Finding Ambivalence & 10 Other Things About MI

Transcription

1 Finding Ambivalence & 10 Other Things About MI Presented by Richard Choate, MA, CADC II February 13, Samson Teklemariam, MA, LPC, CPTM Director of Training and Professional Development NAADAC, the Association for Addiction Professionals steklemariam@naadac.org 2 1

2 Produced By NAADAC, the Association for Addiction Professionals

3 5 Cost to Watch: Free CE Hours Available: 1.5 CEs CE Certificate for NAADAC Members: Free CE Certificate for Non-members: $20 CE Certificate To obtain a CE Certificate for the time you spent watching this webinar: 1. Watch and listen to this entire webinar. 2. Pass the online CE quiz, which is posted at 3. If applicable, submit payment for CE certificate or join NAADAC. 4. A CE certificate will be ed to you within 21 days of submitting the quiz. 6 3

4 Using GoToWebinar (Live Participants Only) Control Panel Asking Questions Audio (phone preferred) Polling Questions 7 Webinar Presenter Richard Choate FAX: rcchoate1@gmail.com Juniper Behavior Consulting 8 4

5 Webinar Learning Objectives The participant will be able to apply the theory and methods of motivational interviewing to the therapeutic relationship with clients with cooccurring disorders The participant will be able to demonstrate specific motivational interviewing skills to respond to resistance and overcome obstacles to recovery The participant will be able to synthesize motivational interviewing techniques with other evidence-based approaches to improve patient outcomes 9 HOW ARE THEY CONNECTED? Motivational Interviewing is not the Stages of Change 10 5

6 References Prochaska, James O., Norcross, John, & DiClemente, Carlo, (1994). Changing for Good: A Revolutionary Six- Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward, New York, Avon Books, Inc. Miller, William R., & Rollnick, Stephen, (2013). Motivational Interviewing, Third Edition: Helping People Change, New York, The Guilford Press. 11 The Stages Of Change Things do not change: We change. -- Henry David Thoreau, Walden 12 6

7 Transtheoretical Change Process How People Change PRECONTEMPLATION 13 Your Guide to the Stages of Change PRECONTEMPLATION I have no intention to change the behavior in the next six months Length: Unknown INFORMATION FEELINGS SOCIAL VALUING Current Behavior Cons Pros 14 7

8 Transtheoretical Change Process How People Change PRECONTEMPLATION CONTEMPLATION 15 Your Guide to the Stages of Change CONTEMPLATION I am seriously considering changing the behavior in the next six months. Length: Two weeks to several years SELF-VALUING Current Behavior Cons Pros 16 8

9 Polling Question #1: When is the best time to use a Decisional Balance tool and explore pro s and con s of someone s current behavior? A. Precontemplation B. Contemplation 17 Transtheoretical Change Process How People Change PRECONTEMPLATION CONTEMPLATION PREPARATION/PLANNING 18 9

10 Your Guide to the Stages of Change PREPARATION I am intending to change in the next month, and I have taken action unsuccessfully in the past year or have made some small behavioral change Length: Two hours to three months, but can last up to six months COMMITMENT Current Behavior Cons Pros 19 Transtheoretical Change Process How People Change PRECONTEMPLATION ACTION CONTEMPLATION PREPARATION/PLANNING 20 10

11 Your Guide to the Stages of Change ACTION I have successfully altered my behavior, from one day to six months, in a way that places me at low risk for problems Length: From one day to six months SUBSTITUTE ALTERNATIVES OPEN UP TO OTHERS AVOID & COUNTER EXPECTED HIGH-RISK SITUATIONS REWARD YOURSELF New Behavior Cons Pros 21 Transtheoretical Change Process How People Change MAINTENANCE PRECONTEMPLATION ACTION CONTEMPLATION PREPARATION/PLANNING 22 11

12 Your Guide to the Stages of Change MAINTENANCE I am remaining free of the behavior and/or I have been engaging in a new (incompatible) behavior for more than six months. Length: At least six months but frequently lasting years and even a lifetime SUBSTITUTE ALTERNATIVES (Still) AVOID & COUNTER UNEXPECTED HIGH-RISK SITUATIONS (Again) New Behavior Cons Pros 23 Transtheoretical Change Process How People Change MAINTENANCE PRECONTEMPLATION ACTION CONTEMPLATION PREPARATION/PLANNING 24 12

13 Transtheoretical Change Process How People Change Also identified 10 specific processes for change: Experiential Processes Behavioral Processes 25 Transtheoretical Change Process Experiential Change Processes Consciousness Raising Dramatic Relief Self Reevaluation Environmental Reevaluation Social Liberation 26 13

14 Transtheoretical Change Process Behavioral Change Processes Stimulus Control Counter Conditioning Reinforcement Management Self-Liberation Helping Relationships 27 Stage of change Transtheoretical Change Process From precontemplation to contemplation From contemplation to preparation From preparation to action From action to maintenance Staying in maintenance Most relevant change processes Consciousness raising Dramatic relief Self reevaluation Environmental reevaluation Decisional balance Self reevaluation Environmental reevaluation Decisional balance Self efficacy Social liberation Self efficacy Self liberation Stimulus control Counterconditioning Helping relationships Self efficacy Self liberation Stimulus control Counterconditioning Reinforcement management Helping relationships Self efficacy Self liberation Stimulus control Counter conditioning Reinforcement management Helping relationships Social liberation 28 14

15 Polling Question #2: Which stage of change are most of your clients in now? A. Precontemplation B. Contemplation C. Preparation/Planning D. Action E. Maintenance 29 Ambivalence and the Righting Reflex I WANT TO AND I DON T WANT TO 30 15

16 Conflict and Ambivalence Decisional Balance Paradoxical Responses Readiness for What? 31 Decisional Balance A Decisional Balance Sheet Continue to drink as before Abstain from alcohol Benefits Costs Benefits Costs Helps me relax Could lose my family Less family conflict I enjoy getting high Enjoy drinking with friends Bad example for my children More time with my children What to do about my friends Damaging my health Feel better physically How to deal with stress Spending too much money Helps with money problems Impairing my mental ability Might lose my job Wasting my time/life 32 16

17 Paradoxical Responses Increasing negative consequences as a deterrent? Psychological reactance An increase in the rate and attractiveness of a problem behavior if a person perceives that his or her personal freedom is being infringed or challenged. Secondary effects Loss of a marriage deprived of only social support to help deter unhealthy behavior = ever greater excess If other sources of positive reinforcement are blocked, the person persists in the one remaining reward. 33 Readiness for What? Why isn t this person motivated? For what is this person motivated? Unwise to assume the cost and benefits of another person s situation. Stomach problems Fines and imprisonment Highly valued to some maybe of little importance to others. People are always motivated for something

18 Sources of Motivation Intrinsic behavior is motivated by personal desire or sense of need intrinsic motivation may develop more slowly, but lead to greater persistence Extrinsic behavior is motivated by situational reinforcement extrinsic motivation may develop more quickly, but may fade quickly as well 35 Motivational Interviewing What people really need is a good listening to. -- Mary Lou Casey 36 18

19 Four Fundamental Principles Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Reflect at least twice for every question Ambivalence is normal (Transtheoretical Model of Change) Develop Discrepancy Perceived consequences matter Consequences that conflict with important goals favor a change The client should present the arguments for change Labeling is unnecessary 37 Four Fundamental Principles Roll with Resistance Avoid arguing for change Perceptions can be shifted New perspectives are invited but not imposed The client is a valuable resource in finding solutions to problems Support Self-Efficacy Belief in the possibility of change is an important motivator The client is responsible for choosing and carrying out personal change There is hope in the range of alternative approaches available Therapist hope is a self-fulfilling prophecy 38 19

20 The Spirit of Motivational Interviewing 39 The Continuum of Styles Directing Guiding Following 40 20

21 Some Verbs Associated with Each Communication Style Directing Style Administer Authorize Command Conduct Decide Determine Govern Lead Manage Order Prescribe Preside Rule Steer Run Take charge Take command Tell Guiding Style Accompany Arouse Assist Awaken Collaborate Elicit Encourage Enlighten Inspire Kindle Lay before Look after Motivate Offer Point Show Support Take along Following style Allow Attend Be responsive Be with Comprehend Go along with Grasp Have faith in Listen Observe Permit Shadow Stay with Stick to Take in Take an interest in Understand Value 41 Spirit Partnership Acceptance Absolute Truth Accurate Empathy Autonomy Support Affirmation Compassion Evocation Some Principles of Person-Centered Care 42 21

22 Four Processes in Motivational Interviewing Engaging Focusing Evoking Planning 43 Three Definitions of MI Layperson s definition Practitioner s definition Technical definition 44 22

23 Engaging The Relational Foundation 45 Early Traps That Promote Disengagement The Assessment Trap The Expert Trap The Premature Focus Trap The Labeling Trap The Blaming Trap The Chat Trap 46 23

24 Factors that influence engagement Desires or Goals Importance Positivity Expectations Hope 47 Listening Understanding the Person s Dilemma 48 24

25 Thomas Gordon s 12 Roadblocks 1. Ordering, directing or commanding 2. Warning, cautioning or threatening 3. Giving advice, making suggestions or providing solutions 4. Persuading with logic, arguing, or lecturing 5. Telling people what they should do; moralizing 6. Disagreeing, judging, criticizing, or blaming 7. Agreeing, approving or praising 8. Shaming, ridiculing, or labeling 9. Interpreting or analyzing 10. Reassuring, sympathizing, or consoling 11. Questioning or probing 12. Withdrawing, distracting, humoring or changing the subject. 49 Gordon s Model of Listening * Model from Thomas Gordon (Parent Effectiveness Training) 50 25

26 Gordon s Model of Listening Communication can go wrong because: The speaker does not say exactly what is meant The listener does not hear the words correctly The listener gives a different interpretation to what the words mean 51 Core Interviewing Skills (OARS) Asking Open Questions Affirming Reflecting Summarizing 52 26

27 Exploring Values and Goals An Open-Ended Values Interview Structured Values Exploration Integrity Exploring Discrepancy 53 Focusing The Strategic Direction 54 27

28 Focusing in Motivational Interviewing Agenda Three Sources of Focus The Client The Setting Clinical Expertise Three Styles of Focusing Directing Following Guiding 55 Counselor Issues That Can Arise in Focusing Tolerating uncertainty Sharing control Searching for Strengths and Openings for Change Clear Direction Choices in Direction 56 28

29 Agenda Mapping Choosing a Change Topic Among Many Changing Direction Getting Unstuck Raising a Difficult Topic Fitting in an Assessment Clarifying your roles in tough circumstances 57 Some Ethical Guidelines for the Practice of Motivational Interviewing 1. The use of MI component processes is inappropriate when available scientific evidence indicates that doing so would be ineffective or harmful for the client 2. When you sense ethical discomfort or notice discord in your working relationship, clarify the person s aspirations and your own. 3. When your opinion as to what is in the person s best interest differs from what the person wants, reconsider and negotiate your agenda, making clear your own concerns and aspirations for the person. 4. The greater your personal investment in a particular client outcome, the more inappropriate it is to practice strategic evoking. It is clearly inappropriate when your personal investment may be dissonant with the client s best interest. 5. When coercive power is combined with a personal investment in the person s behavior and outcomes, the use of strategic evoking is inappropriate

30 Three Special Topics Offering Advice Engage first Use sparingly Ask permission Emphasize personal choice Offer a menu of options Self-Disclosure Is it true? Could it be harmful Is there a clear reason why it would be helpful? Routine Assessment and Feedback Practicalities of initial assessment Sharing the outcome of assessment 59 Types of Ambivalence Approach/Approach Avoidance/Avoidance Approach/Avoidance Double Approach/Avoidance 60 30

31 Polling Question #3: Which of the following statements do you think is most true when it comes to resistance? A. Resistance is 100% about the client s behavior and attitude towards treatment. B. Resistance means the helper has failed. C. Resistance is about the helping relationship. D. Resistance means the helper should try a different approach. 61 Change and Resistance (Discord) Opposite Sides of a Coin 62 31

32 Consonance and Dissonance Dancing vs. Wrestling It takes at least two people to not cooperate. Client resistance behavior is a signal of dissonance in the counseling relationship. 63 Client Resistance Behavior Arguing Challenging Discounting Hostility Interrupting Talking over Cutting off Negating Blaming Disagreeing Excusing Claiming impunity Minimizing Pessimism Reluctance Unwillingness to change Ignoring Inattention Nonanswer No response Side tracking 64 32

33 Counselor s Role in Resistance Arguing for change Assuming the expert role Criticizing, shaming, or blaming Labeling Being in a hurry. Claiming preeminence. 65 The Spirit of Motivational Interviewing Fundamental approach of motivational interviewing Collaboration. Counseling involves a partnership that honors the client s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change. Evocation. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client s own perceptions, goals, and values. Autonomy. The counselor affirms the client s right and capacity for self-direction and facilitates informed choice. Mirror-image opposite approach to counseling Confrontation. Counseling involves overriding the client s impaired perspectives by imposing awareness and acceptance of reality that the client cannot see or will not admit. Education. The client is presumed to lack key knowledge, insight, and/or skills that are necessary for change to occur. The counselor seeks to address these deficits by providing the requisite enlightenment. Authority. The counselor tells the client what he or she must do

34 Importance and Confidence How important would you say it is for you to? On a scale from 0 to 10, where 0 is not at all important and 10 is extremely important, where would you say you are? Not at all important Extremely important And how confident would you say you are, that if you decided to, you could do it? On the same scale from 0 to 10, where 0 is not at all confident and 10 is extremely confident, where would you say you are? 67 Importance and Confidence Group A: Low importance, low confidence These people neither see change as important nor believe that they could succeed in making such a change if they tried. Group B: Low importance, high confidence These people are confident that they could make the change if they thought it were important to do so but are not persuaded that they want to change. Group C: High importance, low confidence Here the problem is not in willingness to change, for these people express desire to do so. The problem is low confidence that they could succeed if they tried. Group D: High importance, high confidence These people see it is important to change and also believe that they could succeed

35 Early Traps to Avoid The Assessment Trap (Q & A) Trap of Taking Sides The Expert Trap The Labeling Trap The Premature-Focus Trap The Blaming Trap The Chat Trap 69 Change Talk and Sustain Talk Two sides of the same coin 70 35

36 Change Talk Phase I. Building Motivation for Change Desire I want to change Ability I can change Reasons It would help me if I changed Need I need to change Recapitulation Summary Key Question: What is the next Step? Ready to go forward I might change Not ready to go forward I m not sure about changing 71 Change Talk Key Question: What is the next Step? Ready to go forward I might change Not ready to go forward I m not sure about changing Phase II. Strengthening Commitment Commitment I will change Taking Steps I attempted change CHANGE 72 36

37 Change Talk Preparatory Desire Ability Reasons Need Mobilizing Commitment Activating Taking Steps 73 Sustain Talk Desire I just love smoking and how it makes me feel. Ability I ve tried and I don t think I can quit smoking. Reason Smoking helps me to relax Need I have to smoke; I can t get through the day without it. Commitment I m going to keep on smoking. Activation I m prepared to accept the risks of smoking. Taking Steps I went back to smoking this week

38 Motivational Interviewing: What it s not Counselor-centered or Non-directive Counselor-centered = What the counselor thinks, sees, hopes for, plans and influences the client to do are what is important Danger is tug of war Non-directive = Counselor follows client, does not try to influence Danger is going around in circles, lack of progress 75 Motivational Interviewing: What it is Client-centered AND Directive Client-centered = What the client thinks, sees, hopes for, plans and does are what is important Directive = Counselor guides conversation toward particular topics, explores client s point of view and then increasingly focuses on certain aspects of the point of view selfmotivational statements or change talk 76 38

39 10 Clarifications About Motivational Interviewing 77 #1: MI is not about the content Relational and Technical Components Evidence Happens with the client not to the client 78 39

40 #2: Assessment of the client is not needed in order to use MI successfully. MI focuses on an evoking process Bring forward what they already know about what they would change Assessment implies a tailored treatment plan Client already know how and why to change address ambivalence Needs help resolving ambivalence about whether to change 79 #3: Giving information to the client may or may not be good practice in MI Knowledge rarely helps people change or address their ambivalence Objective feedback may be useful to create ambivalence. Does giving the information create discord? 80 40

41 #4: MI is not the right thing for every client MI is most useful for clients who are ambivalent Clinicians need a wide variety of skills Clinicians want to keep the spirit 81 #5: MI is an empirically supported treatment but its efficacy is highly variable In some Randomized Control Trials (RCT) it works, in others it does not. Active ingredients are not known Better quality of the interventionist 82 41

42 #6: MI can be learned, but not by everyone Four RCT s directly address this These covered more than 600 therapists Outcomes varied by audio recordings Rule of thirds 1/3 get it easily 1/3 get if if they work at it 1/3 never get it 83 #7: Supervising MI requires direct observation of clinicians What they say happens has a very low correlation to what actually happens Clinicians are not lying. What they don t notice is often what is most important Have to observe to help them learn 84 42

43 #8: Client language during sessions might explain why MI works Change talk is client language. That emerges spontaneously in interpersonal interaction Related to better outcomes Hypothesis is that ambivalent clients decide they intend to change as they hear themselves voice arguments in favor of it What does this mean about sustain talk? 85 #9: Clinicians have a lot to do with what clients say during interview 86 43

44 #10: Sometimes the outcome of MI is that the client realizes that they don t need you to change MI emphasizes client autonomy This means that clinicians must be willing to accept that clients may stop coming Influence is earned and often depends on client characteristics 87 Thank You! Richard Choate FAX: rcchoate1@gmail.com Your Juniper Behavior Consulting 88 44

45 89 Cost to Watch: Free CE Hours Available: 1 CEs CE Certificate for NAADAC Members: Free CE Certificate for Non-members: $15 CE Certificate To obtain a CE Certificate for the time you spent watching this webinar: 1. Watch and listen to this entire webinar. 2. Pass the online CE quiz, which is posted at 3. If applicable, submit payment for CE certificate or join NAADAC. 4. A CE certificate will be ed to you within 21 days of submitting the quiz

46 Upcoming Webinars February 27, 2019 Addressing the Opioid Crisis via Community- Based Technical Assistance by Holly Hagle, PhD March 27, 2019 Guidelines to Developing Competence with Mindfulness-Based Interventions by John Paulson, ACSW, LCSW, MAC, LCAC, CCS, HS-BCP March 13, 2019 April 10, 2019 Hunger for Healing: Evidence-Based Practice for Binge Eating Disorder by Michael Bricker, MS, CADC-II, NCAC-2, LPC Less is More: A Breakthrough Method for Lasting Change by David Mee-Lee, MD and Deborah Teplow, PhD

47 WEBINAR SERIES Over 145 CEs of free educational webinars are available. Education credits are FREE for NAADAC members. MAGAZINE ARTICLES In each issue of Advances in Addiction & Recovery, NAADAC's magazine, one article is eligible for CEs. FACE-TO-FACE SEMINARS NAADAC offers face-to-face seminars of varying lengths in the U.S. and abroad. INDEPENDENT STUDY COURSES Earn CEs at home and at your own pace (includes study guide and online examination). CONFERENCES NAADAC Annual Conference, September 28 October 2, 2019 Orlando, Florida CERTIFICATE PROGRAMS Demonstrate advanced education in diverse topics with the NAADAC Certificate Programs: Recovery to Practice Conflict Resolution in Recovery National Certificate in Tobacco Treatment Practice 93 Thank you for joining! NAADAC 44 Canal Center Plaza, Suite 301 Alexandria, VA phone: / fax: / naadac@naadac.org NAADACorg Naadac NAADAC 94 47