Transcript Motivational Enhancement Therapy

Daniel Schmidt, MSW, LSW
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Introductions
Motivation and Strengths
Motivational Interviewing (MI)
Direct and Indirect Use of MI
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As a Therapy Tool
As a Management Tool
Thoughts, comments, questions
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Attendees will have an understanding of
strengths-based concepts and skills associated
with Motivational Interviewing.
Attendees will understand the use of MI
techniques in clinical settings as well as
supervision and dealing with other
stakeholders.
Attendees will understand the “Ten strategies
for evoking change talk” needed as a basis for
MI.
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Motivation is defined as the desire and action
towards goal-directed behavior.
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Intrinsic Motivation: A person is intrinsically
motivated if the desire for change comes from within
the individual
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Extrinsic Motivation: A person is extrinsically
motivated if the desire for change comes from the
outside, i.e. a bribe or reward to do something.
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Understand the strengths, limitations,
motivation for change, and resistance to change
that are applicable to the persons and systems
involved.
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Family and friends
Education/employment
Problem solving/decision making
Personal qualities and characteristics
Physical and financial resources
Attitudes and perspectives
Miscellaneous strengths
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Who Are You?
Complete the following four “who are you”
statements. They can be adjectives, nouns, or
longer statements.
I am
___________________________________________________
 I am
___________________________________________________
 I am
___________________________________________________
 I am
___________________________________________________
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Who Are You?
Cite your greatest “strengths”. They can involve
anything from personal qualities to talents to
accomplishments. They do not have to be in any
particular order or priority.
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Strength:
___________________________________________________
Strength:
____________________________________________________
Strength:
____________________________________________________
Strength:
____________________________________________________
Who Are You?
How do you think your personal strengths will
help you to work with clients in social work
practice?
How do you think knowing your personal
strengths will help you find strengths in your
clients, supervisees, other involved parties?
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This type of motivation comes from the results
one gets from the task itself or from the sense
of completing or even working on a task.
School Grades
 Monetary Gains
 Awards or Recognition
 Punishment
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Intrinsic versus Extrinsic??
Which is most valuable in Motivational
Interviewing?
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A Definition
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Motivational Interviewing is a person-centered,
strengths-based, directive method of communication
for enhancing intrinsic motivation to change by
exploring and resolving ambivalence.
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Principles in the Practice of MI
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Find Strengths
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Evoke “Change Talk”
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Roll with Resistance
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Support Self-efficacy (directive approach)
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Relapse as an opportunity not a failure
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Focus on Ambivalence
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Stages of Change
Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Relapse & Recycling
Termination
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Ask Evocative Questions: Ask open ended questions,
the answer to which is change talk.
Explore Decisional Balance: Ask first for the good
things about the status quo, and then ask for the notso-good things.
Ask for Elaboration and examples: When a change
talk theme emerges, ask for specific examples.
Look Back: Ask about a time before the current
concern emerged.
Look forward: Ask what may happen if things
continue as they are (status quo). Ask, “if you were
100% successful in making changes, what would that
look like?”
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Query extremes: What are the worst things that might
happen if you don’t make this change? What are the
best things that might happen if you do make this
change?
Use change rulers: Use positive scales.
Explore Goals and Values: Ask what a person’s
guiding values are. What do they want in life?
Come alongside: Explicitly side with the negative
(status quo) side of ambivalence. Perhaps _______ is
so important to you that you won’t give it up, no
matter what the cost.
Change Talk
Problem recognition:
What things make you think that your drinking may
be a problem?
 How has your drinking stopped you from doing
some things you want to do?
 In what ways do you think you or other people have
been harmed by your drinking?
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Change Talk
Concern:
What worries you about your drinking?
 How much does this concern you?
 In what ways does this concern you?
 What do you think will happen if you don’t make a
change?
 How do you feel about your drinking?
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Change Talk
Intention to Change:
What makes you think that you may need to make a
change in your drinking?
 What makes you think it is time for a change?
 What would be the advantage of making a change?
 I can see you are feeling stuck. What is going to have
to change?
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Change Talk
Optimism:
What makes you think if you decide to make a
change in your drinking, you could do it?
 What encourages you that you can change if you
want to?
 What do you think would work for you, if you
decided to change?
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Seeking to understand the client’s frame of
reference is done thru reflective listening.
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Expressing acceptance and affirmation
Eliciting and selectively reinforcing the client’s own
self motivational statements expression of problem
recognition, concern, desire and intention to change,
and ability to change.
Monitoring the client’s degree of readiness to
change, and ensuring that resistance is not generated
by jumping ahead of the client.
Affirming the client’s freedom of choice and selfdirection.
Gordons Twelve Roadblocks To
Good Listening
Ordering or Directing
Warning or Threatening
Giving Advice/Suggestions
Persuading with logic, arguing,
lecturing
Moralizing, preaching
Judging, criticizing, blaming
Agreeing, approving, praising
Shaming, ridiculing, labeling
Interpreting or analyzing
Reassuring, sympathizing, consoling
Questioning or probing
Withdrawing, distracting, humoring
Resistance
Simple Reflection: Re-stating what the client has said
to you to insure you have heard the client correctly.
 Amplified Reflection: Adding something to increase
the intensity of what the client is saying.
 Double-Sided Reflection: Reflect the Ambivalence
that a client is thinking/feeling in responding to
what they are saying.
 Shifting Focus: Moving the client away from a
difficult issue that is not necessary to discuss at this
point in time.
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Resistance
Reframing: Make a change in the meaning of what
the client might say.
 Agreement With a Twist: Use reflection followed by
a reframe in responding to the client.
 Emphasize Personal Choice and Control: Making
sure that the client knows that the choice to change
or not change a behavior is entirely up to them.
 Siding with the Negative: Placing emphasis on the
reasons a client may be resistive to change a thought
or behavior.
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Support Self-Efficacy
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Directive Approach (with a twist)
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The extent or strength of one's belief in one's own
ability to complete tasks and reach goals
Directive counselling is where the therapist follows a
line of therapy right for the client's condition.
Relapse as an opportunity not a failure
“I want to, but I don’t want to”
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Natural phase in process of change
Problems persist when people “get stuck” in
ambivalence
Normal aspect of human nature, not
pathological
Ambivalence is the key issue to resolve for
change to occur
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This is a state of discomfort that needs to exist within
the client, what the client wants from life and the
contradiction of the self-destructive nature of the
addiction. In MI this type of discomfort is not one to
be avoided but rather to be a catalyst for change. The
development of the discrepancy is used to allow the
client to see how the addiction might be at odds with
what they say they want. Here again it is imperative
that the client be the one to discover and explore
these facts with a directive approach. Otherwise
developing discrepancy could turn into resistance
and not benefit the client.
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The Spirit of Motivational Interviewing
MI
Collaboration
Evocation
Autonomy
Self Efficacy
Discrepancy
The Opposite
Confrontation
Education
Authority
Intimidation
Absolute Direction
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Strengths-based intervention
Elicits motivation from within people in order
to promote a change in behavior
Needs a confrontation to arise and confront
ambivalence within the client
Discomfort for the client towards a behavior
should increase the probability of change
Client centered counseling
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Motivation to change is elicited from the client
and not imposed from without.
It is the client’s task, not the counselor’s, to
articulate and resolve his or her ambivalence.
Direct persuasion is not an effective method for
resolving ambivalence.
The counseling style is generally a quiet and
eliciting one.
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The counselor is directive in helping the client
to examine and resolve ambivalence.
Readiness to change is not a client trait but a
fluctuating product of interpersonal
interaction.
The therapeutic relationship is more like a
partnership or companionship than
expert/recipient roles.
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Combines Motivational Interviewing with
client feedback of their assessment results
Not limited to a particular set of assessment
measures, only need comparison to some set of
norms
Asks for client’s responses to feedback rather
than telling clients what they should think or
do
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Differences from other Treatment Approaches
Lack of diagnostic labels
 Emphasizes personal choice regarding future use of
substances
 Non-confrontational
 Uses reflection rather argumentation
 Relies on clients’ own natural change processes and
resources
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A student/supervisee with several years’
experience working with a population who thinks
she/he has mastered the skills needed to work
with that population.
A very timid student/supervisee or one with low
self-esteem or lack of confidence.
A very young, inexperienced, or anxious
student/supervisee dealing with abusive clients.
An angry or judgmental student/supervisee who
may feel the population or work is beneath them.
Students/supervisees with real life experience in
treatment area who may feel that they have all the
answers
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Miller, W. (1995). Motivational enhancement therapy with drug
abusers. Department of Psychology and Center on Alcoholism,
Substance Abuse, and Addictions. University of New
Mexico, New Mexico.
Rollnick, S. (2004). Motivational interviewing. In N. Heather & T.
Stockwell (Eds). The essential handbook of treatment and
prevention of alcohol problems. (pp. 105 – 110) New York:
John Wiley & Sons
Thoughts, Comments, Questions