facilitating change using the relational elements of ... · facilitating change using the...
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Marty Weems, LCSW, LCAS, MINTUNC School of Social Work
10-20-2016
Facilitating Change Using the Relational Elements of Motivational Interviewing
UNC-CH CLINICAL LECTURE INSTITUTE
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Learning Objectives
Understand the theoretical basis of Motivational Interviewing (MI).
Recognize the relational elements of MI.
Incorporate relational elements into the process dimension of psychotherapy.
Develop skills in using the relational elements of MI.
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Theoretical Influences
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What is Motivational Interviewing?
“Motivational Interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.”
(Miller & Rollnick, 2013)
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Theoretical Foundations of MI
Client Centered Therapy
Self Determination Theory
Cognitive Dissonance Theory
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Client Centered Therapy
Developed by Carl Rogers
Core themes
Actualizing tendency
Primacy of experience
Self exploration
Non-directivity
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If I keep from meddling with people, they take care
of themselves,
If I keep from commanding people, they behave
themselves,
If I keep from preaching at people, they improve
themselves,
If I keep from imposing at people, they become
themselves
~Lao Tzu
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Principles of Person-Centered Care
It is vital to activate one’s own strengths, motivations, and resources in order for change to occur.
Change is not a power struggle.
Change is fundamentally self change...we do not install change, we evoke it.
(Miller & Rollnick, 2013)
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Growth Factors in Client Centered Therapy
Therapist-client psychological contact
Client incongruence (vulnerability)
Therapist congruence (genuineness)
Therapist unconditional positive regard
Therapist empathy
Client perception
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Self Determination Theory
A theory of motivation that requires consideration of innate psychological needs
Competence
Autonomy
Relatedness
Essential for understanding the what and why of
goal pursuits
(Ryan & Deci, 2000)https://www.youtube.com/watch?v=3sRBBNkSXpY
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Types of Motivation
(Ryan & Deci, 2000)
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Cognitive Dissonance Theory
Leon Festinger
Principle of cognitive consistency
We have an inner drive to hold all our attitudes and beliefs in harmony and avoid dissonance.
Reducing dissonance
Change in attitudes
Acquisition of new information
Reduce importance of cognitions
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Foundational Elements of MI
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Relational Factors
Technical Factors
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Motivational Interviewing is comprised of…
Spirit Principles
OARSChange
Talk
(Miller & Rollnick, 2013)
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Spirit of MI
Collaboration
Compassion
Evocation
Acceptance
(Miller & Rollnick, 2013)
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Four Points of Acceptance
Absolute Worth
Affirmation Autonomy
Accurate Empathy (Miller & Rollnick, 2013)
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The spirit of MI brings forth feelings of hope, inspiration, and confidence, which provide clients with the outlook necessary to improve their lives.
(Wagner & Ingersoll, 2008)
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MI Principles
1. Express Empathy
2. Develop Discrepancy
3. Roll with Resistance
4. Support Self Efficacy
(Miller & Rollnick, 2013)
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Rolling with Resistance
Dancing vs. Wrestling
Guiding vs. Directing
Tapping vs. Pulling
Consulting vs. Instructing
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In short…
Therapist interpersonal skills increase client:
Engagement
Affect
Disclosure
Cooperation
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Avoid the Righting Reflex
Nixin’ fixin’
We want to make things right or better
In MI, the practitioner doesn’t try to change the client’s behavior.
Change comes from the client’s intrinsic motivation.
RULE
https://www.youtube.com/watch?v=-4EDhdAHrOg
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Understanding Ambivalence
Feeling two ways about something
It is…NORMAL!
In MI, the goal is to help the client to resolve ambivalence and move towards change
(Miller & Rollnick, 2013)https://www.youtube.com/watch?v=RmVnIRgfngc
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Key Points in MI
Motivation to change is elicited from the client.
It is the client's task, to articulate and resolve the ambivalence.
Direct persuasion is not effective.
The counseling style is generally quiet and eliciting.
The counselor is directive, in that they help the client to examine and resolve ambivalence.
Readiness to change is not a trait, but a state.
The therapeutic relationship resembles a partnership or companionship.
(Miller & Rollnick, 2013)
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Microskills
Open-ended questions
Affirmations
Reflections
Simple
Affective
Double-sided
Reframe
Summaries
Agreement with a twist
Metaphor
Amplified
(Miller & Rollnick, 2013)
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Change Talk
Desire
Ability
Reasons
Need
Commitment
Activation
Taking steps
Preparatory Mobilizing
(Miller & Rollnick, 2013)
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Four Processes in MI
Engaging
Establish a working relationship
Focusing
Focus on what the person came to talk about
Evoking
Eliciting the client’s own motivation for change
Planning
The when and how change will take place
(Miller & Rollnick, 2013)
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When to Use MI
When ambivalence to change exists
When there is a clear direction for change
In conjunction with other approaches- it is not designed to be a singular approach
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Dispelling Some Myths
MI is NOT…
a way to trick or manipulate people
a technique
just client centered therapy
A form of CBT or Client Centered Therapy
the transtheoretical stages of change
easy
a panacea
what you are already doing
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Using the Relational Elements of MI
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“Motivational Interviewing is not about the content”
~Theresa Moyers
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Process Dimension of Psychotherapy
“The therapeutic process is metaphorically repeating the same type of conflicted interaction that clients have not been able to resolve in other relationships, and that they have often experienced in formative, attachment relationships”.
(Teyber & McClure, 2011, p. 24)
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What Influences Engagement?
Desires/goals
Importance
Positivity
Expectations
Hope
(Miller & Rollnick, 2013)
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Building the Therapeutic Alliance
Significant relationship between the therapeutic alliance and psychotherapy outcomes.
Therapist attributes that are associated with a high quality alliance include:
Confidence
Warmth
Patience
Flexibility
(Arnow & Steidtmann, 2014)
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Elements of a Positive Alliance
Establishment of trusting working relationship (akin to a holding environment)
Agreement on treatment goals
Collaboration on mutually negotiated tasks
Presence
Holding environment
Corrective emotional experience
(Bordin, 1979)
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Empathy in the Relationship
Empathetic communication
“a respectful attitude and non-judgmental stance towards the client” (Teyber & McClure, 2011, p.59).
Discerns the client’s feelings (beyond surface level feelings)
Effectively communicates understanding
https://www.youtube.com/watch?v=1Evwgu369Jw
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Some Traps to Avoid
Question/Answer Trap
Premature Focus Trap
Assessment Trap
Blaming Trap
Expert Trap
Labeling Trap
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Reflections & Empathy
Reflections convey empathy in a way that questions don’t.
Reflections are also a means of hypothesis testing.
As a therapist, you are “trying to capture the emotional meaning or distill key issues in what the client has just said” ( Teyber & McClure, 2011, p. 63.
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Therapist Vulnerability
Power sharing
Being fully present
Self involving statements
Self disclosure
Immediacy interventions/process comments
Interpersonal feedback
Therapeutic impact disclosure
https://www.youtube.com/watch?v=ZkDaKKkFi6Y
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When Needs Go Unsatisfied
Equifinality
Accommodation
Substitutes or compensatory motives
Development of non-optimal regulatory styles
Behavioral patterns
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Difficult Client Behaviors
Re-enactments
Ruptures
Pathogenic beliefs
Eliciting moves
Testing behaviors
Transference
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Signs of Discord in the Relationship
Defending
Squaring off
Interrupting
Disengagement
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Strategic Responses
Reframing
Shifting focus
Apologizing
Affirming
Emphasizing personal choice
Running head start
Coming along side
(Miller & Rollnick, 2013)
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Summary & Wrap Up
Points of learning
Questions
Thank you!