finding ambivalence & 10 other things about mi...2019/02/13 · 2/12/2019 1 finding ambivalence...

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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

[email protected]

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Produced ByNAADAC, the Association for Addiction Professionals

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


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: [email protected]

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


CONTEMPLATIONI am seriously considering changing the behavior in the next six months.

Length: Two weeks to several years

SELF-VALUING


Pros


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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


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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


Pros


ACTION


CONTEMPLATION

PRECONTEMPLATION


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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


ACTION

MAINTENANCE


CONTEMPLATION

PRECONTEMPLATION


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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


ACTION

MAINTENANCE


CONTEMPLATION

PRECONTEMPLATION


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Also identified 10 specific processes for change:

• Experiential Processes

• Behavioral Processes


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


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


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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: [email protected]

Thank You!

YourJuniper Behavior Consulting

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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


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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February 27, 2019 March 27, 2019

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finding ambivalence & 10 other things about mi...2019/02/13 · 2/12/2019 1 finding ambivalence...

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