Chapter 5- Motivational Interviewing

Front 1

Motivation Interviewing

Back 1

A collaborative, person-centered form of guiding to elicit and strengthen motivation to change

Hint 1

Motivating

Front 2

History of MI

Back 2

-introduced in the early 1980s as a response to confrontational approaches to working with clients struggling with substance abuse and addiction problems

- created in response to following assumptions: a) substance abusers are defective, and it's the therapist's job to fix them, b) substance abusers have nothing to offer in counseling, c) harsh confrontation is necessary to break down denial, and d) patients must admit they are addicts or alcoholics before any change can take place

- developed by William Miller's work

Front 3

Goals of MI

Back 3

-three main goals

* to help increase intrinsic motivation to change a particular behavior

* to help lower resistance in the therapeutic session

* help to resolve ambivalence to change (i.e. being torn between two states)

Front 4

Influences on MI/Stages

Back 4

- MI is considered a gentle, persuasive style designed to elicit and strengthen motivation to change. So it shares qualities with Rogerian counseling but is much more

- it also shares qualities with the transtheoretical model. According to this model, individuals matriculate through a series of stages

-precontemplation: clients are usually forced to attend counseling, do not see a need for it, and may be in denial of the seriousness of their substance abuse

-contemplation: clients display ambivalence about changing but they are considering it

-determination/preparation: clients cognitively recognize the importance of change but do not know how to change

-action: when confidence increases, clients make a commitment to change and take steps to realize their goals

-maintainence: after six months, the client is able to maintain gains made in treatment and after some time move out of the change cycle

-relapse: client re-enters the change cycle or returns to full-blown substance use

* these models are not the same but they mesh

Front 5

Ways to use MI

Back 5

- can be used as a brief therapeutic approach

- can be used as an initial assessment to increase motivation and in conjunction with other modalities such as Gestalt therapy

- can be incoporate as needed

Front 6

MI spirit

Back 6

- Miller and Rollnick said the foundation of MI should be: a partnership that is collaborative ( client and clinician should set agendas, goals, etc..), evocative (including the clients idea about changing or not), autonomy ( client's right to choose) , and should include compassion (promotion of others well being)

- an over reliance on techniques can make the process of MI disingenuine

- Rollnick identified three communication styles: directive (clinician tends to direct, prescribe, advise, and lead), guiding (clinician tends to shepherd, encourage, and motivate...needs to be skillful), following ( the clinician permits, let things be, and simply allows)

Front 7

Principles of MI

Back 7

- MI has five principles that are instrumental which include: avoiding argumentation ( not trying to change the client yourself but guide them and accept their decisions), rolling with resistance ( exploring feelings behind certain decisions and persuading client to consider a new idea while empathizing), expressing empathy ( critical to MI, use reflective listening to explore clients feelings without judging), developing discrepancy (helping clients create a difference between their current situation and their vision for themselves by exploring goals and values and how their behavior affects them), supporting self-effcacy ( aiding client's path to recovery/change by discussing previous victories)

- these principles should reflect R.U.L.E:

1. Resisting the fighting reflex -give only warranted advice that will aid in helping your client

2. Understanding the clients own motivations- develop ways to evoke ideas from the client

3. Listen with empathy- critical to the foundation of MI

4. Empower client- same as self efficacy

Front 8

Processes and Applications of MI

Back 8

- MI is based on four key processes: engaging ( establishing solid collaborative relationship with client) , focusing ( clinician helps client develop a specific goal and a plan to achieveit), evoking ( exploringand respecting clients ideas, thoughts, and feelings of changing behavior), and planning ( encouraging commitment and developing a collaborative way to move ahead)

Applications:

- Increasing importance ( conduct an early assessment of the client's willingness to change)

- reflective listening ( listen contently and ask clarifying questions)

-O.A.R.S (CORE Skills)

Open ended questions- provides for greater exploration and causes the client to respond with more than one word answers

Affirmations- statements of praise regarding clients actions to change

* to avoid coming across as fake and insecure... they must focus on specific behaviors and internal attributes, avoid using " I" statements...make them "you" statements, and nurture a competent rather than deficient view of clients

Reflections

* as a general rule, the reflection/question ratio should be 2:1

Summary- created to keep the counseling session momentum going

* should include the clients ambivalence to change and change talk

* should be three to ten sentences and only two per session...one in the middle and one at the end

Front 9

Specific strategies to increase importance

Back 9

1. Develop discrepancies - having client to compare their current behavior to their goals of what they want to achieve

2. Ruler exercise - having the client measure their potential to change

3. Roll with resistance- understand that their might be resistance but do not scare or harm client. Clients are more likely to change if they don't feel attacked or blamed

4. Worst/best case outcomes - having clients outweigh the good and bad of reducing vs continuing drug use

5. Find out what is important. Negotiate for change- exploring things that the clients wants to talk about in hopes of eventually being able to talk about substance use...bargain with client to talk about substance use

6. Explore importance of events/ behaviors that brought client to counseling- similar to #5 in which you gather client's perspective

Front 10

Methods for eliciting change talk

Back 10

Six main types of change talk:

1. Clients desire to change

2. Clients ability to change

3. Clients reason for change

4.Clients need for chabge

5. Commitment language

6. Taking steps

Use acronym D.A.R.N.C.T.S.

Additional strategies

1. Problem recognition

2. Expression of concern

3. Intention to change

4. Optimism

Front 11

Specific strategies to resolve resistance

Back 11

In general resistance can be lowered by providing reflexive and strategic responses

1. Simple reflection- paraphrase what the client just said

2. Amplified reflection- slight exaggeration or increase in intensity of client statements; amplify resistance element minus sarcasm; can allow student/ client to become aware of extremity of position and back away from this; can be quite playful and you should use only when relationship is strong

3. Double-sided reflection- Captures both sides of the client's ambivalence; try to end on the change side in your reflection

4. Shifting focus- to shift clients attention away from the stumbling blocks precluding the movement toward progress

5. Emphasizing personal choice and control- client has ultimate control

6. Reframe- Seeing things in a different way, turning negatives into strengths. This validates client's observations, but adds new information

7. Agreement with a twist- to initially s ide with the client, but introduce a new consideration or direction, usually in a positive direction. This is a reflection followed by a reframe and is often tricky to do and maybe more complex than other responses

8. Coming Alongside- Clinician defends the counter change side at the time but inquires when the right time will be; should be used as last resort

Front 12

Specific strategies to build confidence

Back 12

1. Open- ended questions focused on ability and strengths

2. Ruler question/exercise focused on confidence

3. Personal supports

4. Past successes at changing behavior

5. Offering information and advice- to be MI consistent we must use elicit-provide-elicit model

*Rosengren provided acronym F (ask permission first). O(offer suggestions and thoughts but try to avoid convincing) .C( be concise). U( use a menu of option).S ( solicit important information from the client)

6. Hypothetical change, envisioning change, and anticipating barriers

7. Explore barriers to change

Front 13

When is a client ready to change and what are change plans?

Back 13

Clients are ready to change when there is abundance of change talk and they are high on importance, confidence, and readiness. Be careful not to push the client before they are ready. Change plans can be completed at once or over time, they include a plan, how to achieve, and any obstacles. It also includes a time frame to achieve and family members who could help