve bellefs
Mouvauon Lo comply
ConLrol bellefs
ercelved power
Internal
Motivation
MI
re-conLemplauon
ConLemplauon
reparauon
Acuon MalnLenance
8elapse
5,&:%'%"2%
30',",&;
<%=$'%>"%++
lnluauon of Acuon
.%=?@%A2$2;
7%8$9/,0*$= 5,"'*,=
B&:=%&%"'$1," /"'%"1,"
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D/"E ', =/?%
F$=0%+ $"> )0*:,+%
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Mixed Model of Change:
Principle 4: Motivation
Principle 4: Motivation
Crucial Transitions:
lacLors LhaL lnhlblL Lhe lnluauon of acuon
Low self-emcacy
Low behavloural conLrol over Lhe acuvlLy
unwllllngness Lo suer shorL Lerm cosLs for long Lerm galns
Plgh lmpulslvlLy (dlsLracuon)
Lack of value auached Lo Lhe goal (ouLcome expecLancy)
Muluple goals
SLress
lncongruence beLween lmpllclL/expllclL mouves
SLraLegles Lo enhance Lhe lnluauon of acuon
Lnhance Lhe value of a goal by auachlng lL Lo llfe values and well-belng
lncrease self-emcacy
lncrease behavloural conLrol Lhrough creaung an auLonomy supporL envlronmenL
ConLrol lmpulslvlLy wlLh mlndfulness
LlmlL Lhe number of posluve goals belng acuvely worked on
Make Lhe lnluauon of acuon 'auLomauc' Lhrough menLal conLrasung and
lmplemenLauon lnLenuons (MCll)
Coal lnLenuon
(lnsumclenL Lo eecL change)
lnluauon: *lmplemenLauon lnLenuon
(speclc plans Lo lmplemenL goal lnLenuons)
When, Where, Pow
Acuon
Lack of goal commlLmenL
rocrasunauon
Low 8ehavloural ConLrol
ShorL Lerm cosLs > Long Lerm beneLs
Plgh lmpulslvlLy
Low self-emcacy
-
-
Principle 4: Motivation
Initiation of Action:
Principle 4: Motivation
The Spirit of MI MI3:
)arLnershlp
3mrmauon
5ompasslon
!vocauon
Principle 4: Motivation
MI Process:
1. Lngage
2. ldenufy roblems
3. LvaluaLe sLage of change
4. LvaluaLe readlness and condence (self-emcacy)
3. SLraLegles Lo lncrease readlness and condence (lncrease change Lalk)
6. Acuon when ln Lhe rlghL space
Principle 4: Motivation
Readiness Rulers:
noL 8eady unsure 8eady
Principle 4: Motivation
Readiness Rulers:
noL CondenL unsure CondenL
Principle 4: Motivation
Use of the Rulers:
use of Lhe ruler wlLhln Ml:
Ask Lhe person Lo raLe on Lhe ruler where Lhey are now ln Lerms of belng ready
Lo change?
Commend Lhe response
Ask why Lhe person dld noL plck a lower number
Ask whaL lL would Lake Lo raLe Lhe number hlgher
1he condence ruler ls usually used once Lhe person has shown some lnLeresL
ln maklng a change. lL can also be used Lo raLe a person's self-emcacy ln general or
ln relauon Lo a range of dlerenL problems.
Principle 4: Motivation
Readiness + Confidence:
8eadlness
Condence
10
10
0
lrusLrauon
Lack of knowledge
Success
Skepuclsm
Principle 4: Motivation
Readiness + Confidence:
8eadlness
Condence
(Self-emcacy)
10
10
0
reparauon
ConLemplauon
re-
conLemplauon
35GB4H MalnLenance
lnLegraLe key sLraLegles lnLo follow-up/Lherapy sesslons
Structured Follow-up Session:
1
1ake opporLunlues Lo reecL and summarlse
Change Lalk
CommlLmenL Lalk
Well-belng Lalk
3a
2
3b 4
Principle 4: Motivation
lnLegraLe key sLraLegles lnLo follow-up/Lherapy sesslons
Motivational Framework for Session Structuring:
1
1ake opporLunlues Lo reecL
& summarlse
Change Lalk
Well-belng Lalk
3a
2
3b 4
8elnforce commlLmenL Lalk SeL Agenda
SplrlL of mouvauonal lnLervlewlng
Principle 4: Motivation
Principle 4: Motivation
Change Talk:
Ieslre
3blllLy
<easons
Heed
5ommlLmenL
. Lo change
!=/2/1"# 58$"#% G$=EJ
Ask for lL
WhaL would you llke Lo see dlerenL?
WhaL wlll happen lf Lhlngs don'L change?
B>%"1?;/"# 58$"#% G$=EJ
Exercise 3: Identifying Change Talk
3
Exercise 4: Reflective Listening
3
Self-Efficacy:
Principle 4: Motivation
1he convlcuon LhaL one can successfully carry ouL Lhe behavlours
needed Lo produce a cerLaln ouLcome
Plgh self-emcacy ls assoclaLed wlLh:
lncreased llkellhood of lnluaung behavlour change
lncreased llkellhood of movlng lnLo acuon phase
Laklng responslblllLy for ouLcome
fasLer recovery from seLbacks
hlgher raLes of goal achlevemenL
Self-Efficacy:
Principle 4: Motivation
SLraLegles Lo lmprove self-emcacy:
Lxperlences of masLery
Cognluve resLrucLurlng
vlcarlous experlence
8educe sLress, anxleLy, faugue and lack of sleep
Speclc feedback - accuraLe buL encouraglng
Soclal supporL
Coplng skllls Lo deal wlLh anxleLy and sLress
ShorL-Lerm achlevable goals
Avold comparlson wlLh oLhers
SupporL auLonomy
Principle 4: Motivation
Mental Contrasting and Implementation Intentions (MCII):
1. MenLal ConLrasung
Choose a speclc LreaLmenL goal
Lnvlslon Lhls goal when successfully compleLed someume ln Lhe fuLure
Lnvlslon where Lhlngs are aL currenLly ln relauon Lo Lhe goal
ldenufy barrlers ln achlevlng Lhe goal
2. lmplemenLauon lnLenuons
1hlnk of Lhe barrlers Lo Lhe goal
1hlnk of sLeps Lo achleve Lhe goal
lan speclc deLalls abouL when Lhe sLeps wlll be underLaken, whaL, how, when
lf.
1hen.
8e very speclc.
Exercise 5: Mental Contrasting and
Implementation Intentions
4%% #(2% 56 0& 7*819**1
Implicit Motivation:
Principle 4: Motivation
!-:=/2/' B&:=/2/'
Consclous non-consclous - unaware
verbal non-verbal
Culdes consclous goal semng lnLuluve goal pursulL
'LhoughL' Llke auLomauc LhoughLs
8oLh sysLems operaLe lndependenLly
Can lnuence each oLher
lncongruence when Lhey conlcL = depresslon, lack of mouvauon
ldenufy lmpllclL mouvauons and emouons by envlslonlng (non-verbal)
and noung Lhe aecL
Action Plans