Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Motivational InterviewingEngaging clients in a conversation about change
16th Annual Social Work ConferenceUniversity of Southern IndianaMarch 2nd, 2018Chad Connor, MSSW, LCSW
So what is Motivational Interviewing?
3
"…a person-centered counseling style for addressing the common problem of ambivalence about change." (Miller & Rollnick, 2013)
Motivational interviewing is…
MI is a COLLABORATIVE
conversation about CHANGE
A Taste of MI(Miller & Rollnick, 2013)
Volunteer needs to be willing to share:
Something you want / need to change, but have not yet (ambivalent about it)
Should be something you’re willing to share with a complete stranger
I need a volunteer to be my client!
4
Which style did you prefer?
Style 1
Highly directive
Clinician "driving the bus“
"Righting reflex"
Statistic re: response to this style
Style 2
Spirit of MI
Conversational
Questions have strategic purpose / elicit responses
from client
Client is put in the role of expert of their own situation
5
“The kind of caring that the client-centered therapist desires to achieve is a
gullible caring, in which clients are accepted as they say they are, not with a
lurking suspicion in the therapist’s mind that they may, in fact, be otherwise.
This attitude is not stupidity on the therapist’s part; it is the kind of attitude
that is most likely to lead to trust, to further self-exploration, and to the
correction of the false statements as trust deepens.”
Carl Rogers and Ruth Sanford
Today’s Objectives
You will understand the values and basic techniques used in MI
You will understand MI’s application to social work practice across various client populations and presenting problems
You will know what to do to further your training / proficiency in MI
Spirit of MI
More than technique, MI is person-centered
Derivative of the work of Carl Rogers
Client is in control of making their own decisions
Relationship is collaborative, built on mutual trust
8Carl Rogers
A Continuum of Communication Styles
(Miller & Rollnick, 2013)
Directing Guiding Following
Spirit of MI
(Miller & Rollnick, 2013)
Social Work Values(NASW, 2017)
ServiceSocialJustice
Dignity And
Worth
HumanRelation
ships
IntegrityCompetence
(NASW, 2017)
(NASW, 2017)
(NASW, 2017)
Congruence with Social Work (table seen in Hohman, 2012, page 7)
Traditional Style VS Motivational Interviewing
Traditional
Clinician as expert
"Righting reflex" / Heavy advice giving
Clinician does much of the talking
"I have the answer and I am going to give it to you"
Motivational Interviewing
Client as expert
Eliciting and reinforcing client's change talk / Conversational yet strategic
Client does 50% or more of talking
"You probably know what you want to change, can decide what to change or not change and, together we can help you become "unstuck"
16
"Righting Reflex" often isn’t the right reflex for our
clients
As professional helpers, we have the tendency to ‘rescue’ others
"Don't do that, there is a better way!”
" If I can persuade them, they will see that they need to do something different.“
The “Righting Reflex” can lead our clients to following experiences:
Need to explain / defend self
"I am not being understood"
Shame or anger
"What's the point of meeting with you?“
“I know this already!”
17
You can arrange the conversation so that people talk themselves into change based on their own values and interests…
Motivation is NOT stable, it is fluid and can be changed!
The way you talk to clients about health, changing beliefs, feelings, attitudes can substantially influence motivation to change and maintain change.
Persuasion (i.e. use of logical arguments) does not work nearly as well as we might think!
Whether change happens is a person's choice. We cannot take this away not matter how hard we try.
* Angela R. Bethea, Ph.D., 2015
18
Challenging the Myth of the Unmotivated Client*
(Miller & Rollnick, 2013 )
Most people know what they need / want to change (why logical arguments fail)
"Decisional balance“ There are reasons for a person to
sustain behavior
There are reasons to change targeted behavior
This is a NORMAL experience
19
What prevents our clients from
making the changes they
need to make?
Ambivalence("I want to change AND I don't want to change")
There are things we can do to get our clients thinking about change….or think about sustain.
20
CHANGE
SUSTAIN
21
We CAN influence how clients talk about change
There are things WE can do to encourage two types of talk about target behavior
• CHANGE talk
• SUSTAIN talk
Research supports the idea that if we can get our clients talk about their own reasons for change, they are more likely to move toward making that change
Is it Change Talk?
Change
I cut back on how many beers I drink
I need to stop hanging around THOSE people
I guess I could give those meetings a try
I know this stuff is going to kill me
Sustain
I don’t have a drinking problem
It’s impossible to stop when it is so easily available
Nothing will help me stop
Why change? Something’s going to kill me anyway, right?
DARN CATS (the way we talk about change)
Desire
Ability
Reasons
Need
23
Miller & Rollnick, 2013
24
Commitment
Action
Taking Steps
DARN CATS (the way we talk about change)
Miller & Rollnick, 2013
Do you remember the
questions asked in the
role play?
They are DARN questions –examples of ways to draw
our change talk from clients
1.“Why would you want to make this change?” (Desire)
2.“How might you go about it in order to succeed?” (Ability)
3.“What are the 3 best reasons to do it, and why?” (Reasons)
4.“On a scale from 0 to 10, how important would you say it is for you to make this change?” (Need)
My last question:
“So what do you think you will do?” (CATS question
25
What can you do to elicit change talk?
“What people really need is a
good listening to.”
Mary Lou Casey
Informing / Advising
OARS
DARN CATS
1. Engaging
2. Focusing
3. Evoking
4. Planning
MI’s Four ProcessesNot necessarily linear*
Miller & Rollnick, 2013
Engaging
Self-determination, collaboration, active listening, mutual
trust
Focusing
Identifying a target behavior, listing concerns, clarifying
direction, developing discrepancies
Evoking
Eliciting and strengthening change talk, avoid / reduce
sustain talk
Planning
Commitment to change, action planning
29
30
Engaging, Focusing and Evoking processes of MI must be present to do MI.
If you are using the skills (reflections, open-ended questions) without initiating a trusting, collaborative approach with your client, it is NOT MI. (Engaging)
If you do not have a behaviorally specific change that is the focus of your work, it is NOT MI. (Focusing)
If you do the above, yet are not concerned with eliciting the client’s own reasons to change, it is NOT MI (Evoking)
MI’s essential ingredients
Miller & Rollnick, 2013
31
But what about Planning?
Miller & Rollnick, 2013
You CAN do MI without getting to the point of engaging in the Planning process
MI is concerned with moving the client forward past ambivalence and through the stages of change
Pre-contemplation Contemplation
Contemplation Preparation
Pre-contemplation Action
Successful
MI!
MI versus non-MI skills & behaviors (Miller and Rollnick, 2013)
Advise w/ permission
Affirm
Emphasize Control
Open Question
Reflect
Reframe
Support
Advise without permission
Confront
Direct
Raise concern without permission
Warn
32
MI-adherence responses (MI-A) MI-Non Adherent Responses (MI-NA)
OARS
OARSOpen ended questions
Affirmations
Reflections
Summaries
• The vehicle for change
• The core skills used in MI
34
Open vs Closed Ended Questions Do you want to stop using marijuana?
VS.
What are some reasons you might have for not using marijuana?
Be careful not to ask too many in rapid succession – can come across as being interrogated!
MI adheres to the strategy of providing at least 2-3 reflections for each question…
35
Open Ended Questions
Affirmations
Verbal recognition and praise of the client’s talk of change
Example: Client: I am thinking about looking into women’s shelters so I have somewhere to
go if I decide to leave Bill.
You: That’s great. It must take a lot of courage to take this first step.
Encourage and solidify the client’s talk about change by affirming them when you recognize change talk.
36
Reflections
37
Conveys active listening and engagement
Allows the client to hear their own talk of change through your reflections
Strategic use of reflection can be used to move a conversation forward or put the client in a position to defend the need to change. (Complex reflection)
Example:
Client: Getting high makes all my problems go away (sustain talk)
You: Smoking makes life easier to deal with, so your life is ok if you continue to smoke.
Client: Nah, well, sort of. My problems feel like they go away when I smoke, but DCS is involved now and I have to do something different I
guess (change talk)
You: On the one hand, smoking is how you have dealt with things, but because DCS is involved now, you have to figure out another way to deal with things. What have you tried before to deal with your problems?
Miller and Rollnick, 2013
Deepening Reflections(simple, amplified, double-sided, metaphor)
1. It’s been fun, but something has got to give. I just can’t go on like this anymore.
2. I’ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work, except having a couple drinks.
3. I’ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work –except having a couple of drinks.
4. So, I’m not too worried, but its been over a year since I’ve had an HIV test.
5. I know I’m not perfect, but why do they have to always tell me what to do. I’m not 3!
Summaries
• Use these at strategic times to “collect” all the change talk statements the client has made and feed back to them to hear their own change talk.
• Can be used after a series of reflections and statements from the client to follow up with a new open-ended question (remember, 3-4 reflections for each open ended question is strongly encouraged)
40
Example:You: “Let me just make sure I am understanding your thinking at this time. On the one hand, you
and your husband have been together for 10 years, but the fighting has gotten so bad that you are not sure how long you can go on like this. You worry that co-workers have noticed your bruises and you are concerned it is getting worse. You are scared to be alone, but you do have a good friend that said she will help you stay on your feet while you go to a shelter if you decide to do that. On a scale of 0 to 10, how important to you is it that you leave your husband?”
Stephen Rollnick, Ph.D
Now that I know a
little about MI, with
whom do I use it?
Anywhere there might be ambivalence to changing a behavior
MI requires a specific target behavior
Addiction
Relationships
Leaving a partner?
Service engagement
Diet / weight loss
Smoking cessation
42
Assessments "MI Sandwich“
MI (5-10 mins) ----> Assessment / Data Collection ----> MI-style feedback (10-5 mins)
MI to engage client / explore reason for referral
MI at end to elicit response to assessment, data collect, explore ambivalence and readiness for change.
Can provide advice (with permission!)
43
How can I work it in non-
counseling / therapy
settings?
Where do I learn more?
The MI "bible" Authors & Founders: William Miller &
Steve Rollnick, 2013
44
Where do I learn more?
For exercises / practice…
Where do I learn more?
FREE at samhsa.gov
MINT (Motivational Interviewing International Network of Trainers)
Website (www.motivationinterviewing.org)
Trainings
Formal supervision from MINT trainers
MITI
47
Where do I learn more?
References
Bethea, A.R. (2015, December). Introduction to motivational interviewing. Lecture presented at 2-day continuing education seminar, Atlanta, GA.
Hohman, M. (2012). Motivational interviewing in social work practice. New York: The Guilford Press.
Miller, W.R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: The Guilford Press.
National Association of Social Workers. (2017). Code of ethics of the National Association of Social Workers. Washington, DC. NASW Press.
Rosengren, D.B. (2009). Building motivational interviewing skills: A practitioner workbook (1st ed.). New York: The Guilford Press