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Motivational Interviewing

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Title: Motivational Interviewing


1
Motivational Interviewing Ed Stellon, Heartland
Alliance
2
Introductions
  • Who are you?
  • With which program and in what capacity are you
    working?
  • What do you hope to learn from this workshop?

3
Heartland AlliancePhilosophy of Care
  • Human Rights
  • Harm Reduction
  • Strength-Based Assessment Intervention
  • Trauma-Informed
  • Invite, Recognize, Embrace Differences

4
Primary Source
  • Miller, W. R. Rollnick, S. (2002). Motivational
    interviewing Preparing people for change, Second
    Edition. New York The Guilford Press.

5
  • Anyone who willingly enters into the pain of a
    stranger is truly a remarkable person.
  • Henri J. M. Nouwen

6
  • When given a choice between changing and proving
    that it is not necessary, most people get busy
    with the proof.
  • John Galbraith

7
Are you Ready?Importance and Confidence
  • How important is it to you now to learn new ways
    to enhance the motivation of your participants?
  • How confident are you that you could employ new
    methods if you wanted to?

8
Stages of Change
9
Research Evidence Suggests
  • A cyclical pattern of movement through specific
    stages of change
  • A common set of processes of change
  • A systematic integration of the stages and
    processes of change (doing the right things at
    the right times)

10
Stages of Change
  • Precontemplation
  • Contemplation
  • Determination/Preparation
  • Action
  • Maintenance
  • Termination

11
Stages of Change
PRE-CONTEMPLATION Not yet considering possibility
of change.
RELAPSE Help renew contemplation, action without
giving up.
CONTEMPLATION Considers change rejects
it.Reasons for concern vs. justifications for
concern
MAINTENANCE Identify Strategies support
to prevent relapse
PREPERATION or DETERMINATION Ive got to
do something about this problem. This is
serious. Something has to change.
ACTION
12
Stages of Change
  • Precontemplation No intention to change
    behavior in the foreseeable future. Individuals
    in this stage are unaware or underaware of their
    problem(s).
  • Not even thinking about it

13
The Five Rs of How and Why People Stay in
Precontemplation
  • Reveling
  • Reluctance
  • Rebellion
  • Resignation
  • Rationalization

14
Stages of Change (cont.)
  • Contemplation A person is aware that a problem
    exists, are seriously considering changing, and
    have not yet made a commitment to take action.
    Contemplators perform a risk-reward analysis.
  • Thinking about it or maybe

15
Stages of Change (cont.)
  • Preparation Individuals are intending to take
    action and may practice some of the behaviors
    necessary.
  • Getting ready to do it
  • Action In this stage individuals modify their
    behavior, experiences, or environment in order to
    overcome their problems. Doing it
  • Maintenance Individuals in this stage work to
    prevent lapse/relapse and consolidate gains.
    Living it
  • Termination The problem ceases to be a problem.
    Moving on

16
STAGES OF CHANGE THERAPIST TASKS
Raise doubt - Increase the participants
perception of risks and problems with current
behavior
PRECONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing Strengthen
self-efficacy for behavior change
CONTEMPLATION
Help to determine the best course of action to
take in seeking change Develop a plan
PREPARATION
Help implement the plan Use skills Problem
solve Support self-efficacy
ACTION
Help identify and use strategies to prevent
lapse/relapse Resolve associated problems
MAINTENANCE
Help recycle through the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
RELAPSE
17
TerminationLeaving the Cycle of Change
  • Low temptation
  • High self-efficacy
  • Firmly established pattern of new behavior
  • New behavior is normative
  • Multiple changes in other dimensions to sustain
    change

18
Approaches to Change
19
Why Do People Change?
  • People change voluntarily only when
  • They become interested in or concerned about the
    need for change
  • They become convinced that the change is in their
    best interests or will benefit them more than
    cost them
  • They organize a plan of action that they are
    committed to implementing
  • They take the actions that are necessary to make
    and sustain the change

20
Motivational Statements
  • The beatings will continue until morale
    improves.
  • If you dont stop crying, Ill give you
    something to cry about.
  • You will take this medicine, because as your
    Doctor, I say so.
  • If you dont stop, I guarantee something bad
    will happen!

21
Motivational Approaches
  • Coercion
  • Persuasion
  • Constructive Confrontation
  • External Contingencies (threats)
  • Bribe/Incentive
  • Beg

22
  • People are generally better persuaded by the
    reasons they themselves discover than by those
    that enter the minds of others.
  • Pascal

23
  • It is the truth we ourselves speak rather than
    the treatment we receive that heals us.
  • O. Hobart Mowrer

24
Predictable Effects of Confrontation
  • Resistance Non-cooperation
  • Reversal Eliciting the Opposite in
    Ambivalence
  • Reactance Assertion of Autonomy

25
Q
Where does the statement
You have a problem.
get you and the participant?
A
26
In motivational interviewing, confrontation is the
GOAL, not a style.
27
The purpose of confrontation is to see and accept
reality,
so one can change accordingly.
28
Ambivalence
  • Conflict between two courses of action
  • Normal, acceptable, and understandable
  • Must be resolved to move forward with change and
    reduce the probability of lapse/relapse

29
What is Motivation?
  • Motivation can be thought of not as a
    participant attribute, but as an interpersonal
    process between therapist and participant.
    Research clearly demonstrates that the
    interaction between therapist and participant
    powerfully influences participant resistance,
    adherence, and change.

30
Motivation The Change Process
  • Participants are not unmotivated. They are just
    motivated to engage in behaviors that others
    consider harmful and problematic or are not ready
    to begin behaviors that others think would be
    helpful.

31
What is Motivation?
  • The proper question is not,
  • Why isnt this person motivated?
  • But rather,
  • For what is this person motivated?

32
Principles of Motivational Interviewing
33
The Spirit of Motivational Interviewing (Miller
Rollnick, 2002)
  • Motivational Interviewing
  • Collaboration
  • Evocation
  • Autonomy
  • Dancing
  • Opposite Approach
  • Confrontation
  • Education
  • Authority
  • Wrestling

34
What is Motivational Interviewing?
Motivational Interviewing is a
directive, client-centered
counseling style that
enhances motivation
for change by
helping the client
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
and where one
is now
wants to be
35
What is Motivational Interviewing?
  • Style
  • Non- Authoritarian
  • Responsibility for change is ultimately left with
    the participant, but the therapist plays a
    crucial role.
  • Evokes high levels of change talk, low levels of
    resistance
  • Consciously collaborative and intentionally
    directive
  • Emphasizes why to change, not how to change

36
Some Things We Do To Get in the Way Roadblocks
to Listening (Gordon, 1970)
  • Ordering, directing, or commanding
  • Warning or threatening
  • Giving advice, making suggestions, or providing
    solutions
  • Persuading with logic, lecturing, or arguing

37
Roadblocks to Listening, cont.
  • Moralizing, preaching, or telling participants
    what they should do
  • Disagreeing, judging, criticizing, or blaming

38
Roadblocks to Listening, cont.
  • Agreeing, approving, or praising
  • Shaming, ridiculing, or labeling
  • Interpreting or analyzing
  • Questioning or probing
  • Withdrawing, distracting, humoring, or changing
    the subject

39
Exercise Roadblocks to Effective Listening
  • Discuss something that you are of two minds
    about. Not trivial and not too revealing.
  • Responder Use at least two of the roadblocks to
    listening.

40
Experience the Problem
  • Ordering, Directing, or Commanding
  • Warning or Threatening
  • Advice, Suggestions, Solutions
  • Persuading, Lecturing, Arguing
  • Moralizing, Preaching, you should
  • Disagreeing, Judging, Criticizing, Blaming.
  • Agreeing, Approving, Praising.
  • Shaming Ridiculing, Labeling.
  • Interpreting, Analyzing.
  • Questioning, Probing.
  • Withdrawing, Distracting, Humoring, Changing
    Subject

41
Principles of Motivational Interviewing
  • Principle 1 Express Empathy
  • Acceptance facilitates change
  • Reflective listening is crucial
  • Ambivalence is normal
  • Necessary, not sufficient
  • Not agreement, approval, permission

42
Express Empathy
  • Convey sense that participants behaviors make
    sense given their context and participants
    current way of thinking about them.

43
Exercise Express Empathy
  • Sentence Stems

44
Principles of Motivational Interviewing
  • Principle 2 Develop Discrepancy
  • Awareness of consequences
  • Change motivated by highlighting discrepancy
    between current behavior and important personal
    goals/values
  • The participant rather than the worker should
    present the arguments for change

45
Principle 2 Develop Discrepancy
  • Examining, exploring, and exercising ambivalence
    requires that participants take more diverse and
    often conflicted experiences and emotional states
    into account
  • Invites participant to consider optionsto create
    space between impulse and action

46
Strategies to Develop Discrepancy
  • Ask open-ended questions that elicit
    self-motivational statements
  • Reflect back, selectively, the self-motivational
    aspects of what the participant states
  • Affirm and reinforce the participant for making
    self-motivational statements

47
Strategies to Develop Discrepancy
  • cont....
  • Offer periodic summaries of self-motivational
    themes
  • Use substance use assessment results

48
Principles of Motivational Interviewing
  • Principle 3 Roll with Resistance
  • Momentum can be used to good advantage
  • Perceptions can be shifted
  • New perspectives are invited, not imposed
  • The participant is a valuable resource in finding
    solutions

49
Principles of Motivational Interviewing
  • Principle 3 Roll with Resistance, cont.
  • Avoid arguing for change defending causes
    defensiveness
  • Resistance is not directly opposed
  • Resistance is a signal to respond differently

50
Principles of Motivational Interviewing
  • Principle 4 Support Self-Efficacy
  • Belief that one can change is an important
    motivator
  • The participant is responsible for choosing and
    carrying out personal change
  • There is hope in the range of alternative
    approaches available
  • The worker's own belief in the persons ability
    to change becomes a self fulfilling prophecy

51
  • If you treat an individual as she is, she will
    stay as she is, but if you treat her as if she
    were what she ought to be and could be, she will
    become what she ought to be and could be.
  • Johann Wolfgang von Goethe

52
Phase 1 Building Motivation for Change
53
Readiness Ruler
Ready
  • Ready A matter of priorities
  • Willing The importance of change
  • Able Confidence for change

Willing
Able
54
Importance and Confidence
55
Phase I Building Motivation To Change
  • Some Early Traps to Avoid
  • Question-Answer Trap
  • Trap of Taking Sides
  • Expert Trap
  • Labeling Trap
  • Premature-Focus Trap
  • The Blaming Trap

56
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
  • -problem recognition -expression of concern
  • -intention to change -optimism about change

57
1. Ask Open Questions
  • Participant should be doing more than half the
    talking
  • Questions that do not invite brief answers
  • Avoid asking three questions in a row
  • Exercise Is It an Open or a Closed Question?

58
2. Listen Reflectively
  • S Face the participant SQUARELY
  • O Adopt an OPEN posture
  • L LEAN toward the participant at times
  • E Maintain appropriate eye contact
  • R Be RELAXED

59
ExerciseLearning to THINK Reflectively
  • Reflective listening
  • One thing I like about myself is
  • You mean that
  • The person initiating may only say, yes or no
    to the reflections
  • Keep going until you have made five correct
    reflections.

60
Reflective Listening
  • There are many clinical skills that are helpful
    when one is doing this work. But the most
    important skill to develop, in practicing harm
    reduction work, is that of listening to our
    clients. They will tell us what they need
    (Little, 2001, p. 31).

61
  • It takes two to speak the truth One to speak,
    and another to hear.
  • Henry David Thoreau

62
3. Affirm
  • Compliments or statements of appreciation and
    understanding

63
4. Summarize
  • Reinforce what has been said
  • Show that you have been listening carefully
  • Prepare the participant to elaborate further
  • Allow participant to hear his or her own change
    talk for a second or third time
  • Type of summaries
  • Collecting
  • Linking
  • Transitional

64
5. Eliciting Change Talk
  • Invite the participant to give the arguments for
    change
  • Types of Change Talk
  • Disadvantages of the status quo
  • Advantages of change
  • Optimism about change
  • Intention to change

65
Methods for Evoking Change Talk
  • Asking Evocative Questions
  • Using the Importance Ruler
  • Exploring the Decisional Balance
  • Elaborating
  • Querying Extremes
  • Looking Back
  • Looking Forward
  • Exploring Goals and Values

66
Questions that Evoke Self-Motivational Statements
  • Disadvantages of the status quo
  • What difficulties have you had in relation to
    your drug/alcohol use?
  • In what ways has this been a problem for you?
  • How does your drug/alcohol use interfere with who
    you want to be?
  • What do you think will happen if you dont change?

67
Questions that Evoke Self-Motivational Statements
  • Advantages of change
  • How would you like for things to be different?
  • What would be the good things about changing?
  • What would you like your life to be like a year
    from now?
  • What are the main reasons you see for making a
    change?

68
Questions that Evoke Self-Motivational Statements
  • Optimism about change
  • 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?
  • Who could offer you support in making this change?

69
Questions that Evoke Self-Motivational Statements
  • Intention to change
  • 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?

70
Decisional Balance
  • Ambivalence is a normal part of the process of
    change
  • Use conflict to promote positive change
  • Weighing pros and cons of behavior
  • Highlighting discrepancy
  • Most useful in Precontemplation and Contemplation
    stages as a tool to increase motivation

71
(No Transcript)
72
Decisional Balance Worksheet
73
Decisional Balance Worksheet
74
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
More control over my life Support from family and
friends Less legal trouble Better health
Not so good things about my drinking
Not so good things about changing my drinking
Disapproval from family and friends Increased
chance of legal and job trouble Costs too
much money
More stress or anxiety Feel more
depressed Increased boredom
75
Conducting a Decisional Balance Discussion
  • Accept all answers. (Avoiding arguing
    with/disputing answers given by participant).
  • Explore answers.
  • Be sure to note both the benefits and costs of
    current behavior and change.
  • Explore costs/benefits with respect to
    participants goals and values.
  • Review the costs and benefits.

76
Exercise
  • Conduct a decisional balance discussion about the
    pros and cons of changing some aspect of his/her
    life, e.g., exercise, smoking, drinking, or diet.

77
Resistance
  • Arises from the interpersonal interaction between
    counselor and participant
  • The participants way of communicating that the
    therapist and participant are at different places
  • Change talk reflects movement of the person
    toward change, resistance represents and predicts
    movement away from change
  • An opportunity

78
Change Talk and Resistance
  • Change Talk
  • Disadvantages of status quo
  • Advantages of change
  • Intention of change
  • Optimism about change
  • Resistance talk
  • Advantages of status quo
  • Disadvantages of change
  • Intention not to change
  • Pessimism about change

79
What causes resistance?
  • Two parties have different goals
  • Mismatch of counselor strategy and participant
    readiness level
  • Participant or counselor start with a high level
    of anger or frustration
  • Roadblocks to communication
  • Misunderstanding of the participants intent
  • Lack of agreement about roles

80
What causes resistance?
  • Counselor Responses
  • Arguing for change
  • Assuming the expert role
  • Criticizing, shaming, or blaming
  • Labeling
  • Being in a hurry
  • Claiming preeminence

81
Strategies for Handling Resistance
  • Simple Reflection (respond with nonresistance)
  • Amplified Reflection (my wife nags she
    doesnt have any reason to worry?)
  • Double-Sided Reflection (on one hand you like
    the effects of pot, but on the other you worry
    about getting caught)

82
Strategies for Handling Resistance
  • Shifting Focus (lets not worry about being
    called an alcoholic, maybe we should focus on the
    consequences)
  • Agreement with a Twist (youre right, alcohol is
    probably not the only thing affecting your
    marriage)
  • Reframing (I know that you could hold your
    liquor from the beginning, but what I suspect, is
    that it indicates a genetic vulnerability)

83
Strategies for Handling Resistance
  • Emphasizing Personal Choice and Control (it is
    you who ultimately determines how this turns
    out)
  • Coming Alongside (maybe you cant live without
    smoking pot)

84
Enhancing Confidence
  • In general people cannot be ready to change until
    they perceive BOTH that they want to (importance)
    and are able to do so (confidence)
  • Confidence is treated as an ambivalence issue it
    is unlikely that the person feels totally unable
    to change
  • Low self-efficacy vs. depression, low self
    esteem, learned helplessness

85
Enhancing Confidence
  • Finding hope and confidence for change is a
    collaborative process in which the counselor is
    privileged to participate (Miller Rollnick,
    2002, p. 125).

86
Confidence Traps
  • Ill take over now, thank you.
  • There, there, youll be fine.
  • Gloom à Deux

87
Eliciting and Strengthening Confidence Talk
  • Evocative Questions
  • Confidence Ruler
  • Reviewing Past Successes
  • Personal Strengths and Supports
  • Brainstorming

88
Eliciting and Strengthening Confidence Talk
  • Giving Information and Advice
  • Reframing
  • Hypothetical Change
  • Responding to Confidence Talk
  • Radical Change

89
How do I know when a participant is ready to
change?
90
Signs of Readiness to Change
  • Decreased resistance
  • the participant stops arguing, interrupting,
    denying, or objecting
  • Decreased discussion or questions about the
    problem
  • the participant seems to have enough information
  • Resolve
  • the participant appears to have reached a
    resolution

91
Signs of Readiness to Change
  • Change Talk
  • statements reflect recognition, concern, openness
    to change, or optimism
  • Increased questions about change
  • the participant wants to know what they can do
    about the problem

92
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

93
  • We found thatdrinkers would not take pressure in
    any form, excepting from John Barleycorn himself.
    They always had to be led, not pushedWe found we
    had to make haste slowly.
  • Bill Wilson

94
Strengthening Commitment to Change
  • The goals are to channel intrinsic motivation
    into a negotiated, workable plan for change and
    to strengthen the participant's commitment for
    carrying out that plan.
  • Does not involve telling people what they must
    do, but rather, eliciting what they want and plan
    to do.

95
Strategies for Strengthening Commitment
  • A few potential hazards
  • Underestimating Ambivalence
  • Over-prescription
  • Insufficient Direction

96
Strategies for Strengthening Commitment
  • Recapitulation
  • -a summary of participants own perception of
    the problem
  • -a summing up of the ambivalence
  • -a review of the objective evidence
  • -a restatement of participant offerings of
    wanting, intending, or planning to change
  • -your own assessment of participants situation,
    particularly when it matches the participants

97
Strategies for Strengthening Commitment
  • Key Questions to get the participant talking and
    thinking about change
  • -what do you think you will do?
  • -what does all this mean about your use?
  • -what do you think has to change?
  • -what could you do, what are your options?
  • -it sounds like things cant stay the same, what
    can you do?

98
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?

99
Strategies for Strengthening Commitment
  • Giving Information and Advice
  • Quite possible and appropriate to share ones
    expertise
  • When a person requests it
  • With the persons permission

100
Giving Information and Advice
  • Have I elicited the participants own ideas and
    knowledge on this subject?
  • Is what I am going to convey important to the
    participants safety, or likely to enhance the
    participants motivation for change?
  • Have I asked the participants permission to
    share some advice?

101
Giving Information and Advice
  • Respect, choice, collaboration
  • Use qualifiers
  • Dont be too eager to offer advice
  • Offer a cluster of options
  • Solicit request from the person for information
    and advice

102
Remember
  • Talk less than the participant does
  • On average, reflect twice for each question you
    ask
  • When you reflect, use complex reflections more
    than half the time

103
Remember
  • When you do ask questions, ask mostly open
    questions
  • Avoid getting ahead of your participants
    readiness (warning, confronting, giving unwelcome
    advice or direction, taking the good side of an
    argument)

104
Additional Resources
  • www.motivationalinterview.org
  • TIP 35 available from www.ncadi.gov
  • The books First Second Editions
  • Articles
  • Additional training and supervision

105
  • I have not the right to want to change another if
    I am not open to be changed.
  • Martin Buber
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