MOTIVATIONAL INTERVIEWING The Art of Possibility in Conversation: Motivational Conversations 101 Presented by Dee-Dee Stout, MA, CADC-II; Member of MINT; Advisor/Trainer, ICCE for Lake County Health Services Lakeport, CA July 2010
Favorite Teacher/Positively Influential Person Teacher, clergy, parent, anyone!
PLEASE, DO NOT REPRODUCE THIS SLIDE Wednesday July 11, 2007 Please copy only in its entirety XML
Bill’s Illustration of Persuasion Or What’s NOT MI
Persuasion(remember: this is NOT MI) • Explain why your client should make this change • Give at least 3 specific benefits to them of making this change • Tell them how to change • Emphasize how important it is for them to change, and • Tell them to “Just Do It!” Please copy only in its entirety
Taste of MI: The Speaker • Topic: Something about yourself you.. • Want to change • Need to change • Should/ought to change • Have been thinking about changing… But you haven’t done yet (ambivalence!) Please copy only in its entirety
Taste of MI: The Listener, Part 1 • Listen intently with the goal of understanding your speaker’s circumstance & ambivalence • Give no advice • Ask these 4 open questions: • Why would you want to make this change now? • How might you go about it, to be successful? • What are your 3 best reasons to make this change? • On a scale of 1-10 (1 is low & 10 is high), how important is it to make this change? • How come you’re a ____ & not a 1? Please copy only in its entirety
Taste of MI: Listener, Part 2 • Give a short summary/reflection of the speaker’s motivations for change • Desire for change • Ability to change • Reasons for change • Need for change • Then ask: “So, what do you think you’ll do?” and just listen with interest Please copy only in its entirety
So, what did you think? Could you see MI helping you work smarter? Would you like to know more?
*8 Strategies to Learning MI (Miller & Moyers, 2007) • Spirit • OARS & client-centered skills • Recognizing & Reinforcing Change Talk • Eliciting & Strengthening Change Talk • Rolling with Resistance • Developing a Change Plan • Consolidating client Commitment • Switching btn MI & other counseling methods Please copy only in its entirety
My hope? Skills, Spirit, Strategies • Spirit • Change, Change Talk, & No Change Talk (resistance/defensiveness) • Skills & Strategies • OARS • Traps • Principles • Readiness • Directiveness: Complex Reflections! Please copy only in its entirety
So How Does MI Work? • MI activates a client’s own motivation for change & adherence to tx (we think!) • Clients exposed to MI v traditional tx are generally more likely to: • Enter tx & stay • Complete tx more • Participate in follow up appts • Decrease drug use Please copy only in its entirety
Excited?? Great! Me, too, so let’s back up a second & talk about change for a bit….
About Change… • Occurs naturally & is similar with or without treatment • Likelihood strongly influenced by interactions (“dancing”) • Very brief (5 mins or less) interventions can trigger change talk & other positive change effects! Please copy only in its entirety
And… • Within treatment, most behavior change occurs in the first few sessions • Resist the “urge to right”– the “Righting Reflex” can be deadly (Cocoon Story?) Please copy only in its entirety
The Heroic ClientScott D. Miller, PhD • “We should be humbled in the presence of our clients for they are the heroes of their lives.” www.talkingcure.com Please copy only in its entirety
“Do you think it’s easy to change? Alas, it is very hard to change and be different. It means passing through the waters of oblivion.” DH Lawrence, “Change” (1971)
How we talk to folks can actually…. increase or decrease motivation & resistance!
Defense Mechanisms (Bill Miller, 2009) • The idea of "defense mechanisms" takes behavior & turns it into a trait. There is no evidence that people w/addictions truly have different (e.g., more immature) defense mechanisms than other people do, when these are directly evaluated via personality assessment. [And] with [defense mechanisms], you can double them or halve them [simply] by changing counselor style. A fourfold shift in "denial" within a matter of minutes doesn't exactly suggest a stable trait. Please copy only in its entirety
Walk-Away Skill #1:Ask, Tell, Ask • Ask what the client knows about the topic • Tell theclient the information (chunklets please) • Ask what their response is to this information Please copy only in its entirety
Faith & Spirit RULE • Resist the Righting Reflex • Righting for others leads to dependency • Understand your client's motivations • If time is short, try simply asking why your client wants to make a change & how they might go about it (instead of that they should) Please copy only in its entirety
Faith & Spirit RULE • Listen, listen, listen to clients • Hard to do well; definitely improves w/practice • Empower Them! • Those who talk about change – the how & why of change – are more likely to do it • Can’t give empowerment; can only get for oneself Please copy only in its entirety
Summary: “Three things in human life are important: The first is to be kind. The second is to be kind. And the third is to be kind.” Henry James in Leon Edel’s Henry James: A Life
The Spirit of MI • Collaboration • Evocation • Autonomy • Perception • Curiosity • Ethics MI treats resistance asthinking NOT as pathology Please copy only in its entirety
Graphic Please copy only in its entirety
Motivational Interviewing is… “Love with a Goal” Simple but not easy!
Motivational Interviewing IS NOT… • A technique but rather a collection of skills & strategies • Learned in a 1 or 2- day workshop (but that’s a good start!) • Practice makes better; coaching improves • Something you use all the time • Use w/ambivalence & target behavior only Please copy only in its entirety
QUOTE • “Treat people as if they are who they can be and you help them to become who they’re capable of being.” -----Johann Wolfgang von GOETHE Please copy only in its entirety
Moving from Spirit to Strategy MI: The Basics
Summary: Our ‘real’ job = • Listen, listen, listen • Enter the client/client’s world • Accept. Believe. Let Go! No ‘plumbing’ practiced here! Please copy only in its entirety
4 Basic Principles of MI • Express Empathy –“Fence-sitting is normal!” • Develop Discrepancy* –“Who do you want to be & what’s getting in your way?” • Avoid Argumentation/Roll with Resistance –“Turn into the Skid” • Support Self-Efficacy -“The Tinkerbelle Effect” • Ethics – Ask permission! Please copy only in its entirety
6 Traps to Avoid • Asking Questions • Being the Expert • Taking Sides/Arguing for Change • Labeling People • Focusing Too Soon • Getting Caught up in Blame/Responsibility • Being Attached to Specific Outcomes (other than the client's!) Please copy only in its entirety
Summary of Key Concepts • Ambivalence = “Fence-sitting” • Getting REAL • Respect • Empathy • Affirm and • Listen! • Develop Discrepancy = Behaviors v Values • Rolling with Resistance = Dancing or Wrestling? • Supporting Self-Efficacy = Whose recovery is this anyway? • Goals of Change = The client’s or mine/agency? Please copy only in its entirety
Lunch! 30 or 60?
Skills! Reflections are the key…and Teflon!
“You mean that…” Thinking in Reflections Dyads/triads
“One thing I like about myself is…” • Speaker: Discuss some quality you like about yourself or that is positive or quirky • Listener: Make your best guess re: what quality the speaker is describing to you by saying “You mean that …” • Speaker: Answer with “Yes” or “No” • Continue until you get a solid “Yes!” Please copy only in its entirety
Video Everybody Loves Raymond (15)
Walk-Away Skill #2: OARS • Open-Ended Questions • Affirmations • Reflections • Summaries Please copy only in its entirety
Getting Directional: 8 Ways to Show We’re Listening/ Options for Responding to No Change (Sustain)Talk • Simple reflection (parroting) • Amplified reflection (take it up a notch) • Double-sided reflection (on the one hand…) • Reframe (get a new pair of glasses) • Emphasize individual choice(who’s recovery is this anyway?) • Change Focus (hit a wall, turn left) • Agreement with a twist (reframe & reflect) • Come alongside (paradox) Please copy only in its entirety
Reflections: Examples • Simple Reflection: lets the client know that you understand what they said • Complex Reflection: adds more substantial meaning - oomph; reflect the emotion & the content of what the client has been describing. Please copy only in its entirety
Simple & Complex: • Them: I’m not the one with the problem. If I don’t take my meds, it’s just because my kids need the money for food. • You: The real reason you don’t take your meds all the time has to do with problems getting your food stamps. (Simple) • You: You’re worried that this treatment isn’t really helping after all this effort. (Complex) Please copy only in its entirety
Resistance is a key to successful treatment if you can recognize it for what it is: An opportunity!
Walk Away Skill #3: RWR Rolling with Resistance: Instead of taking the bait, simply “roll” the conversation back to the client (Teflon) Client: “So, what am I supposed to do now anyway?” You: “This feels so hopeless, it’s really frightening.”
Teflon Demonstration: Dodge Ball!
Practicing OARS Round Robin
So what do we listen for? How do we MI-converse?
Timing: OK, so I’m Ready…Recognizing Readiness to Change • Acceptance • Feels finished • Resolve • Questions about change • Envisioning • Experimenting • Change Talk! Please copy only in its entirety
DARN-CAT: The New Language • Desire (I want to change) • Ability (I can change) • Reasons (It’s important to change) • Need (I should change)=» • Commitment (intention, decision, readiness) • Activate (ready, prepared, willing) • Taking Steps Please copy only in its entirety
More No Change (Sustain) Talk & Resistance strategies • Summarize what the client has said and even how you think he might be feeling • Give him some freedom to decide what to talk about or where to go next in the conversation • Check with her to see if you’ve offended her; remind her you’re not going to push her to make changes she doesn’t want to make • Apologize. A simple, non-dramatic apology can really be helpful Please copy only in its entirety