Motivational Interviewing Engaging clients in a conversation about change

Transcription

1 Motivational Interviewing Engaging clients in a conversation about change 16 th Annual Social Work Conference University of Southern Indiana March 2nd, 2018 Chad Connor, MSSW, LCSW

2 So what is Motivational Interviewing?

3 Motivational interviewing is " a person-centered counseling style for addressing the common problem of ambivalence about change." (Miller & Rollnick, 2013) MI is a COLLABORATIVE conversation about CHANGE 3

4 I need a volunteer to be my client! A Taste of MI (Miller & Rollnick, 2013) Volunteer needs to be willing to share: Something you want / need to change, but have not yet (ambivalent about it) Should be something you re willing to share with a complete stranger 4

5 Style 1 Style 2 Which style did you prefer? Highly directive Clinician "driving the bus "Righting reflex" Statistic re: response to this style Spirit of MI Conversational Questions have strategic purpose / elicit responses from client Client is put in the role of expert of their own situation 5

6 The kind of caring that the client-centered therapist desires to achieve is a gullible caring, in which clients are accepted as they say they are, not with a lurking suspicion in the therapist s mind that they may, in fact, be otherwise. This attitude is not stupidity on the therapist s part; it is the kind of attitude that is most likely to lead to trust, to further self-exploration, and to the correction of the false statements as trust deepens. Carl Rogers and Ruth Sanford

7 Today s Objectives You will understand the values and basic techniques used in MI You will understand MI s application to social work practice across various client populations and presenting problems You will know what to do to further your training / proficiency in MI

8 Spirit of MI More than technique, MI is person-centered Derivative of the work of Carl Rogers Client is in control of making their own decisions Relationship is collaborative, built on mutual trust Carl Rogers 8

9 A Continuum of Communication Styles Directing Guiding Following (Miller & Rollnick, 2013)

10 Spirit of MI (Miller & Rollnick, 2013)

11 Service Social Justice Social Work Values (NASW, 2017) Competence Integrity Dignity And Worth Human Relation ships

12 (NASW, 2017)

13 (NASW, 2017)

14 (NASW, 2017)

15 Congruence with Social Work (table seen in Hohman, 2012, page 7)

16 Traditional Style VS Motivational Interviewing Traditional Clinician as expert "Righting reflex" / Heavy advice giving Clinician does much of the talking "I have the answer and I am going to give it to you" Client as expert Motivational Interviewing Eliciting and reinforcing client's change talk / Conversational yet strategic Client does 50% or more of talking "You probably know what you want to change, can decide what to change or not change and, together we can help you become "unstuck" 16

17 As professional helpers, we have the tendency to rescue others "Righting Reflex" often isn t the right reflex for our clients "Don't do that, there is a better way! " If I can persuade them, they will see that they need to do something different. The Righting Reflex can lead our clients to following experiences: Need to explain / defend self "I am not being understood" Shame or anger "What's the point of meeting with you? I know this already! 17

18 You can arrange the conversation so that people talk themselves into change based on their own values and interests Challenging the Myth of the Unmotivated Client* (Miller & Rollnick, 2013 ) Motivation is NOT stable, it is fluid and can be changed! The way you talk to clients about health, changing beliefs, feelings, attitudes can substantially influence motivation to change and maintain change. Persuasion (i.e. use of logical arguments) does not work nearly as well as we might think! Whether change happens is a person's choice. We cannot take this away not matter how hard we try. * Angela R. Bethea, Ph.D.,

19 What prevents our clients from making the changes they need to make? Ambivalence ("I want to change AND I don't want to change") Most people know what they need / want to change (why logical arguments fail) "Decisional balance There are reasons for a person to sustain behavior There are reasons to change targeted behavior This is a NORMAL experience 19

20 There are things we can do to get our clients thinking about change.or think about sustain. CHANGE SUSTAIN20

21 We CAN influence how clients talk about change There are things WE can do to encourage two types of talk about target behavior CHANGE talk SUSTAIN talk Research supports the idea that if we can get our clients talk about their own reasons for change, they are more likely to move toward making that change 21

22 Change Sustain Is it Change Talk? I cut back on how many beers I drink I need to stop hanging around THOSE people I guess I could give those meetings a try I know this stuff is going to kill me I don t have a drinking problem It s impossible to stop when it is so easily available Nothing will help me stop Why change? Something s going to kill me anyway, right?

23 ARN CATS (the way we talk about change) Desire Ability Reasons Need Miller & Rollnick,

24 ARN CATS (the way we talk about change) Commitment Action Taking Steps Miller & Rollnick,

25 Do you remember the questions asked in the role play? They are DARN questions examples of ways to draw our change talk from clients 1. Why would you want to make this change? (Desire) 2. How might you go about it in order to succeed? (Ability) 3. What are the 3 best reasons to do it, and why? (Reasons) 4. On a scale from 0 to 10, how important would you say it is for you to make this change? (Need) My last question: So what do you think you will do? (CATS question 25

26 What can you do to elicit change talk?

27 What people really need is a good listening to. Mary Lou Casey

28 1. Engaging 2. Focusing 3. Evoking 4. Planning OARS DARN CATS Informing / Advising

29 MI s Four Processes Not necessarily linear* Miller & Rollnick, 2013 Engaging Self-determination, collaboration, active listening, mutual trust Focusing Identifying a target behavior, listing concerns, clarifying direction, developing discrepancies Evoking Eliciting and strengthening change talk, avoid / reduce sustain talk Planning Commitment to change, action planning 29

30 MI s essential ingredients Miller & Rollnick, 2013 Engaging, Focusing and Evoking processes of MI must be present to do MI. If you are using the skills (reflections, open-ended questions) without initiating a trusting, collaborative approach with your client, it is NOT MI. (Engaging) If you do not have a behaviorally specific change that is the focus of your work, it is NOT MI. (Focusing) If you do the above, yet are not concerned with eliciting the client s own reasons to change, it is NOT MI (Evoking) 30

31 But what about Planning? You CAN do MI without getting to the point of engaging in the Planning process MI is concerned with moving the client forward past ambivalence and through the stages of change Pre-contemplation Contemplation Pre-contemplation Contemplation Preparation Action Miller & Rollnick, 2013 Successful MI! 31

32 MI versus non-mi skills & behaviors (Miller and Rollnick, 2013) MI-adherence responses (MI-A) Advise w/ permission Affirm Emphasize Control Open Question Reflect Reframe Support MI-Non Adherent Responses (MI-NA) Advise without permission Confront Direct Raise concern without permission Warn 32

33 OARS

34 OARS The vehicle for change The core skills used in MI Open ended questions Affirmations Reflections Summaries 34

35 Open Ended Questions Open vs Closed Ended Questions Do you want to stop using marijuana? VS. What are some reasons you might have for not using marijuana? Be careful not to ask too many in rapid succession can come across as being interrogated! MI adheres to the strategy of providing at least 2-3 reflections for each question 35

36 Affirmations Verbal recognition and praise of the client s talk of change Example: Client: I am thinking about looking into women s shelters so I have somewhere to go if I decide to leave Bill. You: That s great. It must take a lot of courage to take this first step. Encourage and solidify the client s talk about change by affirming them when you recognize change talk. 36

37 Reflections Conveys active listening and engagement Allows the client to hear their own talk of change through your reflections Strategic use of reflection can be used to move a conversation forward or put the client in a position to defend the need to change. (Complex reflection) Example: Client: Getting high makes all my problems go away (sustain talk) You: Smoking makes life easier to deal with, so your life is ok if you continue to smoke. Client: Nah, well, sort of. My problems feel like they go away when I smoke, but DCS is involved now and I have to do something different I guess (change talk) You: On the one hand, smoking is how you have dealt with things, but because DCS is involved now, you have to figure out another way to deal with things. What have you tried before to deal with your problems? 37

38 Miller and Rollnick, 2013

39 Deepening Reflections (simple, amplified, double-sided, metaphor) 1. It s been fun, but something has got to give. I just can t go on like this anymore. 2. I ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work, except having a couple drinks. 3. I ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work except having a couple of drinks. 4. So, I m not too worried, but its been over a year since I ve had an HIV test. 5. I know I m not perfect, but why do they have to always tell me what to do. I m not 3!

40 Summaries Use these at strategic times to collect all the change talk statements the client has made and feed back to them to hear their own change Example: talk. You: Let me just make sure I am understanding your thinking at this time. On the one hand, you and your husband Can be have used been after together a series for of 10 reflections years, but the and fighting statements has gotten from so the bad client that you are not sure how to long follow you up can with go on a new like this. open-ended You worry question that co-workers (remember, have noticed 3-4 reflections your bruises and you are concerned for each it is open getting ended worse. question You are is scared strongly to be encouraged) alone, but you do have a good friend that said she will help you stay on your feet while you go to a shelter if you decide to do that. On a scale of 0 to 10, how important to you is it that you leave your husband? 40

41 Stephen Rollnick, Ph.D

42 Now that I know a little about MI, with whom do I use it? Anywhere there might be ambivalence to changing a behavior MI requires a specific target behavior Addiction Relationships Leaving a partner? Service engagement Diet / weight loss Smoking cessation 42

43 How can I work it in noncounseling / therapy settings? Assessments "MI Sandwich MI (5-10 mins) ----> Assessment / Data Collection --> MI-style feedback (10-5 mins) MI to engage client / explore reason for referral MI at end to elicit response to assessment, data collect, explore ambivalence and readiness for change. Can provide advice (with permission!) 43

44 Where do I learn more? The MI "bible" Authors & Founders: William Miller & Steve Rollnick,

45 Where do I learn more? For exercises / practice

46 Where do I learn more? FREE at samhsa.gov

47 Where do I learn more? MINT (Motivational Interviewing International Network of Trainers) Website ( Trainings Formal supervision from MINT trainers MITI 47

48 References Bethea, A.R. (2015, December). Introduction to motivational interviewing. Lecture presented at 2-day continuing education seminar, Atlanta, GA. Hohman, M. (2012). Motivational interviewing in social work practice. New York: The Guilford Press. Miller, W.R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: The Guilford Press. National Association of Social Workers. (2017). Code of ethics of the National Association of Social Workers. Washington, DC. NASW Press. Rosengren, D.B. (2009). Building motivational interviewing skills: A practitioner workbook (1 st ed.). New York: The Guilford Press