Transcript PowerPoint Presentation - Motivational Interviewing

Motivational Interviewing
• A directive, client centered counseling style for
eliciting behavior change by helping clients
explore and resolve ambivalence.
• Designed to produce rapid, internally motivated
change by mobilizing the client’s own change
resources.
Miller and Rollnick, 1991
Problems with Standard Practice
• Unwelcome advice elicits resistance
• Advice must match motivation
• Client knowledge of facts is weakly correlated
with behavior
• Only 5% to 10% of the variance in change
behavior due to knowledge
• Variability in personal motivation
Motivational Interviewing:
• Client determines treatment plan
• Avoid unsolicited advice
• Involves the best basic counseling skills
• Express empathy
• Use good nonverbal listening skills
• Problem solving partners
Motivational Interviewing:
• Righting Reflex
• Tendency to set the person on the right path
• Offering single alternatives may yield a “yes, but” response
• Pulls for psychological reactance
• (Reactance theory of Jack & Sharon Brehm of KU)
• Important to inhibit your righting reflex
Common Traps to Avoid
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Question-Answer trap
Confrontation-Denial trap (Mother of all traps)
Expert trap
Labeling trap
Premature focus trap
Blaming trap
OARS
• Open ended questions
• Affirmations: comment on strengths,
effort, intention
• Reflective listening
• Summaries: pulling together the person’s
perspectives on change
Go from questions to reflections
• You...
• It’s as if...
• Sounds like...
• Attend to VOICE inflection at end of
statement, to turn it into a reflection.
• A question demands an answer.
• A reflection invites a response.
Ratio of Reflections to Questions
• When done well, the ratio is 2 reflections to
every question
• Beginners are usually 2 questions for every
reflection
• Shoot for 1-1 as a starting point
Affirmations
• End up being the least often used of the OARS
--Not that they SHOULD be, just that they are.
Motivational Interviewing
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Get permission to proceed
Open ended (starting) questions (to get the ball rolling)
Reflective listening (keep it rolling)
Summarizing (stop, assess, move on)
Elicit self-motivational statements
Menus vs. Single solutions
You provide info., client interprets it
Getting Permission
When Getting Started
“I’d like to spend a few minutes talking
about…
your smoking
your medication
your alcohol use
“Is that ok with you?”
Change the Closed Ended Questions to Open
Ended Questions
ADHERENCE/HEALTH BEHAVIORS
So are you taking your medication everyday?
You’re not experiencing any side effects are you?
Do you have any questions about your new medicine?
Should I call you on Monday? How about 9:00 am.?
You still doing drugs?
Are you still doing drugs because you are too stressed at work to stop?
Open ended ?s: More Practice
• Are you pleased with the new medicine Dr.
Jones gave you last time?
• Does your child like the teachers and kids at
his new school?
• Do you have any major fears about your
upcoming operation?
• Is everything ok with your leg?
Open ended Starters
“I see from your chart that…
You are drinking around 4 drinks a day
Your blood sugar is a bit high
“How do you think this affects your health?”
“What do you make of this…?”
“Tell me about your…”
Open ended Starters
Open
VS
To what extent…
How often…
Why…
Tell me about…
Help me understand…
Closed
Did you…?
Will you…?
Can you…?
Is it…?
Reflective Listening
• Statement, not a question
• Ends with a down turn
• Hypothesis testing
• If I understand you correctly, it sounds like…
• Affirms and validates
• Keeps the client thinking and talking
Universal Safe Reflections
• It sounds like this has been tough for you…
• It sounds like you are not happy with…
• It sounds like you are a bit uncomfortable
about…
• It sounds like you’re not ready to…
• It sounds like you are having a problem
with…
Reflective Listening
Restating
Responding to Content
“It sounds like…..”
Rephrasing
Responding to Affect
“You feel….”
Paraphrasing
Deducing
Responding to Meaning
“You feel….BECAUSE”
Summarizing
Let me see if I understand what you’ve told me
so far…
Ok, this is what I have heard so far…
Follow up with
Ok, how did I do?
What have I missed?
Anything you want to correct?
Summarizing
If there is client ambivalence about the issue
summarize both the pros and cons
So, it sounds like you have several reasons why you
want to (quit, start, increase) but on the other hand
there are things you like about (smoking, cocaine)
that you aren’t sure if you want to give up or things
you are worried about experiencing if you stop
(smoking, cocaine).
Review
• See Change Talk in DARN-C
• Pull for Change Talk using OARS
• Up the Change Talk ante with
evocative questions
elaboration
extremes
looking back
looking forward
explore goals
assessment feedback
readiness rulers
Developing Discrepancy
• No discrepancy, no motivation
• Example 1- Weight Loss
– So, according to your weight today, you gained a few
pounds. What do you make of this?
– According to your food record, you ate at McDonalds twice
this past week. What do you think you should do about
this?
Developing Discrepancy
• Example 2- Addictive Behavior
– You mentioned that your motivation to quit
smoking is a 10 and your confidence is a 9. Yet,
you haven’t quit yet. What do you make of this?
Eliciting SMS
STAGE 2: Building on the positives
Method 1) What would it take…
So, you are…(somewhat) interested in quitting…could
you tell me what it would take to make you very
interested?
You answered “somewhat confident” rather than
very “confident”, could you tell me what it would
take to make you feel very confident in your ability
to quit?
Variation: What can I (or we) do to help you move up
to a 9 or 10?
Eliciting SMS
Stage 1: Diagnosis Strategy 2
Good things and not so good things/Pros and Cons
Could you tell me some of the things you enjoy about…
Could you tell me some of the reasons why you might want to change your …
Could you tell me some of the things you don’t like about…
Could you tell me some of the reasons why you may not want to
change….(fears, barriers)
How might your life be different if you …(lost weight)
What benefits, if any, might there be if you…
How, if at all, does smoking affect your job?
What are some of the negative things about continuing your smoking?
Working with Ambivalence
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Evocative questions
Find and reinforce Change Talk (pick flowers)
Summarize (bouquets)
Explore values
– develop discrepancy between ideal and current
– What do you need to do to live out these values
better?
MENU
Here are some of things that have worked for
other people
1.) Amazing strategy 1
2.) Amazing strategy 2
3.) Amazing strategy 3
Which of these do you think might work best
for you?
Which of thee might you be willing to try?
MENU (Prioritizing)
Controlling your weight may involve several
behavior changes including:
1.) eating less
2.) eating more fruits and vegetables
3.) eating smaller portions
4.) eating fewer desserts
5.) exercising more
Which of these would you like to work on first?
Which of these do you think are more important to
deal with?