Motivational Interviewing

Motivational Interviewing - Part 2 Presented by Dee-Dee Stout, MA, CADC-II; Member of MINT; Advisor/Trainer, ICCE For Lake County Health Services Lakeport, CA July 2010

Quick Review – MI Part 1 • Ask-Tell-Ask • Agenda Setting • 4 Basic Principles • Traps to Avoid • OARS, esp. Reflections Please copy only in its entirety

Day’s Format Talk Look Do

Value Cards Sort Share with another HOW you know these things are important to you? (20)

Walk Away Skill #2 Agenda Setting

Agenda Setting • Agenda Setting • Write out the topics in which the client is asking for your help • Then ask, in a time frame you set (30 minutes, etc), what 1 or 2 items the client would most like to discuss in that time, or ask which are most important, or say “or is something else more important to talk about right now?” • Note: You may also add 1 thing that you need to discuss but talk about that last & only after you ask permission Please copy only in its entirety

Demonstration Read examples or do live?

Reflection Exercise The Penny Game

Building a Rapport Bank • In dyads: 1 Speaker and 1 Listener • Speaker begins by talking about something real though not too tender. • Each time the Listener reflects appropriately, the Speaker moves 1 penny or more from their pile to the Listener’s“bank.” How many is up to the Speaker. • The goal is to get as many of the Speaker’s pennies in front of you. • Return to debrief in big group Please only copy in its entirety

Scenarios Good, Better, Bull’s Eye!

Good, Better, Bull’s Eye! • In your group, find the scenario on the table and read aloud • Using the scenario as a guide, decide what simple reflection you might use with this client that simply shows you’re listening (good) • Think about possible responses to this reflection and consider more “back-story” to form the next reflection, perhaps one more complex (better) • Finally, decide on the most complex reflection you all think accurately shows what you’ve heard in both content & emotion from the client so far, & what you’re NOT hearing this client say with words

Summary What have we discussed so far?

MI - Phase 2: Strengthening the Commitment for Change Change Talk, Commitment Language, and More

Acceptance Less resistance Less problem-talk Change Talk Questions about change Envisioning Experimenting/ taking steps Review: Recognizing Readiness Please only copy 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) • Activation (ready, prepared, willing) • Taking Steps (action) Please only copy in its entirety

Walk Away Skill #4 Pulling for Change Talk

Getting to Change Talk - 1 • Ask evocative questions • Ask clients to elaborate • Use Rollnick’s Rulers • Explore the Decisional Balance OK to reproduce in its entirety only please

Getting to Change Talk - 2 • Query the extremes • Look back • Look forward • Explore clients’ goals & values OK to reproduce in its entirety only please

Desire – Preference for change • I want to… • I would like to… • I wish I could … Please copy only in its entirety

Ability - Confidence • I could… • I can… • I might be able to … Please copy only in its entirety

Reasons–Specific arguments for change • I would probably feel better if I … • I need to have more energy to play with my kids. Please copy only in its entirety

Need –Feeling obligated to change • I ought to… • I have to … • I really should … Please copy only in its entirety

Commitment –Likeliness of change • I am going to… • I will… • I intend to … Please copy only in its entirety

Change Talk v Commitment Language How can we hear the difference? And what does it matter anyway?

Commitment Language Demo • 5 Volunteers: • I want to… • I could… • I need to… • I ought to because I have good reason… • I do or I will… • Oaths What do you think? Which would you want to hear? Please copy only in its entirety

Activation • I’m ready to take this on! • I’m prepared to make this change this time • I’m willing to do anything I need to in order to make this work Please copy only in its entirety

Taking Steps – Action taken! • You might be surprised to hear this but I actually went out and … • This week I started … • That meeting was pretty good last night Please copy only in its entirety

Walk Away Skill #3: Scaling Another way to Assess & to pull for Change Talk

Scaling (DARN-C & more) • Concern • Problem Recognition • Desire/Importance • Ability/Confidence/Optimism • Reasons, Need & /Readiness • Commitment/ Intention to Change Please only copy in its entirety

Concern • What is there about your behavior that you or others might see as a reason for concern? • What worries you about your behavior? • What do you think could happen if you continue? • How do you feel about your behavior? • How much does you behavior concern you? • What do you think might happen if you don’t change your behavior? Please copy only in its entirety

Problem Recognition • What things make you think that this might be a problem? • What difficulties have you had in relation to your use (or other behavior)? • How have you or others been harmed by this behavior? • How has your behavior been a problem for you? • How has your behavior kept you from your goals? • How has your behavior stopped you from doing what you want to do? Please copy only in its entirety

Exploring Importance • What would have to happen for this to become much more important for you to change? • What would have to happen before you seriously considered changing? • Why have you given yourself such a high score on importance? • What would need to happen for your score to move up from (-) to (-)? Based on “Health Behavior Change” by Rollnick, Mason, & Butler, 1999; Churchill Livingstone. Please copy only in its entirety

Enhancing Confidence - 1 • Traps • It’s OK, I’ll take care of things! (plumber) • There, there you’ll be fine (patronize) • You’re right; things are horrible (pessimist) • Enhance confidence before you give advice OK to reproduce in its entirety only please

Enhancing Confidence -2 • Getting & Strengthening Confidence Talk • Ask open questions; use complex reflections • The Confidence Ruler • Look at past successes • Talk up clients’ strengths & support • Brainstorm! • Give info & advice (w/permission only) • Reframe OK to reproduce in its entirety only please

Enhancing Confidence -3 • Getting & Strengthening Confidence Talk • Radical change? • Hypothetical change • Suppose you were going to ___. How might you do that? • Who do you know who’s made this change? How did they do it? - The Miracle Question OK to reproduce in its entirety only please

Confidence • If you decided to change right now, how confident are you that you could be successful? • On a scale of 1 to 10, with 1 being “no way” and 10 being “absolutely no problem”, how confident are you that you could be successful in making this change? • What would it take for you to move to a 4? How would you know if you were at a 7? What indicators would tell you your confidence was down to a 2? • Which of these behaviors are you most confident that you could change if you wanted to? Please only copy in its entirety

Exploring Confidence • What have you learned from the way things turned out the last time you tried to make this change? • If you were to decide to change, what might your options be? Are there any ways you know of that have worked for other people? • What are some of the practical things you would need to do to achieve this goal? Do any of them sound achievable? • What can you think of that would help you feel more confident? Please copy only in its entirety

Exploring Confidence • What would make you more confident about making these changes? • Why have you given yourself such a high score on confidence? • How would you move up higher so that your score goes from – to -? • How can I help you succeed? • What did you find helpful in any previous attempts to change? Please copy only in its entirety

Optimism • What encourages you to see that you are ready to make a change? What helps you to see that you could make a change if you wanted to? • What do you think would work for you if you decide to make a change? Please copy only in its entirety

Before Giving Advice… • Elicit the client’s own ideas & knowledge • Consider the importance of what you will offer (remember the DARN-CAT Bouquet!) • Obtain the client’s permission • Have several options (the Menu) Please only copy in its entirety

Intention to Change - 1 • How come you think you need to change? Why now? • If things were to work out as you want, what would that look like? • What would be different if you were to change? • What makes you think you should not change your behavior? Please copy only in its entirety

Intention to Change - 2 • What are you thinking about your behavior at this point? • What would be the advantages to making a change? Or not? • I can see that you’re feeling stuck right now. What will have to change to get “unstuck?” • What would have to happen for you to be ready to make a change? What would that look like? Please copy only in its entirety

Recap: Possible Key Questions • What do you think you will do? • What does this mean about your ___? • It must be uncomfortable for you now, seeing all this. What’s the next step? • What do you think has to change? • What could you do? What are your options? • How would you like things to turn out for you now, ideally? • What concerns you about changing your use of ____? Please only copy in its entirety

Recap: Possible Key Questions • It sounds like things can’t stay the way they are now. What are you going to do? • Of all the things we’ve discussed here, which do you think are the most important reasons to make a change? How are you going to do it? • What’s going to happen now? • Where do we go from here? Please only copy in its entirety

Negotiating a Change Plan • Setting goals • How would you like for things to be different? • What do you want to change? • If you were completely successful in accomplishing your goal, what would be different? • Let’s take things one step at a time. So, what do you think is the first step? Please only copy in its entirety

Step 2: Considering the Options • Offer a menu of options • Try “warm turkey” approach • Negotiate a period of trial abstinence: “sobriety sampling” • Gradually taper off to abstinence • Period of trial moderation • Offering advice on what type of treatment typically works for whom • The client (& you) may not choose the right treatment approach the first time Please only copy in its entirety

Step 2: Considering Change Options • “The truth is that there is no one approach that is best for everyone. What works for some is unacceptable or ineffective for others. What’s encouraging is that there are quite a few different ways that have been shown to be promising. The question now is which ones would be best for you. We can talk about the options if you want, and I would certainly try to help you find the right approach the first time. But if you try one way and it doesn’t seem to be working, don’t get discouraged. It might only mean that it isn’t the right approach for you. Would you like to hear about some of the possibilities?” Please only copy in its entirety

Step 2: Considering Change Options • Clearly discuss each option • Include what the client can expect from each option and the likely outcomes • Answer any questions clients may have regarding each option • Ask the client what outcome they might expect from each option or what they may expect if they decide to do nothing (which is another option.) Please only copy in its entirety

Step 3: Arriving at a Plan • Arriving at a plan • Evaluate alternative courses of action • Stay with the client! • Summarize the plan based on the client’s goals, needs, intentions, and beliefs • So, how do we know if this plan could work? Try asking: • How would your life be different if you followed this idea and quit altogether? • You have said that you would like to cut down, so let’s talk about that for a while. How do you think this would work? • OK, so that’s your goal. Great! I wonder what obstacles you think might keep you from being successful? • What else do you think might go wrong with this plan? Please only copy in its entirety

Step 4: Eliciting Commitment - Endgame • Make it public! • Arrive at a clear plan • Obtain the client’s verbal decision to follow the plan • Reinforce the client’s decision • Initiate immediate steps for implementing the plan Please only copy in its entirety

Motivational Interviewing - Part 2