Transcript MOTIVATIONAL INTERVIEWING

MOTIVATIONAL INTERVIEWING
The Art of Possibility in Conversation:
Motivational Conversations 101
Presented by Dee-Dee Stout, MA, CADC-II;
Member of MINT; Advisor/Trainer, ICCE
for Lake County Health Services
Lakeport, CA
July 2010
Favorite Teacher/
Positively Influential Person
Teacher, clergy, parent, anyone!
PLEASE, DO NOT REPRODUCE THIS SLIDE
Wednesday July 11, 2007
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Bill’s Illustration of Persuasion
Or What’s NOT MI
Persuasion
(remember: this is NOT MI)
 Explain why your client should make this change
 Give at least 3 specific benefits to them of making this change
 Tell them how to change
 Emphasize how important it is for them to change, and
 Tell them to “Just Do It!”
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Taste of MI: The Speaker
 Topic: Something about yourself you..
 Want to change
 Need to change
 Should/ought to change
 Have been thinking about changing…
But you haven’t done yet (ambivalence!)
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Taste of MI: The Listener, Part 1
 Listen intently with the goal of understanding your
speaker’s circumstance & ambivalence
 Give no advice
 Ask these 4 open questions:
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Why would you want to make this change now?
How might you go about it, to be successful?
What are your 3 best reasons to make this change?
On a scale of 1-10 (1 is low & 10 is high), how important is it to
make this change?
 How come you’re a ____ & not a 1?
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Taste of MI: Listener, Part 2
 Give a short summary/reflection of the speaker’s motivations
for change
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Desire for change
Ability to change
Reasons for change
Need for change
 Then ask: “So, what do you think you’ll do?” and just listen
with interest
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So, what did you think?
Could you see MI helping you work smarter? Would
you like to know more?
*8 Strategies to Learning MI
(Miller & Moyers, 2007)
 Spirit
 Rolling with Resistance
 OARS & client-centered
 Developing a Change Plan
skills
 Recognizing & Reinforcing
Change Talk
 Eliciting & Strengthening
Change Talk
 Consolidating client
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Commitment
 Switching btn MI & other
counseling methods
My hope? Skills, Spirit, Strategies
 Spirit
 Change, Change Talk, & No Change Talk
(resistance/defensiveness)
 Skills & Strategies
 OARS
 Traps
 Principles
 Readiness
 Directiveness: Complex Reflections!
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So How Does MI Work?
 MI activates a client’s own motivation for change &
adherence to tx (we think!)
 Clients exposed to MI v traditional tx are generally more
likely to:
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Enter tx & stay
Complete tx more
Participate in follow up appts
Decrease drug use
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Excited??
Great! Me, too, so let’s back up a second & talk
about change for a bit….
About Change…
 Occurs naturally & is similar with or without treatment
 Likelihood strongly influenced by interactions (“dancing”)
 Very brief (5 mins or less) interventions can trigger change
talk & other positive change effects!
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And…
 Within treatment, most behavior change occurs in the first
few sessions
 Resist the “urge to right” – the “Righting Reflex” can be
deadly (Cocoon Story?)
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The Heroic Client
Scott D. Miller, PhD
 “We should be humbled in the presence
of our clients for they are the heroes of
their lives.”
www.talkingcure.com
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“Do you think it’s easy
to change?
Alas, it is very hard to change and be different. It
means passing through the waters of oblivion.”
DH Lawrence, “Change” (1971)
How we talk to folks
can actually….
increase or
decrease motivation & resistance!
Defense Mechanisms
(Bill Miller, 2009)
 The idea of "defense mechanisms" takes
behavior & turns it into a trait. There is no
evidence that people w/addictions truly have
different (e.g., more immature) defense
mechanisms than other people do, when
these are directly evaluated via personality
assessment. [And] with [defense
mechanisms], you can double them or halve
them [simply] by changing counselor style. A
fourfold shift in "denial" within a matter of
minutes doesn't exactly suggest a stable trait.
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Walk-Away Skill #1:
Ask, Tell, Ask
 Ask what the client knows about the topic
 Tell the client the information (chunklets please)
 Ask what their response is to this information
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Faith & Spirit RULE
 Resist the Righting Reflex
 Righting for others leads to dependency
 Understand your client's motivations
 If time is short, try simply asking why your client wants to make
a change & how they might go about it (instead of that they
should)
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Faith & Spirit RULE
 Listen, listen, listen to clients
 Hard to do well; definitely improves
w/practice
 Empower Them!
 Those who talk about change – the how & why
of change – are more likely to do it
 Can’t give empowerment; can only get for
oneself
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Summary:
things
in human
life
The first is“Three
to be kind.
The second
is to be kind.
And the third isimportant:
to be kind.”
Henry James in Leon Edel’s
Henry James: A Life
are
The Spirit of MI
 Collaboration
 Evocation
 Autonomy
 Perception
 Curiosity
 Ethics
MI treats resistance as thinking
NOT as pathology
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Graphic
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Motivational Interviewing is…
“Love with a Goal”
Simple but not easy!
Motivational Interviewing IS NOT…
A technique but rather a collection of skills
& strategies
Learned in a 1 or 2- day workshop (but that’s
a good start!)
Practice makes better; coaching improves
Something you use all the time
Use w/ambivalence & target behavior only
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QUOTE
 “Treat people as if they are who they can be and you help
them to become who they’re capable of being.”
-----Johann Wolfgang
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von GOETHE
Moving from Spirit to Strategy
MI: The Basics
Summary: Our ‘real’ job =
 Listen, listen, listen
 Enter the client/client’s world
 Accept. Believe. Let Go!
No ‘plumbing’ practiced here!
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4 Basic Principles of MI
 Express Empathy – “Fence-sitting is normal!”
 Develop Discrepancy* – “Who do you want to be & what’s
getting in your way?”
 Avoid Argumentation/Roll with Resistance – “Turn into the
Skid”
 Support Self-Efficacy -“The Tinkerbelle Effect”
 Ethics – Ask permission!
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6 Traps to Avoid
1.
2.
3.
4.
5.
6.
7.
Asking Questions
Being the Expert
Taking Sides/Arguing for Change
Labeling People
Focusing Too Soon
Getting Caught up in Blame/Responsibility
Being Attached to Specific Outcomes (other than the
client's!)
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Summary of Key Concepts

Ambivalence =
“Fence-sitting”

Getting REAL
Respect
 Empathy
 Affirm and
 Listen!
 Develop Discrepancy =
Behaviors v Values

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 Rolling with Resistance =
Dancing or Wrestling?
 Supporting Self-Efficacy =
Whose recovery is this anyway?
 Goals of Change = The
client’s or mine/agency?
Lunch!
30 or 60?
Skills!
Reflections are the key…and Teflon!
“You mean that…”
Thinking in Reflections
Dyads/triads
“One thing I like about myself is…”
 Speaker: Discuss some quality you like about yourself or that
is positive or quirky
 Listener: Make your best guess re: what quality the speaker
is describing to you by saying “You mean that …”
 Speaker: Answer with “Yes” or “No”
 Continue until you get a solid “Yes!”
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Video
Everybody Loves Raymond
(15)
Walk-Away Skill #2: OARS
 Open-Ended Questions
 Affirmations
 Reflections
 Summaries
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Getting Directional: 8 Ways to Show We’re Listening/
Options for Responding to No Change (Sustain)Talk
 Simple reflection (parroting)
 Amplified reflection (take it
up a notch)
 Double-sided reflection (on
the one hand…)
 Reframe (get a new pair of
glasses)
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 Emphasize individual choice
(who’s recovery is this
anyway?)
 Change Focus (hit a wall, turn
left)
 Agreement with a twist
(reframe & reflect)
 Come alongside (paradox)
Reflections: Examples
 Simple Reflection: lets the client know that you understand
what they said
 Complex Reflection: adds more substantial meaning oomph; reflect the emotion & the content of what the client
has been describing.
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Simple & Complex:
 Them: I’m not the one with the problem. If I don’t take my
meds, it’s just because my kids need the money for food.
 You: The real reason you don’t take your meds all the time
has to do with problems getting your food stamps. (Simple)
 You: You’re worried that this treatment isn’t really helping
after all this effort. (Complex)
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Resistance is a key to successful treatment if
you can recognize it for what it is:
An opportunity!
Walk Away Skill #3: RWR
Rolling with Resistance:
Instead of taking the bait, simply “roll” the
conversation back to the client (Teflon)
Client: “So, what am I supposed to do
anyway?”
You: “This feels so hopeless, it’s
frightening.”
now
really
Teflon Demonstration:
Dodge Ball!
Practicing OARS
Round Robin
So what do we listen for?
How do we
MI-converse?
Timing: OK, so I’m Ready…
Recognizing Readiness to Change
 Acceptance
 Questions about change
 Feels finished
 Envisioning
 Resolve
 Experimenting
 Change Talk!
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DARN-CAT:
The New Language
 Desire (I want to change)
 Ability (I can change)
 Reasons (It’s important to change)
 Need (I should change)=»
 Commitment (intention, decision, readiness)
 Activate (ready, prepared, willing)
 Taking Steps
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More No Change (Sustain) Talk &
Resistance strategies
 Summarize what the client has said and even how you
think he might be feeling
 Give him some freedom to decide what to talk about or
where to go next in the conversation
 Check with her to see if you’ve offended her; remind her
you’re not going to push her to make changes she doesn’t
want to make
 Apologize. A simple, non-dramatic apology can really be
helpful
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MI in a Nutshell

Talk less than the client
 Offer 2-3x more reflections (esp
complex) than questions
 Ask 2x more open than closed questions
 Listen empathetically through (lots of)
complex reflections
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Keeping the Spirit Alive
 Collaboration v Confrontation (the old kind)
 Evocation (eliciting) v Education (installing)
 Autonomy (them) v Authority (us)
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“MI is a way of being with people & that way must be of
love. It is love & profound respect that are the music in
motivational interviewing, without which the words are
empty.”
---Bill Miller, 2000
Homework: Value Cards Sort
Please sort through these cards to find your top 10
professional values (there are some blank ones to
write in your own, too). Be prepared to discuss
them tomorrow. Thanks!
End Day 1:
Great work!!
Thanks all!
www.motivationalinterview.org
www.responsiblerecovery.org