Motivational interviewing; another tool at our disposal (is more than just good listening) Deb Hemgesberg, LMSW Project Manager, NEMCMH Aug 10 11, 2017, Culture of gentleness Conf.
Motivational Interviewing Well researched in over 200 clinical trials Originally used for people with substance use and addiction issues. What motivates you? How flexible are you? Does HOW someone says something to us affect how we hear their message? What has made you most successful with people?
Basics But WHAT is it? Simplest Definition (for the layperson): Motivational interviewing is a collaborative conversation to strengthen a persons own motivation for and commitment to change Staff definition ( for those in the business : MI is a person centered counseling method for addressing the common problem of ambivalence about change WE must have the spirit of MI (the mindset and heartset of MI) be in place to be successful.
Motivational interviewing: Is about helping people change. Is VERY person centered and person focused. It is also narrow, focused on specific things for people who want or NEED to change, but are stuck in ambivalence. It is used early in the (counseling) relationship, in the change process for a specific target that the person served supports.
Who benefits? People who want and need to change (motivated). People who have tried to change, and failed in the past.
What gets in the way? Ambivalence Used to be considered a Pathological response to a need for change and something to be fought. However, it is really just a Normal reaction to change, because: 1. We are creatures of habit. 2. Change is hard and often painful. 3. The known, that is bad and hurtful to ourselves, is less scary than the unknown of change. 4. We don t see benefits of change when we weigh the pros and cons. 5. We aren t ready, YET. 6. We haven t hit bottom
TIP: don t argue the negative, focus on the positive which allows the other to go to see and recognize the negative as you have been strengthening the positive. Try this at home: Begin talking, but only about the strengths of a person or situation. Do not recognize nor address any negative information. The human brain will frequently and naturally respond to and focus on the catastrophic or negative experience that is unstated to the positive situation. (generally we do the opposite: we focus on the bad, which has the person focusing on the good and why we are wrong) WE will take the OPPOSITE argument at least in our thinking, to whatever the other person is proposing, as our first response.
Human motivation 101 We change, when WE are ready. We change, when we are forced to. (legal consequences) We change, when we see that the pros of change outweigh the cons of not changing. We change, when we DO hit bottom. We change, when someone LISTENS, while another person talks themselves into changing. People change, when their own awareness of their reasons and need for change is realized by them. Remember: Offering unsolicited advise is something for the receiver (person served) to dispute.
Someone listened While I talked myself into changing, by being able to explore my ambivalence (of my behavior) and the consequences it has brought, in a safe supportive relationship.
Video clip http://www.miforchange.com/videos
Cautions? Unsolicited information. Direction. Giving advice. Prescribing Persuasion I already do this
The EXPERT is who??? The person served is the expert on themselves, their values, their experience.
What can we actually control? When working with a person, what do we truly have control over? Our own thoughts. Our own feelings. Our own behavior. Motivational interviewing supports the autonomy of the person served.
What made you change? Think about the kind of things a mentor or leader (supervisor, teacher, coach, counselor, or family member) who had a major positive influence on you did. What are qualities they had?
Positive change eliciting behaviors: Believed in me. Listened to me. Understood me and was empathic. Sought out my values and ideas Allowed me to make my own decisions Supportive Caring or compassionate Humble Patient Honest and direct, but kind.
What has made you resistant? Recall an incident from your past that elicited resistance to change; what behaviors do you note about that?
Negative eliciting behaviors: Didn t listen to me Acted like I was stupid, condescending Told me what to do; pushy Constantly criticized me, put me down, negative Didn t value my ideas Treated me like a child Knew it all Arrogant Didn t believe in me Was coercive or threatening
Its not rocket science It IS harder than it looks Motivation interviewing is person centered, collaborative, empathic, evocative, honors the autonomy of the person served and focuses on change. MI practice will increase pro change behaviors in us. We evoke intrinsic motivation by partnering and collaborating with the people we serve, towards goals they have identified.
Motivation is? Incentive Inspiration Drive Enthusiasm Purpose Reasons Goals Motivational interviewing is a process for evoking a reason for change, from and with the person you are serving.
Talking about the discrepancy between behavior and any desired changes helps the person served to highlight the motivation needed for change. Keep the conversation open and moving. Discrepancy is when my behavior doesn t match my values, goals, knowledge of self construct. As discrepancy increases, ambivalence decreases, and motivation increases. A teeter totter of experiences that we help call the persons attention to. Like it don t like it
Developing discrepancy Sample interventions to help develop discrepancy: Tell me some good and not so good things about your behavior. How do you think your life would be different if you were not (drinking, smoking, skipping your medication, getting stressed out, etc)? How do you imagine your life to be like if you don t make changes and continue to (use, gamble, smoke, etc)? How does your (risky behavior) fit in with your goals? On one hand, you say that your are important to you, yet you continue to. Help me to understand What do you feel you need to change to achieve your goals? How will things be for you a year from now if you continue to (have risky or compulsive sex, eat a high fat diet, let your blood sugar get out of control, etc)? Hypothetically speaking, if you were to make a change in any area of your life, what would it be? (Braastad, n.d.)
Change talk??? http://www.ccwjc.com/forms/motivational% 20Interviewing/Listening%20for%20Change% 20Talk.pdf
Empathy Sample expressions of empathy: I appreciate how difficult this is. Yes, making change is hard work: VERY hard work! That must have been hard on you. I know where you re at with this. If I were experiencing what you are, I can imagine that I would feel similarly (Braastad, n.d.).
Ambivalence is that dreaded feeling of being stuck. If the person leaves our office without any change in discrepancy, the intervention we provided is likely to have little or no long term effect on the behavior of the person served. We need you to be our cheerleader, even when, and especially when we have made mistakes and have had setbacks in our recovery. You are evoking, not telling people what the problem is and how to fix it.
Amplify Ambivalence Sample amplifying ambivalence interventions: How has your behavior been a problem to you? How has it been a problem for others? What was your life like before you started having problems with (compulsive shopping, smoking, drinking, etc)? If you keep heading down the road you re on, what do you see happening (Braastad, n.d.)?
Motivational interviewing is: Collaboration instead of confrontation. We are equal partners in this relationship. Our client is the consultant to us regarding themselves and their situations. WE are NOT the expert. We need to be careful that we not correct and put people on defensive, stymying any desire for change. Our purpose is in part to search for what matters to this specific person/client.
ROLL with Resistance Here are some examples of resistance talk: Disagreeing: Yes, but... Discounting: I ve already tried that Interrupting: But... Sidetracking: I know you want to talk about how I fell off the wagon (got drunk) last week, but have you noticed how faithful I ve been about attending the AA meetings? Unwillingness: You want me to do that as well? Blaming: It s not my fault. When my partner starts in with... Arguing: I don t care what the research says. How do you know that s true in my case? Challenging: Well, meditation might work for some people, but it doesn t help me at all. Minimizing: I m not that overweight. Pessimism: I keep trying to do better on this, but nothing seems to help. Excusing: I know I should consume less sugar, but with my intense work schedule, there s no bandwidth left over for micro managing my food intake. Ignoring: (The client turns away or changes topic, ignoring your interventions) (adapted from Latchford, 2010).
Avoiding the righting reflex Understandably, as therapists and practitioners, the natural response to resistance talk such as the above tactics evokes in us a felt need to work harder to persuade the client, to let them know that they are wrong (we, of course are right). This righting reflex is to be resisted at all costs, as it is the prime response on our part which feeds an escalating spiral of resistance, to the total detriment of any possible change.
Evoke Evoke is a verb that means to call forth, as an emotion, feeling, or response. The verb evoke most commonly means to bring a feeling, memory, or picture into the mind. When you visit your old elementary school, the smells, sounds, and colors there can evoke memories from the past. What is key here is: it comes from the person. It is not placed with the person
Recognize and respect the clients right to choose. Forcing people does NOT work. Elicit and enhance the clients own resources for change. Recognize our limits. A level of detachment might be necessary for the practitioner. No one likes to be TOLD what to do, we learn more from our own mistakes.
Misconceptions It looks easy until you try it. It is not easy, it takes time and effort to learn, but once mastered, it saves time in the end. Partnership, acceptance, compassion and evocation are MI, not tricking people to do something. Its isn t persuasive, but done properly it seeks to influence a person to adopt a healthier lifestyle. Not a cure all but does improve engagement and retention in treatment. This just isn t active listening (by Carl Rogers), its much more. Its not CBT either, because this methodology installs behavior, not evokes behavior, like MI does. And its not just stages of change. Its a way of being with people, creates essence to the relationship.
Stages of change is that MI? Stages of change: describes how people change. The process of Motivational Interviewing offers clear direction and strategy on how to guide someone through the process of change.
Spirit of MI Acceptance, partnership, compassion and evocation are the backbone of this working with people. These qualities are the framework for the supports we provide just like safe, love, loving and engaged are to a culture of gentleness. Think: Collaboration, alliance, connection, companionship, pulling together and cooperation. Power sharing with the person served IS partnership. We are curious about the ideas of the person served. This is in line with the notion of giving people control whereby they give you greater control to support them. We guide the conversation and allow the expert (the person served) to share their thoughts and feelings regarding changes needed, by evoking this from the expert. This is critical to success
Elements similar to a culture of Gentleness Absolute worth = Unconditional regard Accurate empathy = looking at the world through the person served eyes (deep understanding and conveying this back to person served) Autonomy fosters the clients feeling of choice. Affirmation is an intentional way of being and communicating with people.
Five sanctioned ways you can offer advice within MI Ask permission: If you re interested, I have a recommendation (idea/suggestion/tidbit) for you to consider. Would you like to hear it? Offer advice: Based on my experience, I would encourage you to consider or From what I have observed, it seems that might be a good option for you. In cases where the client s current situation is urgently harmful, you must try to get some action going right away. In this case, you may make a stronger statement: As your (psychotherapist/social worker/health care professional), I urge you to. In my best professional opinion, I must urge you to consider now. Emphasize choice: Of course, it s your decision. Naturally, it s up to you. Elicit response and more change talk: What do you think about this suggestion? How do you think this might fit into your current situation? Voice confidence: I feel confident that if you decide to, you will find a way to do it or I feel certain that if you commit to doing this, you will have the will power to carry it through (adapted from Berg Smith, 2001).
A Review: MI strategies: Express empathy Develop discrepancy Roll with resistance Support efficacy The Foundational (micro skills) of OARs Open ended questions Affirmations Reflective listening Summaries The spirit of MI Partnership Acceptance Compassion Evocation The four processes: Engaging Focusing Evoking Planning
This presentation is only an introduction to motivational interviewing. To build this skill for yourself, to learn this way of serving people, you need to go to: https://www.improvingmipractices.org/online/
Resource www.improvingmipractises.org https://www.ncbi.nlm.nih.gov/books/nbk649 64/ http://www.aipc.net.au/articles/principlesand techniques of motivational interviewing/ www.miforchange.com
Thank you for your time and commitment to people having a life. Deb Hemgesberg, LMSW Current employment: NEMCMH as project manager, where I supervise Adult Case Management and Self Determination dhemgesberg@nemcmh.org (I am always awed a how much more alike and than different, we all are) I m deaf, so email is most likely best.
videos https://www.youtube.com/watch?v=hqwore VFjUo (reflective listening) https://www.youtube.com/watch?v=fzt2tj53ny (MI with Teen) https://www.youtube.com/watch?v=rgqrusy2 MJI (roll with resistance)