Motivational Interviewing for Family Planning Providers. Motivational Interviewing. Disclosure

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1 for Family Planning Providers Developed By: Disclosure I I have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas. To provide the underlying spirit and approach of To recognize reflective listening responses and apply them appropriately to client situations To recognize change talk and be able to evoke it using proper motivational interviewing methods To list and demonstrate several different strategies for eliciting change talk 1

2 Introduction & Perspectives Drs. Miller, Rollnick & Moyers Overview of the Spirit of Motivational Interviewing Early approach: Doctor or therapist seen as expert whose task was to educate persuade cajole confront or coerce from the work of Miller and Rollnick MOTIVATIONAL INTERVIEWING MOTIVATIONAL INTERVIEWING Emphasis was on conditioning medicating punishing training humiliating 2

3 MOTIVATIONAL INTERVIEWING MOTIVATIONAL INTERVIEWING Why Use? Intuitive Focused Helpful with difficult clients / situations Useful in short, brief encounters Central to the efficacy of MI quality of accurate empathy Blended with other interpersonal skills Characterized by collaboration rather than prescription respect for and honoring client autonomy evoking motivation rather than trying to install it Works by causing clients to verbalize their own arguments for change Change Talk client expressing disadvantages of status quo advantages of changing ability to change intention to change 3

4 Evoking Self-Motivational Statements Problem Recognition (I ve noticed that lately ) Concern (I am beginning to feel ) Intent to Change (I am going to do something, I just don t know what) Optimism for Change (I know I can do better or I want to do better) Change Talk Counsel in a way that invites the person to make the arguments for change Common dimensions to ask about (DARN) Desire - want, prefer, wish, etc. Ability - able, can, could, possible Reasons - specific arguments for change - Why do it? Need - important, have to, need to, matter, got to Commitment to change RATIONALE AND BASIC PRINCIPLES MOTIVATIONAL INTERVIEWING Responsibility and capability for change lies within the client. Task to create a set of conditions that will enhance the client s own motivation for and commitment to change. Mobilize the client s inner resources, helping relationships, support intrinsic motivation for change 4

5 MOTIVATIONAL INTERVIEWING MOTIVATIONAL INTERVIEWING Can be used for: Lessening resistance Resolving ambivalence Ambivalence Mixed feelings or emotions; simultaneous and contradictory attitudes or feelings Inducing change eliciting self-motivational statements What Motivational Interviewing is NOT How Do You Know When You Got It Right? Some of the key signals are: 1. You are speaking slowly. 2. The client is doing much more of the talking than you. 3. The patient/client is actively talking about behavior change. 4. You are listening very carefully and gently directing the interview at appropriate moments. 5

6 Eight Skills in Learning 1. Openness to the underlying assumptions and spirit of the method collaborative rather than prescriptive eliciting motivation rather than installing it honoring client autonomy non-confrontational 2. Developing proficiency in interpersonal skills of client-centered counseling accurate empathy skill & comfort in forming accurate reflections 3.Recognizing change talk and distinguishing it from other forms of client s ways of speaking. 4.Learning to elicit change talk (evocation) and to reinforce it 5.Learning to minimize resistance and how to respond to sustain talk 6.Knowing when client is ready to discuss a change plan that is their own. 7.Continuing to elicit client s commitment to the change plan. 8.Flexibly blending MI with other therapeutic methods. 6

7 FOUR BASIC PRINCIPLES FOUR BASIC PRINCIPLES EXPRESS EMPATHY DEVELOP DISCREPANCY ROLL WITH RESISTANCE SUPPORT SELF-EFFICACY EXPRESS EMPATHY EXPRESS EMPATHY Acceptance facilitates change Understanding client s feelings and perspectives without judging, criticizing, or blaming through skillful reflective listening Ambivalence is seen as a normal part of change DEVELOP the DISCREPANCY DEVELOP the DISCREPANCY The client rather than the worker should present the arguments for change Change is motivated by a perceived conflict between present behavior and important personal goals or values 7

8 ROLL WITH RESISTANCE ROLL WITH RESISTANCE Avoid arguing for change Client Should not be directly opposed New perspectives are invited but not imposed A signal to change strategy and respond differently Includes involving the client actively in the process of problem-solving SUPPORT SELF-EFFICACY SUPPORT SELF-EFFICACY Belief in the possibility of change The client, not the worker, is responsible for choosing and carrying out change Worker s belief in the client s ability to change A reasonably good predictor of treatment outcomes Enhances a client s confidence in his/her capability to cope with obstacles and to succeed in change Counselors role is not a directive one of providing solutions, suggestions, or analysis. Instead, the counselor need only offer three critical conditions to prepare the way for natural change: Accurate empathy Non-possessive warmth Genuineness (Carl Rogers) 8

9 Phases of Phase I Building Motivation to Change Has implications to the earlier stages of change Assessing current situation Identifying problems or issues Evoking self-motivational statements Phases of Phase II Strengthening Commitment to Change Most useful in later stages of change Increasing motivation to change Recognizing Readiness to Change Recapitulation Key Questions Traps to Avoid Phase I Question / Answer Trap Confrontation / Denial Trap Labeling Trap Expert Trap Premature Focus Trap Blaming Trap 9

10 OPEN-ENDED QUESTIONS AFFIRMATIONS REFLECTIVE LISTENING SUMMARIZING Forms the acronym OARS from the work of Miller and Rollnick Repeating Stating exactly what was said Paraphrasing Stating what was said in your own words Reframing Early Strategies Putting an issue in a different context Feelings (Deepest Level) Naming the emotions attached to the content from the work of Miller and Rollnick 10

11 OPEN-ENDED QUESTIONS Questions that do not invite brief answers of yes or no Used to encourage clients to talk Client should do most of the talking Helper listens and encourages from the work of Miller and Rollnick AFFIRMATIONS Another way of building rapport Compliments or statements of appreciation and understanding To acknowledge and affirm client s strengths and efforts from the work of Miller and Rollnick REFLECTIVE LISTENING One of the most important / challenging skills in MI Simple Reflection Amplified Reflections Double-sided Reflections from the work of Miller and Rollnick 11

12 SUMMARIZING Used to link together material that has been discussed. Should be done periodically. Reinforces what has been said. Shows that you have been listening carefully. Prepares the client to move on. One of the more directive applications of MI from the work of Miller and Rollnick COMPONENTS OF A GOOD SUMMARY STATEMENT Restates client s statements regarding problem recognition, concern, reasons for change, and optimism about the change Don t ramble - be concise End with an invitation for client to respond: How did I do? If this is a fair summary, are there other points? Is there anything you want to correct or add? from the work of Miller and Rollnick 12

13 Empathic Listening Using the skills of early strategies in MI Watch Your Assumptions Many behavior change consultations fail because the practitioner falls into the trap of making false assumptions. Consider these: This person OUGHT to change. This person WANTS to change. This patient s health is the prime motivating factor for him/her. If he or she does not decide to change, the consultation has failed. Clients are either motivated to change or not. Now is the right time to consider change. A tough approach is always best. I m the expert; he or she must follow my advice. Cash Register Activity ACTIVE LISTENING CLIENT What I say 2 PRACTITIONER What I hear 1 3 What I mean or feel What I understand (Gordon 1970, Miller & Jackson 1985) 13

14 Many statements can have multiple meanings, and your challenge is to identify one meaning that the client is trying to express I wish I were more sociable I wish I were more sociable I feel lonely and I want to have more friends I get very nervous when I have to talk to strangers I should spend more time getting to know people I would like to be popular I can t think of anything to say when I m with people People don t invite me to their parties Active Listening Activity Not Ready Unsure Ready Trying Done Precontemplation Contemplation Preparation Action Maintenance Phase I Phase II Readiness Ruler adapted from Stoff et al 1995 & Thomas Gordon 14

15 ASSESS IMPORTANCE, CONFIDENCE AND READINESS It seems that some people cannot change and others do not want to. Having agreed to talk about a particular behavior there are a number of directions one could take. It has been found that the assessment of importance and confidence is a useful first step. I M P O R T A N C E LOW IMPORTANCE LOW CONFIDENCE 0 LOW IMPORTANCE HIGH CONFIDENCE 0 10 HIGH IMPORTANCE LOW CONFIDENCE HIGH IMPORTANCE HIGH CONFIDENCE 10 C O N F I D E N C E Negotiating a Change Plan 1. Setting goals 2. Considering change options 3. Arriving at a plan 4. Eliciting commitment 15

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