Rolling with Resistance : Using a Motivational Interviewing Approach Presented by Danette Heckathorn, M.S., L.P.C.
Motivational Interviewing • A Humanistic approach to counseling developed by Miller and Rollnick (1991, 2002). • Motivational interviewing (MI) is not a theory. It is a tool to be used in conjunction with other theories.
Agenda • Motivation • What this training will do for you • Stages of Change Model • Major goals of motivational interviewing • How to address negative behavior • Rolling with Resistance • Practice
Motivation • What motivates? • Is motivation enough?
What will this training do for you? • You will learn ways to use motivational interviewing as a tool to roll with client resistance. • This training will give you a taste of MI and introduce you to some resources, but it cannot substitute for a 4-Day comprehensive MI training.
Stages of Change (Prochaska et. al., 1994) • Precontemplation – either unaware of problems related to negative health behavior or lack the desire to change their negative behavior, and they do not report any intention to change their negative habit within the next 6 months.
Contemplation • Individuals recognize that some aspect of their negative behavior is a problem, and they plan to take action in the next 6 months. They are often seen as ambivalent because the perceived costs and benefits of the negative behavior are equivalent (Rollnick et. al., 1991).
Preparation • Commitment to change has been made and they plan to take action in the near future. Action • Begin to actively change behaviors and environmental conditions to overcome problem. Maintenance • Changes have become a regular part of the individual’s lifestyle.
Why Determine Stage of Change? • Identifying a clients stage of change will help you determine the best approach to take with them. • Change is the responsibility of the client but the caregiver is responsible for enhancing motivation to change.
Ways to Determine Their Stage of Change • I noticed (behavior) is this something that is creating a problem for you or something you would like to change? • People differ in how ready they are to change their (behavior) habits. What about you?
Precontemplative Client • “I don’t have any problems with (behavior)” • They may come across defensive • Reluctant • Resigned • Rationalizing • Rebellious • No intention to change
Comtemplative Client • “I have been thinking about changing (behavior)” • They have identified the behavior may be problematic • More troubled about the behavior • Ambivalent but may be weighing pros and cons • Decisional balance exercise useful
Preparation Stage and Client • “How can I change (behavior)?” • More committed • Ready to start • Sharing plans for change • Change becomes a priority
Action Stage and Client • “Here I go” • They decide on a change strategy and try it out • Actively modify behavior including thoughts, feelings, and the environment • Treatment and/or self-help • Persistence and completion or drop-out
Maintenance Stage and Client • “I think this will work and I am going to continue” • Trying to keep the ball rolling • Preventing relapse – learning new coping skills • Watching out for triggers • Acknowledging self for changes made and taking credit • Moving toward more balance
Practice Identifying Stage of Change • Quick Exercise • We will come back to the stages of change after discussing motivational interviewing
Motivational Interviewing • Defined as “...a client-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25) • Let’s break it down
Four Main Principles of MI • Express empathy • Develop discrepancy • Roll with resistance • Support self-efficacy
Strategies Used in MI • Eliciting Change Talk – motivational statements from the client • OARS Method • Open-Ended Questions • Affirming the client • Reflective listening • Summarizing
Change Talk • Client identifies that behavior might be problematic • Client expresses concern about a behavior • Client expresses a desire to change the behavior
Reflective Listening • What is it? • How do you do it? • Levels of reflective listening • Optimal reflective listening • Let’s Practice…
Affirming the Client • The idea here is to enhance self-efficacy • Self-efficacy is our belief in our own ability to achieve a goal or accomplish a task • Strengthen the relationship • Enhance self-esteem
Summarizing • A technique to be used throughout the meeting • Strategically repeat a client’s self-motivational statements • Include reluctance/resistance • Reflect optimism for change
Knowing When a Client is Ready to Change • What do you expect to hear when a client is ready to change? • What do you not expect to hear? • What will the client look like? • What other indications might the client make?
How to Elicit Change Talk • Open-ended questions (handout) • Ruler (handout) • Pros/Cons exercise • Looking forward • Looking back • Goals and values
Change Planning • What changes? • Why change? • Goals – SMART • Steps to take? • First steps – concrete • Help • I will know it is working if • Potential obstacles
Resistance to Change • 4 Categories • Arguing • Interrupting • Denying • Ignoring
NO NO’s for Dealing with Resistance • Arguing, disagreeing and challenging • Judging, criticizing, blaming • Warning of negative consequences • Seeking to persuade with logic • Analyzing • Confronting with authority • Sarcasm
How to Respond to Resistance • Simple reflection • Amplified reflection • Double-sided reflection • Agreement with a twist • Shifting focus • Reframing • Rolling with resistance
Simple Reflection • Stating what you here the client saying • It is sometimes helpful for the client just to hear their own words
Amplified Reflection Reflect with modification Client: I just don’t think that I have a problem with gambling. Caregiver: There is no cause for concern for you. Client: I don’t know how changing my eating habits could help me. Caregiver: You feel your eating habits are perfectly reasonable.
Double-Sided Reflections • Reflect back the statement but also use the other side of the client’s ambivalence • Client:I can’t quit eating sweets. I look forward to having a nice desert each day. • Caregiver:It sounds like you are going to miss eating deserts, but you also don’t want to take diabetic medication. What do you think would be the best way to resolve this situation?
Agreement with a Twist and Shifting Focus Add a slant or twist to the meaning when you reflect back to the client Defuse resistance by shifting focus Client: I can’t imagine quitting drinking. All of my friends drink! Caregiver: It’s hard to imagine giving up a lifestyle that you’re accustomed to. I’m wondering, what can you imagine? • Client: I can’t imagine quitting drinking. All of my friends drink! • Caregiver: It sounds like you’ll really miss the social interaction. And at the same time, it might provide an opportunity to expand your social network like you were wanting.
Reframing • Placing something in a more positive light – (what are the benefits?) • Client – It is really going to be hard for me to quit eating sweets. • Caregiver:While it will be hard to quit eating sweets, you are determined to do it because it will allow you to control your diabetes without taking medication.
Rolling with Resistance • This is where you just want to validate what the client is telling you by letting them know you have heard their problem and understand their ambivalence • It can be one of the most difficult techniques
MI – The BASICS • Don’t ignore the behavior – even if you simply say “Hey, (name) I noticed (behavior). • Try to determine where they are with regards to stage of change. • Let’s Practice…
Summary • The Basics of MI • Can be used to address any negative behavior