Los cargos y las funciones de quienes aprobaron la evaluación jurídica de la oferta

While sophisticated, disorder-specific, interview-based methods of the measure- ment of readiness to change exist, these measures of motivation are probably most useful as research tools, especially if they can be shown to predict outcome. In clinical situations, readiness to change is often rather fluid and can wax and wane within and between sessions. Thus, from a clinical point of view, it may not be reasonable to spend a great deal of effort measuring readiness accurately at one point in time. Rather, a clinician should be able to evaluate these con- cepts within the session whatever the agenda of the moment. This is particularly important at the start of treatment. Linear visual analogue scales (Tables5.1and 5.2), which measure the dimensions of importance and confidence on a con- tinuum, are useful tools which can supplement therapeutic judgement (Keller and Kemp-White,1997; Rollnick et al.,1999; Miller and Rollnick,2002). These concepts can be explored by the questions outlined in Tables5.1and5.2.

Once the level of importance and confidence of one goal – e.g. to work with a therapist on a particular problem behaviour – has been established, then the

Table 5.2 Questions with which to explore confidence

How confident would you say you are, that if you decided to change . . ., you could do it? On a scale of 0–10, where 0 is not at all confident and 10 is extremely confident, where would you say you are?

0 1 2 3 4 5 6 7 8 9 10

Not at all Extremely

confident confident

What would make you more confident about making these changes? Why have you given yourself as high a score as you have on confidence? How could you go up higher so that your score goes from x to y? How can I or anybody else help you succeed?

Is there anything that you found helpful in any previous attempts to change? What have you learned from the way things went wrong last time you tried?

If you decided to change what might your options be? Do you know of any ways that have worked for other people?

What are the practical things you would need to do to achieve this goal? Are they achievable? Is there anything you can think of that would make you feel more confident?

From Treasure and Schmidt,2001.

intervention can be matched. The following techniques can be useful (from Treasure and Schmidt,2001):

r _{Low conviction and low confidence: Find out where there are misconceptions or}

gaps in your patient’s knowledge. Encourage your patient to think about aspects that they may previously not have considered. Provide information that is novel and relevant to the patient. The novelty aspect of information is very important to raise interest (K. Eammons, personal communication). For example, would they be interested in borrowing a new book or videotape? Emphasize their personal choice and freedom. Point out that you understand that their problem does not bother them at the moment. Reflect that you accept them whatever they decide about the possibility of change, but suggest to the patient that they might want to think about the issue. Make it clear that if they should become more interested in changing you would be there to help in any way you can and offer the support necessary.

r _{Low conviction and high confidence: Help the patient identify and discuss discrep-}

ancies between what he wants for himself in the future and where he is at in the present situation. Help him to recognize discrepancies and gaps in the informa- tion that he has. Discuss the patient’s hierarchy of values and help him decide what is important in his life. Again, emphasize the patient’s ultimate freedom of choice.

r _{High conviction and low confidence: Increase confidence by building on past expe-}

riences in which the patient has shown mastery in the face of difficulties and challenges. Work collaboratively with the patient on devising and implementing a change plan consisting of small manageable steps. Get the patient to define the size of each step, so that the plan is realistic and does not set him up for failure.

r _{High conviction and high confidence: Work with the patient to foresee and forestall}

difficult times. Offer information, practical advice and skills training as options, letting the patient decide what might work best in supporting his own efforts. Identify and remove obstacles to maintaining the desired course of action. Attend to progress by noting and affirming.

We have also found that it is useful to have an additional scale that measures how eager close others are to see change. This highlights the social context, in which change occurs. For example, conflict will arise if there is a great disparity between different family members in their readiness for change. Families with a young person with a problem may demand him/her to change instantly, which may lead to an ‘antimotivational’ environment, in which there is confrontation and high negative expressed emotion. Alternatively, differences in opinion between the parents about the urgency of the situation may paralyse any attempts to change. These examples illustrate the need for a broad exploration of the psychosocial environment.