Transcript here - CTAC Home Page
Presented by: Matt Wofsy, LCSW Brian Mundy, LCSW
The Institute For Community Living, Inc.
2012 Clinical Lunch & Learn Webinar Series
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Develop an understanding of Motivational Interviewing (MI) & how it may be used in clinic settings Review the fundamental principles of MI & the Stages of Change Model Acquire an understanding of basic MI techniques 2
Founded by William Miller and Stephen Rollnick in the substance abuse field Based on research involving recorded conversations Has been found efficacious in dozens of other areas, including lifestyle changes, medication adherence, child obesity, diabetes, treatment adherence, etc.
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1. To support the enhancement of intrinsic motivation 2. To support the client’s self-efficacy 3. To assist the client to resolve ambivalence 4
Ambivalence:
Feeling two ways about something Examples of feeling ambivalent every day Ambivalence is natural and an essential part of being human Oftentimes ambivalence for clients is regarding big life changes 5
Ambivalence is a bit like a see-saw …
Part of the person that does not want to change Part of person that wants to make changes
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Ambivalence is a bit like a see-saw … 7
The working assumption is that intrinsic motivation is a necessary and often sufficient factor in instigating change.
Intrinsic vs. Extrinsic motivation ◦ ◦ ◦ Examples of extrinsic motivation: ◦ Child protective services School principal/guidance counselor Parole officer Family court ◦ ◦ Examples of intrinsic motivation ◦ Desire for healthy relationships Increased independence Freedom 8
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◦ ◦ Precontemplation – Not ready to make a change; sees no real problem in need of treatment Example intervention: provide feedback, emphasize client responsibility Contemplation – Unsure whether or not he/she has a problem Decisional balancing (pros/cons) ◦ Determination/Preparation – Recognizes there is a problem and is ready to make a change in near future Explore expectations around change process ◦ Action – Not only recognizes the problem, but is already trying to change Troubleshoot barriers; Normalize that things might be harder ◦ Maintenance – Has already made changes and is now working to hold onto those gains & not slip back into old patterns Relapse prevention ◦ Recurrence – Common, expectable, & likely to happen several times; can occur at any point Emphasize learning from the recurrence 10
The stages of change are more accurately portrayed as a wheel … Recurrence Pre contemplation Contemplation Maintenance Preparation Action 11
True or False?
A person with clinical depression can be in the action stage around attempting behavior change but in pre contemplation around re-visiting the psychiatrist TRUE True or False?
A person can be in action regarding improving parenting skills one week but in pre-contemplation the following week TRUE 12
Which stage of change is indicated? a) Pre-contemplation b) Contemplation c) Preparation d) Action e) Maintenance “I can’t believe that my parents dragged me here. I mean so what if I cut school a few times? Everyone cuts class once in a while. I don’t need therapy, my parents are the ones who need therapy.”
In Pre-contemplation
Which stage of change is indicated? a) Pre-contemplation b) Contemplation c) Preparation d) Action e) Maintenance “The other night we got into a fight again. My boyfriend took it too far this time. I was really close to packing a bag and calling my sister about bringing the kids so we can stay with her. This has been going on for too long.”
In Preparation
E.D.R.S
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Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy
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1.
Express Empathy –The MI therapist seeks to communicate great respect for the consumer: • • • • • Avoid communication that implies a superior/inferior relationship Client’s freedom of choice & self-direction are respected Listen, rather than tell.
Gentle, non-aggressive persuasion.
We communicate an acceptance of clients as they are,while also supporting them in the process of change.
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2.
Develop Discrepancy - motivation for change occurs ◦ ◦ ◦ when people perceive a discrepancy between where they are and where they want to be.
Focus the consumer’s attention of these discrepancies. Precontemplators don’t have this this discrepancy – we have to help create it by exploring the consequences of current behavior. Move the consumer along the stages of change.
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3.
◦ ◦ ◦ ◦ Rolling with Resistance -- ambivalence is normal; resistance is expected. Explore the ambivalence with the consumer in a supportive, unthreatening way. Avoid Arguments – attacking the consumer’s behavior tends to evoke defensiveness, opposition & resistance. No attempt is made to get the consumer to ‘admit’ there is a problem When MI is done well, it is the consumer and not the
counselor who voices the arguments for change!
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4.
Support Self-efficacy – the consumer’s specific belief that he or she can change. • If one has little hope that things could change, there is little reason to face the problem.
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O.A.R.S.
Open-ended Questions
Affirmations
Reflective Listening
Summaries
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Open Questions:
How many children do you have? Vs. Tell me about your family. Did you get in trouble at school today? Vs. Tell me about your day at school.
How often do you visit with friends? Vs. Tell me a little about your friends.
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Affirmations:
Statements that recognize consumer strengths.
Help consumers feel change is possible. (Hope is really important!) Can be used in response to resistance Must be genuine 22
Reflective Listening:
This is the Key Focus on ‘change talk’ Reflect affect Tone of voice is important Keep momentum flowing through reflections Validate where client is coming from before launching into problem-solving. 23
Reflective Listening: Level 1 | Simple Reflection
Simply repeat or rephrase.
Consumer: I don’t want to go to school, that teacher is wack!
Counselor: You don’t like the teacher, so you feel like school is a waste of time Consumer: Therapy sucks; I don’t want to be here right now.
Counselor: You really don’t want to be here.
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Reflective Listening: Level 2 | Reframe Reflection
Listen for client’s “best perceived self” in the statement and reframe it back to client.
Consumer: I don’t want to go to school, that teacher is wack!
Counselor: So school is not meeting your needs right now, and you want to exercise your ability to choose not to go Consumer: Therapy sucks; I don’t want to be here right now.
Counselor: You really value your time and you don’t think that this is the best use of it.
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Reflective Listening: Level 3 | Affective Reflection
Listen for the emotion behind the statement and reflect it back to client.
Consumer: I don’t want to go to school, that teacher is wack!
Counselor: You’re not getting anything from this teacher and this whole conversation about school is getting you frustrated Consumer: Therapy sucks; I don’t want to be here right now.
Counselor: You’re angry that you are here and resent even having to talk about it 26
Summarizing:
Just a special form of reflective listening where you reflect back what the consumer has been telling you Summarizing presents an opportunity to begin mapping out the client’s ambivalence Builds rapport Do frequently 27
Summarizing
“Let me stop and see if I have this right. You clearly don’t want to be here right now and you think that it’s a waste of time. Your foster parents have made you go to therapy in the past, and it really hasn’t gotten you anywhere. You feel like you can call your own shots, and you know what’s best for you. At the same time, you’re tired of getting grounded and fighting with your foster mother. You worry that, if this is left untouched, life in your current foster home will remain stuck and you’ll continue to feel bored and angry most of the time. Did I get that right?” 28
◦ ◦ Six elements of effective MI have been identified and were presented in brief clinical trials, and the acronym FRAMES was coined to summarize them: ◦ Feedback regarding personal risk or impairment us given to the client following assessment of behavioral patterns and associated problems ◦ Responsibility for change is placed squarely and explicitly on the client ◦ Advice about changing, reducing, or stopping problematic behaviors is clearly given to the client by provider in non judgmental manner Menu of Options is developed toward self-directed change Empathic counseling – showing warmth, respect, and understanding – is emphasized ◦ Self-efficacy or optimistic empowerment is engendered in the client to encourage change 29
We clinicians often get activated by felt lack of progress and personal responsibility We feel like we have to do something!
Sometimes this drives us to over-function and take the reins of the change agenda ◦ ◦ Documentation provides a useful framework for slowing the process down and crystalizing clinicians on-the-ground efforts Client remains in pre-contemplation around substance use Clinician provided feedback, emphasized client’s responsibility, and rolled with resistance in the service of maintaining a non-argumentative position with the client 30
The technical aspects of MI – such as decisional balancing, reflective listening, rolling with resistance, feedback, emphasis on natural consequences, and developing discrepancy – are mostly designed to put the argument for change inside the individual As long as the clinician is not sending the client to the hospital, he/she needs to be able to sit with client choices so that his/her change agenda does not get in the way of the development of an internal argument and natural, sustained change on the part of the client 31
http://www.motivationalinterview.org/ http://www.motivationalinterview.org/Documents/1%20A%20MI% 20Definition%20Principles%20&%20Approach%20V4%20012911.p
df Motivational Interviewing as a counseling style: http://kap.samhsa.gov/products/manuals/tipcurriculum/pdf/pm odule05.pdf
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. (2nd ed.). New York: Guilford. Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2008). Motivational interviewing: In the treatment of psychological problems. New York: Guilford.
Narr-King, Sylvie & Suarez, Mariann. (2011) Motivational Interviewing with Adolescents and Young Adults. New York: Guilford.
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Q&A Next Webinar: Visit www.ctacny.com
July 13, 2012-Trauma Part 1: Assessment with Elizabeth Meeker, Ph.D.
And, email us with any questions/ concerns: [email protected]
THANK YOU FOR JOINING US!!
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