2017 ATRA Academy Webinar Series C, Session One 2017 ATRA Academy Webinar Series C, Session One 2017 ATRA Academy Webinar Series C, Session One

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1 2017 ATRA Academy Webinar Program Series C: Behavioral Health Session One: Motivational Interviewing Presented by: Gretchen Snethen, Ph.D., CTRS and Brandon Snead, CTRS Motivational Interviewing Techniques RTs can use to encourage independent community participation in people with psychiatric disabilities Objectives Identify and define 3 motivational interviewing techniques Describe the importance of internal motivation in eliciting behavioral change Connect motivational interviewing strategies to different responses from clients in a case study 1

2 Process Introduction of MI Component Connection of MI Component to Case study Participant identification of consumer response Defining Motivational Interviewing Skillful clinical style for eliciting from patients their own good motivations for making behavioral changes in the interested of their health (p. 6) Collaborative Evocative Honoring the client s autonomy Motivational Interviewing involves guiding more than directing, dancing rather than wrestling, listening at least as much as telling (p. 6) Collaborative Cooperation and collaboration between clinician and client Conversation and joint decision making Client must be on board with actions for behavioral change, as he or she is responsible for the change 2

3 Tamara & The ICAN Collaborative Process Identification of interests History of engagement Values, beliefs Identification of natural supports Meaning of activity, personally desired outcomes Eliciting personal barriers & facilitators Discussion The Collaborative Process Think of a consumer you work with. What are ways you can make the therapeutic relationship collaborative? How can you ensure goals and decisions are consumer driven? Evocative Consumer respected as expert on self Strengths-based Practitioner seeks to evoke what strengths & resources the client has Connecting behavior change with personal values Consumer generated good reasons for change 3

4 Tamara s Strengths, Values & Reasons for Change Strengths Access to gym membership Dedicated to making changes in life Clear on why changes were important Values Relationship with son Potential role model for son Health Consumer identified reasons for change Inspiration for son Feel better in body Increase self-confidence Discussion - Strengths, Values & Reasons for Change Think of a consumer you work with. Identify consumer strengths Identify consumer resources Identify values (do you know them?) What areas of participation do they enjoy? Do those activities connect to values? How so? How do consumer goals connect with values Honoring client autonomy Clients have ultimate choice in their behavior Human nature resists coercion Acknowledging client s right to not change often motivates an individual to change Removing control from the practitioner 4

5 Tamara Is In Control Ultimate choice Gym participation 3x/week Increasing physical activity Resisting coercion Challenging through discussion Encouraging complementary behaviors Using client words to suggest activities Removing control from practitioner, reminding consumer is in control Reinforcing consumer identified values If-then processing Discussion Consumers Choice Think of a consumer you work with. How can agency identified outcomes be achieve through consumer choice? Think of practitioner actions Examples of coercion with good intent Other strategies that promote consumer decision and choice Behavior change requires change talk Facilitate Change Talk Six types of change talk (DARN CAT) Desire: Preference for change I want to Ability: Statements about capability I can Reasons: Arguments for change I d feel better if Need: Feeling obliged to change My doctor told me Commitment: indicates the likelihood of change I will Activation: indicates starting Tomorrow I will Taking steps: Identifying action plan I got a gym membership 5

6 Guiding Principles Resist the righting reflex Understand & explore motivation Listen with empathy Empower the client Resist the righting reflex Don t set clients up to argue for the behavior they re trying to change. Righting Reflex You re doing it wrong approach You spend too much time watching TV You need to engage in more meaningful activities Community-based activities will help you make friends Client response I feel the need to justify my behavior It s my time for relaxation or Since no one is around, the TV keeps me company The things I do have meaning to me I ve been rejected by people in the community Righting reflex leads to a whole lot of buts Yeah, but I like watching TV Yeah, but I m afraid I ll get lost Yeah, but people are unkind We tend to believe what we hear ourselves say. The more clients verbalize the disadvantages of change, the more committed they become to the status quo 6

7 Understand your client s motivations You are better off asking clients why they want to change, rather than telling them why they should Be interested in: Client concerns Client values Client motivations 20/20 vision with values glasses Knowing client values, you can help guide towards activities that are consistent with values More likely to work towards activity goals that are consistent with values Facilitate client s identification of cognitive dissonance towards status quo Listen to your client Answers to behavior change reside within the client Express empathetic interest to confirm understanding Make guesses about meaning 7

8 Empower your client How can the client make a difference in his or her own life? Clients are the consultants of their own life Practitioner facilitates the client s expression of expertise For behavior change to be lasting, client must ultimately choose the goals to work towards and the path to be successful Core Communication Skills Asking Listening Informing Communication Styles Style Features Synonyms Following Listening is key. Follow the other person s lead Helps practitioner understand the client s issue Directing Practitioner takes charge Uneven power dynamic I know how to solve your problem Guiding I can help you solve this for yourself More similar to a tutor Observe Understand Shadow Go along with Manage Lead Reign Take the reins Govern Encourage Motivate Accompany Elicit Awaken Guiding is well suited to helping people solve behaviorchange problems. MI is a refined form of this guiding style. 8

9 Asking Ask where the person wants to go and get to know him or her Practitioner goal: Understand the client s issue Use DARN to guide questions Desire: Why do you want to go to museums? Ability: How could you make going to the museum a reality for you? Reason: What are your reasons for wanting to go to the museum more? Need: How important is this for you? Ask open ended questions Example questions What concerns you most about Tell me more about How do you feel when What do you notice when How can I help you to What do you enjoy about What happens when Activity: Take these questions and related them to recreationrelated behavior change Tips Focus on behavior & feelings Convey acceptance, don t judge Know your assessment and information that needs to be covered Fit the assessment into the interview Be curious Avoid investigating 9

10 Strategies to Avoid Style Example Of Use Possible Response Policing I need to ask you, have you been going to the museum Negative framed Why don t you Why can t you Facilitates a defensive response from client Focuses on client problems Facilitates defensive response Positive Strategies Strategy Example Of Use Possible Outcome Use a ruler Assess Importance & Confidence Pros & Cons Use Hypotheticals How strongly do you feel about On a scale from 1-10, where do you place yourself? High importance and high confidence = behavior change What do you enjoy about your current leisure participation? What do you wish could be different? If you decided to go to the museum two times a month, what benefits do you think you d experience? Facilitates change talk Tells you about client s motivation Identify incongruence Focus change talk where needed Identify ambivalence Develop a balance sheet Less threatening approach Freedom to envision change Listening Practitioner goal: Understand the client s perspective and experience What you say is important to me. I want to hear more Encourages the client to explore and reveal more Helps you gather otherwise missed info Asking and listening are not the same! 10

11 Positive Strategies for Listening Strategy Examples Of Use Possible Outcome Open the door Embrace silence Listen by reflecting Reflect resistance Summarize & Acknowledge value Encourage the client to share with your questions and with body language Audible silence encourages the client to continue sharing Inner silence allows you to listen Helps build rapport Immediate responses often convey judgment and facilitate a defensive response Summarize what the client is telling you Ensures understanding Demonstrates listening Clients often will argue both sides, use reflection to encourage discussion of client s desire to change At the end of an interview, provide a summary of conversation and express appreciation Guides client to see desire to change Guides client s to identify benefits of change Provides a final opportunity for client to Informing This [behavior change] would likely benefit you, how do you feel about it? Practitioner goal: Convey information or knowledge to client Focus on information exchange- consider expertise on both sides Focus on positive messages Consider the client s broader priorities Consider the amount of information Deliver information with care, make sure it s accessible and understood Positive Strategies for Informing Strategy Examples Of Use Possible Outcome Ask permission Can I make a suggestion? Would you like to know some strategies other clients have used? Offer choices Talk about what others do Messages of Hope There are always multiple paths to achieve a goal Some people choose to adjust their budget to be able to pay for less frequent activities; others explore free or inexpensive options. What makes sense to you? Even small changes help you move towards your goal. Just agreeing to meet with me today is an important step. Puts the client in the driver s seat Focuses on guiding, not directing Options allow the client to evaluate perceived ability Puts the client in the drivers seat Demonstrates multiple options to achieve similar goals Hypotheticals are less threatening Provides choice Reinforce the positive steps the client is taking Avoid shaming, making him or her feel guilty 11

12 Bringing it together Strategies to remember Open ended questions Questions that require elaborations Ask ambivalent patients for positives and negatives of a problem Affirmation Compliment, praise, appreciation Reflective listening Say back to patient what you think they said to you in statement format Summarization Link info Decisional Balance How a person weighs the pros and cons of a specific behavior Patient s overall assessment of the good things (positives) and less good things (negatives) TR intervention should be tailored to client s perception of the problem Determine client s awareness of issue Determine desire to change Greater pros increases likelihood for change 12

13 Consistency Motivational interviewing should occur in all client interactions, not just initial assessment Affirming client progress Explore/process ambivalence Encourage client to connect personal values to goals Client future and goal attainment Strengths to navigate barriers Ensure client s perceived importance of goal Questions? For More Information & to Continue this Conversation Gretchen Snethen, PhD, CTRS gsnethen@temple.edu Brandon Snead, @tu_collab 13

14 The 2017 ATRA Webinar Program Series A: Older Adults (April-June) Session A2: The Best Friends Approach to Care for People with Dementia:Strengths-Based Approach for Recreational Therapists Presented by: Nancy Richeson, Ph.D., CTRS Date: May 17, :00 pm Eastern time Session A3: Using an Evidence Based Brain Fitness Program to Address Varying Cognitive Abilities of Older Adults in all Settings Presented by: Laura Kelly, MS, CTRS Date: June 14, :00 pm Eastern Time The 2017 ATRA Webinar Program Series B: Physical Medicine and Rehabilitation (April-June) Session B2: Standardized Assessment Tools Part II Presented by: Heather Porter, Ph.D., CTRS Date: May 24, :00 pm Eastern Time Session B3: Errorless Learning: An Intervention Option for Individuals with Severe Memory Deficits Presented by: Donna Long, M.Ed., CTRS Date: June 21, :00 pm Eastern Time The 2017 ATRA Webinar Program Series C: Behavioral Health (May-July) Session C2: Leisure Education: Addressing Avolition in Adults with Psychiatric Disorders Presented by: Laree Shanda, CTRS Date: June 7, :00 pm Eastern Time Session C3: Active Transportation for Individuals with Mental Health Conditions Presented by: Gretchen Snethen, Ph.D., CTRS and Brandon Snead, CTRS Date: July 12, :00 pm Eastern Time 14

15 The 2017 ATRA Webinar Program Series D: Recreational Therapy in the Schools (July-September) Session D1: Recreation Therapy in the Schools using the Model of Functional Authenticity Presented by: Dan Scaduto, CTRS Date: July 19, :00 pm Eastern Time Session D2: Developing through Dance in Schools Presented by: Rebekah Noe, CTRS Date: August 16, :00 pm Eastern Time Session D3: Adventure Facilitation for Adolescents on the Autism Spectrum: Evidence-Based Interventions for RT Professionals Presented by: Jason Silva, TRS, CTRS Date: September 20, :00 pm Eastern Time The 2017 ATRA Webinar Program Series E: Recreation Therapy in Community Settings (August October) Session E1: Inclusion Process in a Community Parks and Recreation Organization Presented by: Kristen Clatos Riggins, MA, CTRS, ATRIC Date: August 9, :00 pm Eastern Time Session E2: Evidence Based Practice: Community Day Camp for Teens with I/DD Presented by: Kristen Clatos Riggins, MA, CTRS, ATRIC Date: September 6, :00 pm Eastern Time Session E3: The King Adult Day Enrichment Program: A Practical Application of TR in the Community Presented by: Donna Lozano, M.Ed., CTRS Date: October 18, :00 pm Eastern Time The 2017 ATRA Webinar Program Series F: A Comprehensive Overview of the CTRS Certification Process (August-November) Session F1: Certification 101 Presented by: Robin McNeal, CTRS Date: August 23, :00 pm Eastern Time Session F2: NCTRC Internship Guidelines: Ensuring a Quality Internship Presented by: Noelle Molloy, MSEd., CTRS Date: September 27, :00 pm Eastern Time Session F3: NCTRC Recertification: Continuing Professional Competence Presented by: Susan Kaufer, CTRS Date: October 11, :00 pm Eastern Time Session F4: NCTRC Specialty Certification Presented by: Robin McNeal, CTRS Date: November 15, :00 pm Eastern Time 15