Presentation on theme: "Motivational Interviewing Preparing People for Change"— Presentation transcript:
1 Motivational Interviewing Preparing People for Change Opening - centering silence – MertonPipe cleaners -Handouts – see outline – this is roadmap for the day – will refer to handouts occasionally, but primarily supplementalWhat works (homeless service providers)Seek interactive environment – comments, questions welcomed throughoutStrive to accommodate various learning styles – presentation of material, demonstration, modeling, practice/doingClenched fist exerciseMy interest and involvement with MIScale of 1-10 knowledge of MI; practice consciouslyNote concept of “preparing people for change” vs. changing people/getting people to change/convincing people to changeKen KraybillCenter for Social Innovation
2 Sound familiar? I give people my BEST ADVICE, but they won’t listen. I EDUCATE and GIVE OPTIONS; what else can I do?She RESISTS everything I suggest.Some folks just DON’T WANT TO BE HELPED.He’s in TOTAL DENIAL about his problems.Some people just need A GOOD TALKING TO!I give, educate, suggest, help, talk to …
3 Changing the conversation How to make it a transformative conversation?
4 Dedicated to all who are weary… of trying to educate, advise, entice, convince, coax, cajole, persuade, sweet-talk, smooth-talk, guilt-trip, bribe, manipulate … or otherwise get people to changeEducate – from Latin “educare” – to draw out – draw out self-knowledge, true self – “help you discover yourself.” To educate, therefore, is to draw out something that fundamentally is already there. In the process of education, you actually become aware of yourself. You grow, you transform and become the real you. Rather than simply memorizing a bunch of information, you absorb ideas that draw out the inner you and bring you into the world of relationships.Indoctrination is the complete opposite. Indoctrination seeks to put something into you, while education tries to bring something out of you. While an educator is like a gardener, an indoctrinator is like a carpenter. A carpenter imposes one’s own vision on a raw material, while a gardener sets a vision according to the seed; whatever you are, the gardener wants you to become.To indoctrinate is to coerce. It involves imposing the teacher's values-aspirations, identity and character-on the student, so that the student will become like the teacher and reflect the teacher. In the process of indoctrination, a conflict is liable to arise between the teacher and the student because the teacher has a message he wants the student to accept, even at the expense of the student's unique identity and individuality.Rabbi David Aaron
5 Evoking from people what they already have hurtshopesnightmaresdreamsaddictionsdesiresdelusionswisdom,impairmentsstrengthsneedsresourcesWhat do you see? Which glass best represents our clients/patients?What is in our clients’ glasses?Discuss MI consistent “helping” as drawing from vs. pouring in.Giving people what they lackEvoking from people what they already have
6 “People possess substantial personal expertise and wisdom regarding themselves – and tend to develop in a positive direction, given the proper conditions and support.” Miller & Moyers, 2006
7 Motivational Interviewing What is it?Why it matters?What’s it made of?How do you do it?1. What is it? – definitions, hx of MI, tranformative conversation, a way of being, etc2. Why it matters? – we hope people will change, effective approach to foster motivation to change3. What’s it made of (ingredients)? – centered helper, spirit with compassion, OARS, using OARS to explore ambivalence and elicit change talk to guide towards change4. How you do it? - PRACTICE
8 Eight Stages of Learning MI Overall spiritPerson-centered interviewing skills (OARS)Recognizing change talkEliciting change talkRolling with resistanceConsolidating commitmentDeveloping a change planTransition and blending with other methodsWe will address all 8 stages this week. In a 2.5 day workshop, there is usually not sufficient time to develop even threshold proficiency in the last 4 stages. Learning the first 4 stages is enough to begin allowing ones clients to train you. Then, most people need more training to gain real proficiency in all of the 8 steps.
9 Objectives Examine what motivates people to change Learn about the spirit, principles, and core methods of motivational interviewingPractice incorporating MI skills into your workMI: 1) What is it? Why it matters? What’s it made of? How do you do it?
10 Spirit of Motivational Interviewing COMPASSIONATE - come along side, be with, grieve/suffer withCOLLABORATIVE – form a partnership, both parties have expertiseEVOCATIVE – client’s own knowledge, wisdom, strengths, motivation called forthEMPOWERING - person’s right and capacity for self-direction affirmed(p.35)MI is as much a “way of being with people”as it is a series of techniques. One can mimic the techniques of MI but miss the spirit of it.Note contrast in the two approaches in slide.Collaboration - “co-laborers” - provider avoids authoritarian, one-up stance, instead communicating a partner-like relationship.Thus, a focus on exploration vs. exhortation, support vs. persuasion/argument.Provider seeks to create a positive interpersonal atmosphere that’s conducive to change, not coercive. The interpersonal process is a meeting of two people’s beliefs/wishes, which may differ. Provider must be attuned to own beliefs/aspirations.Evocation - provider’s tone not one of imparting wisdom/insight/reality but of eliciting/drawing out these things from the client. Requires a certain humility on part of provider.Latin docere (root of doctor, doctrine, indoctrinate) - implies an expert, imparting roleLatin ducere (root of educare - education) means “to draw out”Autonomy - in MI, responsibility for change is left with the client (where it must lie, despite belief people can be “made”, “permitted” to do and choose. Overall goal is to build intrinsic motivation, so that change arises from within rather than being imposed from without.
11 Motivational Interviewing “A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”An evolving definition. Adapted from Miller & Rollnick’s Motivational Interviewing: Preparing People for Change, Original: “A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”Point out and describe the key components of the definition:Person-centered (vs. program centered or provider centered) – “meeting person where they’re at vs. where you think they should be” – focus on person’s present interests, concerns, perspectives, wishes, values – “hearing person’s story” - Person-centered doesn’t mean passive, but active in guiding vs. directing.Guiding method – MI consciously and carefully guides the client towards exploring and resolving ambivalence, eliciting and reinforcing change statement, etc. MI is a method of communication rather than a set of techniques – not a “bag of tricks” – not something you do to people, but is fundamentally a way of being with and for people – a facilitative approach to communication that evokes natural change.Motivation – MI focuses on enhancing the person’s internal motivation. This is based on the belief that unless a person has an inherent interest in change, it probably won’t happen, or if it does, is less likely to be maintained.Change – Seen as step by step movement towards healthier/less risky behaviors. Very compatible with risk/harm reduction.Exploring and resolving ambivalence – MI views ambivalence as a normal part of the change process. Becomes a problem if one gets stuck there. Resolving ambivalence is a key factor in enhancing motivation to change.
12 Motivational Interviewing A collaborative, person-centered form of guiding to elicit and strengthen motivation for change.Miller & Rollnick, 2/09Person-centered AND counselor-led (strategic direction) = reflective listening is a way to reconcile person-centeredness and guiding style (reflect as a mirror; reflect as mind to go deeper in conversation) – a way of acceptance AND strategic direction
13 Helping people talk themselves into changing Or…Helping people talk themselves into changing"I learn what I believe as I hear myself speak.“ D. Bem Vs. “talking people into changing” – What’s going on when we try to talk people into changing? How well does it work?Whose needs are we trying to meet – our own, theirs, both? What is the message we are sending to the person?Bem, D. J., Self Perception Theory. In L. Berkowitz (ed). Advances in Experimental Social Psychology, Vol 6, "Individuals come to know their own attitudes, emotions and internal states by inferring them from observations of their own behavior and circumstances in which they occur. When internal cues are weak, ambiguous, or not interpretable, the individual is in the same position as the outside observer”. Applies to “internal talk” as well (self-talk)“The more a person argues on behalf of a position, the more he or she is committed to it.”We believe what we hear ourselves say.When a person publicly takes a position, his/her commitment to that position increases.
14 Henri Nouwen – Reaching Out "We cannot change the world by a new plan, project, or idea. We cannot even change other people by our convictions, stories, advice and proposals, but we can OFFER A SPACE where people are encouraged to disarm themselves, lay aside their occupations and preoccupations and listen with attention and care to the voices speaking in their own center.” Henri Nouwen – Reaching OutHospitality – “create a free and friendly space for the stranger” (Nouwen)
15 "People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others.“ Blaise Pascal - French mathematician and philosopher (1623 –1662)
16 “Talking oneself into changing” MI conversationPreparatory change talkCommitment talkTaking stepsMI conversation = spirit + OARS + particular focus + explore ambivalence + elicit and reinforce change talk + change plan
17 Why MI? Evidence-based practice Kindness with skill Effective across populations and culturesApplicable to range of professional disciplinesEffective in briefer encountersActively involves people in own careImproves adherence and retention in carePromotes healthy “helping” role for providersInstills hope and fosters lasting change
18 Five things MI is not William R. Miller A way of tricking people into doing what you want them to doA techniqueEasy to learnPractice as usualA panaceaBill Miller: 10 things that MI is not: (1) the transtheoretical model of change; (2) a way of tricking people into doing what you want them to do; (3) a technique; (4) decisional balance; (5) assessment feedback; (6) cognitive-behavior therapy; (7) client-centered therapy; (8) easy to learn; (9) practice as usual; and (10) a panacea.
19 Why do people change?Because they want to…client motivation is key to changeANDclient motivation is greatly influenced by the providerAlso:Change-talk effectsAutonomy, choice
20 The righting reflex … AKA “helping” “The world is out of jointOh cursed spite that everI was born to set it right.”William Shakespeare (Hamlet)“Those who want to help in the worst way, usually do.” - Unknown authorBut… here’s what typically happens. Humans have built-in desire to set things right – to fix things.Especially people in helping professions – “helping gene”
21 When the righting reflex meets ambivalence… There’s trouble.You get resistance!Consider what happens when person with righting reflex (R) meets ambivalent person (A) -As A talks to R about dilemma of ambivalence, R forms opinion of what course of action A should take. R then proceeds to counsel, advise, persuade to take a particular action.Person A predictably argues the opposite or suggests shortcomings of proposed solution – this is natural because the person is ambivalentWhat happens next? R may up the ante and make the case more strongly for change (sees A as being resistant); A may intensify reaction or withdrawOr R may suggest alternative solutions; A likely will respond with “yes, but…”This interchange is playing out both sides of the ambivalence. Unfortunately, an important principle of social psychology (self-perception theory) – as a person argues on behalf of one position, becomes more committed to it (“As I hear myself talk, I learn what I believe.”In effect, A is inadvertently talked out of making the change needed.What are some common human reactions to the righting complex (the Answer Man/Woman)?Angry, agitated; Oppositional; Discounting; Defensive; Justifying; Not understood; Not heard; Procrastinate; Afraid; Helpless, overwhelmed; Ashamed; Trapped; Disengaged; Don’t come back – avoid; Uncomfortable; ResistantEXAMPLE ROLE PLAY – e.g. smoking, exercise
22 Common human reactions to the righting reflex Angry, agitatedOppositionalDiscountingDefensiveJustifyingNot understoodNot heardProcrastinateAfraidHelpless, overwhelmedAshamedTrappedDisengagedDon’t come back – avoidUncomfortableResistantEssentially, person feels invalidated, actively resists, or withdraws (or some combination). Is this the person/client you want to be talking to?
23 A thought…"People are not resistant to change; they resist being changed." Kevin Eikenberry
24 Activity #2Your counselee is ambivalent about smoking. Simply seek to understand the ambivalence. AVOID any temptation to give “helpful” information or advice!Initially, ASK “Would it be all right if we talk together about your smoking?”Assuming yes, ASK “Tell me about your relationship with smoking. (What are the good things? What are the not so good things?)” (Respond with reflective statements.)i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)
25 Activity #2 (continued) “If you were to cut down or stop smoking, why would you want to make that change?” (reflect)“What would be your best reason(s) to do so?” (reflect)“How might you go about it in order to succeed?” (reflect)i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)
26 Activity #2 (continued) On a scale from 0 to 10, how important would you say it is for you to make this change? What makes you say ___ and not zero?What would it take to move from ___ to (next highest number)?How might I help you with that?” (reflect)i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)
27 Activity #2 (continued) Now, provide a brief summary of both sides of the client’s ambivalence, without taking sides, but with emphasis on the patient’s statements indicating a DESIRE, NEED and IMPORTANCE to change.Then, ask if you missed anything.i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)
28 Common human reactions to being listened to UnderstoodWant to talk moreLiking the counselorOpenAcceptedRespectedEngagedAble to changeSafeEmpoweredHopefulComfortableInterestedWant to come backCooperativeEssentially, person feels affirmed, is open/accepting, and engaged.
29 4 processes of MI planning evoking focusing engaging Engaging, Focusing, Evoking, Planning(ROEM – Approach: making a connection; Companionship: building the relationship; Partnership: enhancing motivation and linking; Mutuality: supporting wellness and stability)engaging
30 4 processes of MI planning evoking focusing engaging Engaging, Focusing, Evoking, Planning(ROEM – Approach: making a connection; Companionship: building the relationship; Partnership: enhancing motivation and linking; Mutuality: supporting wellness and stability)engaging
32 Stages of change Prochaska & DiClemente TerminationMaintenanceActionPreparationContemplationGo through each stage and relapse. E.g. brushing teeth, doing laundry, deciding on what movie to see, what college to go to, exercise, diet, etc. Stages of change are like developmental stages – can’t skip a stage.Precontemplation No intention to change behavior in foreseeable future (next 6 months). Many unaware or barely aware of their problems. Others might wish to change, but not serious considering it in near future.Contemplation Aware problem exists - seriously thinking about addressing it, but not yet committed to preparing for and taking action. Experiencing ambivalence, weighing pros and cons. Can remain stuck here.Preparation Person committed to taking action soon - making concrete steps. Individuals in this stage often report small behavioral changes in positive direction. Ambivalence may still be present but diminishing.Action Individual actively modifies his or her behavior, experiences, or environment to overcome the problem. Person’s commitment is clear. Considerable commitment of time and energy required in this stage. Action is critical part of changing, but not to be confused with change itself, which is a process encompassing all of the stages of change.Maintenance Person continues to work at stabilizing behavioral change and consolidating the gains made during the action phase. Effort is put forth to prevent relapse (can include medically assisted treatment eg. Naltrexone for ETOH;. Buprenorphine and Methadone (also Naltrexone) for opiate addiction and soon (hopefully) a new one for cocaine). This stage not static, but very active. Often requires great deal of hard work and perseverance. Also is a time to enjoy the rewards resulting from the change.(Relapse) Person reverts to the problem behavior. Might happen at any time during change process. The duration of relapse may be very brief or lengthy. Relapse not a stage of change per se, but is seen as a normal occurrence in the change process for many people. Viewed as a temporary loss of motivation and a learning opportunity. Can go back to any stage.Relapse = temporary loss of motivationPrecontemplation
33 Stages of Change: Counselor Tasks PRECONTEMPLATION: Raise doubt; increase person’s perceptions of risk of behavior, dissonance with valuesCONTEMPLATION: Explore ambivalence; evoke reasons for change, risks of not changingPREPARATION: Help individual determine best course of action; develop change plan
34 Stages of Change: Counselor Tasks ACTION: Help person implement plan, use skills, problem-solve; support self-efficacyMAINTENANCE: Help individual identify and use strategies to prevent relapseRELAPSE: Guide through stages of contemplation, preparation, and action without becoming stuck or demoralized due to relapse
35 OARS: Basic Skills of Motivational Interviewing Open QuestionsAffirmationsReflective ListeningSummariesOARS – are the basic interaction techniques/skills of MI – used “early and often” in MI“Way of being” – what does this mean? What are aspects of your “way of being” with clients/patients?degree of welcomingattitudedefensiveness levelposture/body languagefriendlinessopennessaccessibilityhow deal with pt. when symptomatic (using, psychotic, depressed, ambivalent, angry, etc.)empathy shownempowerment shownPay attention to the notes, but never forget that what really matters is the music.Motivational Interviewing is not a series of techniques for doing therapy but instead is a way of being with patients.William Miller, Ph.D.
36 Open Questions Backbone of MI info-gathering process Set tone for non-judgmental settingInvite story – what is important to personDemonstrate genuine interest and respectClarify, help go deeper, provoke thoughtAffirm autonomy, self-directionSome short-reply, info gathering, closed questions may be necessary. Can feel like interrogation. Open questions set non-judgmental tone.Also, help people listen to themselves talk!
37 Sound like… How are things going? What is most important to you right now?What are your concerns about taking these pills?What have you noticed about ____?Hmm… Interesting… Tell me more…How did you manage that in the past?When have you been most likely to share needles?How would you like things to be different?What will you lose/gain if you give up drinking?What do you want to do next?How can I help you with that?Open questions encourage people to talk about whatever is important to them. Help establish rapport, gather information, and increase understanding. Open questions are opposite of closed questions - elicit a limited response e.g. yes or no.Open questions invite others to “tell their story” in their own words without leading them in a specific direction. Closed questions are “leading questions.” Should be used often in conversation but not exclusively. Must be willing to listen to the person’s response.Note that questions are oriented towards the present (green), past (brown), or future (blue). We particularly want to encourage thinking that envisions a different future.To contrast open vs. closed questions, consider the following examples. Note how the topic is the same in both questions, but the likely responses will be very different.1. Did you have a good relationship with your parents?2. What can you tell me about your relationship with your parents?What are examples of open questions you use in you practice?Quiz “Open vs. Closed” – p. 67
38 Converting Closed Questions Are you having a good day?How long have you been homeless?Are you married?How many drinks do you have on a given day?Are the medications working well for you?Will you be able to make it to your appointment?
39 Forming Good Questions So, instead of yelling like I usually do, I went for a walk.I love my kids, but they drive me crazy.I’m really tired of all this crap. Something’s got to change.I don’t see why I have to take these medications.So, I drink a little. It’s no big deal.
40 Guidelines: Open Questions Seek to UNDERSTAND and GUIDE the conversationAsk MORE open questions than closed onesKeep questions CLEAR and BRIEFAVOID NEGATING open questions with closed ones – e.g. How is it going? Have you been taking your medications?
41 Activity: Open Questions Pair up. Decide who will speak and who will “ask and listen.”LISTENER – Ask partner to describe a deeply held value. When you hear signal, ask an open question to draw out more of person’s story. Ask only open questions.SPEAKER – Describe one of your deepest held values.If closed question comes out, convert it into open question. (speaker can help)
42 OARS: AffirmationsRecognize individual’s strengths, personal qualities, core valuesBuild confidence in ability to changeMust be congruent and genuineDifferent from praiseAffirmations are reflected in statements, gestures, and attitudes that recognize client strengths and acknowledge behaviors that lead in the direction of positive change, no matter how big or small. Working in a collaborative, empowering manner with clients in which they are valued for the expertise they bring is also an important part of an affirming relationship. Affirmations in all forms build confidence in one’s ability to change. To be effective, affirmations must be genuine and congruent. Examples of affirming responses:I appreciate that you are willing to meet with me today.You are clearly a very resourceful person.You handled yourself really well in that situation.That’s a good suggestion.If I were in your shoes, I don’t know I could have managed nearly so well.I’ve enjoyed talking with you today.I look forward to seeing you next week.Can also be in form of seeking input/information – a question can be an affirmationWhat’s your opinion about that? How do you see it?Can you tell me about the services they offer at that shelter?What advice would you give me when I refer the next person there?How respected did you feel when you went there?Do you have any thoughts how I might improve the way I work with you?
43 Sound like… You were very kind towards… I noticed that you… You showed a lot of patience…You are a courageous person to…You really value being…I wonder how you found the strength to…That took a lot of persistence to…Thank you for…
44 OARS: Reflective Listening Reflective listening is the KEY to this work…LISTEN CAREFULLY to your clients. They will tell you what has worked and what hasn't. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen.Miller & Rollnick, 2002The first duty of love is to listen. – Paul TillichReflective listening is primary skill - pathway for engaging others in relationship, building trust, and fostering motivation to change. Reflective listening appears deceptively easy, but takes hard work and skill to do well. Sometimes the “skills” we use in working with clients do not exemplify reflective listening but instead serve as roadblocks to effective communication. Examples include misinterpreting what is said or assuming what a person needs.It is vital to learn to think reflectively. This is a way of thinking that accompanies good reflective listening that includes interest in what the person has to say and respect for the person's inner wisdom. Its key element is a hypothesis testing approach to listening. What you think the person means may not be what they really mean. Listening breakdowns occur in any of three places:Speaker does not say what is meantListener does not hear correctlyListener gives a different interpretation to what the words meane.g. What do you know about a person who “eats(,) shoots and leaves”Reflective listening is meant to close the loop in communication to ensure breakdowns don’t occur. The listener’s voice turns down at the end of a reflective listening statement. This may feel presumptuous, yet it leads to clarification and greater exploration, whereas questions tend to interrupt the client's flow. Some people find it helpful to use some standard phrases:“So you feel...”“It sounds like you...”“You're wondering if...”
45 “What people really need is a good listening to.” vs. “what people really need is a good talking to”The first duty of love is to listen. – Paul Tillich“What people really need is a good listening to.”Mary Lou Casey
46 Activity: Nonverbal Listening Pair up. Decide who will speak and who will listen.SPEAKER - Talk for 3 minutes – something you are passionate about.LISTENER – Give partner “a good listening to.” No words, not even “mm hmm.” Do use your best NON-VERBAL listening skills.SPEAKER – Affirm strengths and provide constructive feedback.
47 Reflective Listening A way of… showing acceptance, understanding checking, rather than assuming, what someone meansguiding, deepening the conversationRef lective listening is more than just keeping quiet while the other person talks. Crucial element is how the counselor respondsToo often we put up roadblocks – p. 68 (Thomas Gordon’s 12 Roadblocks) – Read sample interchange p of well-intentioned but unhelpful counselor.Essence of reflective listening to make a reasonable guess what is meant.A statement? Why not a question? A well-formed reflective statement less likely to evoke resistance. A question requires a response. The difference is subtle. It’s in the inflection. Voice tone goes up with a question, gently down at end of a statement.E.g. You’re feeling uncomfortable?You’re feeling uncomfortable.They are statements of understanding.Note importance of “thinking reflectively” – includes continual awareness that what you believe or assume people mean is not necessarily what they really mean. Most statements can have multiple meanings.E.g. I wish I were more sociable. Possible meanings:I feel lonely, I get nervous, I’d like to be popular, I can’t think of anything to say, people don’t invite me to their partiesReflective listening is way of checking rather than assuming you know what someone means.READ interview p good example. Then go back and have participants try their hand at giving a reflective response. OR Show Rounder tape.
48 Thinking reflectively The TROUBLE with wordsListener does not hear the words correctlySpeaker does not say what is meantListener gives a different interpretation to what the speaker meansRequires REFLECTIVE THINKINGInterest in what person has to say and respect for their inner wisdomA hypothesis-testing approach to listeningEssentially asks: “Is this what you mean?”
49 Levels of Reflection SIMPLE Repeating or rephrasing – listener repeats or substitutes words or phrases; stays close to what speaker saidCOMPLEXParaphrasing – listener makes a major restatement that infers or guesses the speaker’s meaningReflection of feeling – emphasizes the emotional aspects of communication; deepest form of listeningThere are three basic levels of reflective listening that may deepen or increase the intimacy and thereby change the affective tone of an interaction. In general, the depth should match the situation. Examples of the three levels include:Repeating or rephrasing – listener repeats or substitutes synonyms or phrases; stays close to what the speaker has saidParaphrasing – listener makes a major restatement in which the speaker’s meaning is inferredReflection of feeling – listener emphasizes emotional aspects of communication through feeling statements – deepest form of listeningVarying the levels of reflection is effective in listening. Also, at times there are benefits to over‑stating or under-stating a reflection. An overstatement (i.e. an amplified reflection) may cause a person to back away from a position while an understatement may lead to the feeling intensity continuing and deepening.Practice making reflective statements:“I had a terrible time at that shelter last night.”“I’ve got to do something about my drinking before it kills me.”“I don’t think there’s any hope for me.”“I’m going to die out here if I don’t get some help.”“Nobody cares about people like me.”“I haven’t had an HIV test in over a year.”
50 Forming Reflections Appears deceptively easy, but requires practice Statement, not a question, voice turns down at endCommon word is “you”You…So you…It sounds like you…You’re wondering…That would be… for you
51 OARS: Summarizing “Let me see if I understand thus far…” Special form of reflective listeningEnsures clear communicationUse at transitions in conversationBe conciseReflect ambivalenceAccentuate “change talk”Summaries are special applications of reflective listening. Can be used throughout conversation but particularly helpful at transition points, e.g., after person has spoken about particular topic, has recounted a personal experience, or when encounter is nearing an end.Summarizing helps to ensure that there is clear communication between the speaker and listener. Also, it can provide a stepping stone towards change.Structure of SummariesBegin with a statement indicating you are making a summary. E.g. “Let me see if I understand so far …Here is what I’ve heard. Tell me if I’ve missed anything.”2) Give special attention to Change Statements - statements made by client that point towards willingness to change. Four types of change statements, all of which overlap significantly:Problem recognition - “My use has gotten a little out of hand at times.”Concern - “If I don’t stop, something bad is going to happen.”Intent to change - “I’m going to do something, I’m just not sure what it is yet.”Optimism - “I know I can get a handle on this problem.”If the person expresses ambivalence, it is useful to include both sides in thesummary statement. For example: “On the one hand …, on the other hand …”It can be useful to include information in summary statements from othersources (e.g. your own clinical knowledge, research, courts, family).Be concise.6) End with an invitation. For example:Did I miss anything?If that’s accurate, what other points are there to consider?Anything you want to add or correct?7) Depending on the response of the client to your summary statement, it may lead naturally to planning for or taking concrete steps towards the change goal.
52 Activity: Summarizing Triads – counselor, client, observer/ coachCLIENT: Talk about something you want/need/should change but haven't changed yet – something you're ambivalent about. COUNSELOR: Facilitate a guided conversation with mix of OPEN QUESTIONS, AFFIRMATIONS and varying levels of REFLECTIONS.OBSERVER: Upon signal from instructor, provide a SUMMARY of client’s statements – especially those indicating the client’s readiness, willingness, or ability to change.
54 Ambivalence“People often get stuck, not because they fail to appreciate the down side of their situation, but because they feel at least two ways about it.”Miller & Rollnick, 2002Ambivalence closely related to concept of conflict which is central to many psychological theories. Conflict comes in several forms:Approach - approach – choosing between two similarly attractive options – the candy story problem – is the best kind of conflict (“Should I work on this HCH team or the other?”)Avoidance – avoidance – choosing between two (or more) evils, options with negative consequences – “caught between a rock and a hard place”. (“Should I work on this HCH team or the other!!”)Approach – avoidance – tend to keep people stuck – both attracted to repelled by the same object – “fatal attraction” – “I can’t live with you and I can’t live without you” (1930’s Fletcher Henderson tune – “My sweet tooth says I want to, but my wisdom tooth says no.”)Double approach – avoidance – torn between two alternatives (lovers, lifestyles) both of which you are drawn to and repelled by; grand champion of all conflicts
55 Ambivalence: The dilemma of change “My sweet tooth says yes, but my wisdom tooth says no”1930’s Fletcher Henderson tune“I’m so miserable without you, it’s almost like you’re here.”Unknown country & western song
56 Sounds like… I can’t figure out what to do about… Maybe… I think I should get tested, but…I can’t make up my mind whether to…On the one hand...on the other hand...It scares me to take all these medicines, but I suppose…I know I’d be better off if…If only it weren’t such a hassle to…No way! I will never, ever do that! Nope, not me!
57 Activity: Clarifying Ambivalence Sample Conversation – Simply seek to understand. Avoid any temptation to give “helpful” information or advice! Do guide the conversation to elicit change talk.“Tell me about _________. What are the good things… and not so good things about _____________?” (reflect)
58 Using Skills: Recognizing, Eliciting and Responding to Change Talk "People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others.“ Blaise Pascal - French mathematician and philosopher (1623 –1662)
59 Change talk = client speech that favors movement in the direction of change The body of research on MI indicates thatChange Talk predicts Commitment TalkCommitment Talk predicts actual behavior change!
60 Change Talk: DARN-CT Preparatory change talk DESIRE to change (want, like, wish)ABILITY to change (can, could)REASONS to change (if … then)NEED to change (need, have to, got to)Activating change talkCOMMITMENT language (intention, decision, readiness)TAKING stepsSo, we want to learn to recognize change talk when we hear it.Change Talk manifests itself in 4 different ways represented by the acronym D-A-R-N.You can distinguish the type of change talk by the verbs that are used as shown on the slide.Why might it be important to recognize change-talk?Hopefully, you will evoke at least the following:because it predicts commitment-talk,so we can reinforce it!
61 Examples of Change Talk D: I’d like to have better control of my drinkingA: I think I could quitR: If I want to get my kids back, then I have to quit drinkingN: I’ve got to do something about my drinkingC: I’m going to quitT: I’m going to call tomorrow to make an appointment
62 Responding to Change Talk: O-A-R-S Open/elaborative questions (e.g., what else; tell me more)AffirmationsReflective statementsSummariesSo, when we hear change talk, how do we reinforce it? By doing what we have been doing: reflecting, elaborating, summarizing and affirming.
63 Eliciting Change TalkChange talk often flows naturally by simply using OARSWhen it doesn’t occur naturally, we can elicit change talk using seven strategies
64 Strategies for Eliciting Change Talk IQ-LEDGEDecisional BalanceGoals & ValuesElaboration QuestionsImportance RulerQueryExtremesLooking Ahead/BackEvocative QuestionsThese are all more specific uses of Open-Ended Questions or Reflections--actually more examples of complex reflections. It is hard to make a clear distinction about where the “client-centered” emphasis ends and the “helper-directive” part begins, but this is a way to talk about this transition. But, it is directive in a different sense than we might usually think about that. It is helping direct the client toward a deep understanding of their ambivalence and helping them be open to the possibility of change. It is NOT telling what they need to do much less must do.
65 Decisional Balance Not Changing Changing Benefits of 1. 4. 2. 3. Costs ofCan use for lots of issues – e.g.Applying SSIGoing to medical clinic to check out persistent coughSee mh worker about depressionCutting back on smokingStaying at the shelter, instead of streetGetting picture IDGetting tested for HIVTelling friend re: your HIV statusGetting on methodoneGoing into inpatient txTaking your meds regularlyChanging dietExerciseEtc.
66 Decisional Balance Drinking Stopping drinking Benefits of 1. Helps me relax; enjoy drinking with friends; eases boredom4. Feel better physically; have more $; less conflict with family, work2. Hard on my health; spending too much $; might lose my job3. Would miss getting high; would change my friendships; have to find other ways to deal with stressCosts ofCan use for lots of issues – e.g.Applying SSIGoing to medical clinic to check out persistent coughSee mh worker about depressionCutting back on smokingStaying at the shelter, instead of streetGetting picture IDGetting tested for HIVTelling friend re: your HIV statusGetting on methodoneGoing into inpatient txTaking your meds regularlyChanging dietExerciseEtc.
67 Importance Ruler ASSESS EXPLORE “On a scale of 1-10, how important is it at this time for you to (change)?EXPLORE“What made you give it a __ and not (several numbers lower)?“What would take to raise that score from a __ to a __ (next highest number)?“How might I help you with that?”Or…"Oh, that's interesting. A 6 rather than a 4. Tell me more about that.“Or…"How convinced are you, on a scale of 1 to 10 that ________ is in your best interest? (“stronger statement” than importance)
68 Confidence Ruler ASSESS “On a scale of 1-10, how confident are you that you could make this change?EXPLORE“Why a __ and not (several numbers lower)?“What would take to raise that score from a __ to a __ (next highest number)?“How might I help you with that?”
69 Evocative QuestionsWhat do you think you will do? What changes, if any, are you thinking of making? What are your options? Of the things we have discussed, which ones concern you most? What happens next? Where do we go from here? How would you like things to turn out for you now, ideally? What could be some good things about making a change?
70 Looking Ahead“If you were to _______, why would you want to make this change?” (reflect)“What would be the best reasons to make this change?” (reflect)“How might you go about it in order to succeed?” (reflect)
71 Using Skills: Responding to Resistance "It's always easier to plow around the stump".
72 Resistance “Ambivalence under pressure” A signal of dissonance in the relationshipInfluenced by clinician responsesResistance vs. cooperation – dancing vs. wrestlingp.43 Consonance and dissonance – two poles on a continuum (“dancing” and “wrestling”)Read dialogue between probation officer and client – p. 44 (Handout)Resistance occurs only in the context of a relationship (in same way as cooperation happens in relational context - can’t say that one person is not cooperating!)What doe resistance look like? Takes 4 basic forms: 1. Arguing, 2. Interrupting, 3. Negating (unwilling to recognize problem, cooperate, accept responsibility), 4. IgnoringWhat causes dissonance in provider-client relationship that leads to resistance?1. Different goals; 2. Mismatch of provider strategy with client’s readiness; 3. If either brings anger, frustration into the room; 4. Not listening, assuming, interrupting; 5. Lack of agreement about roles in relationship (“I’m in charge here” up against “You can’t tell me what to do.”)Provider behaviors that tend to elicit or increase resistance:Arguing for change - tries to persuade client to changeAssuming the expert role - e.g. take on a lecturing roleCriticizing , shaming, blaming - trying to invoke change by instilling negative emotionsLabeling - “that’s because you’re an alcoholic/addict” - focus on what person “is” or “has”Being in a hurry - having little time leads to more forceful tactics (Monte Roberts - with horses - if you act like you only have a few minutes, it can take all day; if you act like you have all day, it may take only a few minutes.)Paternalism - “I know what’s best for you.”
73 Sounds like… You don’t really care about me. Who are you to tell me what to do.Have you ever smoked crack?This place sucks.Stop repeating everything I say.Yeah, whatever.
74 Looks like…Unengaged postureIgnoring, avoidingAngerDoes not return
75 Responding to Resistance Reflective responsesSimpleAmplifiedDouble-sidedOther responsesShifting focusReframingAgreeing with a twistEmphasizing personal choice and controlComing alongside
76 Activity: Responding to Resistance Form triads. Choose who will be 1) client, 2) counselor, and 3) observer.Client chooses an issue about which you are quite resistant to change.Counselor responds to resistance using both reflective responses and other responses. Observer provides counselor with suggestions as needed.
77 Using Skills: Strengthening Commitment Phase 1 of MI = Enhancing and importance and confidence; Phase 2 = Strengthening commitment to changeThere comes a time when person shows signs of readiness to commit to change – counselor needs to know how to identify and respond when the window is open – this requires a change in guiding strategies
78 Strengthening Commitment to Change AWARENESSRecognize signs of readinessBeware of hazardsACTIONRecap/summarizeAsk key questions (and reflect)Give information and adviceNegotiate a change plan
79 Signs of readiness Less resistance More openness Enough talking Sense of resolutionMore change talkQuestions about changeEnvisioning changeExperimenting
80 Recapping SUMMARY OF… Person’s own perceptions of problem Client’s ambivalenceRelevant objective evidenceStatements of desire or intent to changeYour own assessment of person’s situation, especially points of convergence with client’s concerns
82 General Practice Guidelines Talk less than your clientOffer 2 or 3 reflections for every question you askAsk twice as many open questions as closed questionsWhen listening empathically, more than half of your reflections should go beyond simple reflection
83 Traps to Avoid Question – Answer Taking Sides Expert Labeling Premature FocusBlamingp. 55…Question-Answer – read DIALOGUE p. 55 – is less empathic - can be related to counselor anxiety – need to control sessionTaking sides – most important trap to avoid – when you take a side, client who is ambivalent takes the other – read DIALOGUE p. 57Expert – p.60 – desire to help can unwittingly lead counselor into expert trap – trying to “fix” the situation. In MI, in a real sense the client is the expert – esp. re: his/her situation, values, goals, concerns, skills, motivation. MI is about collaboration (side x side) not installation.Labeling – p. 60 – Some counselors believe is important for client to accept the counselor’s diagnosis – “You’re an addict. You’re in denial.” Is little evidence for any benefit from pressuring people to accept a label. Underlying issue is likely a power struggle. Read DIALOGUE p. 61Premature focus – p. 62 – counselors often want to identify and hone in on what they perceive to be the client’s problem; the client may have more pressing concerns – The trap is to persist in draw the client back to talking about your conception of “the problem”Blaming – p. 63 – client may be defensive, wanting to assign blame for the problem – Who’s fault? Who’s to blame? – best to render blame irrelevant – read STATEMENT p. 63
84 ResourcesMotivational Interviewing (2nd Ed.), Miller, WR & Rollnick, S., The Guilford Press, 2002.Motivational Interviewing in Health Care, Rollnick, S, Miller, WR and & Butler, C. The Guilford Press, 2008.Motivational Interviewing in the Treatment of Psychological Problems, Edited by Arkowitz, Westra, H, Miller, WR, & Rollnick, S, The Guilford Press, 2007.TIP # Enhancing Motivation for Change in Substance Abuse Treatment, CSAT, 1999.– NCADIWebsite:
85 Now what (personally)? Read more about MI Observe and discuss professional training videotapesPractice reflective listening with “talk radio”Tape (audio or video) your own practiceWork with a supervisor knowledgeable about MIForm a peer discussion/supervision group to support mutual skill-building
86 Now what (organizationally)? Designate a Skills Developer to provide and promote ongoing training/observation/feedbackOffer various lengths of booster trainingsSupervisors add staff progress in MI skill-building in supervisory sessions and evaluationsRethink the notion of doing intake assessmentsDevelop an MI materials and tools libraryCreate MI posters with MI definition, OARS, etc. as remindersDevelop own MI listserv
87 MI Self Check My clients would say that I… Believe that they know what’s best for themselvesHelp them to recognize their own strengthsAm interested in helping them solve their problems in their own wayAm curious about their thoughts and feelingsHelp guide them to make good decisions for themselvesHelp them look at both sides of a problemHelp them feel empowered by my interactions with themAdapted from Hohman, M. & Matulich, W. Motivational Interviewing Measure of Staff Interaction, 2008.
88 Remember… your clients/patients will teach you!