Applying Motivational Interviewing to Pornography Addiction

1. Applying Motivational Interviewing to Pornography Addiction Jade Mangus LCSW AMCAP – Fall 2008

2. And Client Motivation is Greatly Influenced by the Counselor: • Clients’ motivation, retention and outcome vary with the particular counselor to whom they are assigned, especially with pornography • Counselor style strongly drives client resistance (confrontation drives it up, empathic listening brings it down) • That is, the counselor is one of the biggest determinants of client motivation and change

3. Ambivalence The Dilemma of Change

4. Stages of ChangeProchaska & DiClemente

5. Stages of ChangeProchaska & DiClemente 70% 20%

6. Research • Rory Reid “Assessing Readiness to Change among Clients seeking help for Hypersexual Behavior” (2007)

7. Reid, R. • Therapist assumptions about hypersexual clients • Techniques do not match stage of change, thus increases resistance

8. Reid, R. • “Data collected revealed 70 % of cleints who expressed an interest in receiving help with issues related to hypersexuality also had a high level of ambivelance about the changes they desired to make” (Reid, 2007)

9. Reid, R. • Those with hypersexual issues and ADHD were significantly more likely to be in the contemplation stage than participants presenting with alternative dx.

10. Reid, R. • “Clinicians should carefully assess motivation and readiness to engage in behavioral modification at the outset of tx” • Need to tailor interventions to match the stage of change that the clients are in

11. The Righting Reflex

12. When Worlds Collide 

13. When worlds collide • If------------How • Destination: Fargo

14. A taste of MI

15. A Change of Role • You don’t have to make change happen. You can’t • You don’t have to come up with all the answers You probably don’t have the best ones • You’re not wrestling You’re dancing

16. Motivational InterviewingA Definition • Motivational interviewing is • a person-centered, • directive • method of communication • for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

17. Eight Stages in Learning MI • 1. The spirit of MI • 2. OARS – Client-centered counseling skills • 3. Recognizing and reinforcing change talk (focus) • 4. Eliciting and strengthening change talk • 5. Rolling with resistance (focus) • 6. Developing a change plan • 7. Consolidating client commitment • 8. Shifting flexibly between MI and other methods Miller, W. R., & Moyers, T. B. (in press). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions.

18. Four General Principles • Express Empathy • Develop Discrepancy • Roll with Resistance • Support Self-Efficacy

19. Therapeutic Empathy • Empathy is not: • Having had the same experience or problem • Identification with the client • Let me tell you my story • Empathy is: • The ability to accurately understand the client’s meaning • The ability to reflect that accurate understanding back to the client

20. Empathy in Addiction Counseling • Counselors who show high levels of empathic skill have clients who are: • Less resistant • More likely to stay in treatment • More likely to recover • Less likely to relapse • Empathy is the single best predictor of a higher success rate in addiction counseling • Counselors who are in recovery themselves are neither more nor less effective than others

21. MI Principle 2Develop Discrepancy The person rather than the counselor should make the arguments for change

22. Change Talk • Change talk is client speech that favors movement in the direction of change • Previously called “self-motivational statements”

23. Preparatory Change TalkFour Kinds DARN • DESIRE to change (want, like, wish . . ) • ABILITY to change (can, could . . ) • REASONS to change (if . . then) • NEED to change (need, have to, got to . .)

24. Activating Change Talkreflects resolution of ambivalence • Commitment language (intention, decision, readiness) • Taking steps

25. How to Elicit Change Talk:MI Becomes Directive • Asking Evocative Questions • Using The Importance Ruler • Exploring the Decisional Balance • Elaborating • Querying Extremes • Looking Back / Looking Forward • Exploring Goals and Values

26. Responding to Change Talk • Reflecting • Elaborating • Summarizing • Affirming

27. How Motivational Interviewing is Directive • Selective eliciting questions • Selective reflection • Selective elaboration • Selective summarizing • Selective affirming

28. Change Talk • I think I could quit • I’ve got to do something about my masterbation • I’m probably gonna quit • I want to get my family back, and I can’t do that unless I stop.

29. Put it in reverse: Sustain Talk • I don’t see anything wrong with masturbation, it is natural. • I intend to keep looking at porn and no one can stop me • I don’t think I have to quit

30. Baiting the therapist • “Do I really need to quit?” • What does the therapist respond with?

31. The Evidence Base forMotivational Interviewingwith sexual Compulsivity and Addiction bibliography on www.motivationalinterview.org

32. Applying Motivational Interviewing to the Treatment of Sexual Compulsivity and Addiction Authors: Matthew J. Del Giudice a; Joshua Kutinsky aSexual Addiction & Compulsivity, Volume 14, Issue 4 October 2007 , pages 303 - 319

33. Matthew J. Del Giudice a; Joshua Kutinsky a the client-centered perspective of motivational interviewing offers significant advantages for establishing a therapeutic alliance with sexually compulsive and addicted individuals. Motivational interviewing conceives the client as an inherently capable person, and its specific techniques clearly support client autonomy and self-efficacy (Miller & Rollnick, 2002). In addition, the therapist practicing motivational interviewing functions as an unequivocally empathic and supportive presence. Although we still await research directly comparing motivational interviewing to other treatment approaches for sexual compulsivity and addiction, for the time being, we offer several case studies documenting effective use of motivational interviewing techniques from our recent clinical experience.

34. Research needed • MI has been statistically significant in the treatment of many addictions ( e.g. EtoH, gambling) • Experience has shown that usage of MI has greatly reduced time of treatment. • We need more research!

35. Change Talk and Sustain Talk Opposite Sides of a Coin

36. What is Resistance? • Behavior • Interpersonal (It takes two to resist) • A signal of dissonance • Predictive of (non)change • Highly responsive to counselor style

37. Sustain Talk • Desire for status quo • Inability to change • Reasons for sustaining status quo • Need for status quo • Commitment to status quo

38. Resistance Behaviors • Negating • blaming, disagreeing, excusing, minimizing, claiming impunity • Arguing • challenging, discounting, hostility • Interrupting • Ignoring

39. Responding to Sustain Talk and Resistance: Reflective Responses • Simple Reflection • Amplified Reflection • Double-Sided Reflection

40. Responding to Sustain Talk and Resistance: Other Responses • Shifting Focus • Reframing • Agreeing with a Twist (reflect/reframe) • Emphasizing Personal Control • Coming Alongside

41. MI vs. ConfrontationThe principal difference is in how the counselor responds to “resistance” Client (responding to feedback): I really don’t think it is that bad Confront: How can you sit there and tell me that it’s not that bad. Look at the evidence! MI: This surprises you. It’s not what you expected to hear.

42. When, in MI, do you give information and advice? With permission

43. Giving Information and Advice: 3 Kinds of Permission • The person asks for advice • You ask permission to give advice • You qualify your advice to emphasize autonomy

44. Giving Information and Advice • Get permission • Qualify, honoring autonomy • Ask – Provide – Ask • For suggestions, offer several instead of one

45. Web Sites • www.motivationalinterview.org • http://casaa.unm.edu