Functional Analyses Motivational Interviewing and the Stages of Change

1. Functional AnalysesMotivational Interviewing and the Stages of Change

2. Learning Objectives • -Use motivational interviewing techniques in assessing functional deficits • -Assess the client’s stage of readiness to • change specific identified deficits • -Develop appropriate CPRP interventions based on the identified deficit and the client’s stage of change

3. Who are we? • Jamie Smith, MEd, CCDP-D, PLPC • CPRP Supervisor for Pathways CBH, Inc. in Jefferson City, MO • Supervise the IDDT team within the CPRP

4. Who are we? • Who are you? • Where do you work? • How long have you worked there? • What do you want to get out of this training?

5. Clients in the CPRP What is CPRP? Community Psychiatric Rehabilitation Program 2 Criteria for Client Admission Qualifying Diagnosis Deficit in Functioning

6. Clients in the CPRP Functional Deficit • Activities of Daily Living • Social Role Functioning (Social involvement, social engagement) Qualifying Diagnoses • Schizophrenia and other Psychotic Disorders • Bipolar Disorders and MDD, Rec • Anxiety Disorders • Borderline PD

7. An Important Distinction Constellation of Symptoms Symptoms are the specific characteristics of the illness Qualifying diagnosis A diagnosis is the name of an illness composed of a constellation of symptoms that a client expresses.

8. An Important Distinction For Example We say a client’s depression has worsened or improved. What symptoms of depression indicate a change?

9. An Important Distinction Listed Symptoms of Depression Include: Depressed Feeling Lack of Motivation Crying Spells Guilt Sleep Disturbance Appetite Disturbance Deficit in Functioning in Imporant Areas of Life

10. An Important Distinction 2 Reasons why understanding the distinction is important: • Helps us to create specific objectives in treatment planning: “John will experience an improvement in symptoms of depression.” “John will sleep 8 hours at night 5 of 7 nights in a week.” Understanding specific symptoms can help us create more measurable objectives.

11. An Important Distinction 2 Reasons why understanding the distinction is important: 2. The function of symptoms: some symptoms actually are coping mechanisms. Will discuss later in the presentation

12. Functioning is what sets our clients apart. Wise Words “Our clients aren’t just ill, but their illness interferes with their ability to do things that most people take for granted.” Marti Frazier CPRP Director Central Region

13. Deficits in Functioning The question is not: “Do they have a deficit in functioning?” The question is: “Why do they have a deficit in functioning?”

14. Deficits in Functioning:Daily Living Skills • Some Examples: • Budgeting Skills • Cognitive deficit caused by MI • Lack of emotional regulation to handle money • Never learned the skill of money management due to social circumstances growing up

15. Deficits in Functioning:Daily Living Skills • Some Examples: • Making a phone call: • Client is anxiety driven • Client cannot read to look up the phone number • Client was told to never contact that location again

16. Deficits in Functioning:Daily Living Skills • Some Examples: • No Transportation: • Physical Disability • Off the bus line • Anxiety driven • Narcissistic Personality Disorder

17. Deficits in Functioning:Daily Living Skills • Encompasses but is not limited to: • Self Care • Personal Hygiene, Chronic Physical Illness (Diabetes, HBP, COPD), Maintaining sufficient food, housing, clothing • Activities of Daily Living • Maintenance of home cleanliness, correspondence, mobility, communication skills • Finances • Access to Community Resources

18. Deficits in Functioning:Social Role Engagement The often forgotten reality of our clients.

19. Deficits in Functioning:Social Roles • Who do you turn to when you need help? • Family • Friends • Work Associates • Church • Fill in the blank of NATURAL and COMMUNITY SUPPORTS

20. Deficits in Functioning:Social Roles • We get our clients set up with housing. • We show our clients where to access food pantries and utility assistance. • We teach our clients a better way to budget their finances. • And we help them learn some basic anxiety reduction skills. • Then we leave them, sitting in their apartment alone in “maintenance level of care.”

21. Deficits in Functioning:Social Roles • Many of our clients have isolated themselves from NATURAL SUPPORTS • Family has been overwhelmed by symptomatic behavior • Unable to make or maintain friendships • Employment? • Church community..many have had bad experiences

22. Deficits in Functioning:Social Roles • Ability to engage in social activity is limited Again, the question is not if there is a deficit in social functioning, but if so, why.

23. Functional Skills Assessment Beginning the Process

24. Functional Skills EvaluationContent vs. Process Content The what’s, when’s, how’s, where’s, and who’s of the client’s life. Process This is the treatment that the client receives or, better, The rehabilitation that the client experiences

25. Functional Skills Evaluation Understanding that treatment is a process of change is immensely important. It is a process in which we Empathize and Collaborate with and Affirm the client. The FSE, which occurs at the beginning of treatment (or in the annual review) is not just to gather content, but is the beginning of the treatment process.

26. Functional Skills Evaluation • If we’re going to do an “Evaluation” or “Assessment”, we need to get away from asking “yes” and “no” content questions. • Do you answer the phone when someone calls? • Are you able to sort your mail? • Have you been evicted or been forced to move in the last 12 months?

27. Functional Skills Evaluation These questions don’t tell us anything about our clients. Or, what’s worse: We answer these “yes” and “no” questions for our clients, without ever speaking to them. Then all we know is what WE THINK about our clients.

28. Functional Skills Evaluation Research indicates that more important than any intervention, strategy, or theory of the provider AND more important than any deficit, characteristic, or illness of the patient is…

29. Functional Skills Evaluation THE RELATIONSHIP BETWEEN THE PROVIDER AND THE CLIENT.

30. Functional Skills Evaluation Using the Functional Skills Assessment as a means of building relationship: The tools of Motivational Interviewing are strategies for building that relationship and for beginning the process. OARS with Evoking Change Talk

31. Fuctional Skills Evaluation • OARS • Open Ended Questions • Makes the client feel you are truly interested • Rule of Thumb, never ask 3 open ended questions in a row • Affirmation of the Clients • Every client has something good about them • Reflective Listening • Seeing the world with the client’s eyes • The client feels as if he/she has been truly understood • Summarizing • The white boxes are your friends

32. Functional Skills Evaluation • Evoking Change Talk • Ask evocative Questions • Explore disadvantages of status quo, advantages of change, optimism about change, intention to change • Use rating questions with follow up for change • “What would it take to move you from a ___ to a ___?” • Elaboration • Tell me about the problems you had with ___.” • Query Extremes • “What do you think will happen if you don’t do…?” • Explore goals and values • Look for discrepancy between client’s core values and goals and client’s behaviors.

33. Functional Skills Evaluation The TRAP of “knowing” our clients: Building a box to put them in Defining their needs for them Not doing REHABILITATION work because we’ve decided they’ve reached their highest potential.

34. Stages of Change An Essential Element in the Evaluation

35. Stages of Change Origin Developed during research with smokers who were trying to quit smoking. They’ve been found to be universally applicable to processes of change in many areas of life. Powerful tool that helps refine our interventions.

36. Stages of Change • Defined: 1. Precontemplative: Client is not yet considering change 2. Contemplative: Client acknowledges concerns and is considering the possibility of change, but is ambivalent and uncertain

37. Stages of Change Defined cnt’d: 3. Preparation: Client is committed to and planning to make a change in the future, but is still considering what to do. 4. Action: The client is actively taking steps to change but has not yet reached a stable state in new habits, skills, etc.

38. Stages of Change Defined cnt’d: 5. Maintenance: The client has achieved initial goals, is stable in recovery/management habits, and is working to maintain gains.

39. Stages of Change Recurrence or Relapse: “The 6th Stage” Defined as: The client has experienced a recurrence of symptoms/behaviors and must now cope with consequences and decide what to do next.

40. Stages of Change Recurrence/Relapse • Is considered part of the process rather than a moral fault of the individual. • Can occur at any point once the client has begun to implement change.

41. Stages of Change A Person can be in 2 different stages of change at the same time. • The person who does not acknowledge that she has schizophrenia but is wanting to go to work. • The person who knows he needs to stop drinking alcohol, but the weed really helps him stay calm.

42. Stages of Change Interventions shown appropriate for each stage of change: 1. Precontemplative stage: • Explore events that led client to treatment • Eliciting client’s perceptions of the problem • Offering information about MI • Personalized feedback of assessments • Family/Significant Others interventions • Examining intrapersonal and interpersonal discrepancies

43. Stages of Change: Interventions 2. Contemplation • Normalize Ambivalence • Elicit and weigh pros and cons of change • Examining further values and goals in relationship to change • Emphasize client’s free choice, responsibility, and self-efficacy • Elicit Change Talk • Summarize Change Talk

44. Stages of Change:Interventions 3. Preparation • Clarify client’s goals/strategies for change • Offer a menu of options for change or treatment • Negotiate a change plan and/or behavior contract • Consider and lower client’s perceived barriers to change • Increase sense of self-efficacy • Set a start date for a specific change

45. Stages of Change:Interventions 4. Action • Reinforce the importance of the changes using client’s own words • Support a realistic view of change through small steps • Help the client learn/practice coping strategies • Develop a relapse/recurrence prevention plan • Help the client find reinforcers for positive change • Help the client find natural and community based supports

46. Stages of Change:Interventions 5. Maintenance • Continue to help client find new reinforcers for change • Affirm the client’s resolve and self-efficacy • Help the client continue to learn new coping strategies • Maintain supportive contact • Renew relapse/recurrence prevention plan • Review long-term goals with client

47. Stages of Change:Interventions In case of Relapse/Recurrence: • Help the client reenter the change cycle as quickly as possible • Explore the meaning and reality of the relapse as a learning experience • Help the client learn/practice alternative coping strategies • Maintain supportive contact

48. Stages of Change An Important Concept to Remember: Function of Symptoms

49. Function of Symptoms What does that mean? What we call symptoms may be socially learned mechanisms that the person has learned in order to survive. Implications?

50. Function of Symptoms If we step in with an intervention to remove what we have determined is a symptom, the client may not want to change because that “symptom” is actually securing something for them. We then need to provide a means for them to obtain their goal that is less self-destructive.