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Motivational Interviewing

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Allyson Sproul

on 18 March 2016

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Transcript of Motivational Interviewing

Motivational Interviewing

Clinician Role and Expectations
What is expected of me and how do I apply this to my practice??
OARS
Stages of Change
Stages and Change Talk
It's not THEM, it's US...
Clinician approach is one of the easily overlooked elements of client response to treatment.
MI Traps
Why don't people want to change??
Shame and vulnerability
Personal buy in
Stages of change
Being Client Centered
"Motivational interviewing is a therapeutic style intended to help clinicians work with clients to address their ambivalence"
Helpful Strategies in the Early Stages of Change
What we're going to cover
So many models, so many opinions...
Moral : Sinners and Saints
Medical:

Chemicals, genetics,disease model
Spiritual: 12 Steps, Christianity, Eastern practices
Psychological: deficits in learning, emotional dysfunction, or psychopathology
Sociocultural: socioeconomic status, cultural and ethnic beliefs, availability of substances, the norms and rules of families and other social groups as well as parental and peer expectations, modeling of acceptable behaviors, and the presence or absence of reinforcers, laws and penalties regulating substance use,
Composite biopsychosocial–spiritual model: Embraces all models
MI Style
Check in with yourself...
What stage of change am I in regarding actually applying this style of thinking?

How ready am I to start thinking about people seeking treatment as individuals versus "clients" who fall in to the same category?

How willing am I to let the clients do the work?

Is there anything about this style that is rubbing me the wrong way?
MI Trap
Question-Answer Trap:
Setting the expectation that the therapist will ask questions and the client will then answer, fosters client passivity. Asking open-ended questions, letting the client talk, and using reflective listening are several ways to avoid this trap.

MI Trap
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. This may elicit oppositional “no problem here” arguments from the client. As you argue your view, the client may defend
the other side.

In this situation you can literally talk the client out of changing. You will want to avoid taking sides.
MI Trap
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.

Using reflective listening and reframing, you might say, “Who is to blame is not as important as what your concerns are about the situation.”


Flexible Pacing
We all move at a different pace
Shame and Vulnerability
If you are going to use MI be ready to
So what's next?
Do your best to use MI as a complement to your already awesome clinical skills!!!
Based on Jim Harvey's speech structures
This style goes beyond ambivalence and addresses each change state that occurs during the stages of change.
MI Trap
Premature Focus Trap:
When a counselor persists in talking about her own conception of “the problem” and the client has different concerns, the counselor gets trapped and loses touch with the client. The client becomes defensive and engages in a struggle to be understood.

To avoid getting trapped start with the client’s concern, rather than your own assessment of the problem. Later on, the client’s concern may lead to your original judgment about the situation.
MI Style
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.
In MI style counseling you seek collaboration and give your clients the opportunity to explore and resolve ambivalence for themselves.
MI Trap
Labeling Trap:
Diagnostic and other labels represent a common obstacle to change. There
is no persuasive reason to use labels, and positive change is not dependent upon acceptance of a diagnostic label. It is often best to avoid “problem” labels, or refocus attention.

For example, “Labels are not important. You are important, and I’d like to hear more about…”
*Determine your client's stage of change
*Ambivalence is ok
*Meet them where they're at
*Use stage appropriate interventions
Look for the gap between the future goal and the current behavior

*
How does your (lack of a GED/using drugs/alcohol/peers) fit in with your goals?

*On one hand you say your (Health/Children) are important to you, however, you continue to (Drink/Use Drugs/get arrested), help me to understand….

Developing Discrepancies
1. Ask
o
pen ended questions
2.
A
ffirm
3. Listen
R
eflectively
4.
S
ummarize

Pay off Matrix

* Avoid argumentation
Human beings have a built in desire to set things right (righting reflex)

* When the righting reflex collides with ambivalence, the client begins defending the status quo

* If a person argues on behalf of one position, he/she
becomes more committed to it

* Resistance is a signal to change strategies

Rolling with Resistance
Clinician impact
MI Style
MI Traps
Why people don't want to change
"Resistance" and stages of change
Improving Communication
Empathy and accountability versus power and authority
Listening for change talk DARN-C
COLLABORATION
- MI requires that the therapist
relate to the client in a non-judgmental,
collaborative manner. The client’s experience and
personal perspectives provide the context within
which change is facilitated rather than coerced.
EVOCATION
- The interviewer’s tone is not one of
imparting wisdom, insight or reality, but rather of
eliciting the client’s internal viewpoint. The
counselor draws out ideas, feelings, and wants
from the client. Drawing out motivation, finding
intrinsic motivation for change and bringing it to
the surface for discussion is the essence of MI.
MI Style
AUTONOMY
- Responsibility for change is left
totally with the client. Individual autonomy is
respected. MI style communicates safety and
support, first through an absence of confrontation
or persuasion and second, by acceptance of the
client.
MI Style
ROLL WITH RESISTANCE
- Opposing resistance
generally reinforces it. Resistance, however, can be
turned or reframed slightly to create a new
momentum toward change.
* The interviewer does not directly oppose resistance, but rather rolls and flows with it. Reluctance and ambivalence are not opposed but are acknowledged to be natural and understandable.
*The interviewer does not impose new views or goals, but invites the client to consider new information and offers new perspectives.
MI Style
Empathy means acceptance and understanding another’s perspective and feelings neutrally, without judging or evaluating in any way.
Expressing Empathy
Empathy has been called the defining principle of MI
It means a person’s belief in his or her ability to carry out a specific act or behavior.

Similar to self confidence, but is more specific and tied to a particular activity or behavior.

Self-efficacy is critical in MI because it reflects the “can do” or “can’t do” attitude that can make or break an effort for change.

Use the scale!
Support Self Efficacy
Activity

Step one:

1) Identify a person in your life (teacher, coach, clergy person, supervisor, etc.) whose influence you rejected, avoided, or whom you felt defensive around
2) Tell me about the behaviors of that person that led to these feelings
Step two:
1) Think of a person who had a profound influence on your life
2) Tell me about the behaviors of that person that led to these feelings
Activity
Rolling with Resistance "Batting Practice"
1) Pitch out a "resistant" statement you may have heard before from someone who is not ready to make a change

2) Bat back a reflective statement that will respond to and reduce defensiveness

Let's see how many we can come up with!!
DESIRE
– I want, I wish…..
ABILITY
– I can…..
REASON
- if I can, then I can……
NEED
- I have to….
CAN
– I will….. I am……

DARN-C
Precontemplation:

Not currently considering change.
"Ignorance is bliss"
Validate lack of readiness
Clarify: decision is theirs
Encourage evaluation of self-exploration of current behavior NOT ACTION
Explain and personalize risk
Contemplation:
Ambivalent about change
"sitting on the fence"
Not considering change in the next month
Preparation:
Some experience with change
is trying to change.
"testing the waters"
Planning to act with in one month
Action:
Practicing new behavior for 3-6 months
"I am a doer!!"
Trial and error to see what works
Maintenance:
Continued commitment to sustaining new behaviors
"This is me, this is my routine"
Post 6 months and beyond
Validate lack of readiness
Clarify :decision is theirs
Encourage evaluation of pros and cons of behavior change (PAY OFF MATRIX)
Identify and promote new, positive outcome expecations
Identify and assist in problem solving: getting past the obstacles
Help identify social supports
Verify underlying skills for behavior change
Encourage initial small steps
Focus on restructuring cues and social support
Bolster self-efficacy
Combat feelings of loss and reiterate long term benefits
Plan for follow up support
Reinforce internal rewards
Discuss coping with and possibility of relapse
*Remember: If you start to get "resistance" from the client, you may be approaching them with an inappropriate technique for their stage of change!

*Technique/approach MUST MATCH the client's stage of change in order to "meet them where they are"


Be open to letting the clients do their own work
Abandon the word SHOULD
Practice mindfulness and be willing to check in with countertransference
Meet clients where they're at with SOC appropriate techniques
Enjoy feeling less stressed when working with clients
Be open to building effective relationships with clients
COUNTERTRANSFERENCE
Activity
Read through the set of questions on the "OPEN ENDED QUESTION" paper located in your folder

Identify if the question is
N- Neutral
O- Open-ended
C- Closed-ended

Be prepared to discuss why you made your selection
What types of things would you like us to talk about?
OPEN

Isn't your friend's idea that you should quit using really a good one?
CLOSED

Are there good things about your drug use?
NEUTRAL

Don't you think your wife and kids have been hurt enough by your using?
CLOSED

What would change in your life if you stopped using?
OPEN

How do you think smoking pot is related to the problems you talk about in your marriage?
OPEN

Have you ever thought about taking the stairs instead of waiting in frustration for the elevator to take you up three floors?
CLOSED

How did you first get started drinking?
OPEN

How long have you been concerned about your drug use?
NEUTRAL
What is it???
Transference

Countertransference

What are your values: Activity Time!
Where do our reactions come from?
Where do our emotions come from?
Where do our thoughts come from?
What Motivates Us?
Event (external): What happened


Thought (internal): My thoughts, values and opinions about the event


Emotions(internal): The feelings I feel as a
result of my thoughts


Action Urges(internal): What I want to do as a result of my feelings


Behaviors (external): What I actually do as a result of my thought, feelings
and action urges
What do I do with counter-transference??
Supervision!
How do
you

react
when a client does not want to follow through with your ideas?
What is a name for what we might call this?

How do
you feel
when a client does not want to follow through with your ideas?
What is a name for what we might call this?

Whose responsibility is it to create the changes in the client's life?
What happens to them if they don't change?
What happens to you if they don't change?

Is it possible to care too much about our clients and their success/failures?

If you feel frustrated with a client; what can we call that?
What can you do?
Questions to Consider
Questions to Elicit/Evoke Change Talk

“What would you like to see different about your current situation?”
• “What makes you think you need to change?”
• “What will happen if you don’t change?”
• “What will be different if you complete your probation/referral to this program?”
• “What would be the good things about changing your [insert risky/problem behavior]?”
• “What would your life be like 3 years from now if you changed your [insert risky/problem behavior]?”
• “Why do you think others are concerned about your [insert risky/problem behavior]?”

Elicit/Evoke Change Talk For Clients Having Difficulty Changing: Focus is on being supportive as the client wants to change but is struggling.
• “How can I help you get past some of the difficulties you are experiencing?”
• “If you were to decide to change, what would you have to do to make this happen?”

Elicit/Evoke Change Talk by Provoking Extremes: For use when there is little expressed desire for change.
Have the client describe a possible extreme consequence.
• “Suppose you don’t change, what is the WORST thing that might happen?”
• “What is the BEST thing you could imagine that could result from changing?”

Elicit/Evoke Change Talk by Looking Forward: These questions are also examples of how to deploy discrepancies, but by comparing the current situation with what it would be like to not have the problem in the future.
• “If you make changes, how would your life be different from what it is today?”
• “How would you like things to turn out for you in 2 years?”


http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf
Let's Talk About Empathy
What it is and what it is not
Conclusion
Review of Techniques for creating an atmosphere for change
Activity
Practicing Reflective Listening and Empathy
Let's Practice
Choose a character in the clip and prepare to respond to them with an empathic response.

Step 1: Watch and Listen
How is the person acting?
What is the person saying?

Step 2: Remember
When have you felt the same way?

Step 3: Imagine
How would you feel in this same situation?

Step 4: Ask
How the person is doing
How the person is feeling

Step 5: Show You Care
With your actions an words, let the person know that you understand.
Simple Reflection

One way to reduce resistance is simply to repeat or rephrase what the client has said. This communicates that you have heard the person, and that it is not your intention to get into an argument with the person.

Client: But I can't quit drinking. I mean, all of my friends drink!
Counselor: Quitting drinking seems nearly impossible because you spend so much time with others who drink.
Client: Right, although maybe I should.
Amplified Reflection

This is similar to a simple reflection, only the counselor amplifies or exaggerates the point to the point where the client may disavow or disagree with it. It is important that the counselor not overdo it, because if the client feels mocked or patronized, he or she is likely to respond with anger.

Client: But I can't quit using. I mean, all of my friends use!
Counselor: Oh, I see. So you really couldn't quit using because then you'd be too different to fit in with your friends.
Client: Well, that would make me different from them, although they might not really care as long as I didn't try to get them to quit.
Double-sided Reflection

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 can't quit drinking. I mean, all of my friends drink!
Counselor: You can't imagine how you could not drink with your friends, and at the same time you're worried about how it's affecting you.
Client: Yes. I guess I have mixed feelings.
Shifting Focus

Another way to reduce resistance is simply to shift topics. It is often not motivational to address resistant or counter-motivational statements, and counseling goals are better achieved by simply not responding to the resistant statement.

Client: But I can't quit drinking. I mean, all of my friends drink!
Counselor: You're getting way ahead of things here. I'm not talking about your quitting drinking here, and I don't think you should get stuck on that concern right now. Let's just stay with what we're doing here - talking through the issues - and later on we can worry about what, if anything, you want to do about it.
Client: Well I just wanted you to know.
Rolling with Resistance

Resistance can also be met by rolling with it instead of opposing it. There is a paradoxical element in this, which often will bring the client back to a balanced or opposite perspective. This strategy can be particularly useful with clients who present in a highly oppositional manner and who seem to reject every idea or suggestion.

Client: But I can't quit using. I mean, all of my friends use!
Counselor: And it may very well be that when we're through, you'll decide that it's worth it to keep on drinking as you have been. It may be too difficult to make a change. That will be up to you.
Client: Okay.
Now you try!

Break into pairs and come up with a:

Simple Reflection
Amplified Reflection
Double Sided Reflection
Shifting Focus
Rolling with Resistance


"I don't have time for this, I don't want to be here. The only reason I showed up was so that you can tell CYS that I was here"

What can be a potential danger of sympathy?
Full transcript