© ann d. carden, ph.d. - 20061 motivational interviewing in clinical supervision ann d. carden,...
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© Ann D. Carden, Ph.D. - 2006 1
MOTIVATIONAL MOTIVATIONAL INTERVIEWINGINTERVIEWING
inin
CLINICAL CLINICAL SUPERVISIONSUPERVISION
Ann D. Carden, Ph.D.Ann D. Carden, [email protected]
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Guiding Principle #1
Express Empathy
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Self-Regulation Self-Regulation TheoryTheory
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Intentional change Intentional change
is grounded in awareness of is grounded in awareness of one’s core values and life one’s core values and life goals and the gap between goals and the gap between those values and goals and those values and goals and one’s present behaviorsone’s present behaviors
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““They say you can lead a They say you can lead a horse to water, but you cant’ horse to water, but you cant’ make him drink…but I say, make him drink…but I say, you can salt the oats.”you can salt the oats.” Madeline Hunter
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Guiding Principle #2
Develop Discrepancy
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Trans-theoretical Trans-theoretical Stages of Change Stages of Change
ModelModel
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Stages of ChangeStages of Change
PrecontemplationPrecontemplation
ContemplationContemplation
PreparationPreparation
ActionAction
MaintenanceMaintenance
TerminationTermination
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• Resources – internal & externalResources – internal & external
• Risks – internal & externalRisks – internal & external
• Readiness ------> interventionReadiness ------> intervention
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Guiding Principle #3
Roll with Resistance
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Self-Perception Self-Perception TheoryTheory
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IntentionIntentionCOMMITMENTCOMMITMENT
Cog
nitiv
e Affective
Behavioral
ProblemProblemRecognitionRecognitionREASONSREASONS
ConcernConcernNEEDNEED
DESIREDESIRE
ConfidenceConfidenceABILITYABILITY
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The Flow of Change Talk
DesireDesire
AbilityAbility
ReasonsReasons
NeedNeed
CommitmentCommitment
ChangeChange
MIMI
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Guiding Principle #4
Support Self-efficacy
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Intentional Change is a Intentional Change is a process, not an event! process, not an event! Intentional Change is a Intentional Change is a process, not an event! process, not an event!
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Intentional change is Intentional change is more likely to occur when more likely to occur when goals aregoals are
Small Important to the goal-setter Specific/Concrete/Measurable Present-focused Realistic/Practical A presence rather than an
absence
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Three Phases in the Three Phases in the Intentional Change Intentional Change ProcessProcess
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Common Barriers to Self-Common Barriers to Self-Enhancing Intentional Enhancing Intentional ChangeChange
CluelessnessCluelessness Minimization Minimization Projection of responsibilityProjection of responsibility Immediate gratification Immediate gratification Fear of failureFear of failure Skills deficitsSkills deficits Information gapsInformation gaps Fear of the unknownFear of the unknown Lack of social / material supportsLack of social / material supports Competing stressorsCompeting stressors
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““Given a choice Given a choice between between changing and changing and proving that it proving that it is not is not necessary, most necessary, most people get busy people get busy with the proof.”with the proof.”
John John GalbraithGalbraith
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It’s not so much that we’re afraid of It’s not so much that we’re afraid of change or so in love with the old change or so in love with the old ways, ways,
but it’s that place in between that we but it’s that place in between that we fear … fear …
It’s like being between trapezes …It’s like being between trapezes …
It’s Linus when his blanket is in the It’s Linus when his blanket is in the drier. There’s nothing to hold on to.drier. There’s nothing to hold on to.
Marilyn Ferguson
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AmbivalenceAmbivalence““People often get stuck, notPeople often get stuck, notbecause they fail to appreciate because they fail to appreciate the down side of their situation,the down side of their situation,but because they feel at least but because they feel at least two ways about it.”two ways about it.”
Miller & RollnickMiller & Rollnick
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AmbivalenceAmbivalence
approach-approachapproach-approach
approach-avoidanceapproach-avoidance
avoidance-avoidanceavoidance-avoidance
double approach avoidancedouble approach avoidance
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MotivationMotivationWhen the balance tips away from resistance When the balance tips away from resistance
and toward commitmentand toward commitment
Never completely free of ambivalence Never completely free of ambivalence and resistanceand resistance
Requires on-going “buy in” at the Requires on-going “buy in” at the level of level of
thinkingthinking feelings feelings
actionsactions
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Six Supervisor Six Supervisor GuidelinesGuidelines
1. Adhere to the MI Guiding Principles
2. Avoid Traps / Roadblocks to progress
3. Teach / model the Philosophical Foundations of MI
4. 4. Maintain a clinical focusMaintain a clinical focus
5. Adapt to the Supervisee’s context
6. Assist supervisees to become proficient in MI clinical skills
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Ongoing assessment of Ongoing assessment of client’s:client’s:
stagesstages resourcesresources risksrisks readinessreadiness
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Ongoing assessment of Ongoing assessment of supervisee’s:supervisee’s:
alliance with clientalliance with client MI consistent MI consistent
interventionsinterventions goals for clientgoals for client beliefs about outcomes beliefs about outcomes
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Supervisory Supervisory ResponsibilityResponsibility
““Above allAbove all
do no harm”do no harm”
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Six Supervisor Six Supervisor GuidelinesGuidelines
1. Adhere to the MI Guiding Principles
2. Avoid Traps / Roadblocks to progress
3. Teach / model the Philosophical Foundations of MI
4. Maintain a clinical focus
5. 5. Adapt to the Supervisee’s contextAdapt to the Supervisee’s context
6. Assist supervisees to become proficient in MI clinical skills
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Cultural DiversityCultural Diversity
AgeAge Socio-economic statusSocio-economic status Gender / sexual orientationGender / sexual orientation Ethnicity / raceEthnicity / race Geographic locationGeographic location ReligionReligion Educational level and typeEducational level and type Life rolesLife roles Disability / diagnosisDisability / diagnosis
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Cultural effects ….Cultural effects ….
ValuesValues PerspectivePerspective MeaningsMeanings RelationshipsRelationships Independence Independence Current focus / life taskCurrent focus / life task Time orientation / pacingTime orientation / pacing Communication and learning styleCommunication and learning style Client-counselor allianceClient-counselor alliance
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Client-Related Stressors Client-Related Stressors of Direct Service of Direct Service
ProvidersProviders Client resistance / supervisee’s Client resistance / supervisee’s
unrealistic expectations of client unrealistic expectations of client changechange
Boundary issues/ethical dilemmasBoundary issues/ethical dilemmas Client suicide/attemptsClient suicide/attempts Client anger/hostilityClient anger/hostility Premature terminationPremature termination Client violence toward othersClient violence toward others Client deathClient death
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Job-Related Stressors of Job-Related Stressors of Direct Service ProvidersDirect Service Providers
Isolation / insufficient supportsIsolation / insufficient supports Productivity pressures / time crunchesProductivity pressures / time crunches Paperwork, paperwork, paperworkPaperwork, paperwork, paperwork Organizational politicsOrganizational politics Low payLow pay Self-doubtSelf-doubt Perfectionism / compulsive Perfectionism / compulsive
responsibilityresponsibility Limited training opportunitiesLimited training opportunities
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Moving Toward Moving Toward Melt-down/Freeze-upMelt-down/Freeze-up
Increased absenteeismIncreased absenteeism Over-reactingOver-reacting Physical complaintsPhysical complaints Chronic exhaustionChronic exhaustion Low self-confidenceLow self-confidence Depression / AnxietyDepression / Anxiety ProcrastinationProcrastination Boundary violationsBoundary violations Cynical attitude about job / clientsCynical attitude about job / clients Social withdrawalSocial withdrawal HostilityHostility Us-them mentalityUs-them mentality Disorganized thinking / behaviorDisorganized thinking / behavior
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Six Supervisor Six Supervisor GuidelinesGuidelines
1. Adhere to the MI Guiding Principles
2. Avoid Traps / Roadblocks to progress
3. Teach / model the Philosophical Foundations of MI
4. Maintain a clinical focus
5. Adapt to the Supervisee’s context
6. 6. Assist supervisees to become Assist supervisees to become proficient in MI clinical skillsproficient in MI clinical skills
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MIMI
SpiritSpirit
Principles
Traps
Opening
Strategies
Elicit/Explore
Change Talk
Counter
Sustain Talk
ConsolidateConsolidate
CommitmentMI Core Skills