Transcript Motivational Interviewing: Rapport Building and Client Engagement

Motivational Interviewing:
Rapport Building and Client Engagement
Minnesota Coalition for the Homeless Conference: October 14th 2013
Bradley Dreis, MS, LPCC, CRC, NCC
Thomas Jaeger, Families Achieving Success Today (FAST)
Introduction
• Bradley Dreis
• E-mail: [email protected]
• LPCC (Licensed Professional Clinical Counselor)
• CRC (Certified Rehabilitation Counselor)
• NCC (National Certified Counselor)
• History
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Psychotherapist at Goodwill/Easter Seal’s Working Well Mental Health Clinic
Mental Health & Motivational Interviewing consultant to the FAST program
Motivational Interviewing trainer for Goodwill/Easter Seals of MN
Vocational Evaluator
Case Manager
Introduction
• Thomas Jaeger
• E-mail: [email protected]
• SACIT (substance abuse Counselor in training)
• BS Vocational Rehab UW Stout
• Concentration in Psych-Rehab
• History
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Employment Support Consultant to the FAST program
Motivational Interviewing coach for Goodwill Easter seals
Transitional living skills counselor and Client Advocate Catholic Charities
Chemical Dependency counselor residential treatment facility
Introduction
• A few considerations before we begin:
• Motivational Interviewing will be referred to as “MI”
throughout the remainder of this presentation.
• MI isn’t meant to be delivered in short one-hour
segments, so it is assumed that we have all had at
least some previous MI training.
• Today’s goal is to provide a few new ideas/strategies to
assist you and your clients with making positive
changes.
Introduction
• A Show of Hands: How familiar are you with MI?
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1. No familiarity
2. Brief surface-level introduction
3. Intensive training over multiple days
4. Intensive training(s) and broad familiarity with
periodic use
• 5. Extensive familiarity: Use it often; Maybe even train
others
Founders of MI
• William R. Miller, PhD
• Wrote first MI article in 1983
• Began work in chemical dependency field
• Emeritus Distinguished Professor of Psychology and Psychiatry at
the University of New Mexico
• Stephen Rollnick, PhD
• Clinical psychologist
• Professor of Health Care Communication in the School of
Medicine, at Cardiff University, Wales, United Kingdom
Definitions & Key Concepts
• Brief Refresher of MI Definitions and
Concepts to Assist with Remainder of
Presentation
• Motivational Interviewing (Lay definition)
• Motivational Interviewing is a collaborative
conversation style for strengthening a person’s
own motivation and commitment to change.
(Miller & Rollnick, 2013)
Definitions & Key Concepts
• Change Talk
• Any client speech that favors movement
toward a particular change goal.
• Sustain Talk
• Any client speech that favors status quo rather
than movement toward a change goal.
Definitions & Key Concepts
• Self-Perception Theory
• "Individuals come to know their own attitudes,
emotions and internal states by inferring them
from observations of their own behavior and
circumstances in which they occur”. (Bem, 1972)
• Or…The more somebody verbalizes a
position (either positive or negative), the
more s/he will commit to it.
Definitions & Key Concepts
• Reactance Theory
• The natural human tendency to reassert one’s
freedom when it appears to be threatened.
…even if it hurts them.
Definitions & Key Concepts
• OARS
• An acronym for four basic client-centered
communication skills.
• O: Open questions
• A: Affirmations
• R: Reflections
• S: Summary
Definitions & Key Concepts
• Spirit
• The underlying set of mind and heart within
which MI is practiced.
• Partnership
• Acceptance
• Compassion
• Evocation
Definitions & Key Concepts
• Deceptive Simplicity
• Many MI concepts appear easy at first glance,
but take practice to master and perform
intentionally.
Rapport Building & Client Engagement
• Practical MI Strategies/Techniques for Rapport
Building & Client Engagement
VS
Rapport Building & Client Engagement
• 1. Nobody
is in a Power Position.
• Client’s input is crucial (Instant engagement!)
• Clients are individuals, not “populations”
• Trouble occurs when we start thinking “I know my
typical client population” because we then make
assumptions.
• Clients are perceptive of our assumptions and will
deem us to be “just another professional” in much
the same manner.
Rapport Building & Client Engagement
• 1. Nobody is in a Power Position. …continued
• Taking a few minutes to better understand a
client’s situation can go a long way with building
rapport and maintaining engagement.
• Example of an initial introduction to an appointment:
• A: “Hello. Did you bring your ID? We should probably get
started on updating your plan right away. It’s due today
and I only have a half hour to get it all done”.
• B: “Hello. How was your weekend? We’ll need to update
your plan today, so I’m interested to know if there have
been any changes since we last met”.
Rapport Building & Client Engagement
• 1. Nobody is in a Power Position. …continued
• Both people are working collaboratively towards a
goal. Both people are responsible for doing their
part to attain the goal.
• The practitioner is the “expert” regarding
professional knowledge. The client is the “expert”
regarding their own life and behaviors.
• Both need to work together for maximum benefit.
• Recognizing that we aren’t expected to be the
expert and fully responsible for a client’s success
can be incredibly freeing. This decreases staff
burnout.
Rapport Building & Client Engagement
• 2. Act like you have 30 minutes with a client and
it will take all day. Act like you have all day with a
client and it will take 30 minutes.
• Q: “What if I need to meet certain outcome numbers
and I don’t get much time with my clients?”
• A: It’s important to recognize that some clients are going to
need additional time. This can’t be forced. Some may not
even be appropriate for your program.
Rapport Building & Client Engagement
• 2. Act like you have 30 minutes with a client and it will
take all day. Act like you have all day with a client and it
will take 30 minutes. …continued
• We want to “fish” WITH clients, not be relied
upon by them.
• “Walking” with others instead of solving their
problems for them shows that we believe in their
ability to be independent and resourceful.
Rapport Building & Client Engagement
• 3. Judge if ambivalence is present.
• Use OARS to explore ambivalence while listening
for change talk.
• Always end with Positive Change Talk.
• Even 1% will work!!!
…If no ambivalence, then no MI.
Rapport Building & Client Engagement
• 4. What if there is no ambivalence?
• Use the Hypothetical Question with a focus on
potential change talk.
• Use Open-Ended questions to explore and maybe
start a new way of thinking.
• Keep in mind that this may be the first time that the
client is actively thinking through a problem. This
may cause some initial resistance.
Rapport Building & Client Engagement
• 5. There are always “givens” that can be counted
upon to encourage change talk.
Examples:
• The client showed up and is complying with the
program.
• MI works with both mandated and non-mandated
clients.
• The client has established goals. …even if very
little progress is being made.
**Have you recognized any “givens” with your
clients that are sure to elicit change talk?
Rapport Building & Client Engagement
• 6. “Ambivalence” means that 2 sides of change
exist. We want clients to advocate for the side of
positive change.
• Things to watch for:
• The Righting Reflex
• Self-Reactance Theory
Staff: “Smoking costs so much. You can’t afford it”.
Client: “Sure I can. I can buy a cheaper brand. I could also skip one
AA meeting per week and buy a pack with the saved bus fare.
Staff: “Smoking causes cancer. It will kill you!”
Client: “I don’t think so. My Grandfather lived 90 years and
smoked every day!”
Rapport Building & Client Engagement
• 7. Affirmations are HUGE!
• We may be one of the only people in a client’s life
that is in a position to compliment them.
• There are lots of “givens” that can be used with
affirmations.
• Ex. Arrived on time, Appearance, Completed
homework, etc. …others?
Rapport Building & Client Engagement
• 7. Affirmations are HUGE! …continued
• Leading off a meeting with an affirmation is a
great way to start positive communication and
encourage engagement and rapport.
“Did you bring your activity log? I hope so because it’s due
by 5:00 today. Do you need another bus pass?”
OR
“You arrived on time for the third meeting in a row! I know
it’s been hard to coordinate your son’s new childcare
schedule. You have really done an excellent job prioritizing
your responsibilities.
Rapport Building & Client Engagement
• 8. Arguments should never occur when following
the Spirit of MI. (…but we do like emotional resistance!)
• Arguments are 100% ineffective
• Which person would you rather work with?
• Which one is more passionate?
• Which one cares more about the situation/circumstance?
Rapport Building & Client Engagement
• 8. Arguments should never occur when following the
Spirit of MI. (…but we do like emotional resistance!) …continued
• We want to Roll With Resistance
• We don’t want to waste or discourage their passion!
• Remember that resistance isn’t about us, it’s about
their situation or circumstances
• We can often agree with their frustration, even when
their statements are initially directed at us.
• It is possible to show empathy without condoning or
agreeing with client behaviors.
• Ex. “Yea, it is annoying to be asked to fill out more
paperwork. A lot of these forms do ask similar
questions. I certainly understand your frustration”.
Rapport Building & Client Engagement
• 9. “What can I do when a client just isn’t making
progress and is sitting on my case load for an
extended period of time?”
• Often, a client says that they are motivated and
appears to follow through with requirements, but
they never actually make progress.
• Is the client truly motivated to change, or do they
feel that they are accomplishing something by
merely participating in the “process” of change?
• Ex. A job searcher that seems to sabotage interviews
because they consider the job placement process as
“work” without the responsibilities of an actual job.
Rapport Building & Client Engagement
• 9. “What can I do when a client just isn’t making progress
and is sitting on my case load for an extended period of
time?” …continued
• It may help to assume that the client has low motivation or
doesn’t feel that the change is of high importance.
• Hypothetical and Open-Ended questions can help to explore
ambivalence and potentially evoke change talk.
Rapport Building & Client Engagement
• 10. It’s OK to give advice, but make sure that it is
the client’s decision to pursue the advice.
• We are professionals, but we shouldn’t be
expected to have ALL of the answers.
• Ex. I specialize in mental health treatment, but am
not an expert on solving housing issues even
though unstable housing is often correlated with
increased symptoms.
Rapport Building & Client Engagement
• 10. It’s OK to give advice, but make sure that it is the
client’s decision to pursue the advice. …continued
• Use EPE (Elicit, Provide, Elicit) to provide information
while still maintaining the Spirit of MI.
• We all often look to blame others for negative
outcomes, even if others are trying to help us.
Rapport Building & Client Engagement
• 10. It’s OK to give advice, but make sure that it is the
client’s decision to pursue the advice. …continued
• Which of these clients will likely:
• follow through with the advice?
• blame the practitioner for an unfavorable result?
• feel more engaged in the change process?
“You should tell your boss that you didn’t mean to yell at her.
Maybe then she will give you back your job?”
OR
“Do you mind if I share a suggestion that has worked for a few of
my past clients? Some of them have successfully saved their job
by apologizing for mistakes”.
Audience Findings with MI Strategies
• Have you had success with building rapport and
keeping clients engaged using MI strategies?
Feedback/Questions
Further Resources
• http://www.motivationalinterview.org/
References
• Miller, W.R., & Rollnick, S. (2013) Motivational
Interviewing (3rd ed.). New York, NY: The
Guilford Press.
• Bem, D. J., Self Perception Theory. In L.
Berkowitz (ed). Advances in Experimental
Social Psychology, Vol 6, 1972.