Motivational interviewing
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  • As you review each stage – ask them for client examples – have them explain why they think the client is at that stage.
  • So, its most important to recognize where the client is at in their stage of change because that determines what your intervention should be. Use the AA example – what do you think would happen if you sent someone in precontemplation to an AA meeting? What do you have to do at an AA meeting? (acknowledge that you are an alcoholic) Is someone in precontemplation going to do that? How do you think they would feel at the meeting? How do you think they would feel about ever going to another one?
  • When is it appropriate to use these styles? What is the attitude that might come across to the client with each of these? How do you think that would make them feel about changing anything?
  • Client is strong willed. She lives on her own, and works hard to look after her children, two very active boys. She’s fearful outdoors, gets panic attacks and uses alcohol like medicine. Have them read the conversation and then ask the following questions: What is the attitude or style of the counselor? Who talks about change? What progress does the client make?
  • Have them review this conversation and ask the same questions: What is the counselor’s attitude or style this time? Who talks about change? What progress is the client making?
  • SPIRIT –Everything else is the skills and competencies!
  • Exercise:   Provide Handout for closed and open ended questions. Give a couple minutes to complete and then review as a group.
  • Do affirmations exercise
  • If the client believes that you understand them, they will be more likely to share things with you and more likely to work with you By using reflective listening instead of questioning you encourage the client to continue talking and expressing his or her view and feelings.
  • Client: I feel so full of shakes that I take a drink before I leave the house. Counselor: It helps to settle your nerves. – amplified – use metaphor or feelings Client: And I can go get the kids from school, shop and then feed them. Counselor: and you get quite a lot done. - simple Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time. Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house. – simple paraphrase Client: yes, that’s exactly right. Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it? Client: well as I said, it calms my nerves, but it can’t go on like this forever. Counselor: although it helps, you’re concerned about it. – amplified – double sided Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids. Counselor: you don’t want your life to revolve about drinking. - amplified – metaphor or feeling added. Client: exactly you know I must watch it.
  • What do you think will happen if you do these? How would you feel?
  • 7:00 – 11:00 class 14:40 - end
  • Why is it ambivalence in the contemplation stage? What is happening with the client then? * These are the two most important statements – expect it – be patient – roll with it!
  • It might mean you were judgemental. It might mean you came across as offering advice. So what could you do to change your approach?
  • After each example have them think of clients who fit.
  • Q/A = people don’t feel heard Expert = people like to be the expert of their own lives Taking sides Labeling Premature focus – first thing the client talks about may not be the real problem Blaming Righting reflex – watch for our urge to fix things
  • Review the conversation and identify change talk Client: I feel so full of shakes that I take a drink before I leave the house. Counselor: It helps to settle your nerves. Client: And I can go get the kids from school, shop and then feed them. Counselor: and you get quite a lot done. Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time. Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house. Client: yes, that’s exactly right. Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it? Client: well as I said, it calms my nerves, but it can’t go on like this forever. Counselor: although it helps, you’re concerned about it. Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids. Counselor: you don’t want your life to revolve about drinking. Client: exactly you know I must watch it.
  • Evoke change talk – these questions will do it!
  • Pay off matrix that you have seen before – this can also help with querying the extremes – what is the worst that could happen what is the best, etc.
  • Do the Tipping the Balance exercise.

Motivational interviewing Motivational interviewing Presentation Transcript

  • MOTIVATIONALINTERVIEWING:HELPING OTHERSCHANGECari Guthrie Cho, LCSW-CVP of ProgramsSt. Luke’s House & Threshold ServicesUnited
  • READY TO CHANGE?Willing= In order to be ready to change Able=Importance Confidence The patient must be both willing and able
  • STAGES OF CHANGE Pre-contemplation. Client is unconvinced that s/he may have a mental health and/or substance use problem and does not believe s/he needs to change. S/he may have given up or have not been committed to consistent treatment. Clients often feel pressured by others to seek treatment. Contemplation. Client is actively considering the possibility of change in regards to mental health and or substance use. S/he is evaluating his/her behavior and options, but is not ready to take action yet. S/he may have made attempts to change in the past.
  • STAGES OF CHANGE(CONT) Preparation. Client makes a commitment to change and starts making initial plans to actually change his/her behaviors. Action. Client begins to make actual behavior change, and to use new ways of dealing with situations. Maintenance. Client begins to consolidate new behaviors and new ways of thinking into his/her regular daily life.
  • COMMUNICATIONSTYLESDirect - lead, tell, show the way, take charge of, preside, govern, rule, have authority, exert authority, take the reins, take command, control,Follow - go along with, allow, permit, be responsive to, have faith in, shadow, understand, observeGuide - enlighten, shepherd, encourage, motivate, Support, accompany, collaborate, promote, elicit solutions, evoke insight
  • MI: A WORKINGDEFINITION“Motivational interviewing is a person-centered, goal-oriented method ofcommunication for eliciting andstrengthening intrinsic motivation forpositive change.” (Miller, 2009)
  • 10 THINGS MI IS NOT: A way of tricking people into doing what you want them to do A specific technique (MI is a counseling method; no specific technique is essential) A decisional balance, equally exploring pros and cons of change A form of cognitive-behavior therapy Easy to learn What you were already doing A panacea for every clinical challenge(Miller, 2009)
  • EXERCISE – HAVE A LOOKClient: I just feel so full of shakes that I take a drink before I leave the house.Counselor: Yes it will be good to drink less. How much do you drink these days?Client: Well, I’m not an alcoholic its just that I need it before I leave the house.Counselor: How much would you say you drink each week, even just a guess?Client: Well you know, I don’t know. I only drink wine so maybe just a few glasses a day, sometimes more, I need it to calm down really.Counselor: Yes, I see that’s probably at least around 20 – 30 glasses a week. Do you drink even when you go to pick up the kids?Client: I don’t like to drink as much as I do, but when I am nervous, then I take a drink but its really not very much.Counselor: Yes and how often does this happen when you are with the children?Client: Well, I don’t always drink wine before I go get the kids, but you have no idea how terrified I get, its like walking through a mist out there. Today I had to hang on to a lamp post to keep steady and not faint. Its just horrible.Counselor: And did you have a drink before you came out?Client: Just a little one to be honest but I’m not an alcoholic you know.
  • HAVE A LOOK AGAIN!Client: I feel so full of shakes that I take a drink before I leave the house.Counselor: It helps to settle your nerves.Client: And I can go get the kids from school, shop and then feed them.Counselor: and you get quite a lot done.Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time.Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house.Client: yes, that’s exactly right.Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it?Client: well as I said, it calms my nerves, but it can’t go on like this forever.Counselor: although it helps, you’re concerned about it.Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids.Counselor: you don’t want your life to revolve about drinking.Client: exactly you know I must watch it.
  • REASONS FORPRACTICING MI It works! It’s all in the welcoming, and welcoming is easy It doesn’t cost much Small intervention, big effect! The opposite approach, confrontational counseling, has poor results It fits well with other treatment interventions It makes our jobs easier and more enjoyable Robust and enduring effects when MI is added at the beginning of treatment MI increases treatment retention, adherence and staff-perceived motivation
  • MI SPIRITMI Spirit - a style, attitude or approach. A way of being when talking about change. A powerful ingredient in the fuel that drives good practice. Collaborative – working with the client – respect the client’s expertise; understand their goals. Evocative – drawing out ideas and solutions from the client as the experts about themselves. Honor autonomy – decision making is left to the client. They are ultimately responsible.
  • WHAT ARE THE BENEFITS OF EXPRESSING EMPATHY – (REFLECTIVE LISTENING)?  Establishes rapport  Shows it’s safe to talk  Builds trust  Promotes understanding  Helps us both feel better  Helps client to be more open to self- exploration  Opens doors to finding a solution that meets client motivations  Etc?Guy Azoulai, MINT, Aunay Sous Bois, France, 2006
  • HOW CAN WE EXPRESS EMPATHY ? having clients explore solutions for their own dilemmas keeping our agendas under wraps allowing us to avoid road blocks to listening reflecting what the client says using YOU and WE vs I asking permission before informingGuy Azoulai, MINT, Aunay Sous Bois, France, 2006
  • PERSON-CENTEREDCOUNSELING SKILLS: OARS Open Questions  Open the door, encourage the client to talk  Do not invite a short answer  Leave broad latitude for how to respond Closed Questions   Have a short answer (like yes/no)  Did you drink this week?  Ask for specific information  What is your address?  What medications do you take?  Might be multiple choice  What do you plan to do: quit, cut down, or keep on smoking?  They limit the client’s answer options
  • ARE THESE QUESTIONS OPEN ORCLOSED? What would you like from treatment? Was your family religious? Tell me about your drinking; what are the good things and the not so good things about it? If you were to quit, how would you do it? When is your court date? Don’t you think it is time for a change? What do you think would be better for you – AA or Women for Sobriety? What do you like about cocaine? What do you already know about buprenorphine? Is this an open question?
  • AFFIRMATIONS  Emphasize a strength  You’re a strong person, a real survivor Notice and appreciate a positive action  I appreciate your openness and honesty today  Thanks for coming in today.  I like the way you said that Express positive regard and caring  I hope this weekend goes well for you! Should be genuine Differs from praise – not an opinion or judgment Strengthen therapeutic relationship
  • REFLECTIVE LISTENING Convey understanding of the clients’ point of view and underlying wants without asking a question. Demonstrates to the client that you care and are interested in them. It is an essential tool to build rapport. Does not mean that you will agree with everything the client is saying – it is your attempt to understand the “Gist”, the real meaning of what they are communicating. It asks, in a way, “Is this what you mean?” without asking a question. Reflective statements often start with “So you feel…” “It sounds like you…” or “You’re wondering if…”
  • SIMPLE REFLECTIONS Repetition – simply repeating a word or part of what was said. Do not add anything new. Rephrase – Stay close to what the person is saying by taking some part o what they said and substituting this with a slight rephrase. Here you are adding to and building on what was said. For example:  Client: “I really hate my job. Everyone is always on my case to do this and get that done….”  Staff: “You feel like everyone is demanding a lot from you…”  If you are correct, they will continue to talk and explore; if you are incorrect, they will say “no” and then it is up to you to start to clarify.
  • AMPLIFIED/COMPLEXREFLECTIONS Paraphrase – This is a major statement in which you are inferring or drawing together the meaning in what they are saying and reflecting it back to the client in different words. You are adding something to it. The goal of paraphrasing is to get the client to explore and clarify issues.   Client: “I really hate my job. Everyone is always on my case to do this and get that done….”  Staff: “Sounds like the pressure is too much for you right now”  Reflection of feeling – This is the deepest form of reflection. It is a paraphrase that emphasizes the emotional dimension of the message.   Client: “I really hate my job. Everyone is always on my case to do this and get that done….”  Staff: “Sounds like you are really frustrated right now.”
  • DOUBLE-SIDEDREFLECTIONS With a double-sided reflection, the counselor reflects both the current, resistant statement, and a previous, contradictory statement that the client has made.  Client: "But I cant quit drinking. I mean, all of my friends drink!“  Counselor: "You cant imagine how you could not drink with your friends, and at the same time youre worried about how its affecting you.“  Client: "Yes. I guess I have mixed feelings.”
  • PICK OUT THE REFLECTIVE STATEMENTSClient: I feel so full of shakes that I take a drink before I leave the house.Counselor: It helps to settle your nerves.Client: And I can go get the kids from school, shop and then feed them.Counselor: and you get quite a lot done.Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time.Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house.Client: yes, that’s exactly right.Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it?Client: well as I said, it calms my nerves, but it can’t go on like this forever.Counselor: although it helps, you’re concerned about it.Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids.Counselor: you don’t want your life to revolve about drinking.Client: exactly you know I must watch it.
  • SUMMARIZINGSummarizing – summarizing is a special application of reflective listening that links together discussed material, demonstrates careful listening and prepares the client to move on.  It may begin with a statement indicating that the staff is attempting to summarize. For example:  “Let me see if I understand what you’ve told me so far…”  “Okay, here’s what I’ve heard so far. Listen and tell me if I’ve missed anything….” Make your summary concise. End with an invitation for the client to respond such as:  “How did I do?  “What have I missed?”  “So if that is a fair summary, what other points are there to consider?”  “Is there anything there you want to correct or add to?” Summaries are good to use when you feel lost or if you want to change direction in the conversation.
  • Thomas Gordon’s 12 Roadblocks to Listening1) Ordering, directing2) Warning, threatening3) Giving advice, making suggestions, providing solutions4) Persuading with logic, arguing, lecturing5) Moralizing, preaching6) Judging, criticizing, blaming7) Agreeing, approving, praising8) Shaming, ridiculing, name-calling9) Interpreting, analyzing10) Reasoning, sympathizing11) Questioning, probing12) Withdrawing, distracting, humoring, changing the subject
  • OARS Exercise:  Work in groups of 3 One speaker and two counselors Counselors take turns speakingSpeakers: Describe something about yourself that you  Want to change  Need to change  Should change  Have been thinking about changing  But you haven’t changed yet – i.e. something you are ambivalent aboutListeners:   Respond to the speaker using OARS   Don’t try to fix it or make change happen!  General Guidelines with OARS  Ask fewer questions – 50% of what you say should be reflections Ask more open than closed questions – 20% open questions Don’t ask 3 questions in a row – throw in some reflections and affirmations Offer two reflections for each question asked Summarize when you have gathered a lot of info that you want to organize or to move to another topic or to end the session.
  • Raymond: Active Listening
  • RESISTANCE IS… A defense mechanism that signals to you that the client views the situation differently. This is seen throughout all stages, but is often addressed in the contemplation stage as ambivalence. An important signal of dissonance within the counseling process Often associated with drop-out rates and other poor outcomes It is a signal to staff that they need to change direction or listen more carefully.* It offers an opportunity to respond in a new, perhaps surprising way with out being confrontational.*Normal
  • OK, IT’S NORMAL…NOWWHAT? How we respond to client resistance or sustain talk makes a difference and distinguishes MI from other counseling approaches MI assumes that if resistance or sustain talk is increasing during counseling, it is very likely in response to something the counselor is doing Sometimes the most (and best) we can do with a particular client is to reduce resistance Implicit in the MI approach is an assumption that persistent resistance is not a client problem, but a counselor-approach or -skill issue SO: We can change our style in ways that will decrease client resistance…and decreased client resistance is associated with long-term change!
  • FOUR CATEGORIES OFCLIENT RESISTANCE Arguing – the client contests the accuracy, expertise, or integrity of the clinician or what they are saying by challenging, discounting or being hostile towards the staff person. Interrupting – breaks in and interrupts in a defensive manner by talking over or cutting off the staff. Denying – client is unwilling to recognize problems, accept responsibility, or take advice  Minimizing  Blaming  Rationalizing  Intellectualizing  Diversion  Hostility Ignoring – the client shows evidence of ignoring or not following the clinician by inattention, no response, or sidetracking the conversation.
  • SIX (WELL, SEVEN) TRAPS TO AVOID…ANDTHEY USUALLY ARISE EARLY IN THEINTERVIEW PROCESS AND RE-APPEAR WHENWE ENCOUNTER RESISTANCE The Question-Answer Trap The Expert Trap The Trap of Taking Sides The Labeling Trap The Premature Focus Trap The Blaming Trap And…the Righting Reflex…watch for it throughout…
  • IDENTIFY THE CHANGE TALKClient: I feel so full of shakes that I take a drink before I leave the house.Counselor: It helps to settle your nerves.Client: And I can go get the kids from school, shop and then feed them.Counselor: and you get quite a lot done.Client: yes, those kids keep me going for hours after that, you know the food, playing, going to bed and they are not easy, shouting all the time.Counselor: you’ve told me about those panic attacks, how you work so hard to look after the kids and how you sometimes need a drink before you leave the house.Client: yes, that’s exactly right.Counselor: May I ask you, could we spend a few minutes talking about alcohol, how it helps and what else you’ve noticed about it?Client: well as I said, it calms my nerves, but it can’t go on like this forever.Counselor: although it helps, you’re concerned about it.Client: well, I’m not an alcoholic you know but I can’t be drinking while I am with the kids.Counselor: you don’t want your life to revolve about drinking.Client: exactly you know I must watch it.
  • EVOCATIVE QUESTIONS –MAGIC! For what are you motivated? What change do you want most? On a scale of 1 – 10, how important is it to you to change? What are your most important reasons for changing? What are the benefits of changing? What steps are you willing to take? How will you do it? In what ways are you already able to make the changes you want to make?The answers to all of these are CHANGE TALK!
  • DECISIONAL BALANCE Status-quoBenefits of Changing Benefits of Not Changing ChangeConsequences of Changing Consequences of Not Changing 34
  • SIGNS OF READINESS FORCHANGE Decreased resistance Decreased discussion about the problem Resolve Change talk/self-motivational statements Questions about change Envisioning Experimenting
  • FINAL THOUGHTS… MIreleases us from the draining psychological burden of having to “make” people do the right thing, which is actually an impossible task. Peoplemake choices and we cannot take that away from them…what we CAN do is help them make the choices that are right for them.
  • FOR YOUR INTEREST Miller and Rollnick (2002). Motivational Interviewing: Preparing People for Change, 2nd Edition, New York, Guilford Press. Rollnick, et. al. (1999). Health Behavior Change: A Guide For Practitioners. London and New South Wales, Churchill Livingstone. Miller and White. Confrontation in Addiction Treatment, Counselor, August 2007. Miller, W. R. (2000). Rediscovering Fire: Small interventions, large effects. Psychology of Addictive Behaviors, 14:6-18. www.motivationalinterview.org Enhancing Motivation to Change in Substance Abuse Treatment, CSAT, TIP 35. Hettema, J., Steele, J., & Miller, W. R.. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91- 111. Amrhein, et. al. (2003) Client Commitment Language During MI Predicts Drug Use Outcomes. Journal of Consulting and Clinical Psychology, 71, 862-878.