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Finding Ambivalence & 10 Other Things About MI
Presented by Richard Choate, MA, CADC II
February 13, 2019
Samson Teklemariam, MA, LPC, CPTM
Director of Training and Professional Development
NAADAC, the Association for Addiction Professionals
www.naadac.org
steklemariam@naadac.org
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Produced ByNAADAC, the Association for Addiction Professionals
www.naadac.org/webinars
www.naadac.org/webinars
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www.naadac.org/finding-ambivalence-MI-webinar
Cost to Watch:Free
CE Hours Available:1.5 CEs
CE Certificate for NAADAC Members:Free
CE Certificate for Non-members:$20
To obtain a CE Certificate for the time you spent watching this webinar:
1. Watch and listen to this entire webinar.
2. Pass the online CE quiz, which is posted at
www.naadac.org/finding-ambivalence-MI-webinar
3. If applicable, submit payment for CE certificate or join NAADAC.
4. A CE certificate will be emailed to you within 21 days of submitting the quiz.
CE Certificate
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Using GoToWebinar – (Live Participants Only)
Control Panel
Asking Questions
Audio (phone preferred)
Polling Questions
Richard Choate952-261-2604FAX: 541-241-8074rcchoate1@gmail.com
Webinar Presenter
Juniper Behavior Consulting
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Webinar Learning Objectives
The participant will be able to apply the theory and methods of motivational interviewing to the therapeutic relationship with clients with co-occurring disorders
The participant will be able to demonstrate specific motivational interviewing skills to respond to resistance and overcome obstacles to recovery
The participant will be able to synthesize motivational interviewing techniques with other evidence-based approaches to improve patient outcomes
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HOW ARE THEY CONNECTED?Motivational Interviewing is not the Stages of Change
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Prochaska, James O., Norcross, John, & DiClemente, Carlo, (1994). Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward, New York, Avon Books, Inc.
Miller, William R., & Rollnick, Stephen, (2013).Motivational Interviewing, Third Edition: Helping People Change, New York, The Guilford Press.
References
The Stages Of ChangeThings do not change: We change.
-- Henry David Thoreau, Walden
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PRECONTEMPLATION
Transtheoretical Change ProcessHow People Change
PRECONTEMPLATION
I have no intention to change the behavior in the next six months
Length: Unknown
INFORMATION
FEELINGS
SOCIAL VALUING
Current BehaviorCons
Pros
Your Guide to the Stages of Change
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CONTEMPLATION
PRECONTEMPLATION
Transtheoretical Change ProcessHow People Change
CONTEMPLATIONI am seriously considering changing the behavior in the next six months.
Length: Two weeks to several years
SELF-VALUING
Current BehaviorCons
Pros
Your Guide to the Stages of Change
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Polling Question #1: When is the best time to use a Decisional Balance tool and explore pro’s and con’s of someone’s current behavior?
A. PrecontemplationB. Contemplation
PREPARATION/PLANNING
CONTEMPLATION
PRECONTEMPLATION
Transtheoretical Change ProcessHow People Change
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PREPARATIONI am intending to change in the next month, and I have taken action unsuccessfully in the past year or have made some small behavioral changeLength: Two hours to three months, but can last up to six months
COMMITMENT
Current BehaviorCons
Pros
Your Guide to the Stages of Change
ACTION
PREPARATION/PLANNING
CONTEMPLATION
PRECONTEMPLATION
Transtheoretical Change ProcessHow People Change
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ACTIONI have successfully altered my behavior, from one day to six months, in a way that places me at low risk for problemsLength: From one day to six months
SUBSTITUTE ALTERNATIVESOPEN UP TO OTHERSAVOID & COUNTER EXPECTED HIGH-RISK SITUATIONSREWARD YOURSELF
New BehaviorCons
Pros
Your Guide to the Stages of Change
ACTION
MAINTENANCE
PREPARATION/PLANNING
CONTEMPLATION
PRECONTEMPLATION
Transtheoretical Change ProcessHow People Change
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MAINTENANCEI am remaining free of the behavior and/or I have been engaging in a new
(incompatible) behavior for more than six months.Length: At least six months but frequently lasting years and even a lifetime
SUBSTITUTE ALTERNATIVES (Still)AVOID & COUNTER UNEXPECTED HIGH-RISK SITUATIONS (Again)
New BehaviorCons
Pros
Your Guide to the Stages of Change
ACTION
MAINTENANCE
PREPARATION/PLANNING
CONTEMPLATION
PRECONTEMPLATION
Transtheoretical Change ProcessHow People Change
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Also identified 10 specific processes for change:
• Experiential Processes
• Behavioral Processes
Transtheoretical Change ProcessHow People Change
Experiential Change Processes
• Consciousness Raising
• Dramatic Relief
• Self Reevaluation
• Environmental Reevaluation
• Social Liberation
Transtheoretical Change Process
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Behavioral Change Processes
• Stimulus Control
• Counter Conditioning
• Reinforcement Management
• Self-Liberation
• Helping Relationships
Transtheoretical Change Process
Stage of change From pre‐
contemplation to
contemplation
From contemplation
to preparation
From preparation to
action
From action to
maintenance
Staying in
maintenance
Most relevant change
processes
Consciousness
raising
Dramatic relief
Self‐reevaluation
Environmental
reevaluation
Decisional balance
Self‐reevaluation
Environmental
reevaluation
Decisional balance
Self‐efficacy
Social
liberation
Self‐efficacy
Self‐liberation
Stimulus control
Counter‐
conditioning
Helping
relationships
Self‐efficacy
Self‐liberation
Stimulus control
Counter‐
conditioning
Reinforcement
management
Helping
relationships
Self‐efficacy
Self‐liberation
Stimulus control
Counter
conditioning
Reinforcement
management
Helping
relationships
Social
liberation
Transtheoretical Change Process
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Polling Question #2: Which stage of change are most of your clients in now?
A. PrecontemplationB. ContemplationC. Preparation/PlanningD. ActionE. Maintenance
Ambivalence and the Righting Reflex
I WANT TO AND I DON’T WANT TO
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• Decisional Balance
• Paradoxical Responses
• Readiness for What?
Conflict and Ambivalence
A Decisional Balance SheetDecisional Balance
Continue to drink as before Abstain from alcohol
Benefits Costs Benefits Costs
Helps me relax Could lose my family Less family conflict I enjoy getting high
Enjoy drinking with friends Bad example for my children More time with my children What to do about my friends
Damaging my health Feel better physically How to deal with stress
Spending too much money Helps with money problems
Impairing my mental ability
Might lose my job
Wasting my time/life
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Increasing negative consequences as a deterrent?
Psychological reactanceAn increase in the rate and attractiveness of a “problem” behavior if a person perceives that his or her personal freedom is being infringed or challenged.
Secondary effects• Loss of a marriage – deprived of only social support to help deter
unhealthy behavior = ever greater excess• If other sources of positive reinforcement are blocked, the person
persists in the one remaining reward.
Paradoxical Responses
Why isn’t this person motivated?
For what is this person motivated?
Unwise to assume the cost and benefits of another person’s situation.
Stomach problems
Fines and imprisonment
Highly valued to some maybe of little importance to others.
People are always motivated for something.
Readiness for What?
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Intrinsic – behavior is motivated by personal desire or sense of need –intrinsic motivation may develop more slowly, but lead to greater persistence
Extrinsic – behavior is motivated by situational reinforcement – extrinsic motivation may develop more quickly, but may fade quickly as well
Sources of Motivation
Motivational InterviewingWhat people really need is a good listening to.
-- Mary Lou Casey
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Express Empathy• Acceptance facilitates change• Skillful reflective listening is fundamental• Reflect at least twice for every question• Ambivalence is normal (Transtheoretical Model of Change)
Develop Discrepancy• Perceived consequences matter• Consequences that conflict with important goals favor a change• The client should present the arguments for change• Labeling is unnecessary
Four Fundamental Principles
Roll with Resistance• Avoid arguing for change• Perceptions can be shifted• New perspectives are invited but not imposed• The client is a valuable resource in finding solutions to problems
Support Self-Efficacy• Belief in the possibility of change is an important motivator• The client is responsible for choosing and carrying out personal
change• There is hope in the range of alternative approaches available• Therapist hope is a self-fulfilling prophecy
Four Fundamental Principles
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The Spirit of Motivational Interviewing
The Continuum of Styles
Guiding FollowingDirecting
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Directing Style• Administer• Authorize• Command• Conduct• Decide• Determine• Govern• Lead• Manage• Order• Prescribe• Preside• Rule• Steer• Run• Take charge• Take command• Tell
Guiding Style• Accompany• Arouse• Assist• Awaken• Collaborate• Elicit• Encourage• Enlighten• Inspire• Kindle• Lay before• Look after• Motivate• Offer• Point• Show• Support• Take along
Following style• Allow• Attend• Be responsive• Be with• Comprehend• Go along with • Grasp• Have faith in• Listen• Observe• Permit• Shadow• Stay with• Stick to• Take in• Take an interest in• Understand• Value
Some Verbs Associated with Each Communication Style
Partnership
AcceptanceAbsolute TruthAccurate EmpathyAutonomy SupportAffirmation
Compassion
Evocation
Some Principles of Person-Centered Care
Spirit
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Engaging
Focusing
Evoking
Planning
Four Processes in Motivational Interviewing
Layperson’s definition
Practitioner’s definition
Technical definition
Three Definitions of MI
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EngagingThe Relational Foundation
The Assessment Trap
The Expert Trap
The Premature Focus Trap
The Labeling Trap
The Blaming Trap
The Chat Trap
Early Traps That Promote Disengagement
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Desires or Goals
Importance
Positivity
Expectations
Hope
Factors that influence engagement
ListeningUnderstanding the Person’s Dilemma
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1. Ordering, directing or commanding
2. Warning, cautioning or threatening
3. Giving advice, making suggestions or providing solutions
4. Persuading with logic, arguing, or lecturing
5. Telling people what they should do; moralizing
6. Disagreeing, judging, criticizing, or blaming
7. Agreeing, approving or praising
8. Shaming, ridiculing, or labeling
9. Interpreting or analyzing
10. Reassuring, sympathizing, or consoling
11. Questioning or probing
12. Withdrawing, distracting, humoring or changing the subject.
Thomas Gordon’s 12 Roadblocks
Gordon’s Model of Listening
* Model from Thomas Gordon (Parent Effectiveness Training)
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Communication can go wrong because:
• The speaker does not say exactly what is meant
• The listener does not hear the words correctly
• The listener gives a different interpretation to what the words mean
Gordon’s Model of Listening
Asking Open Questions
Affirming
Reflecting
Summarizing
Core Interviewing Skills (OARS)
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An Open-Ended Values Interview
Structured Values Exploration
Integrity
Exploring Discrepancy
Exploring Values and Goals
FocusingThe Strategic Direction
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Agenda
Three Sources of Focus
The Client
The Setting
Clinical Expertise
Three Styles of Focusing
Directing
Following
Guiding
Focusing in Motivational Interviewing
Tolerating uncertainty
Sharing control
Searching for Strengths and Openings for Change
Clear Direction
Choices in Direction
Counselor Issues That Can Arise in Focusing
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Choosing a Change Topic Among Many
Changing Direction
Getting Unstuck
Raising a Difficult Topic
Fitting in an Assessment
Clarifying your roles in tough circumstances
Agenda Mapping
1. The use of MI component processes is inappropriate when available scientific evidence indicates that doing so would be ineffective or harmful for the client
2. When you sense ethical discomfort or notice discord in your working relationship, clarify the person’s aspirations and your own.
3. When your opinion as to what is in the person’s best interest differs from what the person wants, reconsider and negotiate your agenda, making clear your own concerns and aspirations for the person.
4. The greater your personal investment in a particular client outcome, the more inappropriate it is to practice strategic evoking. It is clearly inappropriate when your personal investment may be dissonant with the client’s best interest.
5. When coercive power is combined with a personal investment in the person’s behavior and outcomes, the use of strategic evoking is inappropriate.
Some Ethical Guidelines for the Practice of Motivational Interviewing
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Offering Advice
• Engage first
• Use sparingly
• Ask permission
• Emphasize personal choice
• Offer a menu of options
Self-Disclosure
• Is it true?
• Could it be harmful
• Is there a clear reason why it would be helpful?
Routine Assessment and Feedback
• Practicalities of initial assessment
• Sharing the outcome of assessment
Three Special Topics
Approach/Approach
Avoidance/Avoidance
Approach/Avoidance
Double Approach/Avoidance
Types of Ambivalence
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Polling Question #3: Which of the following statements do you think is most true when it comes to resistance?
A. Resistance is 100% about the client’s behavior and attitude towards treatment.B. Resistance means the helper has failed.C. Resistance is about the helping relationship.D. Resistance means the helper should try a different approach.
Change and Resistance (Discord)
Opposite Sides of a Coin
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• Dancing vs. Wrestling
• It takes at least two people to not cooperate.
• Client resistance behavior is a signal of dissonance in the counseling relationship.
Consonance and Dissonance
Client Resistance Behavior
• Arguing– Challenging– Discounting– Hostility
• Interrupting– Talking over– Cutting off
• Negating– Blaming– Disagreeing– Excusing– Claiming impunity
– Minimizing– Pessimism– Reluctance– Unwillingness to
change• Ignoring
– Inattention– Nonanswer– No response– Side tracking
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• Arguing for change
• Assuming the expert role
• Criticizing, shaming, or blaming
• Labeling
• Being in a hurry.
• Claiming preeminence.
Counselor’s Role in Resistance
The Spirit of Motivational Interviewing
Fundamental approach of motivational interviewing
Mirror-image opposite approach to counseling
Collaboration. Counseling involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change.
Confrontation. Counseling involves overriding the client’s impaired perspectives by imposing awareness and acceptance of “reality” that the client cannot see or will not admit.
Evocation. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values.
Education. The client is presumed to lack key knowledge, insight, and/or skills that are necessary for change to occur. The counselor seeks to address these deficits by providing the requisite enlightenment.
Autonomy. The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice.
Authority. The counselor tells the client what he or she must do.
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Importance and Confidence
0 1 2 3 4 5 6 7 8 9 10
Not at all Extremelyimportant important
“How important would you say it is for you to __________? On a scale from 0 to 10, where 0 is not at all important and 10 is extremely important, where would you say you are?
“And how confident would you say you are, that if you decided to ____________, you could do it? On the same scale from 0 to 10, where 0 is not at all confident and 10 is extremely confident, where would you say you are?”
Importance and Confidence
Group A: Low importance, low confidence• These people neither see change
as important nor believe that they could succeed in making such a change if they tried.
Group B: Low importance, high confidence• These people are confident that
they could make the change if they thought it were important to do so but are not persuaded that they want to change.
Group C: High importance, low confidence• Here the problem is not in
willingness to change, for these people express desire to do so. The problem is low confidence that they could succeed if they tried.
Group D: High importance, high confidence• These people see it is important to
change and also believe that they could succeed.
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• The Assessment Trap (Q & A)
• Trap of Taking Sides
• The Expert Trap
• The Labeling Trap
• The Premature-Focus Trap
• The Blaming Trap
• The Chat Trap
Early Traps to Avoid
Change Talk and Sustain Talk
Two sides of the same coin
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Change Talk
Phase I. Building Motivation for Change
Desire – I want to change
Ability – I can change
Reasons – It would help me if I changed
Need – I need to change
Recapitulation Summary
Key Question: What is the next Step?
Ready to go forwardI might change
Not ready to go forwardI’m not sure about changing
Change Talk
Key Question: What is the next Step?
Ready to go forwardI might change
Not ready to go forwardI’m not sure about changing
Phase II. Strengthening Commitment
Commitment – I will change
Taking Steps – I attempted change
CHANGE
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Preparatory
• Desire
• Ability
• Reasons
• Need
Mobilizing
• Commitment
• Activating
• Taking Steps
Change Talk
Desire“I just love smoking and how it makes me feel.”
Ability“I’ve tried and I don’t think I can quit smoking.”
Reason“Smoking helps me to relax”
Need”I have to smoke; I can’t get through the day without it.”
Commitment“I’m going to keep on smoking.”
Activation”I’m prepared to accept the risks of smoking.”
Taking Steps”I went back to smoking this week.”
Sustain Talk
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Counselor-centered or Non-directive
Counselor-centered = What the counselor thinks, sees, hopes for, plans and influences the client to do are what is important
Danger is tug of war
Non-directive = Counselor follows client, does not try to influence
Danger is going around in circles, lack of progress
Motivational Interviewing: What it’s not
Client-centered AND Directive
Client-centered = What the client thinks, sees, hopes for, plans and does are what is important
Directive = Counselor guides conversation toward particular topics, explores client’s point of view and then increasingly focuses on certain aspects of the point of view – self-motivational statements or change talk
Motivational Interviewing: What it is
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10 Clarifications About Motivational Interviewing
• Relational and Technical Components
• Evidence
• Happens with the client not to the client
#1: MI is not about the content
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• MI focuses on an evoking process
• Bring forward what they already know about what they would change
• Assessment implies a tailored treatment plan
• Client already know how and why to change – address ambivalence
• Needs help resolving ambivalence about whether to change
#2: Assessment of the client is not needed in order to use MI successfully.
• Knowledge rarely helps people change or address their ambivalence
• Objective feedback may be useful to create ambivalence.
• Does giving the information create discord?
#3: Giving information to the client may or may not be good practice in MI
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• MI is most useful for clients who are ambivalent
• Clinicians need a wide variety of skills
• Clinicians want to keep the “spirit”
#4: MI is not the right thing for every client
• In some Randomized Control Trials (RCT) it works, in others it does not.
• Active ingredients are not known
• Better quality of the interventionist
#5: MI is an empirically supported treatment but its efficacy is highly variable
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• Four RCT’s directly address this
• These covered more than 600 therapists
• Outcomes varied by audio recordings
• Rule of thirds
1/3 – get it easily
1/3 – get if if they work at it
1/3 – never get it
#6: MI can be learned, but not by everyone
• What they say happens has a very low correlation to what actually happens
• Clinicians are not lying. What they don’t notice is often what is most important
• Have to observe to help them learn
#7: Supervising MI requires direct observation of clinicians
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• Change talk is client language. That emerges spontaneously in interpersonal interaction
• Related to better outcomes
• Hypothesis is that ambivalent clients decide they intend to change as they hear themselves voice arguments in favor of it
• What does this mean about sustain talk?
#8: Client language during sessions might explain why MI works
#9: Clinicians have a lot to do with what clients say during interview
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• MI emphasizes client autonomy
• This means that clinicians must be willing to accept that clients may stop coming
• Influence is earned and often depends on client characteristics
#10: Sometimes the outcome of MI is that the client realizes that they don’t need you to change
Richard Choate952-261-2604FAX: 541-241-8074rcchoate1@gmail.com
Thank You!
YourJuniper Behavior Consulting
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www.naadac.org/finding-ambivalence-MI-webinar
Cost to Watch:Free
CE Hours Available:1 CEs
CE Certificate for NAADAC Members:Free
CE Certificate for Non-members:$15
To obtain a CE Certificate for the time you spent watching this webinar:
1. Watch and listen to this entire webinar.
2. Pass the online CE quiz, which is posted at
www.naadac.org/finding-ambivalence-MI-webinar
3. If applicable, submit payment for CE certificate or join NAADAC.
4. A CE certificate will be emailed to you within 21 days of submitting the quiz.
CE Certificate
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