Motivational Interviewing: User Friendly Advanced Applications for the Treatment of Sexual Compulsivity J. Roland Fleck, EdD Jan Parker, PhD National University

2 Transtheoretical Model (TTM) Prochaska & DiClemente (1984) postulated the behavior change process as a sequence of five stages through which people advance as they create, modify or stop behaviors Readiness for change gauge Interventions must match stage of change

3 Precontemplation Stage No recognition of a problem and no intention to change in the foreseeable future Unaware, unwilling, unconcerned or too discouraged to change their behavior Do not perceive behavior as creating adverse consequences or personal crisis The essence of precontemplation is maintaining the status quo

4 Contemplation Stage Recognition of a problem and serious consideration about overcoming it No commitment to take action or change Ambivalence about changing Weighing pros and cons of changing or not changing Decisional balance evaluation process Recognizing where you want to go but not being quite ready to do it

5 Preparation Stage Intention to change the behavior Initial formulation of a plan to act May have already taken some action toward modifying the problem behavior Requires commitment to some type of action plan Includes an evaluation of one’s perceived capabilities (i.e., self-efficacy) for changing Pros for changing the behavior outweigh the cons

6 Action Stage Plan is implemented to stop the old behavior pattern and engage in the new behavior Requires major lifestyle changes requiring considerable commitment of time and energy Path to actually creating a new pattern of behavior begins with this initial action

7 Maintenance Stage Behavior changes are continued and gains are consolidated and integrated New behavior pattern becomes automatic and established Risk of reverting back to the old behavior pattern is present Return to problematic behavior at least once, reverting to a previous stage of change The essence of maintenance is stabilizing behavior change and avoiding relapse

8 Recurrence Most people taking action to modify problem behavior do not succeed on their first attempt Cycle through the stages of change on several occasions before achieving long-term successful behavior change Visualize the stages of change model as a spiral rather than either a linear or circular progression

9 Motivational Interviewing Miller & Rollnick (1991; 2002) developed an interpersonal style that employs a series of principles to help people deal with addictive disorders and other problem behaviors Assumption that the client has both the responsibility and capability to change Role of the counselor is to create an environment that will increase and enhance the client’s motivation for and commitment to change Helping clients resolve the ambivalence that prevents the realization of personal goals

10 Definition of Motivational Interviewing Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared to nondirective counseling, it is more focused and goal-oriented. The examination and resolution of ambivalence is its central purposes

11 Four Assumptions Ambivalence about the problematic behavior (and change) is normal and is a motivational obstacle to behavior change Ambivalence in the client can be resolved by working with his/her intrinsic motivations and values Alliance between therapist and client needs to be a collaborative partnership to which each contributes expertise Change occurs through an empathic, supportive, but directive counseling style

12 Four Principles Used in applying the Motivational Interviewing approach to counseling and therapy Four principles of Motivational Interviewing are considered far more important than any specific strategy or skill used in counseling and therapy

13 Express Empathy Foundation for facilitating change Respectful Understanding Communicate acceptance and understanding Use non-judgmental reflective listening Develop a collaborative relationship Not about agreeing, but trying to understand Possible to accept a person’s thoughts and feelings without agreement and approval

14 Develop Discrepancy Clients are more likely to be persuaded by what they hear themselves say than by what a counselor or other person tells them Create and amplify the discrepancy between the client’s present behavior and his/her broader life goals and values Directive in moving the client toward a resolution of the ambivalence Perceived discrepancy motivates change Client should always present the arguments for change (i.e., change talk)

15 Roll With Resistance Resistance is not viewed as defiance Resistance is perceived as a sign that the client has a different view of the situation Considers this ambivalence to be a normal part of the change process Resistance is not directly confronted Resistance is turned and reframed to create a new momentum toward change Counselor does not argue with the client Invites rather than imposes new perspectives Client is the primary resource in finding solutions

16 Support Self-Efficacy Support self-efficacy by guiding the client toward a belief in his/her own ability to successfully change Self-efficacy is a good predictor of treatment outcome If the client does not perceive the ability to change, the situation will appear hopeless and no effort will be made and the previous effort of the counselor will be of little use Counselor needs to believe in the client’s capacity to change Counselor’s belief in the client empowers the client

17 Summary “Motivational Interviewing honors and respects the individual’s autonomy to choose. It is a collaborative, not a prescriptive, approach, in which the counselor evokes the person’s own intrinsic motivation and resources for change. Implicit is the belief that such motivation and resourcefulness do lie within each individual and need to be evoked rather than imposed” (Miller & Rollnick, 2002, p. 41).

18 Five Strategies of Motivational Interviewing Miller and Rollnick describe five strategies that are effective in guiding clients through the five- stage continuum of change First four strategies are derived largely from client-centered therapy, although they are used for a particular purpose—that of helping clients to explore their ambivalence and express reasons for change Fifth strategy, eliciting self-motivational statements, is more directive and specific to Motivational Interviewing

19 Ask Open-Ended Questions Affirm Listen Reflectively Summarize

20 The acronym OARS is used to describe the four strategies of asking open-ended questions, affirming, reflective listening, and summarizing This acronym presents an image that with sustained effort OARS can take us a long way

21 Elicit Self-Motivational Statements (Change Talk) Rather than trying to persuade the client that change is necessary, the counselor facilitates the client’s expressions of personal concerns and intentions and arguments for change Counselor gives recognition to any type of self- motivational statements including:  Problem Recognition  Concern about the Problem  Commitment to Change  Belief that Change Is Possible

22 Counselor can employ the four strategies described above (i.e., OARS) as well as various specific techniques including:  Asking evocative questions  Exploring pros and cons  Asking for elaboration  Using extremes  Looking back  Looking forward  Exploring Goals

23 Generic Concepts in User Friendly Terminology The following generic concepts are strategies that are user friendly and consistent with the spirit of Motivational Interviewing:  Use respectful understanding and begin where the client is in order to engage him/her  Educate the client about what to expect from you in terms of services you can and cannot provide

24  Broaden your concept of strength by focusing on the client’s unrecognized abilities and accomplishments in order to facilitate the development of self-efficacy  Help the client to identify family and friends who have been supportive in the past in order to explore obstacles that the client perceives to be preventing him/her from seeking support  Look for common ground with the client to allow the client to perceive you as an approachable person who can be trusted  Recognize the difference between rescuing/enabling and empowering

25  Slow down the process in order to establish a collaborative set with the client. Each goal and each action step needs to be patiently and collaboratively developed between the client and the counselor  Help the client define what he/she wants to have happen from working with you  Explore a menu of options with the client emphasizing that the client does have choices and pointing out specifically where the choices exist  Help the client identify the next manageable step that he/she can realistically undertake in moving toward a particular goal  Conduct a thorough assessment and consider the assessment to be your first intervention

26 Confrontation of Denial Approach to Sexual Compulsivity Treatment Premature Advice and Head-on Confrontation Frustration when the Client is Non- Compliant Unresolved Countertransference

27 Rescuing and Enabling Approach to Sexual Compulsivity Treatment Premature Advice and Friendly Persuasion Confrontation Frustration when the Client is Non-Compliant Unresolved Countertransference

28 Stages of Change/Motivational Interviewing Approach to Treatment Recognition of Client’s Stage along the Continuum of Change Client-Centered Motivational Interviewing Strategies Tailored to the Client’s Stage of Change Increases Potential for Engaging and Empowering the Client

29 Non-Compliance Is Viewed as an Indication that the Therapist Needs to:  Change Strategies  Collaboratively Review Obstacles  Collaboratively Re-Negotiate Goals