Counseling and Motivational Interviewing By Dr Mwiya L. Imasiku

Part 1 Counselling

*Definition of CounselingTherapeutic relationship between counsellor and client that leads to growth, change, healing, autonomy, and care for oneself and others

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CHALLENGES OF HELPERS

Dealing with difficult clients Dealing with resistant clients Dealing with clients who think they know everythingDealing with clients in denial that they have a problem

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EFFECTIVE NON-VERBAL BEHAVIORS OF HELPERS

S: Squarely look at the clientO: Maintain an open postureL: Slightly lean toward the clientE: Maintain an appropriate eye contactR: Not being tensed but relaxed

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EFFECTIVE ATTENDING SKILLS OF HELPERS

Nodding your head to indicate you are with the clientProducing sounds- Um or Uh etcSilence - certain brief poses promote self exploration on the part of clients

*Active listeningActive listening to the affect, behavior, experiences [verbal and none verbal behavior] of another person. A good listener does not interrupt

*Active listeningConcentrate on what is being said. Accurately hear the feelings of clientsAsk clarifying questionsParaphrasing shows you have listened well- e.g., you said that... I heard you say that what you are saying is that

*EmpathyTo feel inner world and underlying pain of another. Empathy is listening for meaning. Empathy is the bedrock of all skillsCarl Rogers defined empathy as an attempt to understand an internal framework of another person with accuracy. Empathy is listening for meaning.

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Robert Crackuff devised a scale with four levels of measuring empathy

Level 1 being slightly off track with what the client has said.Level 2 being on track with what the client has saidLevel 3 responses reflects the meaning and feelings of what has been saidLevel 4 responses reflects beyond the meaning and feelings of what has been said

Empathy makes clients understand a deep part of themselves

* GenuinenessTo be honest or authentic and self disclosureI really want us to explore this so that I can understand

* GenuinenessTo be honest or authentic and self disclosuree.g tell client I really want us to explore this so that I can understand

* AcceptanceSometimes called unconditional positive regard. Accepting another without strings attached.e.g., Let client know that you want to hear what he has to say. Show nonverbally that you are prepared to work with someone

*Open MindednessTo be receptive to values of clients by suspending your own values and opinionsE.g., Let him know that you are going to be open to what he is going to say

*Psychological adjustmentTo be mentally healthy

*Cognitive ComplexityBeing reflective and willingness to examine a case from many perspectives.

*Relationship buildingAbility to develop a therapeutic relationship or working alliance

*CompetentBeing willing to acquire knowledge and skills

Part 2 Motivational Interviewing

*REFLECTIVE SKILLS OF HOW SOCIAL WORKERS NEED TO RESPOND TO CLIENTS

Ask clarifying questions. Does not ask other kinds of questions.Paraphrasing: is repeating the same meaning of what has been conveyed to you in a condensed form. Paraphrasing shows you have listened well- e.g., you saying that,,, I heard you say that what you are saying is that if I heard you right you are saying that.Validating clients responses- acknowledging and praising the client for any observed positive progress made or view expressed.

*Definition of Motivational InterviewingMotivational interviewing is a directive,client-centred style of interaction aimedat helping children and adolescents explore and resolve theirambivalence about their negative behaviours which affect thier health and begin to make positive changes.

*In other wordsSome people engage in negative behaviour because they do not fully recognise that they have a problem

*It seems surprisingThat some children and adolescents dont simply stop endulging in negative behaviour, considering that this creates so many problems for them and their families.

*Howeverchildren and adolescents that engage in negative behaviours which affect their health often say they want to stop, but they simply dont know how, are unable to, or are not fully ready to stop.

Understanding How People Change: Models

*Traditional approach (1)Change is motivated by discomfort.If you can make people feel bad enough, they will change.People have to hit bottom to be ready for changeCorollary: People dont change if they havent suffered enoughThe Stick

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Traditional approach (2)

If the stick is big enough,

there is no need for a carrot.You better!Or else!

*Another approach: Motivating (1)People are ambivalent about change

People continue their drug use because of their ambivalence

The carrot

*Another approach: Motivating (1)Motivation for change can be fostered by an accepting, empowering, and safe atmosphere

The carrot

*AmbivalenceAmbivalence: Feeling two ways about something.

All change contains an element of ambivalence.

Resolving ambivalence in the direction of change is a key element of motivational interviewing

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Motivational Interviewing

Why dont some children and adolescents change?

*You would think . . . that when an adolescent has a heart attack, it would be enough to persuade him to quit smoking, change his diet, exercise more, and take his medication.

*You would think . . . that hangovers, damaged relationships, or even being pregnance would be enough to convince an adolescent girl to stop drinking excessively.

Why dont children and adolescents change?

*What is the problem?It is NOT thatthey dont want to see (denial)they dont care (no motivation)They are just early in the stages of change

*Stages of Change

*Activity 1: ReflectionTake some time to think about the most difficult change that you had to make in your live. How much time did it take you to move from considering that change to actually taking action.

*Stages of ChangeRecognising the need to change and understanding how to change doesnt happen all at once. It usually takes time and patience.

Children and adolescents often go through a series of stages as they begin to recognise that they have a problem.

*Helping people change (1)

Helping children and adolescents change involves increasing their awareness of their need to change and helping them to start moving through the stages of change.

Start where the client is Positive approaches are more effective than confrontation particularly in an outpatient setting.

*Helping children and adolescents change (2)Motivational interviewing is the process of helping people moving through the stages of change.

*First Stage: Pre-contemplationChildren and adolescents at this stage:Are unaware of any problem related to their behaviourAre unconcerned about their negative behaviour Ignore anyone elses belief that they are doing something harmful

*Second Stage: ContemplationChildren and adolescents at this stage are considering whether or not to change: They enjoy using drugs, butThey are sometimes worried about the increasing difficulties the use is causing.They are constantly debating with themselves whether or not they have a problem.

*Third Stage: Determination/preparationChildren and adolescents at this stage are deciding how they are going to change

May be ready to change their behaviourGetting ready to make the changeIt may take a long time to move to the next stage (action).?

*Fourth Stage: ActionChildren and adolescents at this stage:Have begun the process of changingNeed help identifying realistic steps, high-risk situations, and new coping strategies

*Fifth Stage: MaintenanceChildren and adolescents in this stage:Have made a change and Are working on maintaining the change

*RelapseChildren and adolescents at this stage have reinitiated the identified behaviour.Children and adolescents usually make several attempts to quit before being successful.The process of changing is rarely the same in subsequent attempts. Each attempt incorporates new information gained from the previous attempts.

*RelapseSomeone who has relapsed is NOT a failure!Relapse is part of the recovery process.

*Stages of Change

*When to use motivational strategiesMotivational interviewing can be used as:An assessment toolAn intervention tool to help move the patient through the change process.A way to facilitate the naturally occurring change process in patientsA method for helping the patient resolve ambivalence.

*Important considerationsThe clinicians counselling style is one of the most important aspects of motivational interviewing:

Use reflective listening and empathy Avoid confrontationWork as a team against the problem

*Motivating for changeMotivating for changePre-contemplationContemplationDetermination/ PreparationActionMaintenance

Principles of Motivational Interviewing

*Principles of Motivational InterviewingMotivational interviewing is founded on 4 basic principles:Express empathyDevelop discrepancyRoll with resistanceSupport self-efficacy

*Principle 1: Express empathyThe crucial attitude is one of acceptanceSkilful reflective listening is fundamental to the patients feeling understood and cared about.Patient ambivalence is normal; the clinician should demonstrate an understanding of the clients perspectiveLabelling is unnecessary

*Example of expressing empathyI am so tired that I cannot even sleep So I drink some wine.You drink wine to help you sleep.When I wake upI am too late for work alreadyYesterday my boss fired me.So you are concerned about not having a job....but I do not have a drinking problem!

*Principle 2: Develop discrepancyClarify important goals for the patient Explore the consequences or potential consequences of the patient s current behaviours.Create and amplify in the patients mind a discrepancy between current behaviour and life goals

*Example of developing discrepancyWellas I said, I lost my job because of my drinking problemand I often feel sick.I only enjoy having some drinks with my friendsthats all. Drinking helps me relax and have funI think that I deserve that for a changeSo drinking has some good things for youNow tell me about the not-so-good things you have experienced because of drinking.

*Principle 3: Roll with resistanceAvoid resistanceIf it arises, stop and find another way to proceedAvoid confrontationShift perceptionsInvite, but do not impose, new perspectivesValue the client as a resource for finding solutions to problems

*Example of NOT rolling with resistanceYou do not have the right to judge me. You dont understand me.I do not want to stop drinkingas I said, I do not have a drinking problemI want to drink when I feel like it.But, Anna, I think it is clear that drinking has caused you problems.

*Example of rolling with resistanceThats right, my mother thinks that I have a problem, but shes wrong.I do not want to stop drinkingas I said, I do not have a drinking problemI want to drink when I feel like it.You do have a drinking problemOthers may think you have a problem, but you dont.

*Principle 4: Support self-efficacyBelief in the ability to change (self-efficacy) is an important motivatorThe client is responsible for choosing and carrying out personal changeThere is hope in the range of alternative approaches available

*Example of supporting self-efficacyI hope things will be better this time. Im willing to give it a try.I am wondering if you can help me. I have failed many times. .

Anna, I dont think you have failed because you are still here, hoping things can be better. As long as you are willing to stay in the process, I will support you. You have been successful before and you will be again.

Part 2: How to Use Motivational Skills in Clinical Settings

*Training objectivesAt the end of this part, you will be able to:

Reflect proficientlyPut into practise the OARS strategies or micro-skillsIncrease your empathic abilities by working on personal issues and role-playing client issues.

TechniquesLearning the Micro-SkillsofMotivational Interviewing

*OARSThe OARS are the skills that can be used by interviewers to help move clients through the process of change.

Open-ended questionsAffirmationReflective listeningSummarising

*OARS: Open-ended questionsOpen-ended questions: What are the good things about your substance use? vs. Are there good things about using? Tell me about the not-so-good things about using vs. Are there bad things about using? You seem to have some concerns about your substance use. Tell me more about them. vs. Do you have concerns about your substance use? What most concerns you about that? vs. Do you worry a lot about using substances?

*OARS: AffirmationThanks for coming today.I appreciate that you are willing to talk to me about your substance use.You are obviously a resourceful person to have coped with those difficulties. Thats a good idea.Its hard to talk about....I really appreciate your keeping on with this.

*OARS: Reflective listeningReflective listening is used to:Check out whether you really understood the clientHighlight the clients ambivalence about their substance useSteer the client towards a greater recognition of her or his problems and concerns, and Reinforce statements indicating that the client is thinking about change.

*OARS: SummariseSummarising is an important way of gathering together what has already been said, making sure you understood the client correctly, and preparing the client to move on. Summarising is putting together a group of reflections.

*OARS: What is change talk?Change talk: An indication that you are successfully using motivational interviewing. If you are using MI successfully you will hear statements that indicate the client:Recognises the disadvantages of staying the sameRecognises the advantages of changeExpresses optimism about changeExpresses the intention to change

*Helping to elicit change talk (1)Ask the patient to clarify their statements or elaborate: Describe the last time this happened, Give me an example of that, or Tell me more about that.

*Helping to elicit change talk (2)Ask the patient to imagine the worst consequences of not changing and the best consequences of changing.

*Helping to elicit change talk (3)Explore the patients goals and values to identify discrepancies between the clients values and their current substance use. What are the most important things in your life?

Part 3:Additional Motivational Strategies for Clinical Settings

*Training objectivesAt the end of this workshop, you will be able to:Use the Pros and Cons FormUse the What Does It Cost? FormIdentify a minimum of 3 situations to avoid when using motivational strategies

*The Pros and ConsOften Children and adolescents can identify many advantages and disadvantages of their negative behaviour. They weigh these pros and cons in an effort to decide whether or not to continue or stop certain behaviors.

*Decision Balance: Pros and ConsProbe the Pros and Cons by talking about the benefits of change and the costs of staying the same.Explore pros and consNormalise ambivalenceReintroduce feedback and information about the consequencesRe-explore values in relation to changeSummarise concernsUse the Pros and Cons and What Does it Cost? forms

*Pros and ConsBenefits of changeCosts of using drugs

Benefits of using drugsCosts of change

*Activity 5: Pros and Cons20 minutesUsing the Pros and Cons and the What Does It Cost? forms, observe the role-playing activityIndicate the number of times that the client expresses a desire to change, the ability to change, reasons to change, a need to change, or a commitment to change. Note examples of these expressions of change that you hear from the client.

*What techniques should I avoid?Techniques to avoid when motivating Children and adolescent patients:Confrontation/denialClosed questionsBecoming the expert problem-solverLabelling

*Roadblocks (1)Ordering, directing, or commandingWarning or threateningGiving advice, making suggestions, providing solutionsPersuading with logic, arguing, lecturingMoralizing, preaching, telling them their dutyJudging, criticising, disagreeing, blaming

*Roadblocks (2)Agreeing, approving, praisingShaming, ridiculing, labeling, name-callingInterpreting, analysingReassuring, sympathising, consolingQuestioning, probingWithdrawing, distracting, humouring, changing the subject.

Thank you for your time!The End

****************************The motivational approach is based on the following assumptions about the nature of motivation: Motivation is a key to change. Motivation is multidimensional since it encompasses the internal urges and desires felt by the client, external pressures and goals, thoughts, perceptions of risks and benefits, etc. Motivation is dynamic and fluctuating. Motivation is influenced by social interactions. Motivation can be modified and improved. Motivation is influenced by the clinician's style (e.g., establishing a helping alliance with the client that leads to better outcomes vs. confronting the client, which can increase resistance to change). So the clinician's task is to elicit and enhance motivation, not to confront or punish the client.

(Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press. Trainers notes adapted from DHHS/SAMHSA-TIP 35, 1999)

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Ask the audience: What are some of the ways that you make people feel motivated?

(Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.)

***(Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.)

*(Sources: Slide adapted by Jeanne Obert, 2006, from Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: Guilford Press.) ***********************Motivational interviewing gives the clinician the potential to help the client see the discrepancy between their drug use and their goals without the client feeling pressured or coerced. When done successfully, this results in the client presenting the reasons for change, rather than the counsellor doing so. It is important to get the client to be telling you that they need to change. People are more persuaded by what they hear themselves say than by what other people tell them. When motivational interviewing is done well, it is not the clinician but the client who explicitly states the concerns and intentions to change (Miller & Rollnick, 1991). *Ask somebody (different from the previous person) in the audience to read Annas role from the slide. You may want to play the role of the clinician or ask a participant to play that role.

Ask the audience how Anna has changed the way that she refers to her drinking.**Ask somebody (different from the previous person) from the audience to play Annas role. You may want to play the role of the clinician or ask a participant to play that role. Use the slide as a sample of not rolling with resistance.

Ask participants to pay attention to the result of the clinicians comment.*Ask somebody (different from the previous person) from the audience to play Annas role. You may want to play the role of the clinician or ask someone to play that role. Use the slide as a sample of rolling with resistance.

Ask the audience to pay attention to the result of the clinicians comment.

Ask the audience the following question:Where could the therapist go from here?*Many clients who have problems with drug and/or alcohol use have tried unsuccessfully to stop using on their own. They have been unable to do so. They are ashamed and embarrassed about their problem and many have been harshly judged by family members and others. They have lost a sense of hope. Restoring their self-esteem and their self-efficacy is an incredible gift that can be provided by therapists who care and who can use motivational interviewing to communicate unconditional positive regard.*Ask somebody (different from the previous person) from the audience to play Annas role. You may want to play the role of the clinician or ask a participant to play that role. Use the slide as a sample of supporting self-efficacy. Notice the use of one of the micro-skills that we will discuss in the next workshop. The therapist supports self-efficacy in part by affirming the client.

Ask the audience to pay attention to the result of the clinicians comment.

*****************This graphic illustrates how the decisional balance works. Encourage the client to weigh the benefits of changing his or her drug using behaviour and the benefits of continuing the use of drugs. *Using the Pros and Cons and the What Does It Cost? formsAsk for a volunteer to play the clients role for this role-play. You will play the clinician. In this session, the client should be in a contemplation stage. You will use OARS strategies in the role-playing and the forms to help the client identify the pros and cons of his substance use*

What situations should I avoid when using motivational interviewing?There are a number of situations that clinicians should avoid, particularly when working with a client who is feeling ambivalent about change or in conflict about his/her drug use (Miller & Rollnick, 1991, p. 65).Confrontation/denialThis is a predictable pattern that can occur, particularly when the client is experiencing a degree of ambivalence. The clinician can get caught up in arguing about the clients problems and the need to change. The client can either agree or argue that there is no such problem and state why they dont wish to change. At this point, the client is often labelled as being in denial and therefore in need of more convincing arguments as to why they should change. This usually reinforces the clients resistance and denial. Hence, the counselling interaction takes a downward spiral with no winners it becomes a push push back conflict.Closed-ended questions Closed-ended questions are usually answered with either a Yes or No, creating a feeling that the session is not going anywhere. Closed-ended questions are usually aimed at revealing what the clinician wants to know. The session is not about whether the client is being right or wrong, however. A more open questioning and reflective style would be more appropriate and also allow the client to hear him/herself speak. If the clinician falls into the trap of closed-ended questions, it can be helpful to make a comment on the process of the session. The expert problem-solverWhen clinicians set themselves up as the expert, it places the client in a position of powerlessness. This results in a passive client who blames the clinician if the advice does not work, or a resistant client who wants to get back some of the power they perceive to have lost. Motivational interviewing works on the basis that the client is, in fact, the expert.LabellingClinicians and clients can get very caught up in the issue of diagnostic labelling. Sometimes, clinicians believe it is important for a client to accept the label of alcoholic/addict. Labelling can also be more subtle, such as by using statements such as your problem. This can lead the client to feel trapped in a position of either accepting the label or risking being labelled as resistant or in denial.*

The twelve roadblocks are common responses that get in the way of good listening. They are not necessary wrong, but they are not listening. They interrupt the persons own exploration, and in order to get back to his or her own process, the person must go around them (hence the term of roadblock)

Review the document Thomas Gordons Twelve Roadblocks with your audience

Gordon, Thomas. Parent Effectiveness Training: The no-Lose Program for Raising Responsible Children. New York: Wyden, 1970.*

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