Advanced Motivational Interviewing

1. Advanced Motivational Interviewing Theodore Godlaski Associate Clinical Professor Emeritus College of Social Work University of Kentucky

3. SPIRIT OF MI MI SPIRIT Miller, W.R. & Rollnick, S (2013) Motivational Interviewing: Helping People Change (3rd ed.) New York: The Guilford Press.

4. Partnership • It is not something done by an expert to a passive recipient, a teacher to a student, a master to a disciple. • It is not something done “to” or “on” someone. • It is a collaboration between two experts. • It is done “for” and “with "a person. • It is not wrestling, it is dancing. • Avoid the “expert trap” and the “righting reflex”. • “This partnership aspect of MI Spirit bespeaks a profound respect for the other. In a way, the MI practitioner is a privileged witness to change; and the conversation is a bit like sitting together on a sofa while the person pages through a life photo album. You ask questions sometimes, but mostly you listen because the story is the person’s own. Your purpose is to understand the life before you, to see the world through this person’s eyes rather than superimposing your own vision”.

5. FOUR ASPECTS OF ACCEPTANCE “To see a person as he is, to be aware of his unique individuality. Respect means that the other should grow and unfold as he is. Eric Fromm “To seek and acknowledge the person’s strengths and efforts. As with worth, autonomy, and empathy, this is not merely a private experience of appreciation, but an intentional way of being and communicating.” William Miller absolute worth affirmation acceptance autonomy “We who lived in the concentration camps remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: . . to choose one’s attitude in any given set of circumstances, to choose one’s own way.” Viktor Frankl “To sense the client’s inner world of private personal meanings as if it were your own, but without ever losing the ‘as if’ quality.” Carl Rogers accurate empathy

6. Evocation • Much of professional consultation is based on a deficit model, that the person is lacking something that needs to be installed: knowledge, insight, diagnosis, wisdom, reality, rationality, or coping-skills. • Evaluation especially is focused on detecting deficits that require correction through professional expertise. • The Spirit of MI starts from a strengths focused premise: that people already have within them much of what is needed to resolve their ambivalence about change. • It is the role of the counselor to call forth (literally in Latin evocare) those resources that are already there; like drawing water from a well. • “This spirit of evocation fits well with the concept of ambivalence People who are ambivalent about change . . . already have pro-changes voices on their internal committee, their own positive motivations for change. These are likely to be more persuasive than whatever augments you might be able to provide. Your task, then, is to evoke and strengthen these change motivations that are already present.”

7. COMPASSION • It is not sympathy or identification. • It is a virtue: a habit of mind and/or will. • It is that habit of mind which inclines us to intelligently understand the experience (suffering) of another from his/her point of view and the habit of will which inclines us to seek the good of that other. • In many ways it is a kind of aspect of love because it prompts to a commitment to pursue the welfare and best interest of others. • It is critical to the Spirit of MI because the other three elements (partnership, evocation, and acceptance)can be practiced in the pursuit of self interest. • “To work with a spirit of compassion is to have your heart in the right place so that the trust you engender will be deserved.”

8. There is a developmental process for cultivating compassion for others . . . The first step is knowledge . . . Then you need to constantly reflect and internalize this knowledge . . . To the point where it will becomes a conviction. It becomes integrated into your state of mind . . . Then you get to a point where it becomes spontaneous. The Deli Lama & Ekman, P. (2008)Emotional Awareness. New York: Times Books, pp. 156-157

9. Principles of Person Centered Care • Our services exist to benefit the people we serve. • Change is fundamentally self-change. • People are the experts on themselves. • We don’t have to make change happen. • We don’t have to come up with all the good ideas. • People have their own strengths, motivations, and resources that it is vital to activate in order for change to occur.

10. Principles of Person Centered Care • Therefore change requires a collaboration of expertise. • It is important to understand the person’s perspective on the situation, on what is needed, and how to accomplish it. • Change is not a power struggle whereby if change occurs I “win”: not wrestling but dancing. • Motivation for change is not installed, it’s evoked: it’s already there and just needs to be called forth. • We cannot revoke people’s choice about their own behavior. People make their own choice about what they will and will not do, and it is not a change goal unless the person adopts it.

11. The Process Action Planning Evoking Focusing Engaging

12. Engaging (the establishing of a mutually trusting and respectful helping relationship) • How comfortable is this person in talking to me? • How supportive and helpful am I being? • Do I really understand this person’s perspective and concerns? • How comfortable do I feel in this conversation? • Does this feel like a collaborative partnership?

13. Focusing • What goals for change does this person really have? • Do I have different aspirations for change for this person? • Are we working together with a common purpose? • Do I feel like we are moving together, not in different directions? • Do I have a clear sense of where we are going? • Does this feel more like dancing or wrestling?

14. Evoking • What are this person’s own reasons for change? • Is any reluctance more about confidence or importance of change? • What change talk am I hearing? • Am I moving too far or too fast in a particular direction? • Is the “righting reflex” pulling me to be the one arguing for change?

15. Planning • What would be a reasonable next step toward change? • What would help this person to move forward? • Am I remembering to evoke rather than prescribe a plan? • Am I offering needed advise or information only with permission? • Am I retaining a sense of quiet curiosity about what will work best for this person?

16. Action • Am I remembering to affirm this person’s actions even if they are not totally successful? • Am I comfortable with incremental change? • Do I offer suggestions only with permission and in a way that allows this person to make the choice of which actions to take? • Do I genuinely recognize how difficult change can be and do I admire this person taking actions to change? • Have I remembered to assist this person in maintaining a sense of self efficacy and continue to explore ambivalence throughout the change process?

17. Two Kinds of Talk • Change Talk • Moves the individual in the direction of change. • Preparatory Change Talk • Mobilizing Change Talk • Sustain Talk • Keeps the individual where they are • If there is more Sustain Talk than Change Talk or an equivalent amount of both, the individual is not likely to change. • If there is more Change Talk than Sustain Talk, The individual is likely to change. • It is not that one is good and the other bad – they are just expressions of the individual’s ambivalence.

18. Preparatory Change Talk • Desire • “I want to. . .” “I would like to . . .” “I wish I could . . .“ “I hope to…” • Ability • “I can . . . “ “I am able to . . .” • “I could . . .” “I would be able to . . .” • Reasons • “I could accomplish more.” “I would feel better.” “I might live to see my grandchildren.” • Need • “I need to . . .” “I have to . . .” “I must . . .” “I can’t keep on like this.”

19. Mobilizing Change Talk • Commitment • “I will . . .” “I promise . . .” “I swear. . . “ “I guarantee . . .” “I give you my word . . .” • Activation • “I am willing to . . .” “I am ready to . . .” I am prepared to . . .” • Taking Steps • “I went to an AA meeting.” “I flushed all my pills.” “I asked someone to be my sponsor.” • These are not an exclusive list of all possible Change Talk. The key is to listen for any language that signals movement toward change and then to ask “Tell me more.”

20. Mobilizing Change Talk Preparatory Change Talk Thinking Planning Action

21. Sustain Talk • Desire • “I just like the way it makes me feel.” “I don’t want to . . .” • Ability • “I’ve tried but I can’t quit.” “My health will be just fine.” I can manage without any help.” • Reasons • “Pot helps me relax.” “Without it I can’t have any fun.” • Need • “I couldn’t get through the day without using.” “If I don’t drink, I can’t sleep.” • Commitment • “I’m going to keep on using.” “I’m not going to any more of those stupid meetings.” • Activation • “I’m prepared to accept the risks.” “I’m just not willing to do what it takes.” • Taking Steps • “I started using again and I feel OK.” “I stopped at the bar on Friday night and it felt great.”

22. An Interesting Side Bar • Neuroimaging studies have shown that among alcohol misusing individual, spontaneous Sustain Talk, activates several key reward pathways while spontaneous Change Talk does not. • Feldstein, Martin, Houck, et al. (2011) How psychological alcohol interventions work: A preliminary look at what fMRI can tell us. Alcoholism : Clinical and Experimental Research, 35 (4):643-641 • Concordant and strongly affiliated relationships also activate reward pathways while discordant and conflicted relationships do quite the opposite. • Boyatzis, Passarelli, Koenig, et al. (2012) Examination of neural substrates activated in memories of experiences with resonant and dissonant leaders. Leadership Quarterly, 23 (2): 259-272.

23. Percent Change Talk and Sustain Talk Vary with Counselor Approach Glynn & Moyers (2010) Chasing change talk: The clinician’s role in evoking client language about change. Journal of Substance Abuse Treatment, 39: 65-70

24. Asking Evocative Questions • Desire: want, wish, and like • “How would you like things to change?” “ Tell me about what you don’t like about how things are now.” “How would you wish your life to be different a year from now?” “ What do you want our work together to accomplish?” • Ability: what can you do, what are you able to do, what could you do • “What kinds of things do you think you might be able to change?” Any ideas about what you can do to change that?” “Of the options you’ve considered, which seems most possible for you to do?” • Reasons: why, what • “Have you thought of any reasons why you might want to change?” “What are some of the advantages of not doing drugs?” • Need: needs, important, urgent, has to, must • “What needs to happen?” How important is it for you to change?” “How serious or urgent does this feel to you?” “Complete this sentence” “I really must________’”

25. Asking About Extremes • “What concerns you most about your drinking in the long run?” • “Suppose you continue using drugs as you have. What do you imagine are the worst thing that could happen?” • “How much do you know about the kinds of things that can happen if you continue to drink during your pregnancy, even if you don’t think they will happen to you?” • “What do you think might be the best results if you do make this change?” • “If you are completely successful in making the changes you want, how would things be different?” • “Imagine that you succeed in doing this. What might be some good things that could come out of that?”

26. Looking Back • “Do you remember a time when things were going well for you? What has changed?” • “What were things like before you started using drugs? What kind of person were you?” • “How do you think your drinking has changed you as a person or stopped you from growing or moving forward?” • ‘Imagine that you never started drinking and doing drugs when you were 14, what would your life be like now?”

27. Looking Forward • “If you did decide to make this change, what do you hope would be different in the future?” • “Tell me, how would you like things to turn out for you in five years? What kinds of choices would you need to make to increase the chances that it would happen?” • “If you could take two weeks off from your problem, what would you do first?” • “Suppose you don’t make any changes, but continue as you have been, what do you think your life will be like five years from now?” • “Given what has happened in your life so far, what do you expect might happen if you don’t make any changes?”

28. Asking About Values and Goals • “If you don’t mind, can you tell me what are the most important things to you as a person?” • “What kind of person would you like to be?” • “What would you like to accomplish in your life?” • What you are looking for are discrepancies between the individual’s values or goals and present behavior. • If such questions evoke discord or defensiveness, don’t press it. The client’s responses are more important than following through on any procedure.

29. Asking For Elaboration • When you hear Change Talk, ask for elaboration. • “Can you tell me more about that?” • “Can you help me understand what you mean by that?” • “In your own mind, what does that look like?” • This is probably the most straightforward way of evoking Change Talk.

30. Adapted fromProchaska, J.O. & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, & Practice, 19, 276-288.

32. Evoking Naturalistic Skills • The best way to assist a person who is taking action to change or sustaining change is to evoke their own skills in the service of change. • “In the past, did you ever deal successfully with a serious problem?” <<pause>> “Tell me about it.” • “In thinking about your current problem, is there anything that comes to mind about how you might make a difference?” • Clinician: “You might be thinking of change as one huge thing that you have to accomplish all at once. Please allow me to ask you, of all the problems we have discussed, which is the worst?” Client: “The problem with my wife.” Clinician: “OK, on a scale of 1, which would be no real problem at all, to 10, which would be the worst problem imaginable, how big a problem is it?” Client: “ I think about 7.” Clinician: “ Is there anything you can think of doing that might make it a 5?”

33. Making Suggestions • If someone has never undertaken a specific change, there is no reason to think they should know everything that might be helpful. • Always ask permission. • Offer your suggestion in the form of a menu. • Ask if any of the possible choices seems like something they might want to try. • “I get the sense that you feel kind of stuck right now. Would you be open to a suggestion?” <<pause>> “I’ve found that when people stop using drugs they can go through a time when they feel very tense and eggy. Do you think that’s the case with you?” <<pause>> “In working with people, I’ve found that learning to do some relaxation exercise or learning some breathing exercises that increase heart rate variability or starting an exercise program can help. I could explain these further if you like and you can decide if any of them might be something you want to try. Is that something that you would like me to do?”

34. Setbacks • The term “relapse” implies that there are only two possible states: perfection or relapse. • Setbacks occur most often because of an unexpected or unanticipated event: an unexpected visitor, an accident, a loss, unexpectedly strong craving, a significant change in lifestyle, etc. • It is best to reframe these not as failures that take the individual back to square one, but as opportunities to expand and strengthen recovery. • Explore with the individual the circumstances and the situations that surround the setback. • What do these indicate in terms of new plans or new actions to prevent future problems. • Remember that significant changes in lifestyle almost always present unanticipated consequences and pose new problems.

35. Supporting Persistence • Sometimes individuals become so focused on present problems that they forget past progress and successes. • “Would you be willing to think back how you were just before we met and how you are today. Is there anything that occurs to you?” • Summarize the changes you have observed over time, be liberal with affirming the progress the person has made. • Replanning • “What next?” “What now?” “What else?” • Resist the “Righting Reflex” or slipping into a directive style.

36. Supporting Persistence • If the individual is struggling with practical issues and becomes demoralized, switch to the hypothetical • “Suppose you did succeed and, and were looking back on it now. What most likely would have worked? How did it happen?” • “Clearly you seem to feel discouraged maybe even demoralized about this. So use your imagination: if you were to try again, what might be the best way to try?” • “If it’s OK with you, I’d like to ask you to do something between this session and our next. I would like you to imagine it’s 5 years from now and you have succeeded in making the changes you want to make. Write a letter to yourself from your future. Can you imagine that? Offer some words of encouragement from this future, wiser self and write about how you managed to accomplish this change.”

37. Supporting Persistence • Reminding • This is a re-evoking of the reasons for change and a re-commitment to the process of change. • “Is this still what you want (need, choose) to do?” • “Let me see of I can remember the reasons you gave me for making this change, and tell me whether these things are still important to you.” • If changes are not occurring as quickly as the individual wants or they have experienced some setbacks, it can erode a sense of self-efficacy. • “You have always impressed me as a capable individual. Maybe you might try a little more ‘easy does it’ kind of approach and relax into some of these changes. What do you think?”

38. Supporting Persistence • Refocusing (often a good way to start each session) • All our lives are dynamic and constantly changing. • What was a priority yesterday might not be a priority today. • Efforts to change may reveal more pressing or underlying concerns that require attention. • Be sensitive to changing priorities. And determine whether the focus of your work together is the same or needs to be redefined. • It is the client’s irrevocable domain to decide what kind of change (if any) to pursue. • The point is to make the person’s autonomous choice conscious and explicit, without blaming or shaming, but recognizing and honoring the person’s power of choice.

39. Supporting Persistence • Refocusing (continued) • As individuals move from establishing initial change to sustaining change, It is most often important to focus on broader goals. • Goals that establish change are generally substitutive goals: substituting a behavior that advances change for one that sustains unwanted behavior. • Goals that sustain change are often broader goals that enhance life and make it more manageable. • “You have really done well with making changes in your life: you’ve stop using drugs and drinking, have developed a better relationship with your wife and children, and have a job you like. I wonder, are there other thigs that you might like to change like dealing better with your finances, or better coping with interpersonal conflict, or managing unpleasant internal feelings like anger and boredom?” • Another approach is to spend part of every session asking the individual if they have had any experiences over the past week that upset them or made them uncomfortable. Ask if they can think of anything they might have done that would have made the situation worse. Then ask if they can think of anything that might have made the situation better.

40. Supporting Persistence • Reengaging • Note that nothing much can happen in therapy without engagement. • Engagement is the establishing of a mutually trusting and respectful helping relationship. • From the clients point of view: • Do I feel respected by the counselor? • Does he/she listen to me and understands me? • Do I trust this person? • Do I have a say in what happens in this consultation? • Am I being offered options rather than a one-size-fits-all approach? • Does he/she negotiate with me rather than dictate to me?

41. Supporting Persistence • Reengaging (continued) • It’s not a bad idea to end every session by asking about the items in the previous slide: • “During this session did you feel respected?” • “Do you fell that during this session I listened to you and tried to understand what you were saying?” • ”Do you feel comfortable enough with me to trust me?” • “Do you feel that during this session you were a participant, that you had a say in what we talked about?” • “Do you feel that I offered you options to choose from rather than dictated to you what you needed to do?”

42. Supporting Persistence • Let the individual know that your relationship is important to you, that it is more than a job. • “ How are things between you and me right now?” • If a client misses an appointment, get in touch to renew contact: phone them or use some other means of contact. • After the period of consultation has ended, contact the individual to see how they are doing • 3 to 6 months after the first visit is the best time.

43. An MI PrayerWilliam Miller Guide me to be a patient companion: to listen with a heart as open as the sky. Grant me vision to see through his/her eyes and eager ears to hear his/her story. Create a safe and open mesa on which we may walk together. Make me a clear pool in which he/she may reflect. Guide me to find in him/her your beauty and wisdom, knowing your desire for him/her to be in harmony: healthy, loving, and strong. Let me honor and respect his/her choosing of his/her own path, and bless him/her to walk it freely. May I know once again that although he/she and I are different, yet there is a peaceful place where we are one