motivational interviewing: preparing people for change

Motivational Interviewing: Motivational Interviewing: Preparing People for ChangePreparing People for Change

Research Project:Research Project:ConsentConsentPre/postPre/post3 mos follow-up3 mos follow-upNames will not be attached to dataNames will not be attached to data

Agenda:Agenda:

MI SpiritMI SpiritMI PrinciplesMI PrinciplesAmbivalenceAmbivalenceOpen-ended Open-ended

questions/Affirmations/Reflections/Summariesquestions/Affirmations/Reflections/Summaries Change Talk Change Talk

ResistanceResistance

Motivational Interviewing

Client-centered Directive method for enhancing Intrinsic Motivation to change by

exploring and resolving Ambivalence

Motivational Interviewing

IS• A method of communication• A fundamental way of being with and for people• A facilitative approach to communication that

evokes natural change.

NOT• A set of techniques• A bag of tricks• Something you do to people

Exercise

Think about a behavior change that you have been considering but haven’t yet made.

Tell me for how long you’ve been thinking about it.

I want you to make a decision right now that you are going to make this change.

How did it feel? What did you think? How would have been more helpful?

MI Spirit

Autonomy◦ The client is the expert and it is her choice to engage

in the change process or not.

Collaboration◦ We, as practitioners, work together with our clients.

Evocation◦ The I hear myself speak, the better I understand what

I think and what I want.

MI Principles

Express Empathy◦ Intra-view.

Develop Discrepancy◦ Verbalize client’s ambivalence.

Roll with Resistance◦ Dance, don’t wrestle.

Support Self-Efficacy◦ Empower the client to succeed in the future.

Ambivalence

Ambivalence

You will come to a place where the streets are not marked.Some windows are lighted. But mostly they're darked.

A place you could sprain both you elbow and chin!Do you dare to stay out? Do you dare to go in?

How much can you lose? How much can you win?

And IF you go in, should you turn left or right...or right-and-three-quarters? Or, maybe, not quite?

Or go around back and sneak in from behind?Simple it's not, I'm afraid you will find,

for a mind-maker-upper to make up his mind.

You can get so confusedthat you'll start in to race

down long wiggled roads at a break-necking paceand grind on for miles across weirdish wild space,

headed, I fear, toward a most useless place.The Waiting Place...

- Dr. Seuss

Core Skills – “OARS”Core Skills – “OARS”

• Open-ended questions

• Affirmations

• Reflections

• Summaries

Closed-Ended QuestionsClosed-Ended Questions

• Yes/No response• Did you apply to this job?• Did you miss class?• Do you like chocolate?

• Limited range of information• How many classes are you taking this

term?• Was were your SAT scores?

Open-Ended Questions

• Wide range of responses• Seek information, invite client’s

perspective, encourage self- exploration

• Where do you see yourself in 5 years?• Tell me more.• What else?• What do you make of that?• What do you like about coming here?

Open-Ended Questions: Exercise• Do you feel depressed?

• How many classes have you missed?

• Do you want to go to college?

• Do you smoke weed?

• Did you fill out your job application?

• Did you pass the math class?

• Is there anything else?

Affirmations

• Express appreciation of who the client is, or what s/he has done• Provide support• Strengthen rapport• Support self-efficacy

• I really appreciate your willingness to be so honest with me.

• It’s not easy to keep trying when things aren’t going so well, and yet you haven’t given up.

• Affirmations are like salt – a little goes a long way.

Summaries

• Collecting• Linking• Transitional

Affirmations and Summaries Activity

• Think back to a time when you received an affirmation that was meaningful to you.

• Describe to your partner exactly what was happening at that time – when it was, where you were, how you felt before, during, and after the affirmation, who provided the affirmation to you, what it was, etc.

• The partner – after listening, summarize what was said. Try to capture the meaning and the feeling behind the experience.

• Switch

Core Skills – “OARS”Core Skills – “OARS”

• Open-ended questions

• Affirmations

• Reflections

• Summaries

Listening Reflectively

• Reflections can:• Check meaning• Reflect both sides of the ambivalence• Reflect the meaning• Reflect the feeling

• Used to move the conversation forward

• Create an intimate dialogue and rapport

Listening Reflectively

• Form a reasonable guess as to what the person meant

• Give voice to that guess in the form of a statement

• A well formed statement is less likely to evoke resistance

• Vocal tone should go gently down at the end of a statement (not up like a question)

Hot Potato Reflections: Exercise

• I will say a statement and throw the ball to one of you. (Example: School is just too hard).

• The person who catches the ball, will reflect my statement (Example: You feel frustrated).

• She/he will say a different statement (something that one of her/his clients might say) and throw the ball to another person. (Example: I don’t think college is for me).

• Everyone will have a turn reflecting.

• Debrief.

Traps

Question-Answer Trap

Taking Sides Trap

Expert Trap

Labeling Trap

Premature Focus Trap

TRIADSCount off by 3.

Break up into your TRIADS.

One person will be the Counselor, the second person willbe the Client, the third person will be the Coach.

For 5 minutes, the Client will talk about a behavior that theywant to change and the Counselor will use OARS to helpthe client.

The Coach will help the Counselor. At any time, the Counselor can ask the Coach for advice.

Switch roles after 5 minutes.

Change Talk

Statements about change that are

Linked to a specific behavior or set of

behaviors,Typically come from the client, and

Are typically phrased in the present tense.

Change Talk

Preparatory Talk

Preparatory Talk

Desire – I wish things were different.

I hope that I can change.

Ability – I think I can do it.

I could make it if I put my mind to it.

Reasons – This is not the kind of person that I am.

Things can’t go on like this any more.

Need – Something’s got to change.

Things have to get better.

Commitment Talk

Commitment Talk

Commitment – I will change.

I plan to change.

Taking Steps – My first step will be…

I have already started making changes.

Drumming for Change Talk

when you hear

Desire (I want….)

Ability (I can….) Reasons (Because….) Need (I have to…)

Commitment (I will…) Taking steps (And this is

how…)

Eliciting Change Talk

Evocative Questions◦ Evoke Change Talk

Elaboration◦ Elaborate on Change Talk

Looking Back◦ Reestablish values, enhance hope, redefine

goals Looking Forward Exploring Values

Change Talk Jeopardy

I will say a change talk statement Someone will ask me a question that would

evoke that statement.

Example:Evocative question: What do you think your first

step might be?Anya: I might meet with my math teacher and ask

for help. [change talk statement]

Reinforcing Change Talk

Use your OARS!

Resistance: The Fist

Break up into dyads.

One person make a fist and hold it tightly together.

The other person – try to get the person you are working with to open up their fist anyway that you can, using what you typically think would work and following your instincts. Be creative!

Switch roles after 3 minutes.

Resistance

Arguing Interrupting

Denying Ignoring

Fifth Category of Resistance

Compliance

Consonance and Dissonance

Continuum of conversation & relationship Fluctuations in the harmony of relationships

are normal Practitioner’s goal is to avoid provoking

resistance When resistance emerges, the first priority is

to reduce it Until resistance is low, nothing else can be

done

Rolling With Resistance

ReflectionsReflection of meaningReflection of feelingDouble-sided reflection

Rolling With Resistance

Shifting Focus Emphasizing Personal Choice and

Control Reframing Coming Alongside Agreement with a twist

Resistance Barometer

I will sit in the middle of 5 chairs.

3 volunteers will come up and sit in front of me.

I will talk about something that I feel ambivalent about.

The volunteers will act as one counselor and reply to my statements (they can also use the larger group for consultation).

If I move left, I am feeling more resistant.

If I move right, I am feeling less resistant.

/Demonstration with Anya/

Batting Practice

Break up into 4 groups

Select 1 person who will be a resistant client

Everybody else will be a collective counselor

The client will make a statement and the first person to her right will respond

The client then will respond to that statement and direct it to the second person to her right

Repeat

Go around the circle 2 times

/Demonstration/

Sentence Stems

I learned __________

I relearned ____________

I gained ______________

I appreciated ____________

One thing that surprised me was _________

I could use MI to _____________

I am more confident now that I can ________________

I can’t wait to try _________

Questions