SHIP Conference Motivational Interviewing. Shannon Garrett, LGSW Mountain Manor Treatment Center

Transcription

1 SHIP Conference Motivational Interviewing Shannon Garrett, LGSW Mountain Manor Treatment Center

2 Substance Abuse Counseling and Motivational Interviewing Discuss risky behaviors that students participate in. Present Stages of Change model. What is Motivational Interviewing? Detailed discussion about Motivational Strategies. Detailed discussion about Motivational Interviewing Principles. MI tools. Experiential Activity Dope Fiend Monopoly

3 Risky Behaviors (to name a few) Drug use Drug dealing Gang involvement Sexual acting out Fighting Stealing Skipping school Self injurious behaviors

4 Evidenced Based Practice Trans-theoretical Stages of Change approach. To begin where the student is. Motivational Enhancement Therapy To build early engagement. Cognitive Behavioral Therapy To teach CBT skills for living without using drugs. Motivational Incentives To motivate and encourage change and participation.

5 Stages of Change (Prochaska, DiClemente) Pre-contemplation: Unwilling or unable to change. I don t have problem Contemplation: Ambivalent and uncertain. Preparation: Committed to finding a plan, making preparations for the change. Action: Actively making the change, but not yet stable. Maintenance: Consistent achievement of change and watchful of relapse.

6 Pre-contemplators To encourage change, individuals in the pre-contemplation stage are motivated to increase their awareness.

7 Contemplators To resolve ambivalence, clients in the contemplation stage are motivated to choose positive change over the current patterns of behavior.

8 Preparers Clients in the preparation stage are motivated to identify potential change strategies and choose the most appropriate one for their circumstances.

9 Action! Clients in the action stage are motivated to carry out change strategies. (This is the stage which most formal substance use treatment is directed.)

10 Maintenance During the maintenance stage, clients may have to develop new tools and skills to help maintain recovery and a healthy lifestyle. If clients relapse, they need help to recover as quickly as possible and reenter the change process.

11 Engagement Treatment is less effective if the patient refuses to participate, or if the patient pretends to be a part of YOUR treatment process and goals. We must learn skills of engagement to increase the effectiveness of treatment, and to motivate the patient to set and reach goals of THEIR own.

12 Unpopular Counseling Beliefs Just stop using and you will be fine. Just change people places and things. Relapsed again? You must have done something wrong. These trainings are never useful.

13 What s in your tool box? Tailoring Motivational Interventions Individuals need and use different kinds of help, depending on which stage of readiness for change they are currently in and to which stage they are moving.

14 Motivational Interviewing A therapeutic approach based on the premise that clients will best be able to achieve change when motivation comes from within, rather than being imposed by the therapist. (Miller and Rollnick, 2002)

15 Bill Miller The father of Motivational Interviewing NIDA brought him out of retirement to speak in New Mexico about MI in April of I had been waiting rather anxiously to hear him speak, and the time finally came. I had my notepad and pen ready for his words of wisdom, and he said

16 It s not so much about the treatment approach you are using, it s mostly about engagement. Does the patient think you can help them and that you want to help them. (Shannon s paraphrase) Be nice, offer them a cup of coffee and listen to what they have to say.

17 Motivational Interviewing Avoids the potential for authoritarian power struggle Maximizes the opportunity for client/counselor dialogue Establishes rapport through expression of genuine interest and a non-judgmental point of view

18 Pitfalls to Avoid with Adolescents Lecturing: Drugs are bad for you, did you know that 34% of all adolescents are plagued by drugs? Ordering: You will stop using marijuana today, because I said so. Criticizing: Your obviously not that smart, or you would have stopped already. Arguing: You don t know what your talking about, of course you have a problem with alcohol too. Moralizing: You must be ashamed of yourself for what you put your parents through. Threatening: If you don t stop using drugs, I m going to call your PO, and you will be locked up.

19 Motivational Strategies Use your O.A.R.S Open-ended questions Affirmations Reflections Summaries

20 Open Ended Questions Questions that elicit more than a simple yes or no response. Questions that encourage the patient to discuss their perception of personal problems, motivation to change, and plans. Questions that communicate an interest in the patient.

21 Open Ended Questions Higher Skill Examples Questions are relevant to the conversation. Questions are simple and direct without leading or judging. Questions are broken up by the use of reflections, avoid question answer trap. Pausing after questions to give patient time to respond.

22 Open Ended Questions Lower Skill Examples Questions are poorly worded or timed, and are not relevant to conversation. Questions are back to back, seeming mechanical. Too many questions at one time. Questions lead or steer the patient. Judgmental or sarcastic tone. Pauses for response are not sufficient.

23 Open Ended Questions Time for a role play. Find a partner This is an exercise to help you get a better sense of how many closed ended questions we rely on, and to give you the opportunity to practice just openended questions.

24 Affirmations Verbally reinforcing the patient s strengths, abilities, or efforts to change behaviors. Helps develop a patient s confidence by praising personal qualities in the patient that may help facilitate change. You help foster the belief that there is hope for change.

25 High Quality Affirmations The affirmations come directly from the conversation. Affirm personal qualities or efforts made by the patient that promote productive change or future change, instead of just general compliments. Being genuine, not mechanical.

26 Affirmations Low Quality The affirmations do not come directly from the conversation with the patient. Affirmations are not unique to the patient s description of their situation. Use an affirmation to cheer up a patient in despair or to encourage a patient to change that does not think they can. Lack of sincerity, mechanical, condescending.

27 Affirmations Let s discuss your feedback sheets for affirmations Let s listen to some examples Any volunteers to listen to some of your tape?

28 Reflections and Summaries Reflective statements restate the patient s comments using language that accurately clarifies and captures the meaning of the patient s communication and lets them know that you understand and are listening to their point of view. Summary statements are a form of reflection where you select several pieces of information and combine them in a summary; inviting exploration or transition.

29 Reflections and Summaries Simple Reflection: simply repeats what was said. Rephrasing: slightly rewording what was said. Paraphrasing: amplifying thoughts or feelings, using analogy, making inferences. Reflective Summary: Let me see if I understand what you have told me so far

30 Reflections and Summaries I can t seem to stay clean when I m hanging out with my best friends. They use drugs, but I really care about them. Reflect Content? Reflect Meaning? Reflect Feeling?

31 MET with Adolescents Hi Johnny, I m Mr. Shannon, one of the counselors here at Mountain Manor. It s nice to meet you. Tell me a little about what you know about Mountain Manor. It s a drug rehab. So you know that this is drug treatment center, can you tell me why you think you are here? My parents think I have a drug problem. It sounds like your parents think you have a drug problem and they have probably made you come here. That s right genius. Can you tell me about what happened that made your parents think you have a drug problem?

32 I don t have a drug problem. So, you don t think you have a drug problem, but it sounds like your parents think you do why do your parents think you have a drug problem? I don t know I got suspended from school for having weed on me. So now they think I have a problem. You were suspended for having weed at school, and it sounds like you think your parents have over reacted. Yea. What do you think your parents could have done better? They could have left me alone. They could have left you alone, but instead brought you to a rehab for counseling. What does the school say about you having weed in school? They say I m suspended until I start counseling. Ouch! So you got suspended for having weed in school, your parents are not happy and now you have to come for counseling. What are your goals for school?

33 I want to graduate. That s a great goal, I think it s awesome that you have the determination to work through this and graduate. Yea. What are you gonna do? I guess I have to go to counseling. Well, I understand that you don t want to be here, but I really admire your ability to do what you have to so that you can graduate, and I would like to be able to work with you. So, what do you think? I guess so. Since we are gonna be here together for awhile, maybe it would be a good idea to come up with some goals to work on. What are a few things in your life that don t seem quite the way you want them? Well I m not really getting along with my parents, and my girlfriend might be having a problem with drinking. Sounds like we may have some things to talk about after all.

34 Readiness Ruler means you are not ready at all, 10 means you are completely ready. How ready are you to make changes with your marijuana use? I would say a 5. Reflect you say you are a 5, it sounds like you are right in the middle. Open ended - Tell me what makes you a 5. Part of me wants to stop and part of me doesn t So it sounds like you are right in the middle and not really sure what you want to do. What would need to happen in your life to get you from a 5 to a 6 or 7?

35 Readiness Ruler How ready are you to start taking medication for your depression? I m about a 4. You re a 4, tell me why a 4? I don t think my depression is bad enough to take medication. What would have to happen for your Readiness to be a 5 or 6? I don t know, maybe if I was thinking about killing myself. So you would be a 5 or a 6 if you were thinking about killing yourself. Probably more like a 9 or 10 when you put it like that.

36 Motivational Interviewing Principles Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Support Self-Efficacy

37 Express Empathy Empathy has been called the defining principle of MI. Websters: the capacity for participation in another s feelings or ideas. Accepting another s perspective and feelings neutrally, without judgment. Listening, make good use of reflections.

38 Reflections and Summaries Reflective listening is listening respectfully and actively to genuinely understand what the person is trying to say. Empathy can be felt when a person is listened to reflectively. Be interested in what the person really means.

39 Developing Discrepancy To develop discrepancy between the way things are and the way a person would like things to be. To help someone get unstuck from feelings of ambivalence to change. Make use of Double-Sided Reflections and a Decisional Balance.

40 Amplified Reflections When you reflect back what the person said in a slightly amplified or exaggerated form. Be careful not to be sarcastic, be genuine. Often the amplified reflection will cause the person to clarify or elaborate on an important aspect.

41 Example I get high on heroin everyday and it s none of my parents dam business. So your health is none of your parents business. The only reason I m in this place is because my parents put me here. So it s all your parents fault that you re in drug rehab?

42 Double-Sided Reflection The intent is to convey empathy and to capture both sides of a person s ambivalence to change. Reflect back the pro s and con s of change. These reflections can summarize as well as demonstrate good listening skills.

43 Example So what you re saying is that on one hand you know that your boyfriend loves you, but on the other hand he was the person who introduced you to heroin for the first time. On one hand you don t plan to stop smoking weed, but on the other hand you don t want to violate your probation either.

44 It is most helpful to let the patient talk about the reasons for change and to identify the discrepancies. Eliciting statements from a patient about future goals and behaviors that come into conflict with those goals focuses on this discrepancy.

45 Decisional Balance Some of the good things Some of the not so good things

46 The Decisional Balance Good things about behavior Good things about changing behavior Not so good things about behavior Not so good things about changing behavior

47 10 Processes of Change (Prochaska, DiClemente) Experiential Processes 1. Consciousness Raising gain knowledge of self and nature of behavior. 2. Dramatic Relief emotional experience related to problem. 3. Self Reevaluation recognition how behavior effects values and goals. 4. Environmental Reevaluation recognition how behavior effects others and environment. 5. Social liberation recognition and creation of alternatives in social environment that encourages change.

48 Behavioral Processes 1. Stimulus Control Avoidance or alteration of cues, so that engagement in behavior is lessened. 2. Counter-conditioning substitution of healthy behavior for unhealthy behavior. 3. Reinforcement Management Rewarding of positive behavior changes. 4. Self-Liberation Belief in one s ability to change, and acting on that belief. 5. Helping Relationships building relationships that provide support, caring, and acceptance.

49 Pre-Contemplation Goal: to motivate the patient to move from pre-contemplation about substance use, to contemplation about change with substance use. Change Process: Consciousness raising, Dramatic relief, Self-evaluation, Environmental reevaluation, and Decisional balance. Motivational Tasks and Cognitive Behavioral Therapy Goal Setting, Happiness Scale, Functional Analysis, Readiness Ruler, Decisional Balance Worksheet, Coping with Cravings.

50 Experiential Engagement Dope Fiend Monopoly Lets have a little fun.

51 RECOVERY It s not just about substance abuse It s about helping motivate people to improve the Quality of their lives.