Strengths and Limitations

Table of Contents:

Some of the strengths ofTTM, Stages of Change and MI are that there are many studies that support their usefulness and effectiveness. In integrating all three — TTM, the Stages of Change and MI — one of the great advantages is that it moves the counselor from the “old” confrontative style to a more empathetic, collaborative and client-centered approach.

In terms of Stages of Change, three of the advantages are that this approach demystifies the change process; “normalizes perceived barriers or complications towards change, such as ambivalence and relapse”; as well as promotes “patience and persistence in efforts to change. Rather than expecting or demanding instantaneous or rapid change (and being disappointed and frustrated with the results)” (Thombs & Osborn, 2019, p. 309).

In terms of limitations, there have been studies examining the stages of change that indicate that the stages are not distinct and sequential (Little & Girvin, 2002). There have been critiques that while there are short-term gains, there is limited and “disappointing” outcomes with longer term gains in the area of activity promotion (Adams & White, 2005. p. 239).

Regarding MI. MI has been applied to other health issues such as HIV/AIDS prevention, eating disorders, diet and exercise (Thombs & Osborn, 2013).There have been many studies showing the effectiveness of MI (Hettema, Steele, & Miller, 2005; Lundahl & Burke, 2009; Miller & Rose, 2009); Miller and Rollnick (2012, p. 1), however, admit that there is an “impressive number of negative trials.” There have been “null findings” for several health-related conditions (eating disorders, drug abuse and dependence, smoking, etc.) and MI (Miller & Rose, 2009, p. 4). Another limitation of MI is that it appears to be best used with people in Precontemplation and Contemplation stages, who are considered to be at low risk for harm. For someone who is actively using to the point where an overdose may be imminent, a more directive approach may be required in order to encourage the individual to seek inpatient detox. MI is not a panacea and may not be appropriate with all clients. Also, another limitation is that it may be helpful (with the client’s permission) to let the family or significant others know you are using this approach, otherwise, they may perceive the counselor as “agreeing” with the clients perception that he or she can continue to use alcohol/drugs non-problematically.They may perceive the counselor as a “professional enabler.”

Case Study

Josie visits an outpatient substance use disorder clinic, seeking a counselor because “my wife Karen thinks I need to stop drinking but I think she is overreacting. She grew up in an alcoholic household and thinks everyone has a problem.”Josie admits that Karen has threatened to leave the house and marriage if Josie doesn’t “get to counseling.”

Josie explains that she is a writer, and although she doesn’t have a writing job at this time, she is a waitress at a local bar. She states that she loves to visit the bar when she is not working, because “the people there are real.” She admits that while she did write for a local newspaper five years ago, she hasn’t had a writing job since being fired. She explains that she was fired because she “didn’t agree with her boss.”

When addressing questions about her drinking,Josie states she does drink daily, but only 5—6 beers. “Beers aren’t as bad as hard liquor,” she states. She later admits to drinking more on the weekends, sometimes 10—12 “on a good day.” When asked about if she wanted to reduce or cease use, she reports the following: “I don’t think I should have to quit because someone is a sensy-bud about booze.Just because her father was an alcoholic doesn’t mean I am. I mean, ya, maybe I should cut back a little — maybe we wouldn’t fight so much ...”

Case Conceptualization

In working with Josie, a substance use disorder counselor would first identify her stage of change.There is some indication that she is in the contemplatives stage of change because she states“! mean,ya, maybe I should cut back a little — maybe we wouldn’t fight so much ...”

For the contemplative stage of change, it is important to work with Josie’s ambivalence. The tasks are to gather and evaluate positive and negative aspects of behavior and resolve the decisional balance, tipping the scale towards change. The change processes involved here include consciousness raising, which involves discovering the negative of behavior and positives toward change; self-evaluation, which involves shifting views and values to emphasize the negatives of the behavior and the benefits of changing; environmental revaluation, which involves recognizing the impact the behavior has on others; and social liberation, which involves observing how others will support the healthier behavior (DiClemente, 2003, p. 151).

Specifically, for this stage, a counselor will engage in the following processes of change: consciousness raising, self-evaluation, environmental revaluation and social liberation.The first (consciousness raising), might be developing a pros and cons list of drinking alcohol as well as working towards reducing or eliminating its use. The second (self-evaluation) might be to evaluate how drinking alcohol impacts her relationship as well as her previous job. The third (environmental re-evaluation) might be to explore the impact alcohol has on her wife, while the last (social liberation) might involve her attending an AA meeting.

Further, the counselor would use such MI skills as expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy. In this particular case, the counselor would use empathy so that Josie feels heard and understood. In developing discrepancy, the counselor may explore her commitment to the relationship and her use of alcohol, and how that use may interfere with her relationship. When Josie starts getting defensive, the counselor can “roll with resistance” instead of trying to force Josie to change. Finally, when Josie states she may have a hard time quitting, the counselor may ask Josie about other “hard things” she has been through and how she has managed — showingjosie that she has the ability to deal with hardship. This may increase her sense of self-efficacy.

References

Adams, J., & White, M. (2005). Why don’t stage-based activity promotion interventions work? Health Education Research, 20(2), 237-243.

Connors, G.J., DiClemente, C.C., Velasquez, M.M., & Donovan, DM. (2013). Substance abuse treatment and stages of change: Selecting and planning interventions (2nd ed). New York: Guilford Press.

DiClemente, C.C. (2003). Addiction and change: How addictions develop and addicted people recover. New York: Guilford Press.

Hettema, J., Steele, J., Miller, W.R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 92-111.

Little, J.H., & Girvin, H. (2002). Stages of change: A critique. Behavior Modification, 2, 223-273.

Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of our meta analyses. Journal of Clinical Psychology, 66(11), 1232-1245.

Miller, W.R., and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd edn). New York: Guilford Press.

Miller,W.R., & Rollnick, S. (2012). Meeting in the middle: Motivational interviewing and self-determination theory. International Journal of Behavioral Nutrition and Physical Activity, 9, 1-2.

Miller, W.R., & Rose G.S. (2009).Toward a theory of motivational interviewing. American Psychologist, 64(6), 527-537

Norcross, J.C., Krebs. P.M., & Prochaska, J.O. (2011). Stages of change In J.C. Norcross (Ed.). Psychotherapy relationships that work: Evidence-based responsiveness (2nd edn, pp. 1— 36). New York: Oxford University Press.

Pro-change Behavior Systems (2018). Transtheoretical Model. Retrieved from www. prochange.com/transtheoretical-model-of-behavior-change

Prochaska, J.O., & DiClemente, C.C. (1982).Transtheoretical therapy:Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 20, 161—173.

Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Application to addictive behaviors. American Psychologist, 47(9), 1102—1114.

Prochaska.J.O., Norcross.J.C., Fowler,J.L..Follick, M.J., & Abrams. D.B. (1992). Attendance and outcome in a work site weight control program: Processes and stages of change as process and predictor variables. Addictive Behaviors, 17, 34—45.

Rosengren, D.B. (2009). Building motivational interviewing skills: A practitioner's workbook. New York: Guilford Press.

Thombs, D.L., & Osborn, CJ. (2013). Introduction to addictive behaviors (4th edn). New York: Guilford Press.

Thombs, D.L., & Osborn, CJ. (2019). Introduction to addictive behaviors (5th edn). New York: Guilford Press.

Strengths and Limitations

Case Study

Recommended Reading and Resources

References