Transcript Motivational Interviewing
Motivational Interviewing
Chapter 6 Phase 1: Building Motivation for Change
Phase one of MI involves building intrinsic motivation for change.
Phase two involves strengthening commitment to change and developing a plan to accomplish it.
The amount of work to be done will depend on the person's starting point
Importance and Confidence
It is useful in understanding a person's ambivalence to know his or her perceptions of both importance and confidence
Importance and Confidence
• You can asses importance and confidence using the scaling questions method • "How important would you say it is for you to __________? One a scale from 0-10, where 0 is not at all important and 10 is extremely important, where would you say you are?" • "How confident would you say you are, that if you decided to ________, you
could
do it? On the same scale from 0-10 where 0 is not at all confident and 10 is extremely confident, where would you say you are?"
• Phase 1 can involve either importance work or confidence work, or both. In essence, you are helping the client to become ready, willing and able to change.
Some Early Traps to Avoid
1)
Question-Answer Trap
- Using a Q&A format, even if it's open ended questions, affords little opportunity for a person to explore motivation and to offer change talk.
Some Early Traps to Avoid
• 1)
Question-Answer Trap
- The optimal approach is usually to ask an open-ended question, then to respond to the client's response not with another question but with reflective listening.
• As a general clinical guideline, avoid asking three questions in a row.
Some Early Traps to Avoid
2)
Trap of Taking Sides
- If people usually enter counseling in a state of ambivalence, they feel two ways about their current situation: they want it and they don't want it. If the counselor argues for one side of the conflict, it is natural for the client to give voice to the other side. Few people enjoy losing an argument or being proved wrong.
Some Early Traps to Avoid
• 3)
Expert Trap
- There is an appropriate time for expert opinion but the focus of Phase 1 is first on building the client's own motivation.
• Within motivational interviewing, in a real sense it is the client who is the expert.
Some Early Traps to Avoid
3)
Expert Trap
- No one knows more about his or her situation, values, goals, concerns and skills.
No one is in a better position to anticipate how change will fit into the person's life.
Motivational Interviewing is about collaboration not installation.
Some Early Traps to Avoid
4)
Labeling Trap
– Can evoke a power struggle.
Counselor’s need to assert control and expertise. A form of judgmental communication.
Can evoke feelings of being cornered.
Some Early Traps to Avoid
4)
Labeling Trap
- The danger, of course, is that the labeling struggle evokes dissonance, which descends into side taking and, in turn hinders progress.
Problems can be fully explored without attaching labels that evoke unnecessary dissonance.
Some Early Traps to Avoid
5)
Premature-Focus Trap
- Resistance may result if client and counselor wish to focus on different topics.
The trap here is to persist in trying to draw the client back to talk about your own conception of "the problem".
5)
Premature-Focus Trap
- Starting with the client's concerns, rather than those of the counselor, will ensure that this does not happen.
5)
Premature-Focus Trap
- Spending time listening to the client's concerns is useful, both in understanding the person and in building the rapport that is the basis for later exploration of other topics. Get a broader understanding of the client's life situation before coming back around to the topic.
Some Early Traps to Avoid
6)
Blaming Trap
- If this issue is not dealt with properly, time and energy can be wasted on needless defensiveness.
Counseling has a 'no-fault' policy.
Rapport
- a feeling of commonality or being 'in-synch' with another person. Harmonious communication.
You are providing a service and you can’t provide it if you don’t listen to the client’s needs.
Five Early Methods
Building Motivation for Change Using OARS+ 1. Ask
O
pen Questions 2. Listening
R
eflectively 3.
A
ffirm 4.
S
ummarize 5. Eliciting
Change
Talk The first four are derived largely from client centered counseling. The fifth method is more clearly directive and is specific to motivational interviewing
O – Open Ended Question
1. Ask Open Questions - The client should do most of the talking at this stage. Use questions that elicit elaboration.
R – Listening Reflectively
2.
Listening Reflectively
- The essence of a reflective listening response is that it makes a guess as to what the speaker means. It's a statement vs. a question. A well-formed reflective statement is less likely to evoke resistance.
2.
Listening Reflectively
- In the dynamics of language, a question requires a response. Reflective statements are statements of understanding.
Keep a continual awareness that what you believe or assume people mean is not necessarily what they really mean. Reflective listening is a way of checking, rather than assuming that you already know what is meant.
Skillful reflection moves past what the person has already said and can include reflection on non-verbal communication such as a smile on the person’s face, the tone of their voice or their body language.
Note: If you overstate the intensity of what a person is saying or doing the person will tend to deny and minimize it.
If you slightly understate the expressed intensity of emotion, however, the person is more likely to continue exploring and telling you about it.
The counselor decides what to reflect and what to ignore.
Change talk is preferentially reflected, so that people hear their own statements at least twice.
Reflection is particularly important after open-ended questions. See page 68 for 12 kinds of responses that are not listening.
A - Affirming
3.
Affirm
- This can be done in the form of compliments or statements of appreciation and understanding. The point is to notice and appropriately affirm the client's strengths and efforts.
S - Summarize
4.
Summarize
- Summary statements can be used to link together and reinforce material that has been discussed.
S - Summarize
Summary statements 1. Reinforce what has been said 2. Show that you have been listening carefully 3. Prepare the client to elaborate further 4. Allow a person to hear his or her own change talk for a third time.
S - Summarize
At least three kinds of summaries are useful in motivational interviewing: 1. Collecting Summaries 2. Linking Summaries 3. Transitional Summaries
S - Summarize
•
Collecting Summary
- Usually short, just a few sentences. Should continue rather than interrupt the person's momentum. It is useful to end them with "What else?" or some other invitation to continue. "What else?" is open-ended where as "Is there anything else?" is a closed-ended question. It's like collecting flowers one at a time and giving them back to the person as a bouquet.
S - Summarize
•
Linking Summary
- Linking summaries are meant to encourage the client to reflect on the relationship between two or more previously discussed items. A linking summary is one way to allow a person to examine the positives and negatives simultaneously, acknowledging that both are present.
S - Summarize
Linking Summary
- To help a person see the two sides of ambivalence yet to highlight the desired change, you can use conjunctions like "yet", "but". As in, "On the one hand you enjoy smoking weed because it helps you feel calm, yet it costs a lot of money and you could probably find better ways to feel calm without having to spend all that money."
S - Summarize
•
Transitional Summary
- Marks and announces a shift from one focus to another. At the end of the first session it can be helpful to offer a substantial transitional summary, pulling together what has transpired thus far.
+ Eliciting Change Talk
5.
Eliciting Change Talk
- The fifth method is consciously directive. Evoking change talk is one of the key motivational interviewing skills.
8 Methods for Evoking Change Talk
1. Asking Evocative Questions 2. Using the Importance Ruler 3. Exploring the Decisional Balance 4. Elaborating 5. Querying Extremes 6. Looking Back 7. Looking Forward 8. Exploring Goals and Values
8 Methods for Evoking Change Talk
1.
Asking Evocative Questions
- Evoke To call forth or up. Use open-ended questions that cause a person to think and reflect on their answer
8 Methods for Evoking Change Talk
2.
Using the Importance Ruler
- (i.e. Scaling Questions) "Why are you at a ______ and not a zero?" Note that one should not ask, "Why are you at a _____ and not a 10?" because to answer that question is to argue against change.
8 Methods for Evoking Change Talk
3.
Exploring the Decisional Balance
Exploring the pros and cons 4.
Elaborating
- Have the client elaborate or expand on the change talk before moving forward. (see examples on next slide)
Ways to elicit elaboration:
1. Asking for clarification: In what ways? How much? When?
2. Asking for a specific example: Can you give me an example?
3. Asking for a description of the last time this occurred: Tell me about a time when this happened in the past 4. Asking "What else?" within the change topic. This is a form of an Open-Ended Question.
8 Methods for Evoking Change Talk
5.
Querying Extremes
- Ask people to describe the extremes of their (or others') concerns, to imagine the extreme of consequences that might ensue. Best case and worst case scenarios
8 Methods for Evoking Change Talk
6.
Looking Back
- Have the client remember times before the problem emerged and to compare these times with the present situation
8 Methods for Evoking Change Talk
7.
Looking Forward
- Helping people envision a changed future. Ask the client to tell you how it might be after a change. Similarly, you can invite the client to look ahead in time and anticipate how things might be if no changes are made
8 Methods for Evoking Change Talk
8.
Exploring Goals and Values
- Ask the client to tell you what things are most important in his or her life. Discover ways in which current behavior is inconsistent with or undermines important values and goals for the person
Summary
Eliciting change talk is a primary method for developing discrepancy. Hearing oneself state the reasons for change tends to increase awareness of the discrepancy between one's goals and present actions. Evoking change talk can serve as a continuing reminder of the reasons for commitment to change.