reflections on motivational interviewing cardiff september 27, 2011
TRANSCRIPT
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Reflections on Motivational Interviewing Cardiff September 27, 2011
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1983
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1991
MI-1
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2002
MI-2
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2008
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2012
MI-3
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2022
MI-4
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Generalized Principles of MI
1. Express Empathy
2. Develop Discrepancy
3. Avoid Argumentation
4. Roll with Resistance
5. Support Self-Efficacy
X
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Two Phases of MI
Phase 1 Strengthen motivation for change
Phase 2 Consolidate commitment to change
X
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RESISTANCE
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The Underlying Spirit of MI
PartnershipEvocationAcceptanceCompassion
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Change is Broader than Behavior
• Decision – to make a choice– Forgiveness, Leaving or staying
• Attitude - to become a different person– To be more Compassionate, Assertive etc.
• Resolution - Acceptance– Complicated grief– Finding peace regarding a decision
• Tolerance for anxiety, uncertainty etc.
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Four Fundamental Processes in
MI
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Relational Motivational Foundation Interviewing 1. Engaging
2. Focusing
3. Evoking
4. Planning
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The processes are somewhat linear ... .
• Engaging necessarily comes first
• Focusing (identifying a change goal) is a prerequisite for Evoking
• Planning is logically a later step
Engage Focus Evoke Plan
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. . . . and yet also recursive
• Engaging skills (and re-engaging) continue throughout MI
• Focusing is not a one-time event; re-focusing is needed, and focus may change
• Evoking can begin very early
• “Testing the water” on planning may indicate a need for more of the above
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Planning
Evoking
Focusing
Engaging
Four Foundational Processes
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Is it MI Yet?
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Can it be MI without . . .
Engaging ?
Focusing ?
Evoking ?
Planning ?
NoNoNoYes
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So it becomes MI when . .
1. The communication style and spirit involve person-centered, empathic listening (Engage)
AND
2. There is a particular identified target for change that is the topic of conversation (Focus)
AND
3. The interviewer is evoking the person’s own motivations (or plans) for change (Evoke)
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A continuum of styles that can be used in all four processes
Directing <=> Guiding <=> Following
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Core counseling skills that can be used in all four processes
• Open questions
• Affirmation
• Reflection
• Summary
• Offering information and advice
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Direction Language
• “Directing” as a counselor behavior
• “Direction” as focus
• “Directional” (not “directive”) as a description of MI as goal-oriented
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Three Essential Elements in any Definition of MI
1. MI is a particular kind of conversation about change (counseling, therapy, consultation, method of communication)
2. MI is collaborative (person-centered, partnership, honors autonomy, not expert-recipient)
3. MI is evocative, seeks to call forth the person’s own motivation and commitment
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DEFINITIONS OF MI
Three levels of definition (of increasing specificity)
1. A layperson’s definition
(What’s it for?)
2. A pragmatic practitioner’s definition (Why would I use it?)
3. A technical therapeutic definition
(How does it work?)
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1. A layperson’s definition(What’s it for?)
Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change
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2. A pragmatic practitioner’s definition (Why would I use it?)
Motivational interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change
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3. A technical therapeutic definition (How does it work?)
Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
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Counseling with Neutrality
• Neutality is not a therapist attribute (like equanimity: composure, balance, emotional stability)
• Neutrality is the conscious clinical decision to try not to influence a client’s direction of choice or change
• Neutrality can be about:– Focusing (whether to pursue a change goal)– Planning (how to pursue a change goal)
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Counselor Aspiration
Should I proceed strategically to favor the resolution of the client’s ambivalence in a particular direction?
or
Do I want to maintain neutrality and not intentionally or inadvertently steer the person in one particular direction?
MI was originally developed for the former situation
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Engaging and Focusing
Identification of Change Goal
Aspiration Equipoise
Evoking Planning
DecisionalBalance
Both choices involve partnership,acceptance and compassion
A conscious choice
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Equipoise is where a classic decisional balance makes sense
Giving intentionally balanced, equal attention to pros and cons in:Inquiry Elaboration Affirmation Reflection Summaries
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Status Quo or Option A
Change or Option B
Advantages
+
Good things about Status Quo or Option A
CON
Good things about Change or Option B
PRO
Disadvantages
-
Less-good things about Status Quo or Option A
PRO
Less-good things about Change or Option B
CON
2 x 2 Decisional Balance GridPROs and CONs of Change
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Change Talk• Change talk is any client speech that favors movement in
the direction of change
• Previously called “self-motivational statements” (Miller & Rollnick, 1991)
• Change talk is by definition linked to a particular behavior change goal
DARN CATs
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Preparatory Change TalkFour Examples
DARN
• DESIRE to change (want, like, wish . . )
• ABILITY to change (can, could . . )
• REASONS to change (if . . then)
• NEED to change (need, have to, got to . .)
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Mobilizing Change TalkReflects resolution of ambivalence
CATs
• COMMITMENT (intention, decision, promise)
• ACTIVATION (willing, ready, preparing)
• TAKING STEPS
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Yet another metaphor
MI Hill
Prepara
tory Change Talk Mobilizing Change Talk
Contemplation Preparation Action(Pre-)
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Responding to Change TalkAll EARS
• E: Elaborating: Asking for elaboration, more detail, in what ways, an example, etc.
• A: Affirming – commenting positively on the person’s statement
• R: Reflecting, continuing the paragraph, etc.
• S: Summarizing – collecting bouquets of change talk
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Change Talk and Sustain Talk
Opposite Sides of a Coin
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Examples of Sustain TalkThe other side of ambivalence
• I really like marijuana (D)• I don’t see how I could give up pot
(A)• I have to smoke to be creative (R)• I don’t think I need to quit (N)• I intend to keep smoking and (C)
nobody can stop me• I’m not ready to quit (A)• I went back to smoking this week (T)
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What is “Resistance”?
Sustain Talk Discord
X
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Sustain Talk and Discord
• Sustain Talk is about the target behavior– I really don’t want to stop smoking– I have to have my pills to make it through the day
• Discord is about your relationship– You can’t make me quit– You don’t understand how hard it is for me
• Both are highly responsive to counselor style
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What is Discord?
• Behavior
• Interpersonal (It takes two to have discord)
• A signal of dissonance in your relationship
• Predictive of (non)change
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Some Discord Signals
• Defensiveness
• Arguing– Challenging Discounting Hostility
• Interrupting– Talking over the counselor
• Ignoring– Inattention Changing the subject
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MI in Child Protection Services
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Dual Roles in CPS
1. To facilitate change in the caregivers
2. To protect and serve the children’s best interests
Similar to dual roles in probation/parole
Fulfilling role #1 serves role #2
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The Righting Reflex
• “Righting” is serious business in CPS
• Passion or anxiety to protect can easily create an adversarial role in which:– The worker advocates for change– The client is defensive and “resistive”
• This is the quintessential clinical dilemma for which MI was developed
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Engaging
• An early and important task in MI
• Promoted primarily by OARS
• Can occur relatively quickly
• An opposite style from fact-questioning
• Research question: Does MI-based engaging yield critical information more honestly and quickly than asking questions?
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Focusing
• Sometimes the worker must set the focus:– Violence– Attending school– Substance abuse
Challenge: How to avoid “rapid focus” problems and unconstructive adversarial interactions when you must address it?
One key: Engage first
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Evoking
• “MI is all about confrontation:
Self- confrontation” - Donald Forrester
• Open questions and reflection help people look in the mirror
• Evoking clients’ own change talk
• Challenge: Practice may jump quickly to planning in CPS due to urgency
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Planning
• With engagement and focus in place,
• and evoking as much motivation and commitment to the goal as feasible
• Develop a specific plan and elicit an implementation intention
• Challenge: Clearly and compassionately explain the consequences
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