Motivational interviewing: Getting started with motivational counseling

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Powerpoint accompanying workshop session from the Homeless and Housing Coalition of Kentucky's 2013 conference. Presented by Patrick McKiernan
Motivational interviewing is a technique that uses a dialogue between a counselor and a client who needs to
change behaviors in his or her life. The purpose of this technique is to be non-confrontational, non-adversarial and
non-judgmental, and uses open-ended questions and reflective listening to forge a relationship between counselor
and client built on trust and empathy. This session will present basic information on how to help increase motivation
to change with individuals considering but uncommitted to change. The discussion will include background, theory,
and techniques related to the change process.

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Motivational interviewing: Getting started with motivational counseling

  1. 1. MOTIVATIONAL INTERVIEWINGGETTING STARTED WITHMOTIVATIONAL COUNSELINGPatrick McKiernan PhD, CADC1
  2. 2. Overall Seminar Goal2• Provide a quick start to motivationalcounseling:– Focus on practical clinical aspects– TRY to limit theory and concepts– Increase ability to implement MI– Increase practice skills– Increase supervision/evaluation skills• Exposure to research that is changingmotivational interviewing practice
  3. 3. MI intervention overview (bigpicture) MI targeted behavior: Create and sustainengagement in an adherence changeplan. Follow Doctor’s recommendations Meditational: Different than actualtreatment adherence. Key point: MI is behavior specific
  4. 4. MI is highly strategic Advanced counselors are more strategic… Strategic: More efficient (briefer) and effective Client state is continually assessed Navigational map Counselor utterance is a strategic response Few client states Relatively few MI strategies Memorize
  5. 5. Influences and References5 Client Centered Therapy (Carl Rogers): NonDirectional Motivational Interviewing (Miller & Rollnick):Directional Approach Self Determination Theory (Deci and Ryan):Psychological Needs & Quality of Motivation Transtheoretical Stages of Change (Prochaskaand DiClemente): Process of change Behavioral Economics (newly applied tochange): Time value and temporal effects ondecision making.
  6. 6. Rooted in Natural Change6• Self-actualization tendency (Rogers)• Adaptive creatures  Systems perspective– Manipulate environment to meet their needsand desires– Opening up a closed system• Self Determination Theory: Human thriving– Subtle nature of motivation… behavior doesn’tfollow behavioral principles…– Better motivation is more value driven
  7. 7. RESEARCH ON MI: MetaAnalysisImportant distinction from Hettama (p. 108)MI does NOT communicate―I have what you need.‖BUT RATHER―You have what you need, and together wewill find it.‖
  8. 8. Research on MI:Works as Standalone or Front End8 Phase I vs. Phase II Before and after commitment to change. MI works as a standalone intervention As a front end for some other interventionto increase treatment adherencePhase IMotivationalCounselingPhase II:Open ended menu of optionsPhase IMotivationalCounselingPhase II:Some prescribed treatmentemphasized (e.g., Lincoln Trail)
  9. 9. Meta Analysis: Summary The evidence base for MI is extremelystrong in addiction and growing in health.Evidence base is vast ―72 target clinicaltrials spanning a range of target problems(Hettema, 2005)‖ Current research is focused on finding―why‖ and ―how‖ it works. Research on learning: Best learnedthrough practice.
  10. 10. Meta Analysis Works better than alternative approaches with with people from ethnic minority groups. angry and resistant, or less ready for changeclients. MI as preparation for any other treatment program High effect sizes are observed Improves tx adherence and retention The effect endures across time When MI is used as a standalone rapid impact of MI gradual de-crease of effect size across time Implications: Booster sessions Use as a stepped care program (followup built in) Used as fallback (followup built in)
  11. 11. What is motivation?How do we change it?
  12. 12. Miller & Rollnick on,What is motivation?• Motivation: Mediates MI  tx adherence• Measurement: Recognition or action– Ambivalence is difficult to measure• Complex construct: Notfeeling, thought, behavior;… rather, a drive / energy / fuel• Dynamic / volatile across time andenvironment• M&R: Ready (committed), willing(important), and able (self-efficacy /confidence)
  13. 13. SIMPLE NAVIGATIONAL MAP13WORKING ALLIANCE(red)Importanceof ChangeCommitment to ChangeChange Plan?? Temporal Effects ??ChangeConfidence
  14. 14. Major influences andtrendsWhat is MI?
  15. 15. Nature of Change Discussion15 Think of some non-trivial behavioral change thatyou or someone you know attempted? Smoking, diet / weight, exercise, etc. What important values or goals were the impetusfor change? Was it self change or aided change? Whathelped? What didn’t help? Did education help? Describe pattern of change across a long periodof time. Lapse?
  16. 16. Application to yourself1. Think of one change you would like to make inyour life.2. How ready do you feel to make this change?3. Use a rating ruler to rate your readiness tochange:NOT READY TO CHANGE UNSURE READY TO CHANGE TAKING ACTION1 2 3 4 5 6 7 8 9 10
  17. 17. Phase I: Continual assessmentdetermines strategy (RICC)171. Relationship: How strong is myrelationship with this person?2. Importance: Is change important tohim/her? Is he or she ambivalent?3. Confidence: How confident are you that you can change if youtried? Will self efficacy support change plan?4. Commitment: What do you want to do?Note: All counselor strategies should be ideally directed at advancingone of the four RICC components.
  18. 18. Therapeutic Relationship (TR orworking alliance) Dilemma18• Strong TR is related to greater change.• How will we know the level of TR?– Will they tell us? Can we ask?– If they do, can you rely on what theysay?– Can you judge?• Can only best be judged throughcounselor behaviors.• Problem: Requires preventive effortsand hyper vigilance.
  19. 19. Therapeutic Relationship (TR)19 Rogers: Create an environment for self-actualization TR Synonym: Working alliance RULE: A TR is a requirement forfacilitating change. No TR / No change. What are risks to TR?
  20. 20. Developing & Maintaining TR20 Spirit of Motivational Interviewing Psychological needs (self-determinationtheory) Autonomy / internal locus of control Challenge / competency / self efficacy Relatedness All of the MI principles aid in increasing TR Express empathy --Support self efficacy Understand resistance --Developdiscrepancy
  21. 21. TR: Risk and Protective FactorsSupportive / Protective Accurateunderstanding(or empathy) Client talks>50% Support autonomy Conveycompetency Sponsor relatedness Affirm and accept(unconditional positiveregard) Understandresistance Discovergoals/values Ask permission for riskfactorsRisk factors*• Observe / confront• Give advice / fix it• Educate / fix it• Share opinion• Take on authorityrole• Debate / argue /defend• Being rushed• Fail to listen• INACCURATE• REFLECTIONS!!!*Avoid wheneverpossible. Askpermission whennecessary.21
  22. 22. Risk created by brevity22 Poor TR  Blocks chance to help Avoid TR risk whenever possible Brevity: Need for balance Know when youare taking risk Calculate risk Mend fences Monitor client relationship Risk is minimized by asking permissionand tone in which you giveadvise, educate, or observe
  23. 23. 3 Strategies to improveimportance1. Assess importance and elicit most importantreasons for change with rulers2. Use decisional balance exercises to fullyassess, clarify, and organize ambivalence3. Life plan discovery: Explore past successesand future plans to achieve important goalsand values (desired or ideal)• Raises discrepancy
  24. 24. Strategies to improve importance1) Use of the Importance Ruler Efficiently assesses importance Also discovers most important reasons forchange. How: ―On a scale of 1 to 10, how important ismaking a change?‖ If client is high (8 or above) inimportance, summarize and move to assessment ofCONFIDENCE If client response is 7 or below, elicit most importantreasons for change with a ruler Why would you say a [stated value] compared to[stated value minus 3 or 4].
  25. 25. Strategies to improve importance2) Decisional Balance Exercises Decisional balance Weighted list of pros/cons. Aids the client (and the counselor) in clarifying level ofambivalence vs. importance. What are the good things and not so good thinksabout recovery? List them. Pros/Benefits/Good things (the pros and change and cons of statusquo) Cons/Costs/Not so good things (cons of change and pros of statusquo) KEY Response: Reflect the underlying value. Every pro or con has an important value/goal attached to it…. ORTHEY WOULDN’T MENTION IT. Making that connections increases brings clarity.
  26. 26. TranstheoreticalStages of ChangeProchaska & DiClemente
  27. 27. Trans. Stages (process) of Change.Where does clinical purpose shift?Stage of Change Precontemplative Contemplative Preparation /Determination Action Maintenance RelapseClient Process Unaware Pre-crystallization Unwilling Discrepancy (conflict withimportant goals/values) Discouraged Support self efficacy Ambivalent Discrepancy tips scale Commit & prepareCollaborate on treatment plan. Carryout Tx plan / learn Relapse prevention / refine Overcome shame / regain confidence27
  28. 28. MI 2nd Edition: 2 Phases of Change1. Uncommitted to change: Resolve ambivalence in twoforms… Important? Awareness of value incongruence. Confidence? Self-efficacy—will it work? can I do it? Phase 2 shift marked by intent / commitment2. Committed: Collaborate on change plan Collaborate / menu of choices for action plan… Continue to assess for importance / confidence Termination
  29. 29. MI Sandwhich MI Assessment “sandwich” concept: MI strategies during opening 20 mins Agency intake assessment MI strategies during closing 20 mins
  30. 30. MI emphasis on ―spirit‖30• Open ended question: Begin with how orwhat.• Spirit (SDT research based version):– Autonomy (emphasize client choice)– Competency (they have what they need),– Relatedness (peer relationship, no authority).• Reflections– Good: Simple (paraphrase)– Complex: Reflect emotion or changemeaning
  31. 31. DISCOVERY: Achieving 2 Ends31• Interview for most important goals andvalues (ideal life)  Achieves 2 ends– People crave to be understood– Initiates the process of raising importance.• Focus on constructing a vision of theclients desired (or ideal) life.– Value clarification• Spirit: Use TR protective strategies andavoid TR risks.
  32. 32. Discovery: CommonValues/Goals32 Health Money / security Relationship with some romantic partner Wellbeing of children and family Psychological needs (SDT): Autonomy /competency / relatedness Will favor experiences that promote these Relatedness: Social support  peer vs.authority.
  33. 33. TR Risk: Nuance33 Some people are harder than others Greater or lesser need for controllinginteraction Depressed people are oftentimes preferringadvice and more assertive TR Trap: Clients are accustomed to beingtreated in an authoritative way. Will they complain if you are typical of otherprofessionals? Normal??? How will they notice if you are ―different thanother counselors.‖ Will they tell you?
  34. 34. Accurate Empathy &Reflections34 Empathy is conveyed with reflections Statement of understanding Simple reflection: Parroting or paraphrasing Complex reflection: Changing or addingmeaning or emotion Reflections are better than questions… Conveys understanding Does not cause pause to consider question. Keeps conversation on Clients track, not ourown. Accelerates the pace of the interview
  35. 35. Motivational Interviewing Clinical Interview:Putting Responsibility for Change on the Patient. Simple Reflection Shifting Focus Reframing Rolling withResistance Siding with theNegative Self-Efficacy Avoiding Arguments Open-endedQuestions Listen Reflectively Expressing Empathy Develop Discrepancy Affirm
  36. 36. REFLECTINGACCURATEEMPATHYOngoing method tocommunicate understandingand stimulate deeperinstropsection36
  37. 37. KEY: Management of Self37 TIMING… Never suggest a planning idea untilPhase II change planning. ***Manage YOUR RIGHTING REFLEX Hard to observe someone in painor suffering without reacting Makes us want to fix Fix it statements are not good Our righting reactions mustbe managed!!! Impatience and burn out are also sources ofreactionary problems.
  38. 38. Myth? Resistance or Denial Despite the common belief, researchershave suggested that there is nodenial, only resistance (caused byparadox). Addicted people are aware of problemsrelated to drinking. People will become resistant in responseto confrontation or emphasizing theneed for change (paradoxicalresponse). It’s not denial it’s resistance caused by paradox
  39. 39. Strategies to improve importance1) Use of the Importance Ruler Efficiently assesses importance Also discovers most important reasons forchange. How: ―On a scale of 1 to 10, how important ismaking a change?‖ If client is high (8 or above) inimportance, summarize and move to assessment ofCONFIDENCE If client response is 7 or below, elicit most importantreasons for change with a ruler Why would you say a [stated value] compared to[stated value minus 3 or 4].
  40. 40. Strategies to improve importance2) Decisional Balance Exercises Decisional balance Weighted list of pros/cons. Aids the client (and the counselor) in clarifying level ofambivalence vs. importance. What are the good things and not so good thinksabout recovery? List them. Pros/Benefits/Good things (the pros and change and cons of statusquo) Cons/Costs/Not so good things (cons of change and pros of statusquo) KEY Response: Reflect the underlying value. Every pro or con has an important value/goal attached to it…. ORTHEY WOULDN’T MENTION IT. Making that connections increases brings clarity.
  41. 41. Strategies to improve importance3) Life planning discovery Clarifies, aids client in healthy life planning Protracted dialogue on achieving the desired(or ideal) life Desired life: Goals and values discovered previously Explore… how can you achieve the desired lifewhile continuing to use… look forward, look back. Explore… how would it be different if you were todecide to change your drinking.

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