Transcript Advanced Motivational Interviewing - Illinois Co

Advanced Motivational
Interviewing
Allyse D. Sturdivant, Ph.D.
Illinois Co-Occurring Center for
Excellence
www.illinoiscoce.org
Training Objectives
• To facilitate a deeper understanding of
Motivational Interviewing principles and
strategies.
• To improve Motivational Interviewing skills.
• To increase self-awareness of competency in
Motivation Interviewing.
To Be…Or Not To Be
Motivational?
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Conflict
Coercion
Persuasion
External Contingencies (threats)
Bribe/incentive
Begging
Fear
What is the goal?
We’re here for a reason. I believe a
bit of the reason is to throw little
torches out to lead people through
the dark.
Whoopi Goldberg
Human Development Approach
Positive Behavior Focused
Purpose/Intent
is to
Purpose/Intent
is to
DO BETTER
THRIVE
Risk
Reduction
Promotion
Purpose/Intent
is to
Purpose/Intent
is to
STOP
OVERCOME
Problem Behavior Focused
Recovery means Change
• The decision to change a behavior
occurs in a series of steps.
• Match help to the stage.
– The kind of help an individual needs
depends on their readiness to change.
Stages of Change Diagram
Termination
Action
Maintenance
Preparation
Relapse
& Recycle
Contemplation
Pre-contemplation
Prochaska, Di Clemente, Norcross 1992
Stages of Change
Stage
Basic Definition
1. Precontemplation
A person that is not seeing a need for a
lifestyle or behavior change
2. Contemplation
A person is considering making a
change but has not decided yet
3. Preparation
A person has decided to make changes
and is considering how to make them
4. Action
A person is actively doing something
to change
5. Maintenance
A person is working to maintain the
change or new lifestyle, possibly with
some temptations to return to the
former behavior or small lapses
Stages of Change & Therapist Tasks
PRECONTEMPLATION
Raise doubt - Increase the client’s perception of
risks and problems with current behavior
CONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing; Strengthen
client’s self-efficacy for behavior change
PREPARATION
Help the client to determine the best course of
action to take in seeking change; Develop a plan
ACTION
Help the client implement the plan; Use skills;
Problem solve; Support self-efficacy
MAINTENANCE
Help the client identify and use strategies to
prevent relapse; Resolve associated problems
RELAPSE
Help the client recycle through the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of
relapse
Readiness Ruler - WAR
• Willing:
The importance of
change
• Able: Confidence
for change
• Ready:
A matter of
priorities
Able
The first step towards getting
somewhere is to decide that you
are not going to stay where you
are.
J. Pierpont Morgan
Motivational Interviewing
Motivational interviewing is a directive, client-centered counseling
style that enhances motivation for change by helping the
consumer clarify and resolve ambivalence about behavior
change.
The goal of motivational interviewing is to create and amplify
discrepancy between present behavior and broader goals.
Create cognitive dissonance between
Where one
Is now
Where one
wants to be
If you treat an individual as he is, he
will stay as he is, but if you treat
him as if he were what he ought to
be and could be, he will become
what he ought to be and could be.
Johann Wolfgang Von Goethe
Motivational Interviewing Assumptions
• Motivation is a state of readiness to change, which
may fluctuate from one time or situation to another.
This state can be influenced.
• Motivation for change does not reside solely within
the client.
• People struggling with behavioral problems often
have fluctuating and conflicting motivations for
change, also known as ambivalence. Ambivalence is
a normal part of considering and making change and
is NOT pathological
Motivational Interviewing Assumptions
• The counselor’s style is a powerful determinant of
client resistance and change. An empathic style is
more likely to bring out self-motivational
responses and less resistance from the client
• Each person has powerful potential for change.
The task of the counselor is to release that
potential and facilitate the natural change process
that is already inherent in the individual.
Defining Motivation
• Motivation is the tipping point for making change happen
• Most of the time it is defined after the fact: if you are
successful, you were motivated
• Alternative terms for motivation:
– Willpower
– Commitment
– Resolution
– Determination
– Readiness
Qualities of a Good Motivational
Counselor
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Respect for individual differences
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Tolerance for disagreement and ambivalence
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Patience with gradual approximations
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Genuine caring and interest in clients served
Motivational Interviewing Spirit
• Collaboration
• Evocation
• Autonomy
• Direction
Motivational Interviewing Principles
1. Express Empathy
2. Develop Discrepancy
3. Roll Resistance
4. Support Self-efficacy
1. Express Empathy
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Acceptance
Warmth
Openness
Personal value
Understanding
Reflective Listening
• Reflective listening is key to accurate empathy.
• Reflective listening is a fundamental skill of
motivational interviewing.
• Use reflective listening when you get ahead of
your client, i.e., when there is resistance.
What people really need is a good
listening to.
Mary Lou Casey
Types of Reflective Statements
• Repeating: Repeat a portion of what
the client has said. May only consist
of one or two words.
• Rephrasing: Stay close to what the
client said, but substitute words or
slightly rephrase.
Types of Reflective Statements
• Paraphrasing: Therapist makes a guess at
the unspoken meaning and reflects this
back in new words.
• Reflection of feeling: Paraphrase which
emphasizes the emotional content of the
consumer’s statement. (Not an
interpretation.)
Summarizing
• Allows individual to hear him/herself a second time.
• Allows the interviewer to reflect both sides of the
ambivalence. “On the one hand… On the other
hand…”
• Provides a summary of the conversation up to that
point.
• Can be used to transition to a new topic.
A fifty-nine-year-old unemployed
teacher says:
“ My life just doesn’t seem worth living any
more. I’m a lousy father. I can’t get a job.
Nothing good ever happens to me.
Everything I try to do turns rotten.
Sometimes I wonder whether it’s worth it.”
More Types of Reflective
Statements
• Simple reflection:
– Client: I don’t have anything to say.
– Counselor: You’re not feeling talkative today.
• Amplified reflection:
– Client: No one I know know takes medication, it just
seems like it would be such a hassle.
– Counselor: So, you can imagine ever taking
medication for something.
More Types of Reflective
Statements
• Double – sided reflection:
– I think I would feel so much better about myself if
I were in better shape, but it’s so hard to stick to a
workout plan.
– Counselor: On the one hand, trying to work out
consistently is challenging, but on the other hand,
you think your self-esteem would improve if you
lost weight.
Roadblocks to Listening
• Ordering, Directing, or Commanding
• Warning or Threatening
• Giving Advice, Making Suggestions, or
Providing Solutions
• Persuading with Logic, Lecturing, or Arguing
Roadblocks to Listening
• Moralizing, Preaching, or Telling Clients what
they “should” do
• Disagreeing, Judging, Criticizing, or Blaming
• Agreeing, Approving, or Praising
• Shaming, Ridiculing, or Labeling
Roadblocks to Listening
• Interpreting or Analyzing
• Questioning or Probing
• Withdrawing, Distracting, Humoring, or
Changing the Subject
From T. Gordon (1970). Parent
Effectiveness Training. New York: Wyden.
2. Develop Discrepancy
• Awareness of consequences is important
• Discrepancy between behaviors and
goals motivates change
• Have the client present reasons for
change
3. Roll with Resistance
• Use momentum to your advantage
• Shift perceptions
• Invite new perspectives, do not impose
them
• Clients are valuable resources in finding
solutions to problems
4. Support Self-efficacy
• Belief that change is possible is important
motivator
• Client is responsible for choosing and
carrying out actions to change
• There is hope in the range of alternative
approaches available
Two Phases of Motivational
Interviewing
Phase I: Building motivation
Phase II: Strengthening commitment to change
Phase I:
Building Motivation To Change
Avoid at all costs:
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Question-Answer Trap
Confrontation-Denial Trap
Expert Trap
The Labeling Trap
Premature-Focus Trap
The Blaming Trap
Usual Indicators of Low Motivation
• Disagrees with worker
• Refuses advice
• Expresses no desire or need for help
or change
• Appears unconcerned about problem
Five Early Strategies: OARS
• Ask Open-ended questions
• Affirm: Try to reinforce anything that leads to
change and builds the relationship.
• Listen Reflectively
• Summarize
• Elicit self-motivational statements/change talk
– DARN C
Eliciting Change Talk
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D = Desire statements
A = Ability statements
R = Reasons statements
N = Need statements
• C = Commitment language
Desire Statements
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“I’d like to quite drinking if I could.”
“I wish I could make my life better.”
“I want to take better care of my kids.”
“Getting in shape would make me feel so
much better about myself.”
Ability Statements
• “I think I could do that.”
• “That might be possible.”
• “I’m thinking I might be able to cut back on
cigarettes.”
• “If I just had someone to help me, I could
probably find a job.”
Questions To Elicit Change Talk
Desire/Ability:
• If you decided to change, what do you think
would work for you?
• What makes you think you can change, even if
you decided to?
• What do you see in yourself in terms of ability
that might be encouraging, if you decided to
change?
Reasons Statements
• “I have to quite smoking because of my
asthma.”
• “To keep my truck driving license, I should
probably cut down on my drinking.”
• “My husband may leave me if I don’t go to
therapy.”
• “I want my kids to have someplace they can
call home.”
Questions To Elicit Change Talk
Reasons:
• What difficulties have you had in relation to
your behavior?
• In what ways has this been a problem for you?
• How does your behavior interfere with who
you want to be?
Need Statements
• “It’s really important to my health to change
my diet.”
• “Something has to change or my marriage
will break.”
• “I’ll die if I keep using like this.”
Questions To Elicit Change Talk
Need:
• What about your behavior causes you concern?
• What worries you about your behavior?
• What can you imagine happening to you as a
result of your behavior?
• In what way does all this concern you?
• What do you think will happen if you don’t
make a change?
Commitment Language
• “I might change.”
• “I could consider changing.”
• “I’m planning to change.”
• “I will change.”
Questions To Elicit Change Talk
Commitment Language:
• What makes you think you need to do something
different?
• What would be the advantage to changing your
behavior?
• What things make you think you should keep
drinking the way you do...and on the other
side...what makes you think you should change?
A fifteen-year-old girl says:
“I’m really mixed up. A lot of my friends,
they stay out real late and do things their
parents don’t know about. They always
want me to come along and I don’t want
them to think I’m weird or something, but I
don’t know what would happen if I went
along either.”
Remember
• Talk less than your client does
• On average, reflect (at least) twice for each
question you ask
• When you reflect, use complex reflections
more than half the time
Remember
• When you do ask questions, ask mostly
open-ended questions
• Avoid getting ahead of your client’s
readiness (warning, confronting, giving
unwelcome advice or direction, taking the
“good” side of an argument)
10 Strategies for Evoking Change
Talk
1. Ask evocative questions
2. Explore decisional balance
3. Ask for elaboration
4. Ask for examples
5. Look back
6. Look forward
7. Query extremes
8. Use change rulers
9. Explore goals and values
10. Come alongside
Decisional Balance
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Ambivalence is a normal part of the process
of change
Use “conflict” to promote positive change
Weighing pros and cons of behavior
Increasing discrepancy
Most useful in Precontemplation and
Contemplation stages as a tool to increase
motivation
Decisional Balance Worksheet
No Change
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PROS (Behavior)
_______________
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CONS (Behavior)
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Change
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PROS (Change)
_______________
_______________
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CONS (Change)
_______________
_______________
_______________
Thinking About Drinking
Here is an example of a woman drinker. Remember,
every person has different reasons in their decisional
consideration about drinking
Good things about my drinking:
Good things about changing my
drinking:
More relaxed
Will not have to think about my
problems for a while
More comfortable with drinking friends
Not so good things about my
drinking:
More control over my life
Support from family and friends
Less legal trouble & Better health
Not so good things about changing
my drinking:
Disapproval from family and friends
More stress or anxiety
Increased chance of legal and job
trouble
Feel more depressed
Costs too much money
Increased boredom
Conducting a Decisional Balance
Discussion
• Accept all answers. (Don’t argue with answers
given by client.)
• Explore answers.
• Be sure to note both the benefits and costs of
current behavior and change.
• Explore costs/benefits with respect to client’s
goals and values.
• Review the costs and benefits.
Phase II:
Strengthening Commitment to Change
The goal of therapy shifts from building motivation
to strengthening commitment
Hazards in Phase II:
-Underestimating ambivalence
-Overprescription
-Insufficient direction
Signs of Readiness to Change
• Decreased resistance
– the client stops arguing, interrupting, denying, or
objecting
• Decreased questions about the problem
– the client seems to have enough information
• Resolve
– the client appears to have reached a resolution
Signs of Readiness to Change
• Self-motivational statements
– statements reflect recognition, concern,
openness to change, or optimism
• Increased questions about change
– the client wants to know what they can do
about the problem
Signs of Readiness to Change
• Envisioning
– talks about how life could be after a change,
or discusses advantages of change
• Experimenting
– begins to try different change approaches
Strategies for Strengthening
Commitment
• Key Questions to get the client talking and
thinking about change:
-what do you think you will do?
-what does all this mean about your behavior?
-what do you think has to change?
-what could you do, what are your options?
-it sounds like things can’t stay the same, what can
you do?
Strategies for Strengthening
Commitment
• Key Questions cont...
-how would you like things to turn out for
yourself?
-of the things that concern you, what are the
most important reasons to change?
-what concerns you about changing?
-what would be some of the benefits of
changing?
Strategies for Strengthening
Commitment
• Negotiating a Plan
Setting goals:
• How would you like things to be different?
• What is it you would like to see changed?
• If you were completely successful in accomplishing
what you want, what would be different?
Strategies for Strengthening
Commitment
• Considering Change Options
-presenting a menu
-patient-treatment matching
• Arriving at a Plan
-the most important reasons why I want to
change
-my main goals for myself, in making a
change are....
Change Plan Worksheet
1. The changes I want to make are:
2. The most important reasons I want to make these
changes are:
3. The steps I plan to make in changing are:
4. The ways people can help me are:
Person
Possible ways to help
5. I will know that my plan is working if:
6. The things that could interfere with my plan are:
I have not the right to want to
change another if I am not open to
be changed.
Martin Buber
8 Stages in Learning
Motivational Interviewing
1.
2.
3.
4.
5.
6.
7.
8.
Overall spirit of Motivation Interviewing
OARS: Client-Centered counseling skills
Recognizing change talk and resistance
Eliciting and strengthening change talk
Rolling with resistance
Developing a change plan
Consolidating commitment
Transition and blending
Motivational Interviewing Tools
• Motivational Interviewing Treatment
Integrity (MITI 3.0)
• Motivational Interviewing Assessment:
Supervisory Tools for Enhancing
Proficiency (MIA:STEP)
– Self-Assessment
References
www.motivationalinterview.org
http://www.midattc.org/MIASTEP/
• Motivational Interviewing:Preparing People for
Change. William R. Miller & Stephen Rollnick. 2nd
Edition. Guilford Press
• Squires, D.D. & Moyers, T.B. (2002). Motivational
Interviewing. Online at www.bhrm.org (There are
actually two different papers, one is in the substance abuse
section and the other is in the MISA section.)