motivational interviewing lecture

MOTIVATIONALINTERVIEWING

sovannpen@hotmail.com

Self-rating

Ability to work with resistant clients? How much do you agree: I am a good

listener? I am confident working with “stuck”

clients? I know how to help a client change?

Expectations: How MI can help

Competence Confidence Creativity

Improved presence Decreased frustration Increased connection

Learning MI

Start with the bad news Recommendation Minimum of two days

8 Step Framework for Learning MI

1. The SPIRIT of MI 2. OARS – client-centered counseling

skills 3. Recognizing and reinforcing change

talk 4. Eliciting and strengthening change talk 5. Rolling with Resistance 6. Developing a Change Plan 7. Consolidating client commitment 8. Shifting flexibly between MI and other

methods

You would think…

Debi Austin

Addiction

Romans 7 I do not understand what I do. For what I want to do I do not do, but what I hate I do. 16 And if I do what I do not want to do, I agree that the law is good. 17 As it is, it is no longer I myself who does it, but it is sin living in me. 18 For I know that good itself does not dwell in me, that is, in my sinful nature.  For I have the desire to do what is good, but I cannot carry it out. 19 For I do not do the good I want to do, but the evil I do not want to do—this I keep on doing. 20 Now if I do what I do not want to do, it is no longer I who do it, but it is sin living in me that does it. 21 So I find this law at work: Although I want to do good, evil is right there with me. 22 For in my inner being I delight in God’s law; 23 but I see another law at work in me, waging war against the law of my mind and making me a prisoner of the law of sin at work within me. 24 What a wretched man I am

People are messy

MI Defined

It is a client-centered, directive method of engaging intrinsic motivation to change behavior by exploring and resolving ambivalence within the client.

William Miller and Stephen Rollnick

MI as a technique

Basic Like scales Different types of music

Science of counseling Art of counseling

Two Phases of MI

Phase I – Explore ambivalence/Build Motivation

Phase II – Change Talk, Planning, Strengthening Commitment

MI Elements

MI Spirit MI Principles DEARS OARS Change Talk

The Spirit of MI

FUNDAMENTAL APPROACH OF MI

MIRROR-IMAGE APPROACH

Confrontation

Education Authority

Collaboration

Evocation Autonomy

The Spirit of MI cont.

Motivation to change is elicited from the client, and not imposed from without.

It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence

Direct persuasion is not an effective method for resolving ambivalence.

The counseling style is generally a quiet and eliciting one.

The counselor is directive in helping the client to examine and resolve ambivalence.

Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction.

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

MI Principles: DEARS

Develop Discrepancy Express Empathy Avoid Argument (Amplify Ambivalence) Roll with Resistance Support Self-Efficacy

MI Principles: RULE

R – Resist the righting reflex U – Understand your client’s motivation L – Listen to your client E – Empower your client

Resisting the Righting Reflex

“We tend to believe what we hear ourselves say. The more patients verbalize the disadvantages of change, the more committed they become to sustaining the status quo.”

“If you are arguing for change and your patient is resisting and arguing against it, you’re in the wrong role. You are taking all the good lines.”

MI in Health Care p. 8

Emotional Intelligence

Personal Competence Self-Awareness Self-Management

Delaying gratification

Social Competence Social Awareness Relationship management

Empathy

Client-centered: Understanding the client’s internal frame of reference and present concerns.

Non-judgmental attitude. Understanding vs condoning

Counselor FAIL

Why don’t you change? How can you tell me that you don’t have

a problem? What makes you think that you’re not at

risk? Why don’t you just…? Why can’t you…?

Gottman’s Four Horsemen

Criticism Defensiveness Contempt Stonewalling

Benefits of Resisting Righting Reflex & Empathy

Permission Authenticity Validation Acceptance Safety Connection Trust

Normalization/Validation

Normalize is not approval. It is common experience. Permission to truly be known and know

themselves Vs Compartmentalization and shame

Their behavior may be a seemingly senseless problem, help them dig deeper to invalidated parts.

Based on a human need and desire…maladaptive ways to get them.

Trauma, codependency “Every problem was a solution to a

previous problem…”

Etiology of the problem

What fear can do

From CNN:Boyfriend: Phobia caused woman's 2-year bathroom stay

"The case drew nationwide attention after Ness County Sheriff Bryan Whipple said it appeared the Ness City woman's skin had grown around the seat in the two years she apparently was in the bathroom.

"We pried the toilet seat off with a pry bar and the seat went with her to the hospital," Whipple said. "The hospital removed it."

Reasons not to change

There is a “value” in staying the same. Freedom from the “cost” of change Freedom of the risk of failure. Safety of low expectations, not taking

responsibility. Freedom from the pressure of success Giving up secondary gains

Therapy is…

Grace and Truth

Not Grace or Truth, Grace vs Truth Grace with Truth

Scalpel Anesthesia

Rogers: “The curious paradox is that when I accept myself just as I am, then I can change.”

On Advice-giving and information

Key strength of MI: You don’t have to be an expert

Insight doesn’t guarantee change. Information doesn’t guarantee change. Diet book, self-help book, formula, plan “If reasons/change talk were enough they

would have made the change already…” (MI in tx of Psych. Problems. P.30)

Cont.

MI isn’t about finding the missing piece of information.

It isn’t necessarily problem-solving or “figuring things out”.

It isn’t “Making People Change” it’s “Preparing People Change”

By helping them fully be aware of their choices, competence and challenges and helping them CHOOSE.

Even if you may not agree with their choice, they are choosing with their eyes wide open.

With this “informed consent” they are being responsible for their life, they are choosing their path, choosing their consequences.

3 Modes of working

Following Guiding Directing

Develop flexibility in shifting modes

“Good leading is gentle, responsive and imaginative.” MI 2nd ed. P. 22

Asking How many times has that happened?

(directing) What kind of change makes sense to you?

(guiding) How have you been since your son died?

(following)

Informing

Your best option is to take these tablets. (directing)

Changing your diet would make sense medically, but how does that feel to you? (guiding)

Yes, it’s a common experience; many patients also feel quite shocked and unsettled about simple things like going to the toilet. (following)

Listening

So you understand what’s going to happen this morning, but you want me to tell you more about what will happen later on. (directing)

You’re feeling concerned about your weight, and you are not sure where to go from here. (guiding)

This has been a huge shock. (following)

Understanding Client’s motivation - Four client Profiles

Group A: Low importance, low confidence Group B: Low importance, high

confidence Group C: High importance, low

confidence Group D: High importance, high

confidence

Four Types of Precontemplators

Reluctance Rebellion Resignation Rationalization

I Thess. 5:14-18

14And we urge you, brothers, admonish

the idle, encourage the fainthearted, help the weak, be patient with them all. See that no one repays anyone evil for evil, but always seek to do good to one another and to everyone. Rejoice always, pray without ceasing, give thanks in all circumstances; for this is the will of God in Christ Jesus for you.

Where Good Ideas Come from

http://youtu.be/NugRZGDbPFU Steven Johnson Where Good Ideas Come From: The

Natural History of Innovation

Thomas Gordan’s Roadblocks

1) Ordering, directing 2) Warning, threatening 3) Giving advice, making suggestions,

providing solutions 4) Persuading with logic, arguing,

lecturing 5) Moralizing, preaching 6) Judging, criticizing, blaming

Roadblocks cont.

7) Agreeing, approving, praising 8) Shaming, ridiculing, name-calling 9) Interpreting, analyzing 1 0) Reasoning, sympathizing 1 1 ) Questioning, probing 12) Withdrawing, distracting, humoring,

changing the subject

OARS

Open-ended questions

Affirmations Reflective listening Summaries

Traps to Avoid

The Question/Answer Trap The Premature Focus Trap The Confrontation Trap The Blaming Trap The Expert Trap The Labeling Trap

Open-ended Questions

How? When? Where? What? Who?

Vs Yes/No

Closed questions: Clarifying questions Using Why?

Affirmations

Compliments Statements of appreciation and

understanding Thanks… I appreciate… You’re clearly a (character quality/value)

person… If I were in your position… You enjoy… I’ve enjoyed talking with you today…

Reflections

It is a hypothesis of what may be going on.

“Do you mean?” It is a statement to understand meaning.

MI: 2-3 reflections per question asked vs 10 questions: 1 reflections in other counseling sessions. About half responses are reflections.

Types of Reflections

Parroting – repeating, using same words Simple – basic paraphrase, acknowledge

feeling, perception or disagreement, small shift in emphasis

Amplified – amplified or exaggerated form

Double-sided – one way to develop discrepancy

Complex – summary, interpretation, metaphor/simile, continuing the paragraph

Amplified or understated?

I just don’t like the way she comments on how I raise my children.

Other Responses beyond Reflection

Shifting FocusShift the person’s attention away from what seems to be a stumbling block in the way of progress. Go around barriers rather than climbing

over them Reframing Agreeing with a twist Emphasizing personal choice and control Coming alongside

Reframing

Sometimes… A part of you… When you tried that in the past… I’m guessing, you might…(tentative)… Some people…when modeling or giving

advice vs self-disclosure.

You feel stuck…

"You feel stuck." sometimes brings the session to an awkward pause or even a grinding halt.

Therapist: "So, you feel stuck."Client: "Yep."[BONK!][Crickets]

Another variation is reflecting "You feel helpless." or "You feel hopeless." or "You feel trapped."

Summaries

Collecting Bouquets Untangle the threads Linking Transitional

Repeat

Amplify Ambivalence

“As I hear myself talk, I learn what I believe.” Decisional Balance The person experiences competing

motivations because there are benefits and costs associated with both sides of the conflict. There are two kinds of weights on each side of a the balance: one has to do with the perceived benefits of a particular course of action; the other has to do with the perceived costs or disadvantages of the course of action (such as taking medication to lower blood pressure).

Decisional Balance

Decisional Balance Sheet

Continue to drink as before Abstain from alcoholBenefitsHelps me relax Enjoy drinking with friends

CostsCould lose my family Bad example for my children  Damaging my health

Spending too much money Impairing my mental ability Might lose my job Losing my time/life

BenefitsLess family conflict More time for my children Feel better physically Helps with money problems

CostsI enjoy getting high What to do about my friends How to deal with stress

Why ask Why?

 Why, besides being an invitation for a fight, is victim language, past focused, it distracts from moving forward and facing change. On one hand, the past is one the best predictors of future behaviors; on the other, we're told Insight doesn't necessarily lead to change.

Search for meaning “Why do I?” “I know/believe…why do I

still?”

Alternatives to Why?

"What was/is going on?""What is happening/happens? when you...""How is pattern continuing? What fuels it?""What did you do? What didn't you do?""Where did this happen?""When did you start believing that [core belief or cognitive distortion]?"

"Where did you start doing that [behavior]?""Who taught you that [behavior/coping]? Who modeled that in your life?""How did you get here? To this place?""What if?""What did they do/say?"

"How did you respond?" (vs. "They made me...[feeling or behavior]")

"What did that look like? What did you feel? What did you experience?""When that happened - What did that mean to you? What did you start telling yourself? About God, others, family, yourself?""What was your role?“

"What would you do if you knew "Why?” How would knowing why? help you." 

Here-and-now

How does this affect you?What are you experiencing?What will you do with this? What do you want/need?Who will you share this with?

What are you feeling?How can you reframe this?What is the alternative?What/How can you change/control?What are the obstacles?

Developing Discrepancy

Awareness of consequences is important A discrepancy between present behavior

and important goals will motivate change The client should present the arguments

for change. A “holy discontent” “Food for thought” vs judgment/criticism “Columbo” technique. “Help me

understand.”

Addiction Thinking

Minimization: where it all begins Rationalization: the plot thickens Denial: a preferred way to live Re-labeling: telling it like it isn’t Justification: I couldn’t help it Entitlement: you deserve a break today

Defense Mechanisms

http://changingminds.org/explanations/behaviors/coping/coping.htm

Adaptive mechanisms: That offer positive help. Attack mechanisms: That push discomfort onto

others. Avoidance mechanisms: That avoid the issue. Behavioral mechanisms: That change what we do. Cognitive mechanisms: That change what we think. Conversion mechanisms: That change one thing

into another. Defense mechanisms: Freud's original set. Self-harm mechanisms: That hurt our selves.

Explore Values

Values and priorities Values are positive. Preferred experiences (for example a

valued career/job) Behavioral ideals

Values Card sort at www.motivationalinterviewing.org

Behaviors that don’t serve one’s values

Self-oriented behaviors that neglect loved ones

Short-sighted behaviors that reap short-term rewards while ignoring long-term costs

Inefficient behaviors that fulfill certain needs at the expense of others

Alignment? How does (behavior) fit with the

importance of (value)? How does (behavior) fit with your desire

to do/be (value)?

Concreteness

Specific examples Clarification: in what ways? How much?

How often? Description of the last time? What else?

Cautions with Discrepancy

Your client can’t “lose” their way to change. Don’t use your clients words against them. Or at least if you do, don’t do a happy dance. Don’t back them into a corner, force them to

swallow their words down. Yeah, yeah, yeah, you’re right. I said that but

you’re a bastard for pointing it out! “A man convinced against his will is of the

same opinion still.” Dissonance and incongruence vs shame or

feeling tricked

Roll with Resistance

Avoiding arguing for change Resistance is not directly opposed New Perspectives are invited but not

imposed The client is a primary resource in finding

answers and solutions Resistance is a signal to respond

differently, to change strategies

Dad rolls his son

http://youtu.be/wsBon3DTwIY

Four process categories of client resistance behavior

1. Arguing – The client contests the accuracy, expertise, or integrity of the counselor.2. Interrupting – The client breaks in and interrupts the counselor in defensive manner.3. Negating – The client expresses an unwillingness to recognize problem, cooperate, accept responsibility or take advice.4. Ignoring – The client shows evidence of ignoring or not following the counselor.

Arguing

Challenging- challenges the accuracy of what is said

Discounting – counselor’s personal authority

Hostility – Client expresses direct hostility

Negating

Blaming Disagreeing Excusing Claiming Impunity (not in danger) Minimizing Pessimism Reluctance Unwilling to change

Ignoring

Inattention Non-answer No response Sidetracking

Other passive Over-compliance Cancellations, no-shows

Yes..But…

Spoken Unspoken

The power of AND

http://youtu.be/h5aSa4tmVNM

Jesus

Rich Young Ruler – Luke 18

Paralytic at Bethesda – John 5

MI – a shortcoming

Not just logically weigh pros and cons, Change Balance Sheet.

Doesn’t fully account for, or address sin. How does our new nature interact with

our flesh, this body of sin? How does the reality of the Holy Spirit

interact with us being sinful? How does the gospel apply? Trying on new clothes. Feels very

uncomfortable, intolerable.

Let That Be Enough Switchfoot

http://youtu.be/rdWEgu7c3i0

I wish I had what I need To be on my own 'Cause I feel so defeated And I'm feeling alone 

And it all seems so helpless And I have no plans I'm a plane in the sunset With nowhere to land 

And all I see It could never make me happy

And all my sand castles Spend their time collapsing 

Let me know that You hear me Let me know Your touch Let me know that You love me Let that be enough 

It's my birthday tomorrow No one here could now I was born this Thursday 22 years ago 

And I feel stuck Watching history repeating Yeah, who am I? Just a kid who knows he's needy 

Moving too fast…

Trust me, “It’s good for you” isn’t good enough. If they feel disrespected or worse,

traumatized/abused. More importantly, we’ve stolen growth/process

from them, we’ve stolen their opportunity to overcome their fear and to make their own free choice.

It may be good for them but it risks mistrust, anger, resentment.

Innoculate them to other risks/changes. Find ways to make change fun, not traumatic.

Support Self-Efficacy

Judge or Attorney

In client’s life who is the judge? Who has the final authority?

Who is hardest critic? You don’t want to be put in the position of

being the judge. You advocate for your client. Eventually advocate for themselves.

Ultimately they stand and give an account for themselves.

Directive Belief in the possibility of change: client’s

and counselors. Self-Fulfilling prophecy. Direct your client to direct themselves Direct your client to “grow up” – not in a

pejorative sense, they are adult, responsible, heroic, significant, God’s workmanship.

This where you “don’t work harder than your client”

You don’t care more, you don’t have all the insights/interpretations of meaning, aha moments.

You are winning when your client is winning, when they come up with the cool meaning and understanding about themselves. When they seem themselves for what they are.

Shifting from an external locus of control, where they are constantly seeking approval or answers outside of themselves to an internal locus of control. (Of course God is sovereign and involved. They do business directly with God. They don’t need an intermediary to discern God’s will for them.)

Bear their weight, carry their own load. Interdependence. Ask for what they want/need. Find what they want and need. Or ask for help.

Humble courage. Authentically know their limits vs

pretense and defensiveness. Not driven to do too much, free to do

much. Passion vs pressure Normalize it takes practice.

Trainer and Spotter Model, teach, coach, come alongside, spot. Start here by casting vision for self-efficacy. Empower client. Affirmations You can do it. You have done it. You might do it. People have done it. (normalize) How did you do it? (talk about successful

changes in the past)

How Not to Change – Bill O’Hanlon Change 101

1. Don't listen to anybody 2. Listen to everybody 3. Endlessly analyze and don't make changes. On the other hand, perhaps: "Don't just do something, stand there." 4. Blame others for your actions or problems. "We have only one person to blame and that's each other." 5. Blame yourself and put yourself down regularly 

6. Keep doing the same things that don't work 7. Keep focusing on the same things when that focus doesn't help 8. Keep thinking the same thoughts when those thoughts don't help 9. Keep putting yourself in the same unhelpful environment 10. Keep relating to the same unhelpful people 11. Put more importance on being right than changing 

Change Talk : DARN C

Recognize and elicit Desire: I want, I’d like to, I wish I could, I

can’t wait… Ability: I could, I can, I might be able to Reason: I would probably feel better if I…,

It would be good if I… Need: I ought, I have to, I really should…

4 Categories of Change Talk

Recognizing the disadvantages of the status quo

Recognizing the advantages of change Expressing optimism about change Expressing intention to change

“What is your client’s change language”

Evoking DARN C

Desire: "What do you want to do about this behavior?"

Ability: "What makes you believe you can do this?"

Reason/Need: "Why would you want to make this change?"

Commitment: "So what are you willing to do now?"

Desire: Why would you want to make this change?

Ability: How would you do it if you decided?

Reason: What are the three best reasons? Need: How important is it? and why? Commitment: What do you think you’ll

do?

Key Questions

“What do you think you will do?” “What does this mean about your

(habit)?’ “What do you think has to change?” “What are your options?’ “What’s the next step for you?” “What would be some of the good things

about making a change?” “Where does this leave you?”

Phase II – Initiating Change

A negotiable, workable plan

Phase II Hazards

Underestimating Ambivalence Over-prescription Insufficient Direction

Recapitulation – Summary

Summary of client’s perception, change talk, importance talk

Summary of ambivalence, positives of status quo

Objective evidence, if any Restatement of DARN-C, confidence talk Your own assessment of client’s situation

Change factors from Change 101

Positive and Negatives from the Past

Positive and Negatives in the Present

Positive and Negatives in the Future

Eliciting Change Talk:MI Becomes Directive

IQ-LEDGE-C Importance/Confidence Ruler Querying Extremes Looking Back / Looking Forward Evocative Questions Decisional Balance Goals and Values Elaborating Coming Alongside

Change Ruler

Scaling

“If on a scale of 1 to 10, 1 is not at all important to give up smoking and 10 is extremely important to give up, what number would you give yourself at the moment?”

“If you were to decide to give up smoking now, how confident are you that you would succeed? On a scale of 1 to

10, 1 means that you are not at all confident and 10 means you are 100% confident you could give up and remain a non-smoker.” “Why are you at (chosen number) and not at 1?” “What would need to happen for you to go from (chosen

number) to (a higher number)?” “How can I help you go from (chosen number) to (a

higher number)?”

Query

What is the worst case scenario? What is the best case scenario?

Looking Back / Looking Forward

With problem Without problem

Evocative questions

Hypothetical How? Or What? Would you do…if…

Desire: "What do you want to do about I this behavior?"

Ability: "What makes you believe you can do this?"

Reason/Need: "Why would you want to make this change?"

Commitment: "So what are you willing to do now?"

Decisional Balance

Goals and Values

Elaborating

Coming Alongside

Paradoxical, “therapeutic paradox” “reverse psychology”

Permission to not change Postpone change “Not ready” “Not the right time” “In the meantime…” Actually “firing” your client or suggesting

referral to another counselor, other solutions.

Responding to change talk - EARS

Reinforce and consolidate change talk Elaborating: In what way… ?; Tell me more…;

What else? Affirming: That took a lot of courage; You’re a

person who can make changes when you need to…

Reflecting: That’s really important to you …; You realize it’s become a problem…

Summarizing: There are a number of things I’m hearing about your situation . First, you’re concerned about….. Also, you feel…, and you are thinking…

Evoke and Strengthen Commitment

I should I might I could I will

Negotiate A Change Plan

Setting Goals Considering Change

options Arriving at a plan Eliciting commitment

Commitment

Have you come to conclusion? Are you ready? How close? Anything else to consider?

Choices to make for plan

Method – What? Preferred strategy – How? Timing – When?

The Adjacent Possible

Scientist Stuart Kauffman quoted by Steven Johnson

The phrase captures both the limits and the creative potential of change and innovation.

What is possible? What is probable? What are the small, next steps? Being faithful with a little first

Building emotional, mental, relational muscles that they haven’t built yet.

What would that look like? What might happen? There is hope in the range of alternative

approaches available. There is no one “right way” to change –

menu of changes

10 Stages of Recovery

SMART Goals

Specific Measurable Attainable Relevant Time-bound

RISE by Stephen Arterburn

"The goal of treatment is to RISE above your problems rather than be controlled and dominated by them." Stephen Arterburn Healing is A Choice

Reduce

Reduce the stress in your life by learning some new management skills

Reduce conflicts that cause inner turmoil and difficulties in your relationships.

Reduce the negative patterns that have set in over your lifetime.

Reduce the substances you use to help cope with the pain in your life.

Increase

Increase your self-awareness and how you affect people who interact with you.

Increase your awareness of your feelings.

Increase your understanding of yourself and why you do the things you do.

Increase your connection with others.

Increase your assertiveness in a way that draws people to you rather than repels them.

Increase the healthy influences in your life.

Increase your time alone with God in the Bible and in prayer.

Substitute positive emotions for negative ones.

  Substitute the willingness to risk for fear.   Substitute humility for arrogance.

Substitute acceptance for anger.   Substitute peace for anxiety.   Substitute surrender for control.

Eliminate

Eliminate addictive behaviors

Eliminate a critical and judgemental spirit.

Eliminate certain repetitive sins in your life.

Change as grief

Sometimes change talk can sound like ambivalence or resistance.

Client may be articulating what they will be giving up.

Even dysfunctional relationships, beliefs, behaviors can be hard to let go of.

For some weight can be a defense, being more attractive can be risky, it opens up opportunity for relationship which in term means more risk at being known and being hurt.

Resources

http://www.motivationalinterview.org/ http://www.motivationalinterview.org/quic

k_links/manuals.html

Motivational Interviewing: Preparing People for Change, 2nd Edition Miller, William R., Rollnick, Stephen (2002)

Building Motivational Interviewing Skills: a practioner workbook Rosengren, David B. (2009)

Motivational Interviewing in Health Care: Helping Patients Change Behavior Rollnick, S., Miller, WR & Butler, CC (2008)

Motivational Interviewing in the Treatment of Psychological Problems Arkowitz, H., Westra, HA, Miller, WR., Rollnick, S editors

Emotional Intelligence 2.0 Bradberry, T., Greaves, J (2009)

Emotional Intelligence Quick Book Bradberry, T., Greaves, J (2003)

Change 101: A Practical Guide to Creating Change in Life or Therapy O’Hanlon, B. (2006)

www.newlife.com www.cloudtownsend.com