All-Ohio Counselors Conference November 2-4, 2005 and Treatment Planning

Integrating Motivational Interviewing, the Stages of Change Model,
and Treatment Planning
Kevin Glavin – Kent State University
[email protected]
Rachel Hoffman – Kent State University
[email protected]
All-Ohio Counselors Conference
November 2-4, 2005
Agenda
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7.
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 Client’s Stage of Change using SOCRATES
Background Information
• During his college years, psychologist James Prochaska, Ph.D., lost his
father to alcoholism and depression. Prochaska reported his father’s
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.
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.
The Stages of Change
Has changed
behavior for more
than 6 months
No intention of
changing behavior
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?rid=hstat5.section.62561
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?rid=hstat5.section.61626
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.
Key Points
5.
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.
6.
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.”
7.
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.
8.
A great deal of importance is placed on the decision making capability
of the individual
Practical Applications
•
Teaching case conceptualization and treatment planning in counselor education
and supervision
– Common concerns of student counselors in supervision:
•
•
•
•
•
•
•
•
•
•
•
“I don’t 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 don’t know where to go”
“I am exhausted, she or he, won’t 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
Integration of Major Therapy Systems
within the Transtheoretical Framework
Levels
Contemplation
Precontemplation
Preparation
Action
Symptom/
Situational
Behavioral
Maladaptive
cognitions
Alderian
Rational
Emotive
Cognitive
Behavioral
Rational
Emotive
Cognitive
Behavioral
Interpersonal
Sullivanian
Therapy
Couples
Couples
Communication
Communication
Transactional
analysis
Transactional
analysis
Family
System
Conflicts
Strategic
Bowenian
Bowenian
Structural
Intrapersonal
Conflicts
Psychoanalytic
Existential
Existential
Gestalt
Gestalt
Conflicts
Maintenance
Structural
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 client’s optimism; Self-Efficacy.
Miller & Sanchez, 1994
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
Stage 1: Precontemplation
Description
Techniques
Questions to ask
Individual’s 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 individual’s 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
• "What would
and thoughts regarding
have to happen
lack of readiness
for you to know
that this is a
• Make client aware it is
problem?“
her/his decision whether or
not to change.
• "What would
you consider as
• Encourage re-evaluation of
warning signs
current behavior
that would let
• Self exploration, not action,
you know that
should be the goal
this is a
• Raise awareness and
problem?"
doubt
• “What things
• Explain and personalize
have you tried
the risk
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.fcgi?rid=hstat5.chapter.61302
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.
Moving from Precontemplation
to 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)
•
Individual’s 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?rid=hstat5.section.61822
Moving from Precontemplation
to 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)?"
Moving from Precontemplation
to 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).
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).
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?"
Contemplation: Strategies
Figure 8-3
Deciding 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?rid=hstat5.table.62797
Contemplation Strategies: Cost Benefit Analysis Scale
Source: Davis & Osborn (2000)
Costs of Use
Benefits of Use
Benefits
Costs
Costs of Sobriety
Benefits of Sobriety
Costs
Benefits
Stage 3: Preparation
Description
Techniques
Individuals in the
• Identify and assist in
preparation stage intend
problem solving, e.g.
to take action (within the
identify barriers and
next month) and may
brainstorm solutions
already have had
• Help identify client
previous failed attempts
resources such as
at trying to change.
social supports
Some may have already • Encourage and
‘tested the waters’ by
support small initial
engaging in small
steps
changes, e.g. going
without a drink for a
night.
Client may have an
initial plan.
Questions to ask
• 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?
Preparation: Activities
•
•
•
Identify client’s 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.
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.)
Stage 4: Action
Description
Techniques
Individuals are actively • Focus on restructuring
changing their behavior
cues and social
and/or environment in a
support
positive manner in order • Bolster self-efficacy for
to address their
dealing with obstacles
problem(s). Client has
• Combat feelings of
changed behavior for
loss and reiterate
less than 6 months.
long-term benefits
Questions to ask
•Use strategies listed for
Preparation Stage if
necessary.
•Continue consolidating
client’s motivation for
change
•What actions have you
taken?
•What has helped/not
helped?
•What might you do to
replace things that have
not helped?
Action: Strategies
• Elicit client’s 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
Stage 5: Maintenance
Description
Techniques
Maintenance involves the individual • Conducting a Functional Analysis
proactively working to prevent
• Developing a Coping Plan
relapse. Change is continuous, it
• Plan for follow-up support
does not end at Maintenance.
In addition to handling problems that can
Triggers
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
Effects
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
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
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.
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 nonsmoking 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.
The Processes of Behavior Change:
How clients can move from one stage to the next
(Prochaska, 1997)
6.
Counter-conditioning — substituting healthier alternatives for problem
behaviors (e.g., using relaxation or meditation techniques instead of eating to
deal with stress)
7.
Stimulus Control — avoiding triggers and cues (e.g., avoiding bars, friends who
still smoke, dessert parties)
8.
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)
9.
Social Liberation — societal support for healthier behaviors (e.g., smoke-free
workplaces; discussions about safer sex in school and communities)
10.
Helping Relationships — seeking and using a strong support system of family,
friends, and co-workers.1
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)
Determining a Client’s 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 described
by 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?rid=hstat5.section.62203#62297
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 client’s LANGUAGE
From Walter & Peller, 1992
Determine the stage of change:
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 &
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