Motivational Interviewing lecture


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  • Already have a solid foundation, been doing MI, whether you know it or not.
  • Smoking, heart disease, drinking, pornography, obesity.
  • Orientation, way of being, a tool, a way of communicating more than a technique.
  • Scales vs. Jazz and improv.The more dialed, the beat, the bass, the groove, the key signature, the more freedom you have to move away from it for a bit. You have the notes. Now we are going to refine.You have some science, no we are going to look at being more artistic and intuitive.Not just playing notes, “Here just say this”, hand you a script. “When they say this, you say this…” Like a Choose Your Own Adventure book.Energy, volume, intensity, pitch, tension, dynamics, use of silence, timing. Knowing the script of a joke, doesn’t guarantee you will be funny. Timing and delivery are key.
  • 1st half Spirit and Principles, 2nd half on OARS, Change talk, Specific tools. Practice if we have time.
  • www.stephenrollnick,com
  • Why doesn’t this work?
  • One cool thing about MI is you don’t have to be an expert. You don’t have to be an expert at ADD, Anxiety, Axis II, Parenting, Career, Marriage, Addiction, etc. You don’t have to be wise beyond your years or super experienced (even though sometimes those things can help).Evoke/Ellicitvs DirectAlso not role to confront, argue, persuade, pressure or coerce your client.Intrinsic vs Extrinsic motivation – Goals, Values, Drive, PassionA lot of this is review.Tendency is yeah, goals, treatment plans, technique, tools, resources, etc. NOW we’re getting to the good stuff.
  • When you get frustrated, impatient, sarcastic with your client, when a husband and wife have Gottman’s Four Horsemen(Criticism, Defensiveness, Contempt, Stonewalling), when you have an angry resistant client. Empathy is the good stuff.Must fundamentally get the sense, you are for them. You cannot have trust without this, the glue for your alliance.
  • What happens in marriage? In workplace? In families? In community, spiritual?
  • Brain or heart surgery
  • If truth (info, advice, plans for change) are the scapel, then grace (empathy, love, patience) is the anesthesia. It is the space, the safety for the digging, the cutting out of stuff, the exploration to happen. Why dig around in the past? Why change? Why risk, try, grow? When the going gets tough in therapy your client needs the safety to continue pressing into new behavior, new ideas, new relationships – to face the pain of their past, present and maybe future.Grace and Truth, not Grace or Truth. Grace with Truth. Grace is True, is a truth. Don’t “switch”, don’t compartmentalize. You will shift words, but even as you work on change, advice, problem-solving don’t leave empathy behind. You will be more effective if you constantly ask yourself am I understanding my client? Are will still on the same side of the table, looking at the problem together?Social intelligence. Personality type affect on being/presence as a therapist.
  • They may choose to stay the same.They may realize they don’t want to change their job, they may realize they want to stay single.They may realize they want to stay married.
  • Different approaches needed but be patient with all.Paul says elsewhere restore those who are in sin gently, lest you fall. Gal.6:1
  • QA: yes, no, interrogated. Passive. Tempting to work harder.Focus: counselor’s agenda, moving on without permission, move too fastConfrontation: defensiveness if counselor takes “problem-change” side of conflict.Blaming: whose fault is problem? Waste of time. Defensive if feel blamed. Expert: having all the answers. Be curious. Be confident but not arrogant. Work with.Labeling: diagnostic label. Focus on client’s inner world.
  • One mirror vs two or more mirrors – you see different angles of yourself.“Who are you to give me advice…you probably never drink.”“My parents always nag me. I haven’t been doing that bad.”
  • Playing chess, outwitting client. Client playing chess with themselves like Pixar.
  • Say more in change talk and tx planning stage.
  • Motivational Interviewing lecture

    1. 1.
    2. 2.  Ability to work with resistant clients?  How much do you agree: I am a good listener?  I am confident working with ―stuck‖ clients?  I know how to help a client change?
    3. 3.  Competence  Confidence  Creativity  Improved presence  Decreased frustration  Increased connection
    4. 4.  Start with the bad news  Recommendation  Minimum of two days
    5. 5.  1. The SPIRIT of MI  2. OARS – client-centered counseling skills  3. Recognizing and reinforcing change talk  4. Eliciting and strengthening change talk  5. Rolling with Resistance  6. Developing a Change Plan  7. Consolidating client commitment  8. Shifting flexibly between MI and other methods
    6. 6.  Debi Austin
    7. 7. I do not understand what I do. For what I want to do I do not do, but what I hate I do. 16 And if I do what I do not want to do, I agree that the law is good. 17 As it is, it is no longer I myself who does it, but it is sin living in me. 18 For I know that good itself does not dwell in me, that is, in my sinful nature. For I have the desire to do what is good, but I cannot carry it out. 19 For I do not do the good I want to do, but the evil I do not want to do—this I keep on doing. 20 Now if I do what I do not want to do, it is no longer I who do it, but it is sin living in me that does it. 21 So I find this law at work: Although I want to do good, evil is right there with me. 22 For in my inner being I delight in God’s law; 23 but I see another law at work in me, waging war against the law of my mind and making me a prisoner of the law of sin at work within me. 24 What a wretched man I am
    8. 8.  It is a client-centered, directive method of engaging intrinsic motivation to change behavior by exploring and resolving ambivalence within the client.  William Miller and Stephen Rollnick
    9. 9.  Basic  Like scales  Different types of music  Science of counseling  Art of counseling
    10. 10.  Phase I – Explore ambivalence/Build Motivation  Phase II – Change Talk, Planning, Strengthening Commitment
    11. 11. MI Spirit MI Principles DEARS OARS Change Talk
    12. 12. FUNDAMENTAL APPROACH OF MI MIRROR-IMAGE APPROACH  Confrontation  Education  Authority  Collaboration  Evocation  Autonomy
    13. 13.  Motivation to change is elicited from the client, and not imposed from without.  It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence  Direct persuasion is not an effective method for resolving ambivalence.  The counseling style is generally a quiet and eliciting one.  The counselor is directive in helping the client to examine and resolve ambivalence.  Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction.  The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.
    14. 14.  Develop Discrepancy  Express Empathy  Avoid Argument (Amplify Ambivalence)  Roll with Resistance  Support Self-Efficacy
    15. 15.  R – Resist the righting reflex  U – Understand your client’s motivation  L – Listen to your client  E – Empower your client
    16. 16.  ―We tend to believe what we hear ourselves say. The more patients verbalize the disadvantages of change, the more committed they become to sustaining the status quo.‖  ―If you are arguing for change and your patient is resisting and arguing against it, you’re in the wrong role. You are taking all the good lines.‖  MI in Health Care p. 8
    17. 17.  Personal Competence  Self-Awareness  Self-Management  Delaying gratification  Social Competence  Social Awareness  Relationship management
    18. 18.  Client-centered: Understanding the client’s internal frame of reference and present concerns.  Non-judgmental attitude.  Understanding vs condoning
    19. 19.  Why don’t you change?  How can you tell me that you don’t have a problem?  What makes you think that you’re not at risk?  Why don’t you just…?  Why can’t you…?
    20. 20.  Criticism  Defensiveness  Contempt  Stonewalling
    21. 21.  Permission  Authenticity  Validation  Acceptance  Safety  Connection  Trust
    22. 22.  Normalize is not approval.  It is common experience.  Permission to truly be known and know themselves  Vs Compartmentalization and shame
    23. 23.  Their behavior may be a seemingly senseless problem, help them dig deeper to invalidated parts.  Based on a human need and desire…maladaptive ways to get them.  Trauma, codependency  ―Every problem was a solution to a previous problem…‖
    24. 24.  From CNN: Boyfriend: Phobia caused woman's 2-year bathroom stay "The case drew nationwide attention after Ness County Sheriff Bryan Whipple said it appeared the Ness City woman's skin had grown around the seat in the two years she apparently was in the bathroom. "We pried the toilet seat off with a pry bar and the seat went with her to the hospital," Whipple said. "The hospital removed it."
    25. 25.  There is a ―value‖ in staying the same.  Freedom from the ―cost‖ of change  Freedom of the risk of failure.  Safety of low expectations, not taking responsibility.  Freedom from the pressure of success  Giving up secondary gains
    26. 26.  Not Grace or Truth, Grace vs Truth  Grace with Truth  Scalpel  Anesthesia  Rogers: ―The curious paradox is that when I accept myself just as I am, then I can change.‖
    27. 27.  Key strength of MI: You don’t have to be an expert  Insight doesn’t guarantee change.  Information doesn’t guarantee change.  Diet book, self-help book, formula, plan  ―If reasons/change talk were enough they would have made the change already…‖ (MI in tx of Psych. Problems. P.30)
    28. 28.  MI isn’t about finding the missing piece of information.  It isn’t necessarily problem-solving or ―figuring things out‖.  It isn’t ―Making People Change‖ it’s ―Preparing People Change‖  By helping them fully be aware of their choices, competence and challenges and helping them CHOOSE.
    29. 29.  Even if you may not agree with their choice, they are choosing with their eyes wide open.  With this ―informed consent‖ they are being responsible for their life, they are choosing their path, choosing their consequences.
    30. 30.  Following  Guiding  Directing  Develop flexibility in shifting modes  ―Good leading is gentle, responsive and imaginative.‖ MI 2nd ed. P. 22
    31. 31.  Asking  How many times has that happened? (directing)  What kind of change makes sense to you? (guiding)  How have you been since your son died? (following)
    32. 32.  Your best option is to take these tablets. (directing)  Changing your diet would make sense medically, but how does that feel to you? (guiding)  Yes, it’s a common experience; many patients also feel quite shocked and unsettled about simple things like going to the toilet. (following)
    33. 33.  So you understand what’s going to happen this morning, but you want me to tell you more about what will happen later on. (directing)  You’re feeling concerned about your weight, and you are not sure where to go from here. (guiding)  This has been a huge shock. (following)
    34. 34.  Group A: Low importance, low confidence  Group B: Low importance, high confidence  Group C: High importance, low confidence  Group D: High importance, high confidence
    35. 35.  Reluctance  Rebellion  Resignation  Rationalization
    36. 36.  14And we urge you, brothers, admonish the idle, encourage the fainthearted, help the weak, be patient with them all. See that no one repays anyone evil for evil, but always seek to do good to one another and to everyone. Rejoice always, pray without ceasing, give thanks in all circumstances; for this is the will of God in Christ Jesus for you.
    37. 37.   Steven Johnson  Where Good Ideas Come From: The Natural History of Innovation
    38. 38.  1) Ordering, directing  2) Warning, threatening  3) Giving advice, making suggestions, providing solutions  4) Persuading with logic, arguing, lecturing  5) Moralizing, preaching  6) Judging, criticizing, blaming
    39. 39.  7) Agreeing, approving, praising  8) Shaming, ridiculing, name-calling  9) Interpreting, analyzing  1 0) Reasoning, sympathizing  1 1 ) Questioning, probing  12) Withdrawing, distracting, humoring, changing the subject
    40. 40. Open-ended questions Affirmations Reflective listening Summaries
    41. 41.  The Question/Answer Trap  The Premature Focus Trap  The Confrontation Trap  The Blaming Trap  The Expert Trap  The Labeling Trap
    42. 42.  How?  When?  Where?  What?  Who?  Vs Yes/No  Closed questions: Clarifying questions  Using Why?
    43. 43.  Compliments  Statements of appreciation and understanding  Thanks…  I appreciate…  You’re clearly a (character quality/value) person…  If I were in your position…  You enjoy…  I’ve enjoyed talking with you today…
    44. 44.  It is a hypothesis of what may be going on.  ―Do you mean?‖  It is a statement to understand meaning.  MI: 2-3 reflections per question asked vs 10 questions: 1 reflections in other counseling sessions. About half responses are reflections.
    45. 45.  Parroting – repeating, using same words  Simple – basic paraphrase, acknowledge feeling, perception or disagreement, small shift in emphasis  Amplified – amplified or exaggerated form  Double-sided – one way to develop discrepancy  Complex – summary, interpretation, metaphor/simile, con tinuing the paragraph
    46. 46.  I just don’t like the way she comments on how I raise my children.
    47. 47.  Shifting Focus Shift the person’s attention away from what seems to be a stumbling block in the way of progress.  Go around barriers rather than climbing over them  Reframing  Agreeing with a twist  Emphasizing personal choice and control  Coming alongside
    48. 48.  Sometimes…  A part of you…  When you tried that in the past…  I’m guessing, you might…(tentative)…  Some people…when modeling or giving advice vs self-disclosure.
    49. 49.  "You feel stuck." sometimes brings the session to an awkward pause or even a grinding halt. Therapist: "So, you feel stuck." Client: "Yep." [BONK!] [Crickets] Another variation is reflecting "You feel helpless." or "You feel hopeless." or "You feel trapped."
    50. 50.  Collecting Bouquets  Untangle the threads  Linking  Transitional
    51. 51.  ―As I hear myself talk, I learn what I believe.‖  Decisional Balance  The person experiences competing motivations because there are benefits and costs associated with both sides of the conflict. There are two kinds of weights on each side of a the balance: one has to do with the perceived benefits of a particular course of action; the other has to do with the perceived costs or disadvantages of the course of action (such as taking medication to lower blood pressure).
    52. 52. Continue to drink as before Abstain from alcohol Benefits Helps me relax Enjoy drinking with friends Costs Could lose my family Bad example for my children Damaging my health Spending too much money Impairing my mental ability Might lose my job Losing my time/life Benefits Less family conflict More time for my children Feel better physically Helps with money problems Costs I enjoy getting high What to do about my friends How to deal with stress
    53. 53.  Why, besides being an invitation for a fight, is victim language, past focused, it distracts from moving forward and facing change. On one hand, the past is one the best predictors of future behaviors; on the other, we're told Insight doesn't necessarily lead to change.  Search for meaning  ―Why do I?‖ ―I know/believe…why do I still?‖
    54. 54.  "What was/is going on?" "What is happening/happens? when you..." "How is pattern continuing? What fuels it?" "What did you do? What didn't you do?" "Where did this happen?" "When did you start believing that [core belief or cognitive distortion]?"
    55. 55.  "Where did you start doing that [behavior]?" "Who taught you that [behavior/coping]? Who modeled that in your life?" "How did you get here? To this place?" "What if?" "What did they do/say?"  "How did you respond?" (vs. "They made me...[feeling or behavior]")
    56. 56.  "What did that look like? What did you feel? What did you experience?" "When that happened - What did that mean to you? What did you start telling yourself? About God, others, family, yourself?" "What was your role?―  "What would you do if you knew "Why?‖ How would knowing why? help you."
    57. 57.  How does this affect you? What are you experiencing? What will you do with this? What do you want/need? Who will you share this with?
    58. 58.  What are you feeling? How can you reframe this? What is the alternative? What/How can you change/control? What are the obstacles?
    59. 59.  Awareness of consequences is important  A discrepancy between present behavior and important goals will motivate change  The client should present the arguments for change.  A ―holy discontent‖  ―Food for thought‖ vs judgment/criticism  ―Columbo‖ technique. ―Help me understand.‖
    60. 60.  Minimization: where it all begins  Rationalization: the plot thickens  Denial: a preferred way to live  Re-labeling: telling it like it isn’t  Justification: I couldn’t help it  Entitlement: you deserve a break today
    61. 61.  oping/coping.htm  Adaptive mechanisms: That offer positive help.  Attack mechanisms: That push discomfort onto others.  Avoidance mechanisms: That avoid the issue.  Behavioral mechanisms: That change what we do.  Cognitive mechanisms: That change what we think.  Conversion mechanisms: That change one thing into another.  Defense mechanisms: Freud's original set.  Self-harm mechanisms: That hurt our selves.
    62. 62.  Values and priorities  Values are positive.  Preferred experiences (for example a valued career/job)  Behavioral ideals  Values Card sort at
    63. 63.  Self-oriented behaviors that neglect loved ones  Short-sighted behaviors that reap short-term rewards while ignoring long-term costs  Inefficient behaviors that fulfill certain needs at the expense of others
    64. 64.  Alignment?  How does (behavior) fit with the importance of (value)?  How does (behavior) fit with your desire to do/be (value)?
    65. 65.  Specific examples  Clarification: in what ways? How much? How often?  Description of the last time?  What else?
    66. 66.  Your client can’t ―lose‖ their way to change.  Don’t use your clients words against them.  Or at least if you do, don’t do a happy dance.  Don’t back them into a corner, force them to swallow their words down.  Yeah, yeah, yeah, you’re right. I said that but you’re a bastard for pointing it out!  ―A man convinced against his will is of the same opinion still.‖  Dissonance and incongruence vs shame or feeling tricked
    67. 67.  Avoiding arguing for change  Resistance is not directly opposed  New Perspectives are invited but not imposed  The client is a primary resource in finding answers and solutions  Resistance is a signal to respond differently, to change strategies
    68. 68. 
    69. 69. 1. Arguing – The client contests the accuracy, expertise, or integrity of the counselor. 2. Interrupting – The client breaks in and interrupts the counselor in defensive manner. 3. Negating – The client expresses an unwillingness to recognize problem, cooperate, accept responsibility or take advice. 4. Ignoring – The client shows evidence of ignoring or not following the counselor.
    70. 70.  Challenging- challenges the accuracy of what is said  Discounting – counselor’s personal authority  Hostility – Client expresses direct hostility
    71. 71.  Blaming  Disagreeing  Excusing  Claiming Impunity (not in danger)  Minimizing  Pessimism  Reluctance  Unwilling to change
    72. 72.  Inattention  Non-answer  No response  Sidetracking  Other passive  Over-compliance  Cancellations, no-shows
    73. 73.  Spoken  Unspoken  The power of AND
    74. 74.
    75. 75.  Rich Young Ruler – Luke 18  Paralytic at Bethesda – John 5
    76. 76.  Not just logically weigh pros and cons, Change Balance Sheet.  Doesn’t fully account for, or address sin.  How does our new nature interact with our flesh, this body of sin?  How does the reality of the Holy Spirit interact with us being sinful?  How does the gospel apply?  Trying on new clothes. Feels very uncomfortable, intolerable.
    77. 77.   I wish I had what I need To be on my own 'Cause I feel so defeated And I'm feeling alone And it all seems so helpless And I have no plans I'm a plane in the sunset With nowhere to land And all I see It could never make me happy  And all my sand castles Spend their time collapsing
    78. 78.  Let me know that You hear me Let me know Your touch Let me know that You love me Let that be enough It's my birthday tomorrow No one here could now I was born this Thursday 22 years ago And I feel stuck Watching history repeating Yeah, who am I? Just a kid who knows he's needy
    79. 79.  Trust me, ―It’s good for you‖ isn’t good enough.  If they feel disrespected or worse, traumatized/abused.  More importantly, we’ve stolen growth/process from them, we’ve stolen their opportunity to overcome their fear and to make their own free choice.  It may be good for them but it risks mistrust, anger, resentment.  Innoculate them to other risks/changes.  Find ways to make change fun, not traumatic.
    80. 80. Judge or Attorney  In client’s life who is the judge? Who has the final authority?  Who is hardest critic?  You don’t want to be put in the position of being the judge.  You advocate for your client.  Eventually advocate for themselves. Ultimately they stand and give an account for themselves.
    81. 81.  Directive  Belief in the possibility of change: client’s and counselors. Self-Fulfilling prophecy.  Direct your client to direct themselves  Direct your client to ―grow up‖ – not in a pejorative sense, they are adult, responsible, heroic, significant, God’s workmanship.  This where you ―don’t work harder than your client‖
    82. 82.  You don’t care more, you don’t have all the insights/interpretations of meaning, aha moments.  You are winning when your client is winning, when they come up with the cool meaning and understanding about themselves. When they seem themselves for what they are.
    83. 83.  Shifting from an external locus of control, where they are constantly seeking approval or answers outside of themselves to an internal locus of control. (Of course God is sovereign and involved. They do business directly with God. They don’t need an intermediary to discern God’s will for them.)  Bear their weight, carry their own load.  Interdependence.  Ask for what they want/need.  Find what they want and need. Or ask for help.
    84. 84.  Humble courage.  Authentically know their limits vs pretense and defensiveness.  Not driven to do too much, free to do much.  Passion vs pressure  Normalize it takes practice.
    85. 85.  Trainer and Spotter  Model, teach, coach, come alongside, spot.  Start here by casting vision for self-efficacy.  Empower client.  Affirmations  You can do it.  You have done it.  You might do it.  People have done it. (normalize)  How did you do it? (talk about successful changes in the past)
    86. 86.  1. Don't listen to anybody 2. Listen to everybody 3. Endlessly analyze and don't make changes. On the other hand, perhaps: "Don't just do something, stand there." 4. Blame others for your actions or problems. "We have only one person to blame and that's each other." 5. Blame yourself and put yourself down regularly
    87. 87.  6. Keep doing the same things that don't work 7. Keep focusing on the same things when that focus doesn't help 8. Keep thinking the same thoughts when those thoughts don't help 9. Keep putting yourself in the same unhelpful environment 10. Keep relating to the same unhelpful people 11. Put more importance on being right than changing
    88. 88.  Recognize and elicit  Desire: I want, I’d like to, I wish I could, I can’t wait…  Ability: I could, I can, I might be able to  Reason: I would probably feel better if I…, It would be good if I…  Need: I ought, I have to, I really should…
    89. 89.  Recognizing the disadvantages of the status quo  Recognizing the advantages of change  Expressing optimism about change  Expressing intention to change  ―What is your client’s change language‖
    90. 90.  Desire: "What do you want to do about this behavior?"  Ability: "What makes you believe you can do this?"  Reason/Need: "Why would you want to make this change?"  Commitment: "So what are you willing to do now?"
    91. 91.  Desire: Why would you want to make this change?  Ability: How would you do it if you decided?  Reason: What are the three best reasons?  Need: How important is it? and why?  Commitment: What do you think you’ll do?
    92. 92.  ―What do you think you will do?‖  ―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 making a change?‖  ―Where does this leave you?‖
    93. 93.  A negotiable, workable plan
    94. 94.  Underestimating Ambivalence  Over-prescription  Insufficient Direction
    95. 95.  Summary of client’s perception, change talk, importance talk  Summary of ambivalence, positives of status quo  Objective evidence, if any  Restatement of DARN-C, confidence talk  Your own assessment of client’s situation
    96. 96.  Positive and Negatives from the Past  Positive and Negatives in the Present  Positive and Negatives in the Future
    97. 97.  IQ-LEDGE-C  Importance/Confidence Ruler  Querying Extremes  Looking Back / Looking Forward  Evocative Questions  Decisional Balance  Goals and Values  Elaborating  Coming Alongside
    98. 98.  ―If on a scale of 1 to 10, 1 is not at all important to give up smoking and 10 is extremely important to give up, what number would you give yourself at the moment?‖  ―If you were to decide to give up smoking now, how confident are you that you would succeed? On a scale of 1 to 10, 1 means that you are not at all confident and 10 means you are 100% confident you could give up and remain a non- smoker.‖  ―Why are you at (chosen number) and not at 1?‖  ―What would need to happen for you to go from (chosen number) to (a higher number)?‖  ―How can I help you go from (chosen number) to (a higher number)?‖
    99. 99.  What is the worst case scenario?  What is the best case scenario?
    100. 100.  With problem  Without problem
    101. 101.  Hypothetical  How? Or What? Would you do…if…  Desire: "What do you want to do about I this behavior?"  Ability: "What makes you believe you can do this?"  Reason/Need: "Why would you want to make this change?"  Commitment: "So what are you willing to do now?"
    102. 102.  Paradoxical, ―therapeutic paradox‖ ―reverse psychology‖  Permission to not change  Postpone change  ―Not ready‖  ―Not the right time‖  ―In the meantime…‖  Actually ―firing‖ your client or suggesting referral to another counselor, other solutions.
    103. 103.  Reinforce and consolidate change talk  Elaborating: In what way… ?; Tell me more…; What else?  Affirming: That took a lot of courage; You’re a person who can make changes when you need to…  Reflecting: That’s really important to you …; You realize it’s become a problem…  Summarizing: There are a number of things I’m hearing about your situation . First, you’re concerned about….. Also, you feel…, and you are thinking…
    104. 104.  I should  I might  I could  I will
    105. 105.  Setting Goals  Considering Change options  Arriving at a plan  Eliciting commitment
    106. 106.  Have you come to conclusion?  Are you ready?  How close?  Anything else to consider?
    107. 107.  Method – What?  Preferred strategy – How?  Timing – When?
    108. 108.  Scientist Stuart Kauffman quoted by Steven Johnson  The phrase captures both the limits and the creative potential of change and innovation.  What is possible?  What is probable?  What are the small, next steps?  Being faithful with a little first
    109. 109.  Building emotional, mental, relational muscles that they haven’t built yet.  What would that look like?  What might happen?  There is hope in the range of alternative approaches available.  There is no one ―right way‖ to change – menu of changes
    110. 110.  Specific  Measurable  Attainable  Relevant  Time-bound
    111. 111.  "The goal of treatment is to RISE above your problems rather than be controlled and dominated by them." Stephen Arterburn Healing is A Choice
    112. 112.  Reduce the stress in your life by learning some new management skills  Reduce conflicts that cause inner turmoil and difficulties in your relationships.  Reduce the negative patterns that have set in over your lifetime.  Reduce the substances you use to help cope with the pain in your life.
    113. 113.  Increase your self-awareness and how you affect people who interact with you.  Increase your awareness of your feelings.  Increase your understanding of yourself and why you do the things you do.
    114. 114.  Increase your connection with others.  Increase your assertiveness in a way that draws people to you rather than repels them.  Increase the healthy influences in your life.  Increase your time alone with God in the Bible and in prayer.
    115. 115.  Substitute positive emotions for negative ones.   Substitute the willingness to risk for fear.   Substitute humility for arrogance.
    116. 116.  Substitute acceptance for anger.   Substitute peace for anxiety.   Substitute surrender for control.
    117. 117.  Eliminate addictive behaviors  Eliminate a critical and judgemental spirit.  Eliminate certain repetitive sins in your life.
    118. 118.  Sometimes change talk can sound like ambivalence or resistance.  Client may be articulating what they will be giving up.  Even dysfunctional relationships, beliefs, behaviors can be hard to let go of.  For some weight can be a defense, being more attractive can be risky, it opens up opportunity for relationship which in term means more risk at being known and being hurt.
    119. 119.   _links/manuals.html  Motivational Interviewing: Preparing People for Change, 2nd Edition Miller, William R., Rollnick, Stephen (2002)  Building Motivational Interviewing Skills: a practioner workbook Rosengren, David B. (2009)
    120. 120.  Motivational Interviewing in Health Care: Helping Patients Change Behavior Rollnick, S., Miller, WR & Butler, CC (2008)  Motivational Interviewing in the Treatment of Psychological Problems Arkowitz, H., Westra, HA, Miller, WR., Rollnick, S editors  Emotional Intelligence 2.0 Bradberry, T., Greaves, J (2009)  Emotional Intelligence Quick Book Bradberry, T., Greaves, J (2003)
    121. 121.  Change 101: A Practical Guide to Creating Change in Life or Therapy O’Hanlon, B. (2006)  