motivational interviewing

1. Motivational Interviewing Level 1 Training Stages of Change and MI Basics

2. Introductions Name Where you work and what you are doing? Experiences with MI and stages of change Expectations for the training

3. Overview of Training Learning Objectives What is MI? The Change Process A Counseling Style Preview of Level 2 Training GOAL is to elicit from an ambivalent client the reasons for concern and the arguments for change!GOAL is to elicit from an ambivalent client the reasons for concern and the arguments for change!

4. Learning Objectives By the end of the session, participants will be able to� Define MI as a counseling style rather than a set of techniques. Describe the Stages of Change. Define the Four Principles of MI. Discuss the MI microskills � OARS

5. Group Exercise Think about a behavior that you have been considering changing, but about which you are ambivalent. Image trapped in room until changeImage trapped in room until change

6. MI: Definition

7. MI: Spirit

8. MI: Spirit Collaboration=Partnerships A counselor or interviewer collaborates with a client to support and explore the possibility of change without imposing one�s own needs or agenda.

9. Goal of MI

10. Cognitive Dissonance

11. MI Background

12. The Change Process: Important Elements of MI

13. Change Basics The model reflects how change occurs 1) naturally 2) with therapeutic interventions The change process in both cases is VERY SIMILAR.

14. Group Exercise Think back to the behavior that you have been considering changing, but about which you are ambivalent. How long have you been considering changing this behavior? What has stopped you from making the change? What would need to happen for you to make the change? Image trapped in room until changeImage trapped in room until change

15. Change Basics Framework for conceptualizing intentional human behavior change. It is a model of change, not psychopathology. Change is viewed as progressive, not as changed or not; a process, not an outcome.

16. Readiness to Change

17. StephRecycle�very common with many behaviors, but especially substance related behaviors.StephRecycle�very common with many behaviors, but especially substance related behaviors.

18. Stages of Change Model Precontemplation: Entry point to the process of change. Person is not yet considering the possibility of change. Does not see themselves as having a problem. Therapeutic tasks: Provide information and feedback to raise awareness of the problem and the possibility of change; raise doubt; increase perception of risks and problems.

19. Stages of Change Model Contemplation: Characterized by ambivalence; both considers and rejects change. Seesaws between reasons to change and reasons to stay the same. Therapeutic tasks: Tip the balance in favor of change; evoke reasons to change; risks of not changing; strengthen client�s belief that change is possible.

20. Stages of Change Model Preparation: Characterized by accepting the need to change; to do something about the problem. At this point, either enters into action or slips back into contemplation. Therapeutic tasks: Help the client determine the best course of action to take in seeking change. Help find a change strategy that is acceptable, accessible, appropriate and effective.

21. Stages of Change Model Action: The person is engaging in particular actions to bring about change (e.g., treatment). The goal is to produce change in the problem areas. Therapeutic tasks: Help the client take steps toward change.

22. Stages of Change Model Maintenance: Maintaining the changed behavior; avoiding the problem behavior. The challenge is to sustain the change accomplished by previous action and to prevent relapse. Therapeutic tasks: Help the client to identify and use strategies to prevent relapse.

23. Stages of Change Model Relapse: A reversion back to problem behavior. Normal, expected occurrences as a person seeks to change any long-standing pattern. Therapeutic tasks: Help the client to renew the process of contemplation, determination, and action without becoming stuck or demoralized because of relapse.

24. Motivational Interviewing and Stages of Change To move clients out of the precontemplation, contemplation and determination stages and into the action stage. Before clients can learn how to change (action) they must first make a commitment to change. The greatest challenge is fostering decision and commitment to change in the client. Confrontational interviewer styles evoke high levels of resistance.

25. Stages of Change Spiral pattern more reflective of actual movement through stages versus linear model 85% of relapsers recycle back to contemplation or preparation Steph This spiral model is probably more reflective of how people actually change than the wheel or circular model. 3-7 change attempts for one behavior is normal. Steph This spiral model is probably more reflective of how people actually change than the wheel or circular model. 3-7 change attempts for one behavior is normal.

26. Ethel The Stages of Change

33. Stage of Change Exercise Bring up the next slide and ask folks to write on a piece of paper what stage of change they are in or have it pre-written on newsprint and have them mark as they go out for break. Bring up the next slide and ask folks to write on a piece of paper what stage of change they are in or have it pre-written on newsprint and have them mark as they go out for break.

35. 40-40-20 Rule In the population at large, for any behavioral problem, 40% are in precontemplation 40% are in contemplation 20% are in preparation or action *Prochaska and DiClemente, 1998

36. Knowing About Stages Of Change Most people are in the midst of changing more than one behavior at a time. Experience the thoughts, feelings and behaviors related to different stages for different issues. Even for one behavior, stage may fluctuate. We say someone is �in� a stage for practical purposes.

37. When is a client considered motivated? Agrees with the therapist�s view Accepts the counselor�s diagnosis States a desire for help Shows distress, depends on therapist Complies with treatment Has a successful outcome Add transition hereAdd transition here

38. Favorite Teacher Think of your favorite teacher from school What did you like ? How did you feel when you were in that teacher�s class? How would you rate your learning?

39. Least Favorite Teacher Now think of your least favorite teacher from school What didn�t you like ? How did you feel when you were in that teacher�s class? How would you rate your learning?

40. Exercise:Favorite Teacher Ask everyone to write down the name of their favorite teacher and what subject he/she taught. Also, write down name and subject of least favorite teacher. Ask for volunteers and ask questions. What was the class like? What made the teacher so appealing or unappealing? How did he/she act toward you? How did you respond? Did you enjoy the subject? How did you do in the class?Ask everyone to write down the name of their favorite teacher and what subject he/she taught. Also, write down name and subject of least favorite teacher. Ask for volunteers and ask questions. What was the class like? What made the teacher so appealing or unappealing? How did he/she act toward you? How did you respond? Did you enjoy the subject? How did you do in the class?

41. Favorite teacher activity exemplifies� The interpersonal nature of motivation We are affected by how others act toward us and vice versa. Motivation fluctuates across time and situations. Add transition hereAdd transition here

42. Motivation is influenced by� Counselor Style Miller, Benefield and Tonigan, 1993 Counselor Expectancies Leake & King, 1977 Biases toward clients Client Expectancies Self change literature Add transition hereAdd transition here

43. Ambivalence Ambivalence is normal. Feeling two ways about something. �I want to and I don�t want to.�

44. Decisional Balance

45. Decisional Balance Exemplifies� Ambivalence is part of the picture. Clients have good reasons to keep doing a behavior and to quit doing a behavior. Resolving this ambivalence is key to success in treatment. Joining with reasons why a client wants to change will force him/her to protect the side that doesn�t want to change. Add transition hereAdd transition here

46. Dancing Not Wrestling

47. Four Principles of Motivational Interviewing Express empathy Roll with resistance Promote self-efficacy Develop discrepancy

48. Express Empathy Acceptance facilitates change. Skillful reflective listening is fundamental. Ambivalence is normal.

49. Traps/ Pitfalls Question-Answer Confrontation-Denial Expert Trap Labeling Trap Premature Focus Blaming Trap Adapted from Thomas Gordon�s communication model. Possible exercise: Forming Reflections Use dyads, setup issue for role play Speaker says �One thing I like about myself is that I..� Listener can only ask, �Do you mean that you are..� Speaker can only respond with �Yes� or �No� without elaborating Debrief � statements can have multiple meaningsAdapted from Thomas Gordon�s communication model. Possible exercise: Forming Reflections Use dyads, setup issue for role play Speaker says �One thing I like about myself is that I..� Listener can only ask, �Do you mean that you are..� Speaker can only respond with �Yes� or �No� without elaborating Debrief � statements can have multiple meanings

50. Develop Discrepancy Amplify cognitive dissonance. Difference between where one is and where one wants to be. Awareness of consequences is important. Encourage client to present reasons for change. Elicit self-motivational statements.

51. Roll with Resistance Use momentum to your advantage. Try to shift perceptions. New perspectives are invited, not imposed. Clients are valuable (best?) resource in finding solutions.

52. Exercise: Divide up equally One team calls out resistant statements and anyone on the other team can try to �dodge� or �roll� with themDivide up equally One team calls out resistant statements and anyone on the other team can try to �dodge� or �roll� with them

53. Support Self-Efficacy Belief in possibility of change is critical. Client is responsible for choosing and carrying out change. There is hope in the range of alternatives available. One�s belief in his or her ability to carry out and succeed with a specific task Both client and counselorOne�s belief in his or her ability to carry out and succeed with a specific task Both client and counselor

54. MICRO-SKILLS( OARS) Open Ended Questions Affirm The Person Reflect What the Person Says Summarize Perspectives on Change

55. MI �Micro� Skills (OARS) What are some typical statements clients make in the first one or two sessions? Write some of these down

56. Open-ended Questions An open-ended question is one where there is more than a yes or no response Practice open-ended questions using statements just written down

57. Affirming Affirmations are client focused and are aimed at: Supporting client�s involvement Encouraging continued attendance Assisting client to see the positives

58. Affirming The client states: �This is a waste of my time. I don�t think you can help me. I have managed this long without anybody�s help.�

59. Reflective Listening Listening not only to what client says, but also for what the client means Checking out assumptions Creating an environment of unconditional positive regard and acceptance

60. Reflective Listening Watch for judging, criticizing or blaming The client and counselor do not have to agree Be aware of intonation

61. Reflective Listening: Fine Tuning Level One: Repeat/restate using some or all of the same words Level Two: Rephrase using similar words, but in a slightly different way Level Three: Paraphrase capturing meaning and feelings, perhaps adding something implied but not stated

62. Summarizing Special form of reflection Counselor chooses what to include and emphasize Include client�s concerns about change, problem recognition, optimism about change, ambivalence about change Let client know you are listening Invite client to respond to your summary

63. Forming Reflections Speaker starts with: �one thing I would like to change about myself is _____________.� Listener responds with: �You mean you _________.� �It sounds like __________.� It seem to you that _________.� Speaker can elaborate. Switch roles and repeat.

64. Exercise: PRACTICING Your OARS Something You Have Been Thinking About Changing Get in triads Speaker talk about the thing you feel ambivalent about Listener use OARS Observer record use of OARS Debrief Rotate rolesGet in triads Speaker talk about the thing you feel ambivalent about Listener use OARS Observer record use of OARS Debrief Rotate roles

65. Key Points MI is a style or way of interacting with a client that has many features of other brief therapy approaches. MI assumes that motivation is a state rather than a trait and is strongly influenced by interactions. MI assumes acknowledging and actively exploring a client�s ambivalence is critical. Add transition hereAdd transition here

66. Key Points Eliciting self-motivational statements from clients about their own reasons for change is important. Prochaska & DiClemente�s stages of change underlies the readiness concept. It is intended to resolve ambivalence and get a person moving toward change. It is empowerment oriented. Add transition hereAdd transition here

67. Key Points People often recycle through the stages before becoming successful in making a behavior change. A variety of processes and motivational strategies can be used to help move people along in the change process.

68. Key Points

69. Preview of Level II Continued FUN, review, new information, and practice. More on how to roll with resistance. More on how to elicit self motivational statements. Using importance and confidence rulers. Developing change plans.

70. Resources CSAT TIP 35 manual, Enhancing Motivation for Change in Substance Abuse Treatment (1999). Miller, W. R. & Rollnick, S. (2002).� Motivational Interviewing:� Preparing people for change.� New York:�The Guilford Press Prochaska, J., DiClemente, C. C. (1984).� The transtheoretical approach:� Crossing traditional boundaries of therapy.� Homewood, IL:� Dow Jones/Irwin. Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994).� Changing for good.� New York:� Avon Books. www.motivationalinterview.org

71. For more informationMid-Atlantic ATTCwww.mid-attc.org804.828.9910or to order TIPSNCADI800.729.6686