How Motivational Interviewing Can Help Engage At-Risk Youth

How Motivational Interviewing Can Help Engage At-Risk Youth
VaRonica Little, LCSW November 2017

What I hope to accomplish today
Motivational Interviewing Goal: To get people to resolve their ambivalence (i.e., conflict) about changing their behavior, while not evoking resistance (e.g., get confrontational, blame, label). You must be non-judgmental in your thoughts and interactions! How to deal with the battle within

Key Elements to MI Express Empathy Develop Discrepancies Roll with Resistance/ Reflect Discord Support Self-efficacy What I hope to accomplish today Motivational Interviewing

Express Empathy What I hope to accomplish today Motivational Interviewing Express Empathy Everyone’s thoughts and feelings are their truth!

Express Empathy O open ended questions A affirmations R reflective listening S summary reflections What I hope to accomplish today Motivational Interviewing Express Empathy OARS Open Ended Questions (allowing the client to share their story, don’t give them the option to give a yes or no answer), Affirmations (Statements of strengths, recognizing behaviors that are moving the client in a positive direction), Reflective Listening (Close the loop in communication breakdowns by repeating or rephrasing, paraphrasing, reflection of feeling), Summary Reflections (start by telling the client you are summarizing “Here is what I have heard, tell me if I missed something”, Give special attention to change statements (Problem Recognition, Concern, Intent to change, Optimism), Identify both sides of ambivalence that has been discussed “on one hand… on the other hand…”, Include collateral information or your own clinical observations, Be concise, End with an invitation “Did I miss anything, Anything you want to add or correct?”, Depending on the response, planning for taking concrete steps towards the change goal.

Develop Discrepancies What I hope to accomplish today Motivational Interviewing Express Empathy OARS Develop Discrepancies Create a gap between where the person has been or currently is and where they want to be; goal is to resolve discrepancy by changing behavior;---- picture Internl conflict, food Tell me some of the good things and less good things about your behavior/concern. What will your life be like (# years from) if you don’t make changes and continue to use? Explore how a client’s life would be different if he/she did not have the problem or were not engaging in the behavior. What was your life like before you started having problems with (the behavior)? Describe a typical day.

Develop Discrepancies What I hope to accomplish today Motivational Interviewing Express Empathy OARS Develop Discrepancies Reframing Places a different meaning on what the person says so that the person doesn't seem so resistant

Develop Discrepancies Point Out Ambivalence Recognize Verbalize Elaboration Colombo Technique Therapeutic Paradox Motivational Interviewing Express Empathy OARS Develop Discrepancies Reframing Point Out Ambivalence Recognizing Ambivalence (decisional balance) What are the good things about your behavior? What are the less good things about your behavior? If you keep heading down the road that you’re on what can you imagine happening? What would be the best outcome you could see for yourself? Verbalizing Ambivalence In what ways has your behavior been a problem? What have other people said? If it is not viewed as a problem now, how might your use eventually become a problem? In what ways has it been inconvenient for you? Elaboration: When clients offer something bad about their behavior, ask them to talk more about it. Ask for an example, and then ask for another example. Colombo Technique: Used when clients are presenting conflicting information or behaviors Therapist: “On the one hand you say you are terrified of going to prison, but you continue to (engage in the behavior). I'm confused. Help me understand this." Therapeutic Paradox: side with the side of the ambivalence; presents the client with a challenge; do not have sarcasm in your voice for this needs to be stated genuinely Example 1 (therapist): "Maybe what I'm asking is just too difficult for you. Maybe you are not ready to change.” Example 2 (therapist): “You have been continuing to drink heavily and yet you say that you want to get you children back. Maybe you are not ready to change.”

Develop Discrepancies Motivational Interviewing Express Empathy Develop Discrepancies Reframing Point Out Ambivalence Emphasize Choice Emphasizing Personal Choice and Control: If you tell someone what to do this is confrontational and fosters resistance. Allowing personal choice and control over their problems can help minimize resistance

Develop Discrepancies Motivational Interviewing Express Empathy Develop Discrepancies Reframing Point Out Ambivalence Emphasize Choice Comparisons Looking Forward If you keep going the way you are going where will you be five years from now? Where would you like to be five years from now? What goals/things do you want for yourself? Have them list these on cards, and then put the cards in order of priorities. Which is most important? Which is least important? Then ask them where their behavior fits in. Point to the highest priorities and ask them “How many of your priorities would you be willing to give up for your current behavior?” Looking Back – client reflects on effective strategies used with past successes; have them think back to time in life when things were going well describe this and what has changed now Looking Forward have client think about their hopes for the future if they make this change; how would they like things to be different; what are realistic options now – what could you do now; what are the best results you could imagine if you make this change

Roll with Resistance Amplified Reflection Double Sided Reflection Clarification Shift the focus away from the stumbling block Decision Balance Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Amplified Reflection Double Sided Reflection Clarification Shift away Decision Balance Amplified Reflection (Another strategy is to reflect the client's statement in an exaggerated form--to state it in a more extreme way but without sarcasm.) Double Sided Reflection (Acknowledge the resistance and add a reflective statement about the other side of your client's ambivalence. Use material your client previously offered, maybe even from another session. Be sure to use “and” rather than “but” to maintain balance of emphasis) Clarification (verify your understanding matches the client’s perspective ) Shift the focus away from the stumbling block (pointing out what they have accomplished, what they are doing well in other area’s of life, discuss interests) Emphasize Personal Choice and Control (assure the person that in the end, it is the client who determines what happens) Decision Balance Worksheet/ Activity Good things about X Good things about change (Y) Not so good things X Not so good things about Y

Roll with Resistance Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Amplified Reflection Double Sided Reflection Clarification Shift away Decision Balance Desire vs Ability Reason vs Need Emphasize Personal Choice and Control Emphasize Personal Control Yes this is on here twice because it is very important Coping skills, friends, what you attend, everything is within our control that we do. Our consequences are the only thing that is out of our control.

Roll with Resistance Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Amplified Reflection Double Sided Reflection Clarification Shift away Decision Balance Desire vs Ability Reason vs Need Emphasize Personal Choice and Control Traps to Avoid— Question Answer pitfall, keep the questions Socratic or open ended Labeling- dx… often it feels defeating when someone is labled Premature Focus (don’t let your concerns be the main focus, stick with client concerns when possible) Expert—remember you are not the expert in this relationship, they are the expert on them. Taking Sides –Do this with caution because it can get heated real fast and break down alliances. Blaming Others (blaming is not as important as identifying concerns and working through them)

Roll with Resistance Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Amplified Reflection Double Sided Reflection Clarification Shift away Decision Balance Desire vs Ability Reason vs Need Emphasize Personal Choice and Control If working with Coerced Clients.. Ask their view of the referring person’s expectations or ideas of the identified problem Whose idea was it that you come here? Who suggested you come here? What makes (name referring person: nrp) think that you need to come here? What will convince (nrp) that you don’t need to come here? What does (nrp) think is the reason that you have (name of the behavior)? What does (nrp) say you need to do differently?

Support Self Efficacy Readiness Ruler Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Readiness Ruler Readiness to Change Ruler (Supporting Self Efficacy) People come into treatment with different levels of motivation (or readiness) to change At the assessment/first session, ask “On the following10-point scale from 10 to 10 where 0 is ‘Not Ready’ and 10 is ‘Ready’ where are you now in terms of changing your behavior? People move forward and back along this readiness to change scale A therapist needs to operate at the same level of change where the client is in order to minimize resistance and gain cooperation

Support Self Efficacy Encourage Change Talk Preparatory Change Talk Desire Ability Reason Need Implementing Change Talk Commitment Activation Taking Steps Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Readiness Ruler Encourage Change Talk Encourage Change Talk Preparatory Change Talk Desire (I want to change) Ability (I can change) Reason (It’s important to change) Need (I should change) Implementing Change Talk Commitment (I will make changes) Activation (I am ready, prepared, willing to change) Taking Steps (I am taking specific actions to change)

Support Self Efficacy Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Readiness Ruler Encourage Change Talk We need to remind our clients that them showing up and being there is the first right step in making changes, but who am I kidding we need to remind ourselves that, them showing up is the first right step in making change too. Change is hard and our motivation for change doesn’t always come easy and doesn’t stay consistent. We will get with these youth, it will just take time and needs to be a continued process.

Support Self Efficacy Ingredients of Change D desire A ability R reasons N need C commitment A action T tracking Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Readiness Ruler Encourage Change Talk DARN CAT DARN CAT Desire (why would you want to make this change) Ability (how might you go about that) Reasons (what are the 3 best reasons for that) Need (how important is it for you to make this change) Commitment (so what do you think you will do) Action (Set specific short term goal) Track (Establish Monitoring, how will you know when you have accomplished this)

Support Self Efficacy E express A affirm R reinforce S summarize Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Readiness Ruler Encourage Change Talk DARN CAT EARS EARS you are doing better than you think you are Explore Affirm Reinforce ---Cheerleader picture Summarize

Support Self Efficacy Build Confidence and Self Esteem Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Readiness Ruler Encourage Change Talk DARN CAT EARS Confidence and Esteem The only way that we make changes is if we believe that we can. Never stop reinforcing to the youth you work with that they can change, that they are amazing people and they are capable of so much more than they know at this time.

Putting it all together Express Empathy Develop Discrepancies Roll with Resistance Support Self-efficacy Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Putting it all together Putting it all together Express Empathy this decreases resistance Develop Discrepancies this builds motivation Roll with Resistance it is normal developmentally and it will change Support Self-efficacy builds confidence, creates long lasting change

Putting it all together Get out of your head Own it Just Be You Take Action Now Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Putting it all together Get out of your head Focus on and listen to your client Own it Learn and Practice the skills Just Be You Relate & Empathize Take Action Now There is no magic wand just keep working

Questions and Comments Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Putting it all together

References Martino, S., Carroll, K. M., O'Malley, S. S., & Rounsaville, B. J. (2000). Motivational interviewing with psychiatrically ill substance abusing patients. American Journal on Addictions, 9(1), Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to change (2nd edition). New York: Guilford. Resnicow, K., Dilorio, C., Soet, J. E., Borrelli, B., Hecht, J., & Ernst, D. (2002). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21(5), Rollnick, S., & Allison, J. (2001). Motivational interviewing. In N. Heather, T. J. Peters & T. Stockwell (Eds.), International handbook of alcohol dependence and problems (pp ). New York: John Wiley. Sobell, L. C., & Sobell, M. B. (2003). Using motivational interviewing techniques to talk with clients about their alcohol use. Cognitive and Behavioral Practice, 10, Substance Abuse and Mental Health Administration. (1999). Enhancing motivation for change in substance abuse treatment (Treatment Improvement Protocol Series). Rockville, MD: U.S. Department of Health and Human Services. Otani, A. (1989). Client resistance in counseling: Its theoretical rationale and taxonomic classification. Journal of Counseling and Development, 67, Motivational Interviewing Express Empathy Develop Discrepancies Roll with Resistance Support Self Efficacy Putting it all together

For more information about trainings, programs and services, please visit: dsamh.utah.gov
VaRonica Little, LCSW Division of Substance Use and Mental Health 195 N W. Salt Lake City, UT 84116

How Motivational Interviewing Can Help Engage At-Risk Youth

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How Motivational Interviewing Can Help Engage At-Risk Youth

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