Transcript Motivational Interviewing 101

Motivational
Interviewing - Part 2
Presented by Dee-Dee Stout, MA, CADC-II; Member
of MINT; Advisor/Trainer, ICCE
For Lake County Health Services
Lakeport, CA
July 2010
Quick Review – MI Part 1
 Ask-Tell-Ask
 Agenda Setting
 4 Basic Principles
 Traps to Avoid
 OARS, esp. Reflections
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Day’s Format
Talk
Look
Do
Value Cards Sort
Share with another HOW you know these things are
important to you?
(20)
Walk Away Skill #2
Agenda Setting
Agenda Setting
 Agenda Setting
 Write out the topics in which the client is asking for your help
 Then ask, in a time frame you set (30 minutes, etc), what 1 or 2
items the client would most like to discuss in that time, or ask
which are most important, or say “or is something else more
important to talk about right now?”
 Note: You may also add 1 thing that you need to discuss but talk
about that last & only after you ask permission
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Demonstration
Read examples
or do live?
Reflection Exercise
The Penny Game
Building a Rapport Bank
 In dyads: 1 Speaker and 1 Listener
 Speaker begins by talking about something real though not too
tender.
 Each time the Listener reflects appropriately, the Speaker moves
1 penny or more from their pile to the Listener’s “bank.”
How many is up to the Speaker.
 The goal is to get as many of the Speaker’s pennies in front of
you.
 Return to debrief in big group
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Scenarios
Good, Better, Bull’s Eye!
Good, Better, Bull’s Eye!
 In your group, find the scenario on the table and read aloud
 Using the scenario as a guide, decide what simple reflection you
might use with this client that simply shows you’re listening
(good)
 Think about possible responses to this reflection and consider
more “back-story” to form the next reflection, perhaps one more
complex (better)
 Finally, decide on the most complex reflection you all think
accurately shows what you’ve heard in both content & emotion
from the client so far, & what you’re NOT hearing this client say
with words
Summary
What have we discussed so far?
MI - Phase 2: Strengthening the
Commitment for Change
Change Talk,
Commitment Language, and
More
Review:
Recognizing Readiness
 Acceptance
 Questions about change
 Less resistance
 Envisioning
 Less problem-talk
 Experimenting/ taking
 Change Talk
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steps
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)
 Activation (ready, prepared, willing)
 Taking Steps (action)
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Walk Away Skill #4
Pulling for Change Talk
Getting to Change Talk - 1
 Ask evocative questions
 Ask clients to elaborate
 Use Rollnick’s Rulers
 Explore the Decisional Balance
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Getting to Change Talk - 2
 Query the extremes
 Look back
 Look forward
 Explore clients’ goals & values
18
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Desire – Preference for change
 I want to…
 I would like to…
 I wish I could …
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Ability - Confidence
 I could…
 I can…
 I might be able to …
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Reasons – Specific arguments for change
 I would probably feel better if I …
 I need to have more energy to play with my kids.
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Need – Feeling obligated to change
 I ought to…
 I have to …
 I really should …
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Commitment – Likeliness of change
 I am going to…
 I will…
 I intend to …
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Change Talk v
Commitment Language
How can we hear the difference?
And what does it matter anyway?
Commitment Language Demo
 5 Volunteers:


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I want to…
I could…
I need to…
I ought to because I have good reason…
I do or I will…
 Oaths
What do you think?
Which would you want to hear?
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Activation
 I’m ready to take this on!
 I’m prepared to make this change this time
 I’m willing to do anything I need to in order to make this
work
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Taking Steps – Action taken!
 You might be surprised to hear this but I actually went out
and …
 This week I started …
 That meeting was pretty good last night
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Walk Away Skill #3: Scaling
Another way to Assess
& to pull for Change Talk
Scaling (DARN-C & more)
 Concern
 Problem Recognition
 Desire/Importance
 Ability/Confidence/Optimism
 Reasons, Need & /Readiness
 Commitment/ Intention to Change
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Concern
 What is there about your behavior that you or others might
see as a reason for concern?
 What worries you about your behavior?
 What do you think could happen if you continue?
 How do you feel about your behavior?
 How much does you behavior concern you?
 What do you think might happen if you don’t change your
behavior?
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Problem Recognition
 What things make you think that this might be a problem?
 What difficulties have you had in relation to your use (or other
behavior)?
 How have you or others been harmed by this behavior?
 How has your behavior been a problem for you?
 How has your behavior kept you from your goals?
 How has your behavior stopped you from doing what you want to
do?
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Exploring Importance
 What would have to happen for this to
become much more important for you to
change?
 What would have to happen before you
seriously considered changing?
 Why have you given yourself such a high
score on importance?
 What would need to happen for your score
to move up from (-) to (-)?
Based on “Health Behavior Change”
by Rollnick, Mason, & Butler, 1999; Churchill Livingstone.
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Enhancing Confidence - 1
 Traps
 It’s OK, I’ll take care of things! (plumber)
 There, there you’ll be fine (patronize)
 You’re right; things are horrible (pessimist)
 Enhance confidence before you give advice
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Enhancing Confidence -2
 Getting & Strengthening Confidence Talk
 Ask open questions; use complex reflections
 The Confidence Ruler
 Look at past successes
 Talk up clients’ strengths & support
 Brainstorm!
 Give info & advice (w/permission only)
 Reframe
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Enhancing Confidence -3
 Getting & Strengthening Confidence Talk
 Radical change?
 Hypothetical change
 Suppose you were going to ___. How might you do that?
 Who do you know who’s made this change? How did they do it?
- The Miracle Question
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Confidence
 If you decided to change right now, how confident are you that
you could be successful?
 On a scale of 1 to 10, with 1 being “no way” and 10 being
“absolutely no problem”, how confident are you that you could be
successful in making this change?
 What would it take for you to move to a 4? How would you know
if you were at a 7? What indicators would tell you your
confidence was down to a 2?
 Which of these behaviors are you most confident that you could
change if you wanted to?
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Exploring Confidence
 What have you learned from the way things turned out the
last time you tried to make this change?
 If you were to decide to change, what might your options be?
Are there any ways you know of that have worked for other
people?
 What are some of the practical things you would need to do
to achieve this goal? Do any of them sound achievable?
 What can you think of that would help you feel more
confident?
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Exploring Confidence
 What would make you more confident about making these




changes?
Why have you given yourself such a high score on
confidence?
How would you move up higher so that your score goes from
– to -?
How can I help you succeed?
What did you find helpful in any previous attempts to
change?
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Optimism
 What encourages you to see that you are ready to make a
change? What helps you to see that you could make a change
if you wanted to?
 What do you think would work for you if you decide to make
a change?
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Before Giving Advice…
 Elicit the client’s own ideas & knowledge
 Consider the importance of what you will offer (remember
the DARN-CAT Bouquet!)
 Obtain the client’s permission
 Have several options (the Menu)
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Intention to Change - 1
 How come you think you need to change? Why now?
 If things were to work out as you want, what would that look
like?
 What would be different if you were to change?
 What makes you think you should not change your behavior?
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Intention to Change - 2
 What are you thinking about your behavior at this point?
 What would be the advantages to making a change? Or not?
 I can see that you’re feeling stuck right now. What will have
to change to get “unstuck?”
 What would have to happen for you to be ready to make a
change? What would that look like?
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Recap: Possible
Key Questions
 What do you think you will do?
 What does this mean about your ___?
 It must be uncomfortable for you now, seeing all this. What’s




the next step?
What do you think has to change?
What could you do? What are your options?
How would you like things to turn out for you now, ideally?
What concerns you about changing your use of ____?
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Recap: Possible
Key Questions
 It sounds like things can’t stay the way they are now.
What are you going to do?
 Of all the things we’ve discussed here, which do you
think are the most important reasons to make a change?
How are you going to do it?
 What’s going to happen now?
 Where do we go from here?
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Negotiating a Change Plan
 Setting goals
 How would you like for things to be different?
 What do you want to change?
 If you were completely successful in accomplishing your goal,
what would be different?
 Let’s take things one step at a time. So, what do you think is the
first step?
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Step 2:
Considering the Options
 Offer a menu of options
 Try “warm turkey” approach
 Negotiate a period of trial abstinence: “sobriety sampling”
 Gradually taper off to abstinence
 Period of trial moderation
 Offering advice on what type of treatment typically
works for whom
 The client (& you) may not choose the right treatment
approach the first time
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Step 2:
Considering Change Options
 “The truth is that there is no one approach that is best for
everyone. What works for some is unacceptable or ineffective for
others. What’s encouraging is that there are quite a few different
ways that have been shown to be promising. The question now is
which ones would be best for you. We can talk about the options
if you want, and I would certainly try to help you find the right
approach the first time. But if you try one way and it doesn’t
seem to be working, don’t get discouraged. It might only mean
that it isn’t the right approach for you. Would you like to hear
about some of the possibilities?”
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Step 2:
Considering Change Options
 Clearly discuss each option
 Include what the client can expect from each option and
the likely outcomes
 Answer any questions clients may have regarding each
option
 Ask the client what outcome they might expect from
each option or what they may expect if they decide to do
nothing (which is another option.)
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Step 3: Arriving at a Plan
 Arriving at a plan
 Evaluate alternative courses of action
 Stay with the client!
 Summarize the plan based on the client’s goals, needs, intentions, and
beliefs
 So, how do we know if this plan could work? Try asking:
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How would your life be different if you followed this idea and quit altogether?
You have said that you would like to cut down, so let’s talk about that for a
while. How do you think this would work?
OK, so that’s your goal. Great! I wonder what obstacles you think might
keep you from being successful?
What else do you think might go wrong with this plan?
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Step 4: Eliciting Commitment Endgame
 Make it public!
 Arrive at a clear plan
 Obtain the client’s verbal decision to follow the plan
 Reinforce the client’s decision
 Initiate immediate steps for implementing the plan
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Using MI:
The Change Plan Interview
“Maria”
(15)
5-Chair Exercise
This will bring it all together for us –
LIVE!
LETTING GO
“If you let go a little you’ll have a little peace; if you let go a
lot you’ll have a lot of peace; and if you let go completely,
you’ll have complete peace.”
---Author Unknown
“The ideal change plan is one to which you as
consultants have contributed nothing.”
---Allan Zuckoff, PhD; MINT member
“MI is a way of being with people and that way must be
of love. It is love and profound respect that are the
music in motivational interviewing, without which the
words are empty.”
---Bill Miller, 2000
DONE – WOOHOO!
Thanks to all of you, John D. & The Crew!!
Dee-Dee Stout
www.responsiblerecovery.org
www.motivationalinterviewing.org
[email protected] or [email protected]