motivational interviewing for ceaps

Motivational Interviewingfor CEAPs

Tom Broffman, PhD, LICSW, LCDP. LCDS, CEAPClinical Professor

University of St. JosephDepartment of Social Work & Latino Community Practice

[email protected]

Disclaimer: MI Not Appropriate for

1. People who are acutely homicidal or suicidal2. Unstable psychiatrically3. Having problems meeting their basic human

needs (food, clothing, shelter, safety)4. Impaired or under the influence of alcohol or

drugs5. Traumatic brain injury6. Memory or cognitive impairment7. Children & pre‐adolescents

2Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP

2 Opening Questions

1. What do you already know aboutmotivational interviewing?2. Based on what you already know about MI, what would like to learn more about?


Why Do People Change?1. ?2. ?3. ?4. ?5. ?6. ?


Why Don’t People Change?1. ?2. ?3. ?4. ?5. ?6. ?


The Change Exercise

6

Exercise: The Change Exercise

1. Stand up and turn to stand face to face in pairs. 2. Silently observe your partner for 30 seconds. 3. Now turn back to back and change 3 things

about yourself. [appearance] 4. When you are done, turn back to face your

partner. 5. Each person should take a minute to name the 3

things your partner has changed.

7

Change Exercise Questions1. What was your comfort level during this

exercise?2. What made you comfortable or uncomfortable?3. How hard was it to change things? 4. How did you decide what things to change about

yourself?5. What does this exercise tell us about change?6. Look around you did you notice how quickly

people changed back to the way they started as soon as they sat down?

7. What implications might this have about change for people and ourselves?

8

Change Exercise Key Points1. Change is difficult2. Change is not always comfortable3. Change requires creativity4. We tend to go back to old ways5. It is easier to stay the same6. We like our comfort zones7. Change requires an open mind8. Change has emotional and cognitive components

9

Change Exercise Key Points

9. Change is a process10.Change happens over time11.The process is as important as the result12.Watch out for measuring success only if a change

occurred13.Often there is a difference between what

someone knows they should do and there readiness to do it.

14.Greatest chance to impact change is pacing it to the specific stage of change

10

PrecontemplationMaintenance

Action Preparation

ContemplationRelapse

Stages of Change

11Tomas E. Broffman, PhD, LICSW,LCDP,

LCDS CEAP

REMEMBER:“READINESS TO CHANGE”

IS A STATE, NOT A TRAIT.

12 Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP

DEFINITION APPLICATION

Not even thinkingabout it

Not consideringpossibility of change

Does not feel there is a problem

Goal: Raise awareness

Task: EngageInform and encourage Validate lack of readiness

Pre‐contemplation


•On a scale of 1 to 10, how important is it for you to make a change?

14

1 2 3 4 5 6 7 8 9 10

Not at all important

Somewhat important

ExtremelyImportant

Importance Ruler “Willing”

Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP

•On a scale of 1 to 10, how important is it to your family for you to make a change?

15

1 2 3 4 5 6 7 8 9 10

Not at all important

Somewhat important

ExtremelyImportant

Importance Ruler “Willing”


•On a scale of 1 to 10, how confident are you that you could make a change, if you wanted to?

16

1 2 3 4 5 6 7 8 9 10

Not at all confident

Somewhat confident

Extremelyconfident

Confidence Ruler “Able”


•On a scale of 1 to 10, how ready are you to make a change?

17

1 2 3 4 5 6 7 8 9 10

Not at all Ready

Somewhatready

ExtremelyReady

Readiness Ruler“Ready”


18

Simplified Motivational CategoriesImportance of Change

Confidence in Ability Low High

Low

Group 1 – Little interest in change; don’t think they could even if they wanted to.

Group 2 – Want to change, but don’t think they are able.

High

Group 3 – Believe they could change, but not interested right now.

Group 4 – Want to change and believe they have the ability.


Contemplation

19


Thinking about their situation

Ambivalent

“On the fence”

Goal: Explore motivation andConfidence

Task: Explore ambivalenceEvaluate pros and cons


Appreciate Ambivalence

It is the Spirit of MI to…


Decisional BalanceCONTINUING BEHAVIOR

Benefits Costs

1. 1.

2. 2.

3. 3.

4. 4.

CHANGING BEHAVIOR

Costs Benefits

1. 1.

2. 2.

3. 3.

4. 4.


2 Clarifying QuestionsLook Backward, Look Forward

Worst case Scenario, Best case Scenario

Look Forward 6 Months

Look Backward 6 Months

Best case

scenario

Worst case

scenario

Preparation

23


Making a plan to change by setting achievable goals

Goal: Negotiate a plan

Task: Facilitate decision makingExplore:1. Fears of change2. Barriers to change3. Strengths to change


Change Plan

1. The changes I want to make (or continue making) are:

2. The reasons why I want to make these changes are:

3. The steps I plan to take in changing are:

4. The ways other people can help me are:

5. I will know that my plan is working if:

6. Some things that could interfere with my plan are:

7. What I will do if my plan isn’t working:


Action

25


Implementation ofspecific action stepsInitiate changes in attitude, feelings, thoughts and behaviors

Goal: Implement the plan

Task: AffirmSupport self-efficacy


Maintenance

26


Continue to maintain changes for at least 6 monthsProactively explorerelapse warning signs

Goal: Maintain change and deal with issues of ongoing recovery

Task: Identify strategies to cope with high risk situations, urges, cravings, and social pressure


Something to Consider About Relapse

• Confucius said: "Our greatest glory is not in never falling, but in rising every time we fall."

• This quote is most helpful in working with people who experience a relapse.


Motivational Interviewing is:

1. A theory2. A set of skills 3. A way of thinking4. A way of relating


Beliefs About Motivation (True or False?)

1. Until a person is motivated to change, there is not much we can do.

2. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change.

3. Motivation is influenced by human connections.

4. Resistance to change arises from deep‐seated defense mechanisms.


Beliefs About Motivation (True or False?)

5. People choose whether or not they will change.

6. Readiness for change involves a balancing of “pros” and “cons.”

7. Creating motivation for change usually requires confrontation.

8. Denial is not a client problem, it is a therapist skill problem.


• A collaborative, person‐centered form of guiding [or clinical method] to elicit or strengthen motivation for change

• By exploring and resolving ambivalence

• Not just a series of technique but a way of being with people that improves with considerable practice over time

• Miller and Rollnick, 2009

MI Defined


So What’s Motivational Interviewing?• It’s about helping people to resolve their ambivalenceto change

• By NOT, increasing their resistance to change


Four Guiding MI Principles:1. Resist the righting reflex• If a client is ambivalent about change and

the clinician champions the side of change…

33

“Righting” Reflex Ambivalence


Four Guiding MI Principles:

2. Understand your client’s motivations• With limited consultation time, it is more

productive asking clients what or how they would make a change rather than telling them that they should.



3. Listen to your client• When it comes to behavior change, the

answers most likely lie within the client, and finding them requires some listening



4. Empower your client• A client who is active in the consultation,

thinking aloud about the what and how of change, is more likely to do something about it.


Core MI Strategies

Four Early Change Strategies: OARS Open Questions

Affirming

Reflective Listening

Summarizing

Goal: Elicit

Positive “Change

Talk”

• “What worries you about your current situation?” (disadvantages of status quo)

• “How would you like your life to be five years from now?” (advantages of change)

• “What encourages you that you can change if you want to?” (optimism about change)

• “What would you be willing to try (intention) or what do you think you might do?”

Open Ended Questions


• “Thanks for coming on time today”• “That’s a good suggestion”• “It seems like you’re a spirited and strong person”• “You enjoy being happy with other people and making them laugh”

• “You are clearly a resourceful person to cope with such difficulties for so long”

Affirmations


Client: “I know we made all these goals about my getting out and meeting people, but I’m just not comfortable around other people.”

Worker: “Getting the support you need hasn’t been easy.”

Client: “I just don’t like the way my family talks to me about my drinking.”Worker: “You’re annoyed with your family.”Client: “Yes, it just irritates me how they are always judging me.”

Reflective Listening


“Look, it’s not like I’m lazy. I just haven’t found the right job yet. ”

How Might You Reflect This Statement?


“I am never in one place and so it’s hard to check my blood sugars when I’m supposed to.”



“These medications the doctor prescribed just make me feel tired and depressed. Why should I take meds that make me feel worse?”



• Special form of reflective listening• Structure:

– Indicate you’re about to summarize– Be selective– Note ambivalence & attend to change statements– Be concise!– End with invitation

• Use to change directions or ask a key question

Summaries


Avoid Righting Reflex:“Taking Sides” Trap

Helper Helpee“You must change” “I don’t want to change”

“You’ll be better off” “Things aren’t half bad”

“You can do it!!” “No I can’t!!”

“You’ll die…” “Uncle Fred is 89 and healthy as can be”

AutonomyPerson is responsible for change

CollaborationWork in partnership with

person

EvocationLearn from the person

Versus ‐Authority

Versus‐ Confrontation

Versus‐ Explanation

Spirit Of Motivational Interviewing

Listen For Change Talk

47

Desire I want/wish/prefer to

Ability I can, could, able, possible

Reason Why do it? What would be good?

Need Important, have to, matter, got to

Commitment I will/am going to – signals behavior change


Desire


Ability


Reasons


Need


Commitment


Why Do We Want The Reasons For Change To Come From Them?

Change talk predicts change!


Confrontation Is Not Consistent With MI


Common Misconceptions

1. This person OUGHT to (or should WANT to) change.2. Clients are either motivated or not. If not, there’s

nothing we can do for them.3. Now is the right (only?) time to change.4. A tough approach is always best.5. I’m the expert, so he/she should follow my advice.6. If the person decides not to change, the consultation

has failed.


Closing Thought

MI is dancing & not wrestling!


Motivational Interviewing’sMoney Back Guarantee


• MI is an evidence based practice• A large body of literature shows that MI can directly impact client outcomes

• Both the relational and technical attributes of MI contribute to outcome

• Training in MI has been shown to improve clinician performance on MI skills that are themselves related to client outcomes (workshops and coaching combined)

In Summary


• Learning MI takes practice and feedback.• Starting with a few skills is usually more effective than trying to use every skill you’ve learned at once.

Where Do We Go From Here?


• Motivational Interviewing: Preparing People for Change, Miller and Rollnick, Guilford 2012 [http://www.amazon.com/Motivational‐Interviewing‐Helping‐Edition‐Applications/dp/1609182278]

• Ten Things that Motivational Interviewing Is Not, Miller and Rollnick, Behavioural and Cognitive Psychotherapy, 2009, 37, 129‐140

• www.motivationalinterviewing.org• [email protected] Office: 860.465.5164

Sources of Information on MI


Helpfulness Ruler

On a scale of 1 to 10, how helpfulwas today’s presentation?

61

1 2 3 4 5 6 7 8 9 10Not at all Helpful

Somewhat Helpful

ExtremelyHelpful


Thank You For Being Open to Learning About Motivational Interviewing!

Any Questions?

62 Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP

motivational interviewing for ceaps

Healthcare