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MOTIVATIONAL INTERVIEWING: HELPING OTHERS CHANGE Cari Guthrie Cho, LCSW-C VP of Programs St. Luke’s House & Threshold Services United

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Page 1: Motivational interviewing

MOTIVATIONAL INTERVIEWING: HELPING OTHERS CHANGE

Cari Guthrie Cho, LCSW-CVP of ProgramsSt. Luke’s House & Threshold Services United

Page 2: Motivational interviewing

READY TO CHANGE?

In order to be In order to be readyready to change to change

The patient must be both The patient must be both willingwilling and and ableable

Willing=Willing=ImportaImportance nce

Able=Able=ConfidenConfidencece

Page 3: Motivational interviewing

STAGES OF CHANGE Pre-contemplation. Client is unconvinced

that s/he may have a mental health and/or substance use problem and does not believe s/he needs to change. S/he may have given up or have not been committed to consistent treatment. Clients often feel pressured by others to seek treatment.

Contemplation. Client is actively considering the possibility of change in regards to mental health and or substance use. S/he is evaluating his/her behavior and options, but is not ready to take action yet. S/he may have made attempts to change in the past.

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STAGES OF CHANGE (CONT)

Preparation. Client makes a commitment to change and starts making initial plans to actually change his/her behaviors.

Action. Client begins to make actual behavior change, and to use new ways of dealing with situations.

Maintenance. Client begins to consolidate new behaviors and new ways of thinking into his/her regular daily life.

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COMMUNICATION STYLESDirect - lead, tell, show the way, take charge of,

preside, govern, rule, have authority, exert authority, take the reins, take command, control,

Follow - go along with, allow, permit, be responsive to, have faith in, shadow, understand, observe

Guide - enlighten, shepherd, encourage, motivate,

Support, accompany, collaborate, promote, elicit solutions, evoke insight

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MI: A WORKING DEFINITION

“Motivational interviewing is a person-centered, goal-oriented method of communication for eliciting and strengthening intrinsic motivation for positive change.”

(Miller, 2009)

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10 THINGS MI IS NOT: A way of tricking people into doing what you

want them to do A specific technique (MI is a counseling

method; no specific technique is essential) A decisional balance, equally exploring pros

and cons of change A form of cognitive-behavior therapy Easy to learn What you were already doing A panacea for every clinical challenge

(Miller, 2009)

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EXERCISE – HAVE A LOOKClient: I just feel so full of shakes that I take a drink before I leave the house.

Counselor: Yes it will be good to drink less. How much do you drink these days?

Client: Well, I’m not an alcoholic its just that I need it before I leave the house.

Counselor: How much would you say you drink each week, even just a guess?

Client: Well you know, I don’t know. I only drink wine so maybe just a few glasses a day, sometimes more, I need it to calm down really.

Counselor: Yes, I see that’s probably at least around 20 – 30 glasses a week. Do you drink even when you go to pick up the kids?

Client: I don’t like to drink as much as I do, but when I am nervous, then I take a drink but its really not very much.

Counselor: Yes and how often does this happen when you are with the children?

Client: Well, I don’t always drink wine before I go get the kids, but you have no idea how terrified I get, its like walking through a mist out there. Today I had to hang on to a lamp post to keep steady and not faint. Its just horrible.

Counselor: And did you have a drink before you came out?

Client: Just a little one to be honest but I’m not an alcoholic you know.

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HAVE A LOOK AGAIN!Client: I feel so full of shakes that I take a drink before I leave the house.

Counselor: It helps to settle your nerves.

Client: And I can go get the kids from school, shop and then feed them.

Counselor: and you get quite a lot done.

Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time.

Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house.

Client: yes, that’s exactly right.

Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it?

Client: well as I said, it calms my nerves, but it can’t go on like this forever.

Counselor: although it helps, you’re concerned about it.

Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids.

Counselor: you don’t want your life to revolve about drinking.

Client: exactly you know I must watch it.

Page 10: Motivational interviewing

REASONS FOR PRACTICING MI It works! It’s all in the welcoming, and welcoming is

easy It doesn’t cost much Small intervention, big effect! The opposite approach, confrontational

counseling, has poor results It fits well with other treatment interventions It makes our jobs easier and more enjoyable Robust and enduring effects when MI is

added at the beginning of treatment MI increases treatment retention, adherence

and staff-perceived motivation

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MI SPIRIT

MI Spirit - a style, attitude or approach. A way of being when talking about change. A powerful ingredient in the fuel that drives good practice.

Collaborative – working with the client – respect the client’s expertise; understand their goals.

Evocative – drawing out ideas and solutions from the client as the experts about themselves.

Honor autonomy – decision making is left to the client. They are ultimately responsible.

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WHAT ARE THE BENEFITS OF EXPRESSING EMPATHY – (REFLECTIVE LISTENING)?

Establishes rapportShows it’s safe to talkBuilds trustPromotes understandingHelps us both feel betterHelps client to be more open to self-

explorationOpens doors to finding a solution that

meets client motivationsEtc?

Guy Azoulai, MINT, Aunay Sous Bois, France, 2006Guy Azoulai, MINT, Aunay Sous Bois, France, 2006

Page 15: Motivational interviewing

HOW CAN WE EXPRESS EMPATHY ?having clients explore solutions

for their own dilemmaskeeping our agendas under

wrapsallowing us to avoid road blocks

to listeningreflecting what the client says using YOU  and WE vs  I asking permission before

informingGuy Azoulai, MINT, Aunay Sous Bois, France, 2006Guy Azoulai, MINT, Aunay Sous Bois, France, 2006

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PERSON-CENTERED COUNSELING SKILLS: OARS Open Questions

Open the door, encourage the client to talk Do not invite a short answer Leave broad latitude for how to respond

Closed Questions  Have a short answer (like yes/no)

Did you drink this week? Ask for specific information

What is your address? What medications do you take?

Might be multiple choice What do you plan to do: quit, cut down, or keep on

smoking? They limit the client’s answer options

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ARE THESE QUESTIONS OPEN OR CLOSED?

What would you like from treatment? Was your family religious? Tell me about your drinking; what are the good

things and the not so good things about it? If you were to quit, how would you do it? When is your court date? Don’t you think it is time for a change? What do you think would be better for you – AA

or Women for Sobriety? What do you like about cocaine? What do you already know about buprenorphine? Is this an open question?

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AFFIRMATIONS  Emphasize a strength

You’re a strong person, a real survivor Notice and appreciate a positive action

I appreciate your openness and honesty today

Thanks for coming in today. I like the way you said that

Express positive regard and caring I hope this weekend goes well for you!

Should be genuine Differs from praise – not an opinion or judgment Strengthen therapeutic relationship

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REFLECTIVE LISTENING Convey understanding of the clients’ point of view

and underlying wants without asking a question. Demonstrates to the client that you care and are

interested in them. It is an essential tool to build rapport.

Does not mean that you will agree with everything the client is saying – it is your attempt to understand the “Gist”, the real meaning of what they are communicating.

It asks, in a way, “Is this what you mean?” without asking a question.

Reflective statements often start with “So you feel…” “It sounds like you…” or “You’re wondering if…”

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SIMPLE REFLECTIONS Repetition – simply repeating a word or part of

what was said. Do not add anything new.

Rephrase – Stay close to what the person is saying by taking some part o what they said and substituting this with a slight rephrase. Here you are adding to and building on what was said. For example:

Client: “I really hate my job. Everyone is always on my case to do this and get that done….”

Staff: “You feel like everyone is demanding a lot from you…”

 If you are correct, they will continue to talk and explore; if you are incorrect, they will say “no” and then it is up to you to start to clarify.

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AMPLIFIED/COMPLEX REFLECTIONS

Paraphrase – This is a major statement in which you are inferring or drawing together the meaning in what they are saying and reflecting it back to the client in different words. You are adding something to it. The goal of paraphrasing is to get the client to explore and clarify issues.

  Client: “I really hate my job. Everyone is always on my case

to do this and get that done….” Staff: “Sounds like the pressure is too much for you right

now”  Reflection of feeling – This is the deepest form of

reflection. It is a paraphrase that emphasizes the emotional dimension of the message.

  Client: “I really hate my job. Everyone is always on my case

to do this and get that done….” Staff: “Sounds like you are really frustrated right now.”

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DOUBLE-SIDED REFLECTIONS With a double-sided reflection, the counselor

reflects both the current, resistant statement, and a previous, contradictory statement that the client has made. Client: "But I can't quit drinking. I mean, all of

my friends drink!“ Counselor: "You can't imagine how you could

not drink with your friends, and at the same time you're worried about how it's affecting you.“

Client: "Yes. I guess I have mixed feelings.”

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PICK OUT THE REFLECTIVE STATEMENTS

Client: I feel so full of shakes that I take a drink before I leave the house.

Counselor: It helps to settle your nerves.

Client: And I can go get the kids from school, shop and then feed them.

Counselor: and you get quite a lot done.

Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time.

Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house.

Client: yes, that’s exactly right.

Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it?

Client: well as I said, it calms my nerves, but it can’t go on like this forever.

Counselor: although it helps, you’re concerned about it.

Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids.

Counselor: you don’t want your life to revolve about drinking.

Client: exactly you know I must watch it.

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SUMMARIZINGSummarizing – summarizing is a special application of reflective

listening that links together discussed material, demonstrates careful listening and prepares the client to move on.

  It may begin with a statement indicating that the staff is

attempting to summarize. For example: “Let me see if I understand what you’ve told me so

far…” “Okay, here’s what I’ve heard so far. Listen and tell me

if I’ve missed anything….” Make your summary concise. End with an invitation for the client to respond such as:

“How did I do? “What have I missed?” “So if that is a fair summary, what other points are there to

consider?” “Is there anything there you want to correct or add to?”

Summaries are good to use when you feel lost or if you want to change direction in the conversation.

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1)1) Ordering, directingOrdering, directing

2)2) Warning, threateningWarning, threatening

3)3) Giving advice, making suggestions, providing solutionsGiving advice, making suggestions, providing solutions

4)4) Persuading with logic, arguing, lecturingPersuading with logic, arguing, lecturing

5)5) Moralizing, preachingMoralizing, preaching

6)6) Judging, criticizing, blamingJudging, criticizing, blaming

7)7) Agreeing, approving, praisingAgreeing, approving, praising

8)8) Shaming, ridiculing, name-callingShaming, ridiculing, name-calling

9)9) Interpreting, analyzingInterpreting, analyzing

10)10) Reasoning, sympathizingReasoning, sympathizing

11)11) Questioning, probingQuestioning, probing

12)12) Withdrawing, distracting, humoring, changing the subject Withdrawing, distracting, humoring, changing the subject

Thomas Gordon’s 12 Roadblocks to Listening

Page 26: Motivational interviewing

OARS Exercise: 

Work in groups of 3 One speaker and two counselors Counselors take turns speaking

Speakers: Describe something about yourself that you

Want to change Need to change Should change Have been thinking about changing But you haven’t changed yet – i.e. something you are ambivalent about

Listeners:  Respond to the speaker using OARS  Don’t try to fix it or make change happen!

  General Guidelines with OARS  Ask fewer questions – 50% of what you say should be reflections Ask more open than closed questions – 20% open questions Don’t ask 3 questions in a row – throw in some reflections and affirmations Offer two reflections for each question asked Summarize when you have gathered a lot of info that you want to organize

or to move to another topic or to end the session.

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Raymond: Active ListeningRaymond: Active Listening

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RESISTANCE IS… A defense mechanism that signals to you

that the client views the situation differently. This is seen throughout all stages, but is often addressed in the contemplation stage as ambivalence.

An important signal of dissonance within the counseling process

Often associated with drop-out rates and other poor outcomes

It is a signal to staff that they need to change direction or listen more carefully.*

It offers an opportunity to respond in a new, perhaps surprising way with out being confrontational.*

Normal

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OK, IT’S NORMAL…NOW WHAT? How we respond to client resistance or sustain

talk makes a difference and distinguishes MI from other counseling approaches

MI assumes that if resistance or sustain talk is increasing during counseling, it is very likely in response to something the counselor is doing

Sometimes the most (and best) we can do with a particular client is to reduce resistance

Implicit in the MI approach is an assumption that persistent resistance is not a client problem, but a counselor-approach or -skill issue

SO: We can change our style in ways that will decrease client resistance…and decreased client resistance is associated with long-term change!

Page 30: Motivational interviewing

FOUR CATEGORIES OF CLIENT RESISTANCE Arguing – the client contests the accuracy, expertise, or

integrity of the clinician or what they are saying by challenging, discounting or being hostile towards the staff person.

Interrupting – breaks in and interrupts in a defensive manner by talking over or cutting off the staff.

Denying – client is unwilling to recognize problems, accept responsibility, or take advice Minimizing Blaming Rationalizing Intellectualizing Diversion Hostility

Ignoring – the client shows evidence of ignoring or not following the clinician by inattention, no response, or sidetracking the conversation.

Page 31: Motivational interviewing

SIX (WELL, SEVEN) TRAPS TO AVOID…AND THEY USUALLY ARISE EARLY IN THE INTERVIEW PROCESS AND RE-APPEAR WHEN WE ENCOUNTER RESISTANCE

The Question-Answer Trap The Expert Trap The Trap of Taking Sides The Labeling Trap The Premature Focus Trap The Blaming Trap

And…the Righting Reflex…watch for it throughout…

Page 32: Motivational interviewing

IDENTIFY THE CHANGE TALKClient: I feel so full of shakes that I take a drink before I leave the house.

Counselor: It helps to settle your nerves.

Client: And I can go get the kids from school, shop and then feed them.

Counselor: and you get quite a lot done.

Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time.

Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house.

Client: yes, that’s exactly right.

Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it?

Client: well as I said, it calms my nerves, but it can’t go on like this forever.

Counselor: although it helps, you’re concerned about it.

Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids.

Counselor: you don’t want your life to revolve about drinking.

Client: exactly you know I must watch it.

Page 33: Motivational interviewing

EVOCATIVE QUESTIONS – MAGIC! For what are you motivated? What change do you want most? On a scale of 1 – 10, how important is it to you

to change? What are your most important reasons for

changing? What are the benefits of changing? What steps are you willing to take? How will you do it? In what ways are you already able to make the

changes you want to make?The answers to all of these are CHANGE

TALK!

Page 34: Motivational interviewing

DECISIONAL BALANCEChangeChange

Costs

Costs

Status-quoStatus-quo

Benefits

Benefits

Benefits of Changing Benefits of Not Changing

Consequences of Changing Consequences of Not Changing

34

Page 35: Motivational interviewing

SIGNS OF READINESS FOR CHANGE

Decreased resistance Decreased discussion about the problem Resolve Change talk/self-motivational statements Questions about change Envisioning Experimenting

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FINAL THOUGHTS…

MI releases us from the draining psychological burden of having to “make” people do the right thing, which is actually an impossible task.

People make choices and we cannot take that away from them…what we CAN do is help them make the choices that are right for them.

Page 37: Motivational interviewing

FOR YOUR INTEREST Miller and Rollnick (2002). Motivational Interviewing:

Preparing People for Change, 2nd Edition, New York, Guilford Press.

Rollnick, et. al. (1999). Health Behavior Change: A Guide For Practitioners. London and New South Wales, Churchill Livingstone.

Miller and White. Confrontation in Addiction Treatment, Counselor, August 2007.

Miller, W. R. (2000). Rediscovering Fire: Small interventions, large effects. Psychology of Addictive Behaviors, 14:6-18.

www.motivationalinterview.org Enhancing Motivation to Change in Substance Abuse

Treatment, CSAT, TIP 35. Hettema, J., Steele, J., & Miller, W. R.. (2005).

Motivational interviewing. Annual Review of Clinical Psychology, 1, 91-111.

Amrhein, et. al. (2003) Client Commitment Language During MI Predicts Drug Use Outcomes. Journal of Consulting and Clinical Psychology, 71, 862-878.