Motivational Interviewing: An Overview

1. Motivational Interviewing: An Overview Jeremy Wampler, LCSW, LADC, ICGC-II, BACC Director, DMHAS Problem Gambling Services Jeremy.Wampler@ct.gov

2. What is Motivational Interviewing?

3. MOTIVATIONAL INTERVIEWINGW. Miller & S. Rollnick • Trapped by Ambivalence • Procrastination, Self Esteem, Self Assertion • Conflict between Indulgence & Restraint • Self-Regulation, Draw on Principles of Social, Cognitive and Motivational Psychology • Client Matching • Nothing Works for Everyone • Counselors must be comfortable with this or they may feel frustrated with a slow paced, ineffectual approach

4. Motivational Interviewing • Based on “Stages of Change” (Prochaska & DiClementi) • Interventions based on enhancing client’s presenting level of motivation

5. Motivational Interviewing • Counselor/case manager is not the expert • Client has responsibility for change • Strategies are more persuasive than coercive • Moresupportivethanargumentative • Counselor/case manager seeks to create a positive atmosphere conducive to change

6. Motivation • It is impossible to have an unmotivated client. • Everybody is always motivated towards something. • The question is what?

7. Why Do People Change? • 1. ? • 2. ? • 3. ?

8. What prevents people from change? • 1. ? • 2. ? • 3. ?

9. Key Points about Change • Change is difficult and not always comfortable • It is easier to stay the same • We tend to go back to old ways • Change requires creativity • Change requires an open mind • Change has emotional and cognitive components Broffman, 2011

10. Key Points about Change • Change happens over time • The process is as important as the result • Often there is a difference between what someone knows they should do and there readiness to do it. • Greatest chance to impact change is pairing it to the specific stage of change. Broffman, 2011

11. Spirit of Motivational Interviewing Collaboration Evocation Autonomy

12. Collaboration Helper approaches consumer as a partner Non-authoritarian Exploration and support Opposite: Confrontational or coercive approach

13. Evocation Eliciting or drawing out motivation from a client Drawing on the clients own goals and perceptions presumed to reside in the client Opposite: Education, enlightenment by an expert

14. Autonomy All responsibility for change lies with the client Respect for autonomy of the client Client freedom to accept or not accept counsel Opposite: Client told what to do or what he/she should do

15. Motivational Cycle and Stages of Change Action Maintenance Lapse or Relapse Planning Contemplation Precontemplation

16. Matching Intervention to Motivation Precontemplation • Not thinking about change • Not seeing the problem

17. Matching Intervention to Motivation Precontemplation Goals: • Understand current behaviors/patterns • Understand nature of client’s resistance to consider change • Assess client’s sense of self-efficacy • Express empathy and acceptance • Provide new information • Identify client’s goals for health & well-being • “Just think about it”

18. Matching Intervention to Motivation Contemplation • Willing to consider a possibility of change • Contemplation is not commitment HOWEVER • Ambivalence can keep client stuck

19. Matching Intervention to Motivation Contemplation • Anticipate obstacles to change • Work on enhancing coping skills and self-efficacy • Small steps toward change and commitment • Cost-Benefit Analysis of behavior and of change • Evaluate past attempts at changing behavior Goals: • Decrease ambivalence • Strengthen intention to change

20. Decisional Balance

21. Matching Intervention to Motivation Preparation • Commitment to stop/change doesn’t make it happen automatically • Assess strength of client’s commitment • Anticipate problems and pitfalls • Provide choices • Develop coping skills and specific action plan Goal: Take action

22. Matching Intervention to Motivation Action • Ready to implement plan • Use counseling as reinforcement of commitment • External support and motivator • Help increase self-efficacy • Can offer information about range of options for action and change • Monitor change Goal: Support action and change

23. Matching Intervention to Motivation Maintenance • Relapse prevention and coping • Recycle through stages Goal: Maintain new behaviors, continue positive change

24. Matching Intervention to Motivation • Recurrence/Lapse/Relapse • Encourage client to reenter change cycle and reinforce willingness to do so. • View recurrence as learning opportunity vs. failure. • Reinforce use of coping strategies (don’t use shortcuts). • Maintain supportive contact.

25. Basic Methods Open questions Affirmation Reflective listening Summary Miller & Rollnick, 2002

26. Open-ended questions • Open-ended questions are ones that require more than one word answers.  • “What are you planning to buy today at the grocery store?” • “Why is it that every time I talk with you, you seem irritated?” • “What is your favorite flavor of ice cream and why?”

27. Affirmations • Ways to point out the positive aspects of person • Behavior • Intention • Struggles • Thinking • Feelings • Traits, qualities • Affirmations are free • Used not nearly enough

28. Reflective Listening Client: “I know we made all these goals about my getting out and meeting people, but I’m just not comfortable around other people.” Worker: “Getting the support you need hasn’t been easy.” Broffman, 2011

29. Summary • Special form of reflective listening • Structure: • Indicate you’re about to summarize • Be selective • Note ambivalence and attend to change statements • Be concise! • End with invitation • Use to change directions or ask a key question Broffman, 2011

30. Eliciting Change Talk • Pushing the ambivalence envelope • Decisional balance between change and the status quo. • Disadvantages of the status quo. • Advantages of change. • Optimism about change. • Intention to change. Miller & Rollnick, 2002

31. Listen for Change Talk Broffman, 2011

32. Assessment Outline: Strengths • Support systems • Life Accomplishments • Recovery Experience • Employment/Job skills and training • Finances • Character Assets • Health

33. Brief Interventions • Focus on motivation is not counseling, skill training etc. • Once motivational decision is made - client may proceed to apply his or herown natural skills to accomplish change

34. Motivational Traps • Question – Answer Trap • Close ended questions – brief responses • Leading questions that address cm agenda • Active cm – passive client

35. Motivational Cycle: Case Manager vs. Client Action Maintenance Counselor/CM Lapse or Relapse Planning Client Contemplation Precontemplation

36. Motivational Traps • Question – Answer Trap:Solution • Use questionnaires to get specific information • Open ended questions followed by reflective listening • Avoid asking too many questions in a row (even open ended ones)

37. Motivational Traps • Confrontation-Denial Trap • Counselor through best intentions presents information to move client to awareness of their problem and its consequences and prescribes course of action too quickly • Client response: “ My problem isn’t that bad and I don’t really need to do all that”

38. Motivational Traps • Confrontation-Denial Trap • Natural result of client’s ambivalence. • In conflict over some awareness of need to change gambling and reluctance to give up hopes, fantasies, familiar behavior • If counselor argues for one side of the conflict, client will take opposing side

39. Motivational Traps It’s not that bad. It’s under control You have a Big Problem

40. Motivational Traps • Becomes win – lose dynamic • When confronted more forcefully, client can argue themselves out of any change at all in order to “win”

41. Motivational Traps • Confrontation – Denial Trap: Solution • How can the client “win” therapy • Listen • Empathic reflection • Elicit self-motivating statements

42. Motivational Traps • Labeling Trap • Labels can carry stigma • Can create power struggle • Client can feel trapped • Lead to confrontation-denial trap Difficult

43. Motivational Traps • Labeling Trap: Solutions • De-emphasize label • If client raises the issue can respond with reflection and reframing

44. Motivational Traps • Premature Focus Trap • Focusing on one issue as the problem while the client’s focus is on other issues • The Blaming Trap • Client’s sensitivity to being “blamed”

45. Difficult Clients:Client Resistance • Client resistance is a helper problem • Extent to which clients “resist” is strongly related to helper’s style • Resistance from the interpersonal interaction of helper and client • Means there is something helper can do about it

46. Difficult Clients:Styles of Client Resistance • Arguing • Interrupting • Denying • Blaming, Disagreeing, Excusing, Claiming impunity, Minimizing, Reluctance, Unwillingness to change, Pessimism • Ignoring • Misdirection, Inattention, No answer, Not responding

47. Responses to Avoid Never meet resistance head-on via • arguing, disagreeing, challenging • judging, criticizing, blaming • warning of negative consequences • persuading via logic or evidence • interpreting or analyzing reasons for resistance • confronting with authority • using sarcasm or incredulity *Remember the key is to Roll with the Resistance

48. Difficult Clients:Strategies • Shifting Focus • Going around barrier, taking a detour • Rolling with Resistance • Agreeing in part with resistance and slightly changing emphasis or focus • Emphasizing Personal Choice and Control • Reframing • Acknowledge validity of client’s observations while offering a new interpretation

49. Difficult Clients:Strategies • Self-Motivational Statements • Problem Recognition • Expression of Concern • Intention to Change • Optimism about Change

50. Difficult Clients: Strategies Eliciting Self-Motivational Statements • Evocative Questions • Cost-Benefit Balance • Elaboration • Describing Extremes • Looking Back • Looking Forward • Exploring Goals