Furthering Your Motivational InterviewingSkills Presenter: Ann Fields, M.S.E., CADC III, CGAC II
“I HAVE ALWAYS KNOWN THAT AT LAST I WOULD TAKE THIS ROAD, BUT YESTERDAY I DID NOT KNOW IT WOULD BE TODAY” Narihira
THREE THINGS TO REMEMBER • AMBIVALENCE IS NORMAL • EFFECTING CHANGE IS A PROCESS • CLIENTS NEED TO COME UP WITH THEIR OWN ARGUMENTS FOR CHANGE
3 FACTORS THAT INFLUENCE MOTIVATION • WILLING • READY • ABLE
MI WITHIN THE STAGES OF CHANGE Precontemplation RELAPSE CONTEMPLATION “LAPSE” MAINTENANCE PREPARATION ACTION Provider’s Role: To engage clients by utilizing an empathic style of reflective listening and to assist them in exploring and resolving their ambivalence.
What does not motivate people? • Think of characteristics of your “Worst Teacher / Coach” • What were things he / she did that made you feel defensive, avoidant and resistant? Chart: Ineffective Motivators
What does motivate people? • What were the characteristics of your “Most Favorite Teacher / Coach”? • Why was this person an influence on you? Chart: Effective Motivators.
MILLER’SRESEARCH A PROVIDER CAN SIGNIFICANTLY INFLUENCE CLIENT MOTIVATION MOTIVATION IS NOT SEEN AS A CLIENT TRAIT, BUT THE INTERPERSONAL PROCESS BETWEEN CLIENT AND PROVIDER HOW A PROVIDER THINKS ABOUT MOTIVATION AND CHANGE GREATLY INFLUENCES WHAT A PROVIDER DOES
What is Motivational Interviewing? …a collaborative, person-centered form of guidance to elicit motivation for change” Miller & Rollnick 2008
SPIRIT OF MI • EMPATHIC • COLLABORATIVE • RESPECTS ONES AUTONOMY, CHOICE AND DECISION MAKING • EVOCATIVE • DIRECTIONAL
Early Counseling Traps “I’m the expert here.” “Hey! You’re not listening!”
Traps To Avoid • Question-Answer Trap • Confrontation-Denial Trap • Labeling Trap • Premature Focus • Blaming Trap • Expert Trap
Beware Of The Righting Reflex Our desire to keep people from going down the wrong path, and to set things aright Born of concern and caring There’s a problem? Let’s fix it! Fails to consider ambivalence in change process May engender resistance
MILLER’S BROAD PRINCIPLES Express empathy Develop discrepancy Roll with resistance (Avoid argumentation) Support self-efficacy
CONFRONTATION IS THE GOAL, NOT THE STRATEGY Assist clients in exploring their own arguments for change Clients come face to face with a difficult reality in a way that will change them
Getting Moving On OARS OPEN QUESTIONS Affirm Reflect Summarize
Open-ended QuestionsQuestions that cannot be answered “yes/no”, but which encourage clients to express their thoughts, feelings, or concerns
Change to Open-Ended Questions • Do you feel you have a problem with alcohol? 2. Is it important to you to complete supervision successfully? • Anything else? Handout – c / o questions
Yes / No Role Play • (1) Speaker: “One thing I like about myself is…” • (2) Listeners: Tag team “By that do you mean…” • Speaker: Only respond by saying: “Yes or No” *Everyone takes a turn.
Getting Moving On OARS Open Questions AFFIRM Reflect Summarize
AffirmationExpression of appreciation for client’s efforts or participation.
Affirmations Include… Commenting positively on an attribute • You’re a strong person, a real survivor. A statement of appreciation • I appreciate your openness and honesty today. Catch the person doing something right • Thanks for coming in today! An expression of hope, caring, or support • I hope this weekend goes well for you! A statement to support self-efficacy • I noticed you showed up on time – How did you manage that?
Practicing Affirmations Write down 4 affirmations for the following statement: “I'm sick of this, everything just keeps getting messed up. I do good for a week and then the other kids start getting on my nerves, talking about my family. I go to that program, I'm learning stuff. I think it's helping and then the same day I get into a huge fight and end up in lockdown. Staff doesn't like me, I can't do anything right. They're always on my case. I don't know what you all want from me. I'm just trying to get by in here. It's not as easy as you make it sound.” Handout
Getting Moving On OARS Open Questions Affirm REFLECT Summarize
Reflective ListeningAccurate understanding of client’s experience, communicated in a warm, non-judgmental manner.
Simple Reflections Repeat- These reflections add nothing at all to what the client has said, but simply repeat or restate it using some or all of the same words. Rephrase- These reflections stay close to what the client has said, slightly rephrase it, usually by substituting a synonym. It is the same thing said by the client, but in a slightly different way.
Complex Reflections Paraphrase- These reflections change, or add to what the client has said in a significant way to infer the client’s meaning. Reflect Emotion- Regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimensions through feeling statements. Reflect Double – Sided Ambivalence – Sustain Talk & Change Talk – “good things and not so good things” about keeping the status quo.
Levels of Reflections C. Even though nothing has happened I’ve been feeling more depressed lately. I wish it would go away. Repeat:You’ve been more depressed lately. Rephrase:So your sadness is getting worse and you don’t know why. Emotion:You’re worried that nothing is going to change. Paraphrase:You would like to understand why your mood changes like that. Double-Sided:So on the one hand you’ve been living with depression and on the other hand you’re tired of it and wondering what to do.
Increase Quality of Reflections BY: • Making sure inflection is a statement • Strip statement down • Clear and Concise • Use reflections to continue the paragraph
Reflective Listening Exercises “I don’t know why this is such a big deal for everyone else. All my friends drink like I do.” “Everyone should just relax. I’m doing the best I can with trying to find a job.” “I know I’m suppose to take my meds but you don’t know my friends. It’s basically impossible to take them when we hang out.”
Reflective Listening Exercises “I am feeling very trapped and hopeless about my situation. No one seems to want to help me.” “People are always making me do things I don’t want to do. Even my wife keeps nagging me about taking those pills.”
Reflection Role Play • (1) Speaker: “One thing about myself I’d like to change…” • (2) Listeners: Use reflections only; no questions. Make sure inflection is a statement and not a question. * Speaker stays in role and talks. ______________________________ Video : Miller – Simple / Complex Reflections
Getting Moving On OARS Open Questions Affirm Reflect SUMMARIZE
SummarizingBringing together of several of the client’s previously expressed thoughts, feelings, or concerns, often including the clinician’s understanding of how these fit together.
Summaries can: • Collectmaterial already offered • Link something just said with something discussed earlier • Transition:Draw together what has happened and transition to a new task
Practice Summaries Groups of 3 - 1 Speaker – 2 Listeners 1 Speaker talks about something that has bothered you.. 2 Listeners just listen(no comments or questions). At the end provide 2 Summaries: 1st Listener – Collect 2’nd Listener – Link or Transition Switch Roles
OARS TO…. AROSE • Affirmation • Reflective Listening • Open-ended Questions • Summarizing • Elicit Change Talk
Change talk v. Sustain talk • Sustain talk is client speech that favors the status quo • Change talk is client speech that favors movement in the direction of change
ElicitChange Talk Why Is Change Important? Problem Recognition Concerns Optimism Intentionto Change
Evocative Questions Open-ended questions related to behavior, that elicit change talk. “What do you want to do about this behavior?”“What makes you believe you can do this?”“Why would you want to make this change?” Handout
RecognizeChange Talk • Desire: I want to • Ability: I can • Reason: It’s important • Need: I should Drumming Exercise
RESPONDING To Change Talk EARS • Elaborating • Affirming • Reflecting • Summarizing *It’s important to recognize and respond to Change Talk using the above skills.
Being Strategic with MI Strategies Client:“I don’t know, I really don’t want to go to that drug treatment program. I know I can quit on my own.” Non-Strategic Reflection: You don’t want to participate in the drug treatment program. Strategic Reflection: It’s really important to you to address your drug use and you realize that quitting is a strategy that will work for you.
Using EARS R I’d like to have better control of my drinking. E I think I could quit. R If want to get along with my family, then I have to do something about my temper E I’ve got to do something about my anger. A I’m goingto start my cog program today E I am embarrassed about my lack of control. R If I want a good job, I have to get my GED. E I want to be a better dad to my son. R If I get a DUI, I will lose my license. E I finished my vocational program. R I’m not guilty, but I will go to the program. E I am under so much stress, all I do is yell at my family. Handout
Select something about yourself you want to change, you know you should change, but you haven’t yet changed….a health behavior or quality
Exercise: Eliciting Change Talk Groups of 3: 1 Speaker,1 Listener,1 Observer Eliciting need/desirechange talk • What might be some of the not-so-good things about your behavior? • How do you feel about your future if you continue to live the way you’re living now? • What kinds of things can you imagine happening in your life if you decide to make this change? Handout - (S-Talk about behavior L -EARS, O -Code Sheet Observer give Feedback / Debrief
Exercise: continue Switch Roles: Groups of 3: 1 Speaker,1 Listener,1 Observer Eliciting abilitychange talk • What gives you the courage to go after what you want? • What do you already do well that will help you make this happen? • What kinds of things are you really good at? Handout - (S-Talk about behavior L -EARS, O -Code Sheet Observer give Feedback / Debrief
Exercise: continue Switch Roles: Groups of 3: 1 Speaker,1 Listener,1 Observer Eliciting reasonchange talk • If you were to change your behavior, what would be your reasons? • What would be the good things about changing your behavior? • If you were able to change your behavior, what would the payoffs be for you? Handout - (S-Talk about behavior L -EARS, O -Code Sheet Observer give Feedback / Debrief