INTRODUCTION TO MOTIVATIONAL INTERVIEWING PRESENTED BY: BRIAN SERNA LPCC LADAC SERNA SOLUTIONS LLC

Transcription

1 INTRODUCTION TO MOTIVATIONAL INTERVIEWING PRESENTED BY: BRIAN SERNA LPCC LADAC SERNA SOLUTIONS LLC

2 Why don t people change?

3 Work with one other person General rule for all practice exercises: Don t be in the same group with your boss or supervisor Speaker: Role play a client presenting for an fitness evaluation and recommendations. You are ambivalent about your diet, and somewhat resistant to changing activity patterns.

4 THE DOCTOR PHIL APPROACH EXPERT CONFRONT SHAME GUILT OFFER A RESCUE/REMEDY

5 Find out a little about the client s lifestyle and then: Explain why the client should change Give at least three specific benefits that would result from quitting sugar and processed foods Tell the client how to get healthier Emphasize how important it is for the client to change Tell the client to do it! P.S. It is OK to have fun with this

6 I am the expert on why and how people should change. It is my responsibility to rectify gaps in knowledge.

7 The Righting Reflex Ambivalence

8 Angry, agitated Oppositional Discounting Defensive Justifying Not understood Not heard Procrastinate Afraid Helpless, overwhelmed Ashamed Trapped Disengaged Don t come back avoid Uncomfortable Resistant

9 WHAT IS MOTIVATIONAL INTERVIEWING? Motivational Interviewing is a person centered, goal oriented approach for facilitating change through exploring and resolving ambivalence. (Miller, 2006)

10 You don t have to make change happen. You can t You don t have to come up with all the answers You probably don t have the best ones You re not wrestling You re dancing

11 Understood Want to talk more Liking the counselor Open Accepted Respected Engaged Able to change Safe Empowered Hopeful Comfortable Interested Want to come back Cooperative

12 GIVING UNSOLICITED ADVICE IS RARELY EFFECTIVE It s Not About the Nail

13 SOME BENEFITS OF MOTIVATIONAL INTERVIEWING Gains rapport and reduces resistance Resolves Ambivalence-Gets People Unstuck! Increases retention and engagement in treatment

14 SOME BENEFITS OF MOTIVATIONAL INTERVIEWING Particularly useful with angry clients and those in the early stages of change Prevents burnout

15 MOTIVATIONAL INTERVIEWING Has been connected to Prochaska and DiClemente s Stages of Change. Is often associated with Carl Rodger s Client Centered Approach Has similarities with Leon Festinger s Cognitive Dissonance Theory

16 COGNITIVE DISSONANCE Focuses on how humans strive for internal consistency. When inconsistency (dissonance) is experienced, individuals largely become psychologically distressed. Attitude Belief Inconsistent with Attitude Dissonance

17 HOW DO WE REDUCE THE DISSONANCE? Change Behavior Stop drinking Rationalize and/or Justify behavior I don t drink as much as my father Change attitude or thoughts Drinking is actually good for my health

18 HOW DO WE WORK WITH DISSONANCE IN MI? While supporting out clients, we hold them in their own dissonance until they resolve it.

19 MOTIVATIONAL INTERVIEWING IS DIRECTIVE Selective reflection Selective elaboration Selective summarizing Selective affirmations

20 MI: How it Works Increase Change talk Counselor is conscious and aware of their own behaviors and using strategies and techniques to Decreased Resistance

21 AMBIVALENCE

22 LEAKE & KING (1977) Psychologists tested patients in three different treatment programs They identified patients with particularly high alcoholism recovery potential (HARP) HARP vs. non-harp patients did not differ from each other on prior treatment history or severity of alcoholism

23 COUNSELOR RATINGS DURING TREATMENT SHOWED HARPS TO BE: More motivated for counseling More punctual in meeting appointments Showing greater self-control Neater and more attractive in appearance More cooperative Trying harder to stay sober Showing better recovery

24 THROUGHOUT 12 MONTHS OF FOLLOW-UP HARP PATIENTS SHOWED: Higher rates of abstinence Longer spans of abstinence Fewer slips More employment

25 THE HARPS WERE SELECTED AT RANDOM!

26 KEY CONCEPT REVIEW Motivation Not a quality that a client has or has not. It is the result of a dynamic process between clinician and client.

27 KEY CONCEPTS Resistance is not Resistance It is either ambivalence or a sign of discord in the therapeutic relationship.

28 KEY CONCEPTS Ambivalence Is a normal and common human experience Needs to be worked through by the client not the clinician

29 KEY CONCEPTS Empathy Seeing the world through the client's eyes, thinking about things as the client thinks about them, feeling things as the client feels them, sharing in the client's experiences is critical When clients perceive empathy on a counselor's part, they become more open to gentle challenges by the counselor about lifestyle issues and beliefs about substance use.

30 Collaboration Compassion Acceptance MI Spirit Evocation MI SPIRIT

31 THE FOUR PROCESSES IN MI Engaging Focusing Evoking Planning

32 BASIC SKILLS USING YOUR OARS Open Ended Questions Affirmations Reflections Summaries

33 OPEN ENDED QUESTION EXAMPLES What types of things would you like us to talk about? How did you first get started drinking? What would change in your life if you stopped using? How do you think smoking pot is related to the problems you talk about in your marriage?

34 Affirmation Statements of recognition of client strengths. Build confidence in ability to change. Must be congruent and genuine.

35 AFFIRMATION I appreciate your honesty (if you know the client is being honest). I can see that caring for your children is important to you. It shows commitment to come back to therapy. You have good ideas.

36 REFLECTIVE LISTENING Listening reflectively is about being quiet and actively listening to the client, and then responding with a statement that reflects the essence of what the client said, or what you think the client meant.

37 LEVELS OF REFLECTIONS Surface Level Repeating Parroting Deeper Level Rephrasing Paraphrasing Deepest Level Emotion Meaning

38 TYPES OF REFLECTIVE STATEMENTS General Reflections Amplified Reflection Double Sided Reflection

39 AMPLIFIED REFLECTION With this type of reflection, you reflect back what the person said in a slightly amplified or exaggerated form. CAUTION: Make sure to do it genuinely because any hint of sarcasm may elicit an angry reaction and be perceived as un-empathic. Often, the amplified reflection will cause the client to clarify or elaborate on an important aspect of what was said, especially when what was amplified revealed resistance.

40 DOUBLE SIDED REFLECTION The intent of a double-sided reflection is to convey empathy. These statements are meant to capture both sides of a person s ambivalence. In using these, you can reflect back both the pros and cons of change that the client has said or at least hinted.

41 DOUBLE SIDED REFLECTIONS Typically, the two sides are joined by the phrase, on the other hand. Double-sided reflections have the bonus of summarizing as well as demonstrating that you heard the client and provide the opportunity to bring together discrepant statements.

42 Summarize Communicates that you have tracked what the client said and that you have an understanding of the big picture. Helps structure a session so that neither client nor counselor gets too far away from important issues and can help you link what a client just said to something he offered earlier.

43 WHAT IF THERE ISN T MUCH TO WORK WITH? Develop Discrepancy

44 DEVELOP DISCREPANCY Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be Counselors work to develop this situation through helping clients examine the discrepancies between their current behavior and future goals

45 DEVELOPING DISCREPANCY When clients perceive that their current behaviors are not leading toward some important future goal, they become more motivated to make important life changes. The client should present arguments for change.

46 SUPPORT SELF-EFFICACY Client's belief that change is possible is an important motivator to succeeding in making a change. Clients are held responsible for choosing and carrying out actions to change One source of hope for clients using the MI approach is that there is no "right way" to change.

47 ELICITING CHANGE TALK

48 ELICITING CHANGE TALK Asking evocative questions Using the importance ruler Exploring decisional balance Elaborating

49 ELICITING CHANGE TALK Querying extremes Looking forward Looking back Exploring goals and values

50 RESPONDING TO CHANGE TALK Reflecting Elaborating Summarizing Affirming

51 CHANGE TALK MOUNTAIN (Pre) Contemplation Preparation Action

52 WHAT IS DISCORD? Behavior Interpersonal A signal of dissonance Predictive of (non)change Highly responsive to counselor style

53 ROLLING WITH RESISTANCE Resist fighting client resistance roll with it.

54 ROLLING WITH RESISTANCE Statements demonstrating resistance are not challenged, instead use the client's "momentum" to further explore their views

55 Dealing with Discord Strategic Responses Shifting focus Agreement with a twist Coming Alongside Reframing Emphasizing personal choice/control Disclosure (Self) 55

56 Shifting focus We ve talked about what other people say about your drinking; let s now talk about what you think.

57 Agreement with a t w i s t Reflection with a REFRAME

58 Coming Alongside It sounds like the pros of using still far outweigh the cons. So it may be that you decide smoking is something that you don t want to give up.

59 Emphasizing Personal Choice/control It really is your choice about what you do in this situation. No one can make you do this. The decision is yours.

60 Self Disclosure I m getting a stuck feeling as we sit here. And I m wondering whether you feel the same?

61 ROLLING WITH RESISTANCE EXERCISE Break into pairs Partner 1: Focus on the behavior that you wrote down previously as something that someone else wants you to change. Partner 2: Find out about your partner s behavior in question while rolling with resistance.

62 Traps to Avoid 1. Question-Answer Trap 2. Labeling Trap 3. Premature Focus Trap 4. Expert Trap

63 TRAPS Question-Answer Trap Setting the expectation that the therapist will ask questions and the client will then answer, fosters client passivity.

64 Traps Labeling Trap. Diagnostic and other labels represent a common obstacle to change. There is no persuasive reason to use labels, and positive change is not dependent upon acceptance of a diagnostic label.

65 Traps Premature Focus Trap. When a counselor persists in talking about her own conception of the problem and the client has different concerns, the counselor gets trapped and loses touch with the client. The client becomes defensive and engages in a struggle to be understood.

66 Traps Expert Trap. When you give the impression that you have all the answers, you draw the client into a passive role.

67 BUILDING SKILLFULNESS Ongoing training Supervision and feedback Reading MI books and articles Watching training videos Watching or listening to your own sessions Coding sessions

68 Moving Toward the Finish Line Somethings I learned. Something I liked Something that surprised me The first thing I am going to do to use MI in my job is. I will become better in using MI after this training by

69 THANK YOU! Brian Serna LPCC LADAC