IMR Booster Training April 30 th 2007

1. IMR Booster TrainingApril 30th 2007 Tim Gearhart MSW Alan McGuire MS

2. Tentative Agenda 9am-noon • Spirit of MI • OARS • Elliciting Change Talk • Responding to Change Talk • Responding to Resistance 1p-4p

3. Spirit of Motivational Interviewing • “Words without the music”. • Spirit + OARS = close but not quite MI • Docere – Expert • Ducere – Calling forth that which is already there. • Acceptance • “The curious paradox is that when I accept myself just as I am, then I can change.” Carl Rogers

4. What MI is Not p. 21 • Ask Questions: Why haven’t you made the change? What is in the way? • You should change because... • It’s important for you to change because… • If you don’t change…will happen. • You could make the change by… • I’m sure that you will make this change because…

5. Favorite Teaching Exercise • Why were they your favorite? • What characteristics did they have that you admired?

6. Exercise • Rules: No giving advice. Just listen. • 1. Why would you want to make this change? • 2. If you decided to do it, how would you go about it? • 3. What are the 3 best reasons to make this change? • 4. From 0 – 10 how important is this to you? Why not 0? • 5. Provide a summary statement. • 6. So what do you think you’ll do?

7. Thomas Gordon 2. What the speaker says. 3. Words the listener hears. 1. What the speaker means. • 4. What the listener thinks the speaker means.

8. Exercise 1: Hypothesis Testing 42 • Cl: “One thing I like about myself is that…” • T: “Do you mean…” • Cl: “Yes/No”

9. Types of Reflective Statements • 1. Repeating: restating what the speaker said. • 2. Rephrasing: slightly rephrase what was offered. • 3. Paraphrasing: continuing the paragraph or inferring meaning. • 4. Reflection of feeling: a paraphrase that emphasizes the emotional dimension via metaphors.

10. Exercise 2: Forming Reflections • Cl: “One thing about myself I’d like to change…” • T: responds only with reflective statements. Questions are not allowed. • Cl: elaborates following the reflection.

11. OARS • Open ended questions. • Affirmations. • Reflections. • Summaries.

12. Open or Closed Questions? • Is this an open or closed ended question? • Do you want to stay in the system forever? • What are the important reasons to make this change? • If you were less depressed how would life look differently? • In what way does this concern you?

13. Change TalkChapter 7 of 2nd addition • “It is the truth we ourselves speak rather than the treatment we receive that heals us.” O. Hobart Mowrer • The more one makes statements utilizing change talk, the more likely they will make a change (Amrhein et al) • Given this information, what should our goal be as clinicians?

14. Types of Change Talk • D – Desire (ex. “I’d really like to …”) • A – Ability (ex. “I think I could change if…”) • R – Reason (ex. “I should try because…”) • N – Need (ex. “I need to change because…”) • C – Commitment (“Do you take this woman to be your lawfully wedded bride?) • Change talk is preparatory language to commitment language.

15. How to Elicit Change Talk • OARS • Asking Evocative Questions • Using the importance ruler • Exploring the decisional balance • Looking Back/Forward • Exploring Goals and Values

16. DARN C Exercise:

17. Responding to Change Talk • Reflect it • Ask more about it • Affirm it • Summarize it (bouquet's)

18. Responding to Resistance • Simple reflection: acknowledge the person’s disagreement, feeling, or perception. • Amplified reflection: reflect back in an exaggerated form • Double-sided reflection: acknowledgment + adds to the other side of ambivalence

19. Cont… • Shifting focus: diverting the focus • Reframing: validate and build new meaning • Agreeing with a twist: (reflect/reframe) • Emphasize personal control • Coming alongside: (therapeutic paradox) recommend that they continue the behavior or even increase it. Need to be done non-manipulatively.

20. How does all of this relate to IMR? • Lots of opportunity to explore interest/motivation in changing specific behaviors. • Assists in developing meaningful goals. • The Spirit of MI is consistent with the values of Recovery.

21. Giving advice or going over material. • ASK: Prior to getting into the material you should make sure that you have the permission of the client. • TELL: Work through some material. • ASK: What do you think about that?

22. Exercise RoleplayCl. Didn’t complete hmwk.? • Team Consult Role Play • Demographics • Life situation • Target Behaviors • Reasons to change • Agree to be a 5 on importance/confidence

23. Cognitive-Behavior Techniques for IMR Alan McGuire MS, Tim Gearhart MSW ACT Center of Indiana

24. Scope & Goals • CB Techniques vs. CBT-P • Why all the SZ? • Applied to IMR • A little hx/philosophy • Tools • Your goals

25. Definition and History

26. Definition of CBT • A broad set of approaches to improving adaptive and emotional functioning based on theories of learning and behavior change.- Penn, 2006

27. Brief History • Early Therapy Research • Psychoanalytic • Unsuccessful • Hiatus • Problem/Symptom focus

28. CBT-P Onslaught! Gould, R. A., et al., (2000). Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 48, 335-342. Penn, D. L., Waldheter, E. J., Mueser, K. T., Perkins, D. O., & Lieberman, J. (2005). Psychosocial treatment for first episode schizophrenia: A research update. American Journal of Psychiatry, 162, 2220-2232. Pilling, S. et al. (2002). Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763-782. Rector, N. A., & Beck, A. T. (2001). Cognitive therapy of schizophrenia: A quantitative review. Journal of Nervous and Mental Disease, 189, 278-287. Tarrier, N., & Wykes, T. (2004). Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale? Behaviour Research and Therapy, 42, 1377-1401. Turkington, D., Kingdon, D., & Weiden, P. (2006). Cognitive behavioral therapy for schizophrenia. American Journal of Psychiatry, 163, 365-373. Zimmermann et al. (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77, 1-9.

29. Research Conclusions •  Positive & Negative Sx • Effects increase in follow-up •  Dropout Rates •  Time to Hos. Release • Subjects • Med Resistant • Acute Psychosis • Severity  Outcome

30. Theoretical Foundations • Basic Learning Theory • Cognitive Theory

31. Basic Learning Principles • Classical conditioning (learning by association) • Operant conditioning (learning by consequences) • Social learning (learning by observation)

32. The Cognitive Model • Most people: • Actuating event Consequence • ABC Model • Actuating eventBelief Consequence • “ABC Model”

33. CBTechs in IMR

34. “Cognitive-behavioral techniques involve the systematic application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.” -IMR Workbook

35. Importance of Approach • “The general approach is concerned with understanding and making sense, working to achieve collaboration between the person … and the therapist, rather than didactic, interpretative, or confrontational styles.” • -Garety, Fowler, and Kuipers (2000)

36. Basic Clinical Skills • Active listening (exercise) • Non-verbals • Empathy statements (exercise) • You feel _____ because ____

37. Targets of CBT • Positive Sx • Hallucinations • Delusions • Negative Sx • Depression/Anxiety • Relapse Prevention

38. Dealing with Sx • Important to consumer? • Relevant to Goal • + Sx • Cognitive Flexibility •  Distress • ‘Work within’

39. The Tools • Reinforcement • Modeling/role-play • Relaxation Training • Cognitive Restructuring • Challenging Delusions* • Activity scheduling* • Shaping

40. Reinforcement • Positive Reinforcement • Examples? • Negative Reinforcement • Examples? • Why not extinction/punishment?

41. Modeling • Explain what your modeling • Model • Elicit feedback • Model Modeling

42. Role-play • Who uses? How? • Barriers to role-play? • Advantages? • Points to remember • Combine w/ Modeling • Positive feedback

43. Relaxation Training • Helps people learn techniques for reducing tension • Breathing • Progressive muscle relaxation • Guided imagery

44. Relaxation Tips • What does consumer use now? • Incorporate relaxation techniques into the daily routine • Make a relaxation tape • Practice, practice, practice • Help person set up a specific plan to practice

45. Cognitive Restructuring • Connection between thoughts and feelings (ABC) • Use for: • Affective Sx • Deal with psychotic Sx • Steps • Teach the idea • Assess connections • Change thoughts/beliefs

46. Teaching the connection • Explain ABC • Automatic thoughts

47. Automatic thoughts • All or nothing thinking • “Must,” “should,” or “never” statements • Overgeneralization • Catastrophizing • Mind-reading • Emotional reasoning • Disqualifying the positive • Personalization

48. Assessment • Thought record • Mood record • Downward arrow

49. Thought Record • SEE HANDOUT • This requires the client to record: • The event • Emotions (type and degree [1-100]) • ATs (type and belief [1-100]) • Rational Response (type and belief [1- 100]) • Outcome (Re-rate belief in ATs and emotion)

50. Mood Record • Choose emotion • Track for week • ~3-4x per day • 1-10 on intensity • Review • Trends • What was going on then?