Copyright 2014, Glenn Duncan Do not reproduce any workshop materials without express written consent. Motivational Interviewing Glenn Duncan LPC, LCADC, CCS, ACS

2 Traits of an Effective Therapist Core Tasks of an Expert Therapist - Working with Addicted Clients 1. Develop a Therapeutic Alliance 2. Nurture Hope 3. Understand & Implement Best Practices in Theory and Application knowledge of the main therapeutic paradigms when working with addicted clients individually, in group settings and with their families. Be able to properly assess individual client problems and needs and tailor theory and techniques that best suite individual client needs. 4. Teach Skills emotional regulation, relaxation, problem-solving, cognitive restructuring skills, interpersonal skills, tolerance and acceptance skills. 5. Provide Ongoing Education to the Client the ability to conduct accurate assessments, working with the client towards individualized, behavioral treatment planning, having the client engaged in self-monitoring of thoughts, feelings and behaviors, enhance client awareness of the addition process.

3 Traits of an Effective Therapist Core Tasks of an Expert Therapist - Working with Addicted Clients (continued) 6. Build in Generalization and Maintenance Procedures understand the concept of skill generalization to the target problem, involve significant others as allies in obtaining generalization of targeted positive behaviors, feelings and thoughts, and helping with the maintenance of them. 7. Assess/Possibly Treat/Possibly Refer Co-occurring Problems be able to look past substance specific issues to accurately identify possible Co-occurring problems and treat (if education ethically provides the ability to do so), or refer client to have Co-occurring problems addressed. 8. Assess For & Conduct Relapse Prevention assess and work with relapse triggers and high risk situations that will occur for the client. 9. Ensure Clients Take Credit and Ownership for Their Changes foster independence and client ownership of the changes made. 10. Other important clinician factors include: experience, personal characteristics of the counselor and therapist, cultural competence, and comfort with ambiguity.

4 Definition of Motivational Interviewing Motivational interviewing is a collaborative conversation style for strengthening a persons own motivation and commitment to change. The overall style of MI is one of guiding style that is in the middle of the continuum of styles: Directing Guiding Following A skillful guide is a good listener and also offers expertise where needed. MI lives in this middle ground of styles between directing and following, often incorporating elements of both but doing too much of either.

5 Definition of Motivational Interviewing Ambivalence Ambivalence is a normal part of preparing for change and a place where a person can remain stuck for some time. When a helper uses a directing style and argues for change with a person who is ambivalent, it naturally brings out the persons opposite reaction. People are more likely to be persuaded by what they hear themselves say.

6 Spirit of Motivational Interviewing Partnership MI is not something done to a passive recipient by an expert. MI is not done to or on someone, but is rather done for and with a person. MI is an active collaboration between experts. When it comes to change, the counselor cannot do it alone. The client has a vital expertise that is complementary to the clinicians; the expertise of themselves. Activation of that expertise is vital for change. The interviewer seeks to create a positive interpersonal atmosphere that is conducive to change but not coercive. The interpersonal process of MI is a meeting of aspirations which may differ from client to counselor. Honesty about aspirations is essential.

7 Spirit of Motivational Interviewing Acceptance MI is about an attitude of profound acceptance of what the client brings. To accept does not necessarily mean you approve of their actions or acquiesce to the status quo. Acceptance has 4 aspects. Absolute Worth acceptance of the person as an individual, respect for them as having worth, and a belief that the person is fundamentally trustworthy. Accurate Empathy an active interest in and effort to understand the others internal perspective, to see the world through their eyes. Autonomy Support the persons irrevocable right and capacity of self-direction. Affirmation to seek and acknowledge the persons strengths and efforts (more than just a private experience of appreciation, but it is the search for what is right with people).

8 Spirit of Motivational Interviewing Compassion New to MI when describing the essence of MI To be compassionate is to actively promote the others welfare, to give priority to the others needs. This was added to MI because it was felt that many clinicians could practice the principles of MI in the pursuit of self-interest. Knowledge and techniques can be used to exploit, to pursue ones own advantage and gain undeserved trust and compliance. 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.

9 Spirit of Motivational Interviewing Evocation Premise: People already have within them much of what is needed, and your task is to evoke it, to call it forth. The message is: You have what you need, and together we will find it. Approach: To draw out: MI perspective is the belief that there is a deep well of wisdom and experience within the person from which the counselor can draw. MI is about evoking that which is already present, not installing what is missing. People who are ambivalent already have the pro-change argument and the pro status-quo argument within them. The client likely already has the pro-change arguments within them, and those arguments are likely more persuasive than any you could make. Your task, then, is to evoke and strengthen these change motivations already present.

10 Spirit of Motivational Interviewing Evocation - Guard Against The righting reflex. The righting reflex involves the belief that you must convince or persuade the person to do the right thing. Counselors not realizing they are in the midst of this often think/feel: They just need to ask the right questions They just need to find the proper arguments They need to provide the client with critical information. The need to provoke the decisive emotions to make change occur. They need to pursue the correct logic to make the person see and change. This brand of counseling was, and still sometimes is, rampant in substance use counseling. It is the belief that clients had to have their pathological defenses torn down before they could change. The formula goes as follows: A. Confront the client. Louder = Better. B. Provide the solution. The saltier the solutions was provided the cooler the counselor. C. If you meet denial/resistance pump up the volume on A and B. D. Rinse/repeat

11 Spirit of Motivational Interviewing Evocation Questions that are the opposite of the righting reflex Some questions beginning counselors using MI can ask, that do not incorporate the righting reflex: 1. Why would you want to make this change? 2. How might you go about it in order to succeed? 3. What are the three best reasons for you to do it? 4. How important is it for you to make this change, and why? 5. How confident do you feel about being able to make this change, and why? 6. So what do you think youll do?

12 Definition of Motivational Interviewing Lay Persons Definition Motivational interviewing is a collaborative conversation style for strengthening a persons own motivation and commitment to change. Practitioners Definition Motivational interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change.

13 The Method of Motivational Interviewing Four Processes in Motivation Interviewing Engaging engaging is the process by which both parties establish a helpful connection and a working relationship. Focusing process of engaging leads to a focus on a particular agenda: what the person came to talk about. The provider may also have an agenda, some of which may overlap with the client and some of which may not. One or more change goals may emerge. The focusing process helps clarify direction. Evoking evoking involves eliciting the clients own motivation for change. Most simply put, evolving is having the person voice the arguments for change. Planning planning encompasses both the commitment to change and formulating a specific plan of action.

14 Method of MI Questions to Ask Yourself Engaging 1. How comfortable is this person in talking to me? 2. How supportive and helpful am I being? 3. Do I understand this persons perspective and concerns? 4. How comfortable do I feel in this conversation? 5. Does this feel like a collaborative partnership?

15 Method of MI Questions to Ask Yourself Focusing 1. What goals for change does this person really have? 2. Do I have different aspirations for change for this person? 3. Are we working together with a common purpose? 4. Does it feel like we are moving together, not in different directions? 5. Do I have a clear sense of where we are going? 6. Does this feel more like dance or wrestling?

16 Method of MI Questions to Ask Yourself Evoking 1. What are this persons own reasons for change? 2. Is the reluctance more about confidence or importance of change? 3. What change talk am I hearing? 4. Am I steering too far or too fast in a particular direction? 5. Is the righting reflex pulling me to be the one arguing the change?

17 Method of MI Questions to Ask Yourself Planning 1. What would be a reasonable next step towards change? 2. What would help this person to move forward? 3. Am I remembering to evoke rather than prescribe a plan? 4. Am I offering needed information or advice with permission? 5. Am I retaining a sense of quiet curiosity about what will work best for this person?

18 The Skills of Motivational Interviewing Core Skills and the Four Processes of MI Asking Open Questions open questions are those that invite the person to reflect and elaborate. Open questions help you understand the persons internal frame of reference. This helps in engaging by strengthening a collaborative relationship and finding a clear direction. Affirming The counselor in general respects and honors the client as a person of worth. The counselor also comments on the clients particular strengths, abilities, good intentions, and efforts. Reflective Listening statements that make a guess about the clients meaning which can deepen understanding by clarifying the accuracy of the guess. Summarizing reflections that collect what a person has been saying and offering it back. They can be used to: 1) Pull together information; 2) suggest links between present and past material; 3) used as a transition; 4) promote understanding; 5) direct the flow of change talk or discussion.

19 Definition of Motivational Interviewing Lay Persons Definition Motivational interviewing is a collaborative conversation style for strengthening a persons own motivation and commitment to change. Practitioners Definition Motivational interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change. Technical Definition Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation and commitment to a specific goal by eliciting and exploring the persons own reasons for change within an atmosphere of acceptance and compassion.

Working Alliance The working alliance, or collaboration to change is common in to all models of therapy, and common to the supervisory relationship. It is composed of 3 elements: 1. The bond between therapist and client. 2. The extent to which they agree on goals. 3. The extent to which they agree on tasks to obtain the goals. The real change in therapy occurs during the process of weakening of the relationship and then repair of the relationship.

Working Alliance Main Features There are 4 main features in viewing the working alliance: 1. The therapist must possess certain facilitating human qualities, the qualities of a good parent. 2. These qualities permit the potential establishment of a power base for the therapist, in which the therapist uses the clients desire to please as leverage. 3. Within the context of the therapeutic relationship, experiential learning occurs through the normal developmental processes of imitation and identification. 4. The success of this relationship-based learning experience depends on preexisting client qualities that permit at least a beginning level of trust and openness.

Working Alliance Goals Goals in the working alliance model are defined (in part) as the expectations to the nature and quality of the therapeutic relationship. For example one such goal would be to ensure a constructive therapeutic environment, that fosters an awareness of others, of oneself in terms of motivation, self-efficacy. Foster two-way feedback with client. Expectations can be defined as a persons anticipatory beliefs about the nature (i.e., roles, behaviors, interactions, and tasks) or outcome of a particular event. The congruence of expectations (i.e., shared goals) between or among people in a relationship is at least as important, and likely more important, than the expectations of any one individual.

MI - Engagement Factors that can influence engagement and disengagement: Desires or goals. What did you want or hope for in going? What is it that youre looking for? Importance. How important is what youre looking for? How much of a priority is it? Positivity. Did you feel good about the experience? Did you feel welcomed, valued, and respected? Were you treated in a warm and friendly manner? Expectations. What did you think would happen? How did the experience fit with what you expected? Did it live up to (or even exceed) your expectations? Hope. Do you think that this situation helps people like you to get what youre seeking? Do you believe that it would help you?

MI - Listening Factors that can influence engagement and disengagement: Desires or goals. What did you want or hope for in going? What is it that youre looking for? Importance. How important is what youre looking for? How much of a priority is it? Positivity. Did you feel good about the experience? Did you feel welcomed, valued, and respected? Were you treated in a warm and friendly manner? Expectations. What did you think would happen? How did the experience fit with what you expected? Did it live up to (or even exceed) your expectations? Hope. Do you think that this situation helps people like you to get what youre seeking? Do you believe that it would help you?

MI Reflective Listening Using reflection to encourage continued personal exploration broad goal of reflective listening. Overshooting. Overstating the intensity of an emotion. The person will tend to deny and minimize it. Undershooting. Slightly understating the expressed intensity of an emotion, the person is more likely to continue to explore and tell you about it. Length. The reflection should not be longer than the statement. If longer, then make it purposeful by placing emphasis on particular content. Direction. Clients provide a variety of material even within a short 5 minute time span. Reflection can therefore be used to shine a light on certain aspects of what a person has said or to reframe its meaning slightly.

26 Building Motivation for Change (cont) Listening Reflectively a. The crucial element to reflective listening is how the counselor responds to what the client says. What responses are not considered to be listening: Ordering, directing, or commanding Warning or threatening Persuading with logic, arguing, or lecturing Moralizing preaching or telling clients what they should do Disagreeing, judging, criticizing, or blaming Shaming, ridiculing, or labeling Withdrawing or distracting b. Reflective listening isnt making a statement that is a roadblock, but rather a guess about what the person means.

27 Other Engagement Skills 1. Assess Motivation, which consists of the following: - Importance the extent to which one wants, desires, or wills change. - Readiness what is the priority level of the presenting problem(s). - Confidence self-efficacy, or the perceived ability to make a change. 2. Ask open ended questions to the client in response to their answers during the assessment period. - (e.g., What are some other ways marijuana has interfered with other areas that are important to you? versus Is marijuana a problem for you?) 1. Affirmation - To recognize and acknowledge that which is good including their inherent worth. AFFIRMATION IS NOT PRAISE - To accentuate the positive - To support and encourage. Focus on the client, do not make affirmations self-focused.

28 Other Engagement Skills 4. Summarizing - Reflections that pull together several thoughts or topics that that the client is talking about. - They can be affirming (imply that youre listening, remembering and putting together how things connect). - To support and encourage. Focus on the client, do not make affirmations self involved. Collecting Summary recalls a series of interrelated items as they accumulate. Linking Summary reflecting what the person has said and link it to something else you remember from prior conversation Transitional Summary to wrap up a task or topic in order to shift to either a new topic or to steer the direction where you want the conversation to turn.

29 Empathic Communication Scale Level 1: Low-Level Empathic Responding The practitioner communicates little or no awareness or understanding of even the most obvious of the clients feelings. The practitioners responses can be irrelevant, often abrasive, hindering, rather than facilitating communication. Styles of Communication: changing the subject, arguing, giving advice prematurely, lecturing, or other ineffective styles that block communication. Nonverbal responses are often not appropriate to the mood and content of the clients statements. Client reaction: can become confused, defensive, argumentative, withdrawing into silence, begin discussing superficialities, change the subject. RESULT: Clients energies are diverted from exploration and/or working on the problems.

30 Empathic Communication Scale Level 2: Moderately Low-Level Empathic Responding The practitioner responds to the surface message of the client but erroneously omits feelings or factual aspects of the message. The practitioner may also inappropriately qualify client feelings (e.g., youre somewhat agitated about this issue with your mother, isnt that a little bit exaggerated. The practitioner may inaccurately interpret clients feelings (e.g., identifying hurt as anger, being tense for fear). Responses may come from the practitioners own conceptual formulations about the client, which may be diagnostically accurate, but which are not empathically attuned to the clients expressions or attuned to the clients phenomenological realities. RESULT: Level 2 reactions are partially accurate, they do convey an effort to understand, thus do not completely block clients communication.

31 Empathic Communication Scale Level 3: Interchangeable or Reciprocal Level of Empathic Responding The practitioners verbal and nonverbal responses at this level convey understanding and are essentially interchangeable with the obvious expressions of the client. The practitioner accurately reflects factual aspects of the clients messages and surface feelings or state of being. These responses do not add affect or reach beyond the surface feelings, nor do they subtract from the feeling or the tone expressed. Responses of this level facilitate further exploration and problem-focused responses by the client. RESULT: Level 3 responses are effective, working responses that should be sought by practitioners as a base level of empathic responding.

32 Empathic Communication Scale Level 1 3 type of responses Client statement: I dont trust you people. You do everything you can to keep me from getting back my son. I have done everything I am supposed to do and you people always come up with something else. Level 3 response: Youre really angry about the slow progress in your case and are wondering if your efforts are going to succeed. Level 2 response: You feel angry because your case plan has not been more successful to date. Maybe youre expecting too much too soon; theres a lot of time yet. Level 1 response: Just think what would have happened if you had devoted more energy in the last year to carry out your case plan; you would have been further along and less frustrated than you are now.

33 Empathic Communication Scale Level 4: Moderately High-Level Empathic Responding Responses at this level are somewhat additive, accurately identifying implicit underlying feelings and/or aspects of the problem. The practitioners response highlights subtle or veiled aspects of the clients message, enabling the client to get in touch with somewhat deeper-level feelings and unexplored meanings. Level 4 responses are aimed at enhancing clients self-awareness.

34 Empathic Communication Scale Level 5: High-Level Empathic Responding Responses at this level reflect each emotional nuance. The practitioner accurately responds to the full range and intensity of both surface and underlying feelings and meanings. The practitioner may connect current feelings and experiencing, to previous expressed experiences and feelings. Responses may also identify goals embodied in the clients message, which enhance self-awareness while paving the way for potential action. This type of response facilitates the clients exploration of feelings and problems in a much greater breadth and depth than at lower levels.

35 Empathic Communication Scale Level 4 5 type of responses Client statement: I dont trust you people. You do everything you can to keep me from getting back my son. I have done everything I am supposed to do and you people always come up with something else. Level 4 Response: You feel very frustrated with the lack of progress in getting your son back. You wonder if there is any hope in working with a new worker and this system which you feel hasnt been helping you. (additive reflecting the clients deeper feelings of suspicion of institutional racism). Level 5 Response: Not succeeding in getting custody of your son by now has angered and frustrated you very much. Im sensing that youre unsure of whether any efforts will succeed and maybe thinking the system is stacked against me. You want to be able to trust that efforts are likely to succeed and that I and this child welfare system will do all we can do to assist you. (substantially additive to both institutional suspicion and primal fear of never regaining son).

36 Empathic Communication Scale Exercise Client Statement Group member: Its really hard for me to say what I want to say in this group. When I do start to talk, I get tongue tied and my heart starts beating faster. I feel like some of you are critical of me. Group Leader/Member Responses What Level Response?: Yeah, I feel that same way sometimes, too. What Level Response?: It is frightening to you to try to share you feelings with the group. Sounds like you find yourself at a loss for words and wonder what others are thinking of you. What Level Response?: I know youre timid, but I think its important that you make more of an effort to talk in the group, just like youre doing now. Its actually one of the responsibilities of being a group member. What Level Response?: You get scared when you try to talk in the group.

37 Empathic Communication Scale Exercise Client Statement Group member: Its really hard for me to say what I want to say in this group. When I do start to talk, I get tongue tied and my heart starts beating faster. I feel like some of you are critical of me. Group Leader/Member Responses What Level Response?: I sense that youre probably feeling pretty tense and tied up inside right now as you talk about the fear youve had in expressing yourself. Although youve been frightened of exposing yourself, I gather theres a part of you that wants to overcome that fear and become more actively involved with the rest of the group. What Level Response?: What makes you think were critical of you? You come across a bit self-conscious, but thats no big deal. What Level Response?: You remind me of the way I felt the first time I was in a group. I was so scared, I just looked at the floor most of the time. What Level Response?: I wonder if weve done anything that came across as being critical of you.

38 Empathic Communication Scale Exercise Client Statement Group member: Its really hard for me to say what I want to say in this group. When I do start to talk, I get tongue tied and my heart starts beating faster. I feel like some of you are critical of me. Group Leader/Member Responses Level 1 Response: Yeah, I feel that same way sometimes, too. Level 4 Response: It is frightening to you to try to share you feelings with the group. Sounds like you find yourself at a loss for words and wonder what others are thinking of you. Level 2 Response: I know youre timid, but I think its important that you make more of an effort to talk in the group, just like youre doing now. Its actually one of the responsibilities of being a group member. Level 2 Response: You get scared when you try to talk in the group.

39 Empathic Communication Scale Exercise Client Statement Group member: Its really hard for me to say what I want to say in this group. When I do start to talk, I get tongue tied and my heart starts beating faster. I feel like some of you are critical of me. Group Leader/Member Responses Level 5 Response: I sense that youre probably feeling pretty tense and tied up inside right now as you talk about the fear youve had in expressing yourself. Although youve been frightened of exposing yourself, I gather theres a part of you that wants to overcome that fear and become more actively involved with the rest of the group. Level 1 Response: What makes you think were critical of you? You come across a bit self-conscious, but thats no big deal. Level 2 Response: You remind me of the way I felt the first time I was in a group. I was so scared, I just looked at the floor most of the time. Level 2 Response: I wonder if weve done anything that came across as being critical of you.

40 Empathic Communication Scale Exercise Client Statement Male, age 17, in a weekly visit to social work probation officer. I dont see the sense in having to come here every lousy week. I havent been in trouble now since I went to court 3 months ago. You should know by now that you can trust me. Probation Officer Responses What Level Response?: 3 months isnt very long you know, youre on probation for at least 1 year. And how can I be sure youre staying out of trouble? What Level Response?: I gather youd rather not have to see me. I can understand that, but the judge ordered it and youd be in trouble with him if you didnt meet the conditions of you probation. What Level Response?: Has it been 3 months since we went to court? I didnt think it had been that long. What Level Response?: Youd prefer not coming here and feel youve earned my trust.

41 Empathic Communication Scale Exercise Client Statement Male, age 17, in a weekly visit to social work probation officer. I dont see the sense in having to come here every lousy week. I havent been in trouble now since I went to court 3 months ago. You should know by now that you can trust me. Probation Officer Responses What Level Response?: Having to come here each week gripes you, and I gather youre irritated with me for encouraging you to follow the judges order. What Level Response?: Lets take a look at who exactly got themselves into this mess dont complain to me if you dont like it. Maybe youd like to talk the Judge into changing her mind. What Level Response?: It irritates you to have to come here each week. Youd like to get me off your back. What Level Response?: Youre confused about why you have to come here and wish you didnt have to.

42 Empathic Communication Scale Exercise Client Statement Male, age 17, in a weekly visit to social work probation officer. I dont see the sense in having to come here every lousy week. I havent been in trouble now since I went to court 3 months ago. You should know by now that you can trust me. Probation Officer Responses Level 1 Response: 3 months isnt very long you know, youre on probation for at least 1 year. And how can I be sure youre staying out of trouble? Level 2/3 Response: I gather youd rather not have to see me. I can understand that, but the judge ordered it and youd be in trouble with him if you didnt meet the conditions of you probation. Level 1 Response?: Has it been 3 months since we went to court? I didnt think it had been that long. Level 2 Response?: Youd prefer not coming here and feel youve earned my trust.

43 Empathic Communication Scale Exercise Client Statement Male, age 17, in a weekly visit to social work probation officer. I dont see the sense in having to come here every lousy week. I havent been in trouble now since I went to court 3 months ago. You should know by now that you can trust me. Probation Officer Responses Level 3 Response: Having to come here each week gripes you, and I gather youre irritated with me for encouraging you to follow the judges order. Level 1 Response: Lets take a look at who exactly got themselves into this mess dont complain to me if you dont like it. Maybe youd like to talk the Judge into changing her mind. Level 2/3 Response: It irritates you to have to come here each week. Youd like to get me off your back. Level 2 Response: Youre confused about why you have to come here and wish you didnt have to.

44 Constructing Reciprocal Responses To reach level 3 on the empathic scale (the baseline of what you want to accomplish with clients), you must be able to forumlate responses that accurately capture the content and the surface feelings in the client message. It is also important to frame the message so that you simply dont restate the clients message. You can use the following to help master the skill of empathic responding: You feel ______________ about (or because) ______________ (Accurately (Accurately identifies describes situation feelings of client) or event referred to by the client)

45 Multiple Uses of Empathic Communication 1. Establishing relationships with clients in initial sessions (research shows that empathic communication, along with respect and genuineness, facilitate the development of the working relationship). 2. Staying in touch with clients (meeting the client where theyre at). 3. Accurately assessing client problems (evidence shows that the levels of empathy offered by practitioners correlate with the levels of exploration by clients). 4. Responding to the nonverbal messages of clients. 5. Making confrontations more palatable (be prudent when deciding when to use confrontation, however, empathic responses attuned to client reactions immediately following confrontation can be an effective tool.

46 Multiple Uses of Empathic Communication 6. Handling obstacles presented by the client (What is often interpreted as unconscious resistance may be a negative reaction to poor interviewing and intervention techniques, or to client confusion and misunderstanding. Empathic communication can be used to carefully monitor client reactions and to deal directly and sensitively to their feelings). 7. Managing anger and patterns of violence (empathic communication can be an essential tool in helping clients work through these feelings). 8. Utilizing empathic responses to facilitate group discussions (facilitating discussion by using empathic responses to reflect the observations of various group members).

47 Focusing Focusing in MI is an ongoing process of seeking and maintaining direction. The 3 sources of focus: 1. Client people come through the door with presenting problems 2. Setting agencies are funded to address specific issues and provide certain services 3. Clinical Expertise client coming with 1 goal in mind and the clinical perceiving another goal need to be of focus. The challenge is to explore the clients willingness to entertain this additional focus. The 3 styles of focusing: 1. Directing this is where the provider determines the focus, rooted in their own agenda or the agenda of the agency. 2. Following the opposite where the focus solely depends on client priorities. 3. Guiding the focus, momentum and content are mutually forged utilizing client priorities, constraints of the agency and setting, and expertise of the clinician.

48 Focusing Issues that may arise 3 Common Focusing Scenarios 1. The focus is clear. 2. There are options to choose from. 3. The focus is unclear. Issues regarding focus: 1. Tolerating Uncertainty and Ambiguity resisting the righting reflex. 2. Sharing Control sharing control of the flow of the interview/session. 3. Searching for strengths and openings for change be careful not to over focus on risks, problem management, and completion tasks and keep a focus on a clients strengths or a small nugget of change talk that could easily be overlooked by over- focusing on problems.

49 Focusing Issues that may arise When there are options to choose from Agenda Mapping Agenda mapping is a tool to help you focus faster, and with a more active client, to avoid unnecessary confusion about direction. First make it clear what you are doing, with a structuring statement such as would you mind if we consider some topics that could discuss? Considering options 1. Allow clients the space to reflect and express their preferences. 2. Include information and support as appropriate. 3. Allow the client to raise completely new ideas that havent been discussed yet. 4. Use hypothetical language such as we might or you could gliding over the landscape of options. 5. Include your own opinion, in a modest way that acknowledges their autonomy.

50 Focusing Differing Goals & Ethics An ethical issue within helping relationships is whether the clinician should encourage resolution of ambivalence in a particular direction. Ethical concerns arise particularly in situations where the clinician or agency has an aspiration for change that the client does not yet share. Four key ethical considerations in such situations include nonmaleficence (do no harm), beneficence (provide benefit), autonomy (self-determination) and justice (fairness). It is inappropriate to use MI to influence choice when the practitioner has a personal or institutional investment in a certain outcome, especially when this is combined with coercive power. MI should be adapted to clients needs, e.g., evoking may be unnecessary with clients who have already decided to make a change.

51 Focusing Information Exchange Elicit before providing information. 1. Ask permission. 2. Explore clients prior knowledge. 3. Querrying interest in the information available. Provide the information. 1. Prioritize. Focus on what the client most wants or needs to know. 2. Clear and Manageable. Present clearly and in manageable doses. 3. Support Autonomy. When the information has implications for client change, you language needs to support their autonomy. Self Disclosure 1. Is it true? Focus on being genuine without selfish/inappropriate disclosure. 2. Could it be harmful? 3. Is there a clear reason why it would be helpful?

52 Principles of Motivational Interviewing The strategies of Motivational Interviewing are more persuasive than coercive, more supportive than argumentative. The counselor seeks to create a positive atmosphere that is conducive to change. The overall goal is to increase the clients intrinsic motivation, so that change arises from within, rather than being imposed from without. There are 5 general principles underlying motivational interviewing:

53 Principle Express Empathy Empathy is NOT an ability to identify with a persons experiences. Empathy is a learnable skill for understanding anothers meaning through reflective listening, whether or not youve had similar experiences yourself. This is done without judging, criticizing or blaming but with acceptance. Empathic listening requires sharp attention to each new client statement, and a continual generation of hypotheses as to the underlying meaning. Your interpretation as to the meaning is reflected back to the client, often adding to the content that was overtly stated.

54 Principle Develop Discrepancy Create and amplify, in the clients mind, a discrepancy between present behavior and broader goals. Motivation for change is created when people perceive a discrepancy between their present behavior and important personal goals. MI Therapist wants to develop discrepancy, make use of it, increase it, and amplify it until the discrepancy overrides attachment to the present behavior. This change needs to occur within the client (not external forces), the client should present the arguments for change.

55 Principle Avoid Argumentation A key principle to MI is to avoid arguments and head-to-head confrontations. One place that arguments are very likely to emerge is in regard to the applicability of a diagnostic label. Some counselors place great importance on a clients willingness to admit to a label such as alcoholic. AA the emphasis is more on self-recognition. We do not like to pronounce any individual as alcoholic, but you can quickly diagnose yourself. (Bill W.) Ambivalence and sustain talk is a signal for the therapist to change strategies.

56 Principle - Roll with Ambivalence or Sustain Talk Reluctance and ambivalence are not opposed, but are acknowledged by the therapist to be natural and understandable. The therapist does not impose new views or goals. Rather, the client is invited to consider new information and is offered new perspectives. Rolling with ambivalence includes involving the client actively in the process of problem solving. The client is a valuable resource in finding the solution to their problems.

57 Principle Support Self-Efficacy Self-efficacy is a persons belief in his/her ability to carry out and succeed with a specific task. General goal of MI is to increase the clients perceptions of his/her capability to cope with obstacles and to succeed in change. The client not only can, but must make this change for themselves. There is hope in the range of alternative approaches available. Thus a person who has failed in the past, may not have found the right approach.

58 Common Therapist Traps The Confrontation Denial Trap The Expert Trap The Labeling Trap The Premature Focus Trap The Blaming Trap

59 Building Motivation for Change (cont) Elicit Self-Motivational Statements This is the guiding strategy that helps clients to resolve their ambivalence. Self-motivational statements fall into four general categories: 1. Problem recognition 2. Expression of concern 3. Intention to change 4. Optimism about change These four kinds of statements reflect cognitive (recognition, optimism), affective or emotional (concern), and behavior (intention to act) dimensions of commitment to change.

60 Eliciting Self-Motivational Statements Asking Evocative Questions (e.g., problem recognition, asking areas of concern). Exploring Pros and Cons Asking for Elaboration (tell you more about it, give you an example of it, to talk you through one). Imagining Extremes (best and worst things that could come out of making a change like this).

61 Eliciting Self-Motivational Statements Looking Forward (think ahead five years, where would you like to be and what would you like your life to be like) Getting at a persons hopes and desires. - What would it take for you to give up a certain behavior? - If behavior changes, if behavior doesnt change, where would your life be 5 years from now? Looking Backwards (contrast present situation by looking back before the problem behavior(s) were present. Case Example

62 Eight General Motivational Strategies What strategies can a counselor use to enhance motivation for change? Giving Advice Removing Barriers Providing Choice Decreasing Desirability Practicing Empathy Providing Feedback Clarifying Goals Active Helping

63 MI view of Confrontation Confrontational clinicians, groups, and programs have been linked to poorer outcomes. Successful outcomes have been linked to therapists showing high levels of accurate empathy. The linguistic root of the verb to confront means to come face to face. Thus we are trying to allow our clients to come face to face with with a difficult and often times threatening reality. In this light, confrontation is a goal of therapy. What is the best way to achieve that goal?

64 MI View of Confrontation (cont.) Evidence is strong that direct, forceful, aggressive approaches are perhaps the least effective way to help people consider new information and change their perceptions. Such confrontation increases the very phenomenon it is supposed to overcome defensiveness and decreases the clients likelihood of change. The goal of the MI therapist is to evoke from the client statements of problem perception and the need for change. This is the opposite of those strategies in which the therapist is responsible for voicing these perspectives (e.g., Youre an alcoholic, and need to stop drinking.) and persuading the client to the truth.

65 Client Ambivalence People struggling with addictive problems usually enter counseling with fluctuating and conflicting motivations. This conflict is known as ambivalence. Ambivalent clients are often seen as abnormal or unacceptable, and having poor motivation. In this thinking the client needs to be persuaded and educated regarding the negative effects. This can lead to the confrontation - denial trap. Ambivalence is normal, acceptable, and understandable. Working with ambivalence is the heart of the problem in MI.

66 Some Complications of Ambivalence 1. Values - Never assume that the client will view a given cost or benefit the same way you do. 2. Expectancies - People have certain expectancies regarding the likely results of certain courses of actions. 3. Self-esteem - Sometimes bolstering self-esteem is a necessary prerequisite to motivation for change. 4. Social Context - A clients motivational system cannot be understood outside the social context of family, friends, and community. 5. Impaired Control - A person may persist in a harmful behavior through a breakdown of normal self-regulation (self-control) processes.

67 Dealing with Ambivalence and Sustain Talk MI has stopped using the term resistance, but now focuses on ambivalence. Sustain talk is a normal part of ambivalence. Sustain talk is that which occurs in treatment, and shows that the client may be moving away from the direction of change. Sustain Talk and Discord can be determined by therapist style. Therefore, your style as a therapist will determine how much ambivalence, sustain talk and discord is elicited by the client. Discord signals dissonance in the working alliance. An important goal of Motivational Interviewing is to avoid eliciting or strengthening sustain talk.

68 Dealing with Ambivalence 4 Types 1. Arguing The client contests the accuracy, expertise or integrity of the clinician. 2. Interrupting The client breaks in and interrupts the clinician in a defensive manner. 3. Denying The client expresses an unwillingness to recognize problems, cooperate, accept responsibility, or take advice. 4. Ignoring The client shows evidence of ignoring or not following the clinical advice.

69 Strategies for Handling Ambivalence Simple Reflection This is responding to ambivalence/sustain talk with non- resistance. A simple acknowledgement of the clients disagreement, emotion, or perception can permit further exploration rather than defensiveness. Client: I dont think that anger is really my problem. Counselor: You anger hasnt cause any real difficulties for you. Client: Well, sure it has. Anyone who gets into scraps as much as I do is about to have some consequences.

70 Strategies for Handling Ambivalence (cont.) Amplified Reflection Reflecting back what the client has said in an exaggerated form, to state it in an even more extreme form than the client did. These responses must be straightforward and supportive, not in a tone of sarcasm or impatience. Client: I think things are just fine in our marriage the way they are. Counselor: Things couldnt possibly be better in your marriage than they are right now. Client: Im pretty satisfied, but I guess both of us arent.

71 Strategies for Handling Ambivalence (cont.) Double-Sided Reflection This is acknowledging what the client has said, and add to it the other side of the clients ambivalence. This may require material that the client has offered previously. CLIENT: OK, maybe Ive got some problems with drinking, but Im not an alcoholic. (minimizing) THERAPIST: You dont have any problem seeing that your drinking is hurting you, but you surely dont want to be labeled.

72 Strategies for Handling Ambivalence (cont.) Shifting Focus This is shifting the clients attention away from what seems to be a stumbling block standing in the way of progress. Such detouring can be a good way to ambivalence/discord when encountering a particularly difficult issue. Client: I know that you want me to give up drugs completely, but Im not going to do that! (unwillingness) Therapist: What is it that you would like out of this. Client: I want that witch of a probation officer out of my life. Therapist: So lets discuss that issue, what problems are you experiencing with her?

73 Strategies for Handling Ambivalence (cont.) Emphasizing Autonomy - Personal Choice and Control This works in working with discord that comes from REACTANCE. When people think their freedom of choice is being threatened, they tend to react by asserting their liberty. Antidote for reactance is to assure the client it is he/she who determines what happens. CLIENT: I know that you want me to give up drugs completely, but Im not going to do that! (unwillingness) THERAPIST: Nobody can change your drug usage for you, its totally your choice to either stop using or continue using.

74 Strategies for Handling Ambivalence (cont.) Reframing This approach acknowledges the validity of the clients raw observations, but offers a new meaning or interpretation for them. The clients information is viewed in a new light that is more likely to be helpful and to support change. Case Example: CLIENT: I can hold my liquor just fine. Im still standing when everybody else is under the table. THERAPIST: I hear you saying that you can drink a lot more without looking or feeling drunk. When people start feeling the effects of being drunk, they tend to curb their drinking. Sometimes that built in warning system changes due and can result in a higher tolerance for alcohol than existed previously.

75 Siding with the Negative This is where the Clinician presents, or takes up, the negative voice in the discussion the voice of precontemplation and status quo. This works well with clients still in contemplation, and needing to elicit self- motivational, change oriented statements but needs help doing so. Taking the negative side can evoke a response of the positives for change from the client, thus the client would be making your argument for you. This is often times called a paradoxical intervention or prescribing the problem. Therapist: From what Im seeing, you dont have a problem, everything is functioning perfectly well in your life, and there doesnt appear a need to continue addressing this issue. Client: Well there have been some problems, I do have 1 DWI, my wife has been complaining recently because of my drinking away from home, and my kids have made comments to me, so I wouldnt go so far to say there is no problem.

76 Tracks of Services Precontemplation = Contemplation = Preparation = Action = Maintenance = Relapse/Recycling = Discovery Track Discovery Track Discovery/Recovery Tracks Recovery Track Recovery Track Relapse Track

77 MI is not based on: Stages of Readiness for Change Model Precontemplation The client is not ready to change and identification with the problem is marked with positive associations. Goal is to get client to form some ambivalence regarding problem. Contemplation Ambivalence exists with the client regarding problem (the association with the identified problem are now good and bad). Goal is to move the client into preparation stage. Preparation Client has substantially resolved ambivalence and prepares to commit to a change in the problem behavior. Goal is to move the client into the action stage.

78 MI is not based on: Stages of Readiness for Change Model Action The client has committed to specific actions intended to bring about change, but needs help in maintaining this level of change. Goal is to provide client with help in this area and work client towards next stage. Maintenance The client enters the point of being able to sustain the changes accomplished previously. Replacing problem behaviors with new, healthy life-style. Termination Person exits the cycle of change without fear of relapsing to previous behavior. Much debate over whether certain problems can be terminated. Relapse/Recycling Relapse to one of the first three stages of change. Expectable setbacks and hopefully learn from relapse before committing to a new cycle of action. Multidimensional assessment to explore relapse reasons.

79 Defining Termination of a Problem How far and how long must a client go before the problem can be considered to be terminated? How can you distinguish the real signs of termination from the rationalizations that will cause a client to return to the problem behavior?

80 A New Self-Image If a significant revision in your attitude and self-image takes place, there is a good chance a client will approach termination. A feeling (understanding) that the change in the problem is theirs. More than just the mastering of the problem behavior(s), this is where a clients holds a new self-image , one that is consistent with healthier behavior(s).

81 No temptation in Any Situation No temptation to return to the problem behavior(s), regardless of the situation. No temptation to return to the problem behavior(s), no matter how you are feeling. These clients experience themselves in the same way as individuals who have never experienced the problem.

82 Solid Self-efficacy Clients who transfer their center of gravity from their problems to themselves. They look, act, and feel with genuine confidence, not false bravado. In regards to addictive behaviors, confidence peaks after one year after action begins, but temptation does not bottom out until 2 or 3 years after action begins.

83 A Healthier Lifestyle Life changes are essential for the maintenance of a problematic behavior; however, a new lifestyle is essential for termination. The difference is permanence of change. In the maintenance stage, a client modifies parts of their life (e.g., social contacts, daily schedules, behavior patterns), to overcome their problem. In termination, clients institute a healthier lifestyle as a means of preserving their gains and promoting new growth.

84 MI - Planning There comes a time in therapy when the emphasis shifts from building motivation to strengthening commitment to change. Signs of Readiness for Change 1. Decreased ambivalence 2. Decreased questions about the problem 3. Resolve 4. Self-Motivational statements 5. Increase questions about change 6. Envisioning or imagining aspects of change (good or bad) 7. Experimenting

85 MI - Planning Recapitulation Summarizing clients current situation. The time to move from evoking to planning is clinical judgment call guided by signals of readiness from the client. Developing a change plan usually involves moving from general intention to a specific implementation plan 3 planning scenarios: 1. The Change plan is already clear 2. There are options among which to choose in path mapping 3. The way forward is unclear and a change plan needs to be developed from scratch.

86 MI - Planning Negotiating a Plan - Setting Goals (client centered goals) - Considering Change Options (possible methods for obtaining goals, what would happen with different courses of change, client may not choose the correct option the first time prepare clients for this). - Arriving at a Plan Endgame - Eliciting Commitment to Action - Transition to the Action Phase

87 Bibliography Bordin, E. S. (1979). The Generalizability of the Psychodynamic Concept of the Working Alliance. Psychotherapy: Theory, Research and Practice, 16, pp. 252-260. Botvin, G. J., Baker, E., Dusenbury, L., Tortu, S., & Botvin, E. (1990). Preventing adolescent drug abuse through a multimodal cognitive- behavioral approach: Results of a 3-year study. Journal of Consulting and Clinical Psychology, 58(4), 437-446. Brown, J. M. & Miller, W. R. (1993). Impact of motivational interviewing on participation and outcome in residential alcoholism treatment. Psychology of Addictive Behaviors, 7, 211-218. Carey, K. B., Purnine, M. M., Maisto, S. A., & Carey, M. P. (1999). Assessing readiness to change substance abuse: A critical review of instruments. Clinical Psychology: Science and Practice, 6, 245-266.

88 Bibliography Carkhuff, R. R., Anthony, W. A., Cannon, J. R., Pierce, R. M., & Zigon, F. J. (1979). The skills of helping: An introduction to counseling skills. Amherst, MA: Human Resource Development Press. Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001). Substance abuse treatment and the stages of change: Selecting and planning interventions. New York: Guilford Press. Dunn, C., DeRoo, L., & Rivara, F. P. (2001). The use of brief interventions adapted from motivational interviewing across behavioral domains: A systemic review. Addiction, 96(12), 1725-1742. Foote, J., DeLuca, A., Magura, S., Warner, A., Grand, A., Rosenblum, A., & Stahl, S. (1999). A group motivational treatment for chemical dependency. Journal of Substance Abuse Treatment, 17, 181-192.

89 Bibliography Hepworth, D., Rooney, R. H., & Larsen, J. A. (1996). Direct Social Work Practice: Theory And Skills (5th ed.). Belmont, CA: Wadsworth Publishing. Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioral Psychotherapy, 11, 147-172. Miller, W. R. (1999). Enhancing motivation for change in substance abuse treatment (Treatment Improvement Protocol [TIP] Series No. 35). Rockville, MD: Center for Substance Abuse Treatment. Miller, W. R. & Heather, N. (Eds.). (1998). Treating addictive behaviors: Process of change (2nd ed.). New York: Plenum Press.

90 Bibliography Miller, W. R. & Rollnick, S. (2013). Motivational Interviewing, 3rd Edition. Guilford Press. New York, NY. Prochaska, J. O., Norcross, J.C., & DiClemente, C. C. (1995). Changing For Good. Avon Books, New York, NY. Richardson, L. (2012). Motivational interviewing: Helping patients move toward change. Journal of Christian Nursing, 29(1), 18-24. Rollnick, S. (1998). Readiness, importance, and confidence: Critical conditions of change in treatment. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Process of change (2nd ed., pp. 49-60). New York: Plenum Press. Rollnick, S., Mason P. & Butler C. (1999). Health behavior change: A guide for practitioners. London: Churchill Livingstone.

91 Bibliography Schilling, R. F., El-Bassel, N., Finch, J. B., Roman, R. J., & Hanson, M. (2002). Motivational interviewing to encourage self-help participation following alcohol detoxification. Research on Social Work Practice, 12(6), 711-730. Schneider, R. J., Casey, J., & Kohn, R. (2000). Motivational versus confrontational interviewing: A comparison of substance abuse assessment practices at employee assistance programs. Journal of Behavioral Health Services and Research, 27(1), 60-74. Sobell, M.B. & Sobell, L. C. (1998). Guiding self change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Process of change (2nd ed., pp. 189-202). New York: Plenum Press. Swanson, A. J., Pantalon, M. V., & Cohen, K. R. (1999). Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients. Journal of Nervous and Mental Disease, 187, 630- 635.