Session 14Motivational Interviewing Assessment

Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, NCCExecutive Director, AllCEUs.com

Components of a Motivational Interviewing Assessment

Examine Motivational Interviewing styles and traps Define the MI Assessment “sandwich” Develop MI Micro-Skills OARS Discuss skills to identify, explore and handle

resistance in clients Examine appropriate interventions for each stage of

change

Objectives

Dr. Jonathan Fader discusses Motivational Interviewing

Introduction

Use of client-centered MI style MI strategies that can be integrated into the agency’s

existing intake assessment process Methods that can be used with diverse substance use

problems Skills for assisting clients in assessing their own substance

use Understanding the client’s perception and willingness to

enter into a treatment process

Components of a Motivational Interviewing Assessment

Person-centered versus disorder-centered approach Motivation is a state or stage, not a fixed character trait Client defensiveness or resistance is a therapeutic process Effect of therapist style on client behavior Emphasis on collaboration, not confrontation Examining resistance and change talk: opposite sides of

ambivalence Respect for client autonomy and choice Define change talk DARN-C

Motivational Interviewing as a Style

Styles◦ Collaboration◦ Evocation◦ Autonomy◦ Roll with Resistance

MI Styles and Traps

Question-Answer Trap◦ Have clients fill out questionnaires in advance◦ Ask open ended questions◦ Use reflective listening

Labeling Trap◦ Labels are not important to change◦ Can foster resistance

MI Traps

Premature Focus Trap.◦ When a counselor persists in talking about her own

conception of “the problem” Taking Sides Trap.

◦ When you detect some information indicating the presence of a problem and begin to tell the client about how serious it is and what to do about it, you have taken sides.

Blaming Trap. ◦ Some clients show defensiveness by blaming others for

their situation. It is useful to Diffuse blaming by explaining that the placing of blame is not

a purpose of counseling. Expert Trap.

◦ When you give the impression that you have all the answers, you draw the client into a passive role.

◦ In MI the client is the expert about his/her situation, values, goals, concerns, and skills.

◦ Seek collaboration and give clients the opportunity to explore and resolve ambivalence for themselves

Express empathy Develop discrepancy Roll with resistance, avoiding argumentation Support self-efficacy

Underlying Principles of MI

MI Strategies (20 minutes)◦ Building rapport◦ Using the OARS micro-skills to elicit a discussion of

the client’s perception of his/her problems Agency Assessment MI Strategies (20 minutes)

◦ Recapitulate◦ Develop a change plan

MI Assessment “Sandwich”

Open-ended questions Affirmations: Reward what is being done

◦ I appreciate your honesty ◦ I can see that your children are important to you.◦ It shows commitment to come back to therapy.◦ You have good ideas.

Reflective listening Summaries

MI Micro-Skills: OARS

Types of reflections◦ i. Simple◦ ii. Amplified◦ iii. Double-sided—On one hand…., but on the other

hand…. Levels of reflection

◦ i. Repeat--Parrot◦ ii. Rephrase◦ iii. Paraphrase– Including underlying meaning

Decision balance Developing discrepancy

◦ i. Exploring goals and values◦ ii. Looking forward

Exploring Ambivalence

Types of Resistance◦ Arguing◦ Interrupting◦ Negating or “denial”◦ Ignoring

Give examples of how you have experienced each of these ◦ In your practice◦ In your relationships◦ In yourself

What is the function of resistance?

Identifying Resistance

What is it◦ A cue to change strategies◦ A normal reaction to having freedoms decreased or

denied◦ An interpersonal process

Explore Resistance

Reflections focus on their change talk and provide less attention to non-change talk

Shift focus from obstacles and toward choice Reframe offering a new and positive

interpretation of negative information provided by the person

Emphasize personal choice and control

Ways to Roll

Motivational Interviewing Demonstration by Dr. Thad Leffingwell

Videos

Precontemplation◦ Client is not considering, is unwilling or unable to change

◦ Establish rapport, ask permission, and build trust

◦ Raise doubts or concerns in the client about use

◦ Explore what brought client in & results of previous treatment

◦ Offer actual information about the risks of substance use

◦ Provide personalized feedback about assessment findings

◦ Explore the pros and cons of substance use

◦ Examine discrepancies between the client's and others' perceptions of the problem

◦ Express concern and keep the door open

Stages of Change

Contemplation◦ The client acknowledges concerns but is ambivalent

◦ Normalize ambivalence.

◦ Help the client "tip the decisional balance scales"

◦ Elicit and weigh pros and cons of substance use & change

◦ Change extrinsic to intrinsic motivation

◦ Examine client's personal values in relation to change

◦ Emphasize client's free choice, responsibility, & self-efficacy

◦ Elicit self-motivational statements of intent and commitment

◦ Elicit perceived self-efficacy & expectations re: treatment

◦ Summarize self-motivational statements

Stages of Change

Preparation◦ Client is planning to change but is still considering options

◦ Clarify the client's own goals and strategies for change.

◦ Offer a menu of options for change or treatment.

◦ With permission, offer expertise and advice.

◦ Negotiate a change--or treatment--plan

◦ Help the client enlist social support.

◦ Explore treatment expectancies and the client's role.

◦ Elicit what has worked for him or others whom he knows.

◦ Assist the client to identify and negotiate potential barriers.

◦ Have the client publicly announce plans to change

Stages of Change

Action◦ The client is actively taking steps to change but is not yet stable

◦ Engage the client in treatment and reinforce the importance of remaining in recovery.

◦ Support a realistic view of change through small steps.

◦ Acknowledge difficulties for the client in early stages of change.

◦ Help the client identify high-risk situations through a functional analysis

◦ Develop appropriate coping strategies to overcome these.

◦ Assist the client in finding new reinforcers of positive change.

◦ Help the client assess sources of support

Stages of Change

As related to stages of change Methods of measuring

◦ i. Readiness ruler

◦ ii. Instruments like URICA and SOCRATES

Key questions◦ “What does this mean about your (habit)?’

◦ “What do you think has to change?”

◦ “What are your options?’

◦ “What’s the next step for you?”

◦ “What would be some of the good things about change?”

◦ “Where does this leave you?”

Concept of Readiness

DARN-C◦ Desire◦ Ability◦ Reasons◦ Needs◦ Commitment level

Eliciting change talk◦ Evocative questions◦ Elaborations

Change Talk: DARN C

Change Discussion◦ The desired changes◦ Reasons for wanting to make those changes,◦ Steps to make the changes,◦ People available to support the change plan,◦ Impediments or obstacles to change and how to address them◦ Methods of determining whether the plan has worked.

Role of information and advice Menu options Asking for commitment

Developing a Change Plan

Motivational Interviewing Assessments use OARS to empower the client to examine motivations for change

Motivational Interviewing styles and traps: question-answer; labeling; premature focus and taking sides

Develop MI Micro-Skills OARS Open-ended questions; Affirmations; Reflective listening; Summaries

Discuss skills to identify, explore and handle resistance in client: Reflection, reframe, shift focus

Identify change talk DARN-C: Desire, Ability, Reasons, Needs, Commitment level

Summary