© ann d. carden, ph.d. - 20061 motivational interviewing in clinical supervision ann d. carden,...

© Ann D. Carden, Ph.D. - 2006 1

MOTIVATIONAL MOTIVATIONAL INTERVIEWINGINTERVIEWING

inin

CLINICAL CLINICAL SUPERVISIONSUPERVISION

Ann D. Carden, Ph.D.Ann D. Carden, Ph.D.CardenAnn@aol.com

© Ann D. Carden, Ph.D. - 2006 2

Guiding Principle #1

Express Empathy

© Ann D. Carden, Ph.D. - 2006 3

Self-Regulation Self-Regulation TheoryTheory

© Ann D. Carden, Ph.D. - 2006 4

Intentional change Intentional change

is grounded in awareness of is grounded in awareness of one’s core values and life one’s core values and life goals and the gap between goals and the gap between those values and goals and those values and goals and one’s present behaviorsone’s present behaviors

© Ann D. Carden, Ph.D. - 2006 5

““They say you can lead a They say you can lead a horse to water, but you cant’ horse to water, but you cant’ make him drink…but I say, make him drink…but I say, you can salt the oats.”you can salt the oats.” Madeline Hunter

© Ann D. Carden, Ph.D. - 2006 6

Guiding Principle #2

Develop Discrepancy

© Ann D. Carden, Ph.D. - 2006 7

Trans-theoretical Trans-theoretical Stages of Change Stages of Change

ModelModel

© Ann D. Carden, Ph.D. - 2006 8

Stages of ChangeStages of Change

PrecontemplationPrecontemplation

ContemplationContemplation

PreparationPreparation

ActionAction

MaintenanceMaintenance

TerminationTermination

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• Resources – internal & externalResources – internal & external

• Risks – internal & externalRisks – internal & external

• Readiness ------> interventionReadiness ------> intervention

© Ann D. Carden, Ph.D. - 2006 10

Guiding Principle #3

Roll with Resistance

© Ann D. Carden, Ph.D. - 2006 11

Self-Perception Self-Perception TheoryTheory

© Ann D. Carden, Ph.D. - 2006 12

IntentionIntentionCOMMITMENTCOMMITMENT

Cog

nitiv

e Affective

Behavioral

ProblemProblemRecognitionRecognitionREASONSREASONS

ConcernConcernNEEDNEED

DESIREDESIRE

ConfidenceConfidenceABILITYABILITY

© Ann D. Carden, Ph.D. - 2006 13

The Flow of Change Talk

DesireDesire

AbilityAbility

ReasonsReasons

NeedNeed

CommitmentCommitment

ChangeChange

MIMI

© Ann D. Carden, Ph.D. - 2006 14

Guiding Principle #4

Support Self-efficacy

© Ann D. Carden, Ph.D. - 2006 15

Intentional Change is a Intentional Change is a process, not an event! process, not an event! Intentional Change is a Intentional Change is a process, not an event! process, not an event!

© Ann D. Carden, Ph.D. - 2006 16

Intentional change is Intentional change is more likely to occur when more likely to occur when goals aregoals are

Small Important to the goal-setter Specific/Concrete/Measurable Present-focused Realistic/Practical A presence rather than an

absence

© Ann D. Carden, Ph.D. - 2006 17

Three Phases in the Three Phases in the Intentional Change Intentional Change ProcessProcess

© Ann D. Carden, Ph.D. - 2006 18

Common Barriers to Self-Common Barriers to Self-Enhancing Intentional Enhancing Intentional ChangeChange

CluelessnessCluelessness Minimization Minimization Projection of responsibilityProjection of responsibility Immediate gratification Immediate gratification Fear of failureFear of failure Skills deficitsSkills deficits Information gapsInformation gaps Fear of the unknownFear of the unknown Lack of social / material supportsLack of social / material supports Competing stressorsCompeting stressors

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““Given a choice Given a choice between between changing and changing and proving that it proving that it is not is not necessary, most necessary, most people get busy people get busy with the proof.”with the proof.”

John John GalbraithGalbraith

© Ann D. Carden, Ph.D. - 2006 20

It’s not so much that we’re afraid of It’s not so much that we’re afraid of change or so in love with the old change or so in love with the old ways, ways,

but it’s that place in between that we but it’s that place in between that we fear … fear …

It’s like being between trapezes …It’s like being between trapezes …

It’s Linus when his blanket is in the It’s Linus when his blanket is in the drier. There’s nothing to hold on to.drier. There’s nothing to hold on to.

Marilyn Ferguson

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AmbivalenceAmbivalence““People often get stuck, notPeople often get stuck, notbecause they fail to appreciate because they fail to appreciate the down side of their situation,the down side of their situation,but because they feel at least but because they feel at least two ways about it.”two ways about it.”

Miller & RollnickMiller & Rollnick

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AmbivalenceAmbivalence

approach-approachapproach-approach

approach-avoidanceapproach-avoidance

avoidance-avoidanceavoidance-avoidance

double approach avoidancedouble approach avoidance

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MotivationMotivationWhen the balance tips away from resistance When the balance tips away from resistance

and toward commitmentand toward commitment

Never completely free of ambivalence Never completely free of ambivalence and resistanceand resistance

Requires on-going “buy in” at the Requires on-going “buy in” at the level of level of

thinkingthinking feelings feelings

actionsactions

© Ann D. Carden, Ph.D. - 2006 24

Six Supervisor Six Supervisor GuidelinesGuidelines

1. Adhere to the MI Guiding Principles

2. Avoid Traps / Roadblocks to progress

3. Teach / model the Philosophical Foundations of MI

4. 4. Maintain a clinical focusMaintain a clinical focus

5. Adapt to the Supervisee’s context

6. Assist supervisees to become proficient in MI clinical skills

© Ann D. Carden, Ph.D. - 2006 25

Ongoing assessment of Ongoing assessment of client’s:client’s:

stagesstages resourcesresources risksrisks readinessreadiness

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Ongoing assessment of Ongoing assessment of supervisee’s:supervisee’s:

alliance with clientalliance with client MI consistent MI consistent

interventionsinterventions goals for clientgoals for client beliefs about outcomes beliefs about outcomes

© Ann D. Carden, Ph.D. - 2006 27

Supervisory Supervisory ResponsibilityResponsibility

““Above allAbove all

do no harm”do no harm”

© Ann D. Carden, Ph.D. - 2006 28

Six Supervisor Six Supervisor GuidelinesGuidelines

1. Adhere to the MI Guiding Principles

2. Avoid Traps / Roadblocks to progress

3. Teach / model the Philosophical Foundations of MI

4. Maintain a clinical focus

5. 5. Adapt to the Supervisee’s contextAdapt to the Supervisee’s context

6. Assist supervisees to become proficient in MI clinical skills

© Ann D. Carden, Ph.D. - 2006 29

Cultural DiversityCultural Diversity

AgeAge Socio-economic statusSocio-economic status Gender / sexual orientationGender / sexual orientation Ethnicity / raceEthnicity / race Geographic locationGeographic location ReligionReligion Educational level and typeEducational level and type Life rolesLife roles Disability / diagnosisDisability / diagnosis

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Cultural effects ….Cultural effects ….

ValuesValues PerspectivePerspective MeaningsMeanings RelationshipsRelationships Independence Independence Current focus / life taskCurrent focus / life task Time orientation / pacingTime orientation / pacing Communication and learning styleCommunication and learning style Client-counselor allianceClient-counselor alliance

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Client-Related Stressors Client-Related Stressors of Direct Service of Direct Service

ProvidersProviders Client resistance / supervisee’s Client resistance / supervisee’s

unrealistic expectations of client unrealistic expectations of client changechange

Boundary issues/ethical dilemmasBoundary issues/ethical dilemmas Client suicide/attemptsClient suicide/attempts Client anger/hostilityClient anger/hostility Premature terminationPremature termination Client violence toward othersClient violence toward others Client deathClient death

© Ann D. Carden, Ph.D. - 2006 32

Job-Related Stressors of Job-Related Stressors of Direct Service ProvidersDirect Service Providers

Isolation / insufficient supportsIsolation / insufficient supports Productivity pressures / time crunchesProductivity pressures / time crunches Paperwork, paperwork, paperworkPaperwork, paperwork, paperwork Organizational politicsOrganizational politics Low payLow pay Self-doubtSelf-doubt Perfectionism / compulsive Perfectionism / compulsive

responsibilityresponsibility Limited training opportunitiesLimited training opportunities

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Moving Toward Moving Toward Melt-down/Freeze-upMelt-down/Freeze-up

Increased absenteeismIncreased absenteeism Over-reactingOver-reacting Physical complaintsPhysical complaints Chronic exhaustionChronic exhaustion Low self-confidenceLow self-confidence Depression / AnxietyDepression / Anxiety ProcrastinationProcrastination Boundary violationsBoundary violations Cynical attitude about job / clientsCynical attitude about job / clients Social withdrawalSocial withdrawal HostilityHostility Us-them mentalityUs-them mentality Disorganized thinking / behaviorDisorganized thinking / behavior

© Ann D. Carden, Ph.D. - 2006 34

Six Supervisor Six Supervisor GuidelinesGuidelines

1. Adhere to the MI Guiding Principles

2. Avoid Traps / Roadblocks to progress

3. Teach / model the Philosophical Foundations of MI

4. Maintain a clinical focus

5. Adapt to the Supervisee’s context

6. 6. Assist supervisees to become Assist supervisees to become proficient in MI clinical skillsproficient in MI clinical skills

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MIMI

SpiritSpirit

Principles

Traps

Opening

Strategies

Elicit/Explore

Change Talk

Counter

Sustain Talk

ConsolidateConsolidate

CommitmentMI Core Skills