Using Motivational Interviewing To Enhance Engagement

PCCYFS Annual Spring ConferenceThursday, April 14, 20118:30 - 10:00

Dave VactorChristy Pfleger

“MI Preparation Prayer”Guide me to be a patient companion

To listen with a heart as open as the skyGrant me vision to see through her eyes

And eager ears to hear her storyCreate a safe and open mesa on which we may walk

togetherMake me a clear pool in which she may reflect

Guide me to find in her your beauty and wisdomKnowing your desire for her to be in harmony-healthy,

loving, strongLet me honor and respect her choosing of her own path

And bless her to walk it freelyMay I know once again that although she and I are different

Yet there is a peaceful place where we are one-Bill Miller, co-founder of MI, Rollnick and Miller 1995

Purpose Provide an overview of the process

of change and basic MI skills

Explore how to use MI skills to effectively engage families

Learn strategies to help clients tap into their motivation for change

So What Exactly is MI?

Definition: a perspective that views a client as the most

influential agent of change and aims to empower the client to actively engage in the process of change.

a method or approach, not a technique, that is not based on a singular theory.

“A directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence.”-Rollnick and Miller, 1995

Rollnick and Miller 2006

Benefits of using MI Address and move past ambivalence

Motivate towards change

Helping the decision making process

Address and decrease resistant behaviors

History MI was developed in 1983 by Bill Miller for use

with substance abuse clients.

Empirical data has been collected for use of MI treatment with: drug and alcohol abuse, smoking cessation, psychiatric disorders, HIV related risk behaviors, diet and exercise.

Note: These effects did not diminish significantly over time.

Beliefs Essential to the MI process

Person-Centered (closely linked to Rogerian Theory)

Resistance to change and ambivalence are natural human processes

• Lack of motivation=unresolved ambivalence

• Negative feelings and experiences can inhibit change

• Change occurs when it is connected to something of importance and value

The client needs to show you the reason for change in order to proceed successfully (“change talk”)

What people say and how they talk about change is important.

Defensiveness = Change

Confrontation = Change

“Change Talk”

Confidence and Self-Efficacy

When people and service providers believe that change can happen, it is more likely it will happen

Self-efficacy=hope that change can occur

Empathy facilitates change Positive reinforcement increases likelihood of

trying new behaviors Sets up the collaborative relationship “Friendly consultant” role

Approach Direct persuasion is not an effective

method for resolving ambivalence Increases resistance behaviors, decreases willingness

for change

The style is generally a quiet and eliciting one Focus is on drawing out from the client, and providing

guidance through questions, scaling, etc. 60/40

Approach, continued

o The counselor is directive in helping the client to examine and resolve ambivalenceo Readiness to change is a not a client trait, but fluctuating product of interpersonal interaction

• Resistance and denial are a product of the client’s interactions with the world around him, not a personality trait

Three Key Components Collaborate (Partner)

Empathy, respect

Evocation (Draw Out) Guided questions, reflection

Autonomy (Client stands on own) Implements and sustains change

Identifying “Change Talk” Disadvantages of status quo

Advantages of change

Optimism

Intention to change

What is Unique about MI? MI is Directive Client-Centered= focused on client’s interest

and concerns• Do not teach new skill, alter thought patterns

or look to the past MI is a method of communication

• Not something we do to, but we are with and for clients

Change is not forced or imposed (i.e., through punishment, pressure, financial gain)

The client is the expert to their situation

Wheel of Change

Motivational Interviewing and the Trans-theoretical model to change were developed separately but synchronously.• Trans-theoretical model of change is

used to breakdown the concept of readiness to change into stages.

The Wheel of Change was created to to assess what MI strategies to use for forward movement.

Prochaska, Di Clemente and Norcross, 1992

Wheel of Change

Based on self-help change, but applies to all types of change.

Tool to help us understand where clients are in their cycle of change.

Assists in engaging clients to help them want to change.

Relapse is viewed as an inevitable stage of change.

Wheel of Change

Prochaska, Di Clemente and Norcross, 1992

Stages of Change

Pre-Contemplation Contemplation Preparation Action Maintenance Relapse

Stage 1: Pre-Contemplation

Characteristics: No intention of changing anytime soon

Unaware that a problem exists “ignorance is bliss”

Discouraged, Rationalization, Denial, Minimization

Persons close to them are aware of problems

If a pre-contemplative person is in treatment - normally a result of coercion by someone in their environment. (e.g. spouse, employer, legal, agency)

Pre-Contemplation

Techniques/Strategies: Avoid giving advice Validate lack of readiness Clarify: decision is theirs Encourage self-exploration, not action Engage by acknowledging thoughts, fears,

feelings, concerns Information and feedback Explain and personalize the risks

Stage 2: Contemplation

Characteristics: Ambivalence: “Sitting on the fence”

Reasons for concern more evident

Justification for lack of concern

Beginning recognition of problem

Evaluating pro’s and con’s

Contemplation

Techniques/Strategies: Avoid giving advice Create awareness of defenses Identify relationships that help not enable Increase perception of risks &

consequences Engage by acknowledging thoughts, fears,

feelings, concerns Identify and promote new positive

outcome expectations

Stage 3: Preparation

Characteristics: Intention to change, but no specific goals

Attempts to change: “Testing the waters”

Reduction in poor choices, negative behavior

Changes have a minimal impact on their life

Temporary exit and return to pre-contemplation

Preparation

Techniques/Strategies: Identify and assist in problem

solving i.e. obstacles, barriers Help identify positive social support Validate client’s underlying skills for

behavior change Encourage small initial steps Articulate choices in client’s words

Stage 4: Action

Characteristics: Changes in environment to achieve

goals Doing things to make change Experience of success (may remain

here) Client gain sense of hope Combat feelings of loss, isolation,

despair

Action

Techniques/Strategies: Cheering on/Encouraging Reflecting on goals Bolster self-efficacy Pointing out long-term benefits Maintain focus on accomplishments

and social supports

Stage 5: Maintenance

Characteristics: Continued commitment to sustain

change Post 6 months to 5 years Working to prevent relapse New skills drawn out are practiced

Maintenance

Techniques/Strategies: Identify and Reflecting on goals Bolster self-efficacy Pointing out long-term benefits Maintain focus on accomplishments

and social supports

Stage 5: Relapse

Characteristics: Oops Step backward Slip=minor Off the wagon=major Challenge is to start again Use relapse as opportunity to grow

Relapse

Techniques/Strategies: Help prepare for expected relapse Avoid demorilzation Don’t give up Clarify consequences Liken to experience of loss -Shock, Denial, Anger, Bargaining, Acceptance, Moving on

Using MI with the Stages of Change Each stage contains certain

helping behaviors that are particularly constructive

Assist in measuring/gauging• Readiness• Confidence• Motivation

Instead of asking “Why isn't this person motivated?” ask “What is this person motivated by?”

Resistance Behaviors

Arguing Interrupting Denying Ignoring Overt compliance/Covert defiance

Skills Get Permission Drawing from past successes Scaling Imagine ideal future and change needed

to get there Extremes-worst and best possible

outcomes of change ScalingMandated Clients: Acknowledge mandate Provide choices Empathize with lack of choice

Principles

Express Empathy

Develop Discrepancies

Roll with Resistance

Support Self-Efficacy

How to Make it Work

o Express empathy- reference listening, reflective listening

o Develop discrepancies – bring client on board with the importance for change by:

• highlighting differences between current behavior and personal values

• Have the person argue for change

Rolling with Resistance

Accept it Respect it Flow with it “Roll with it” rather than

oppose it

Supporting Self-Efficacy

Empowering the client to be the change agent

Have confidence in client’s ability Be a cheerleader!! Punctuate positives and strengths Convey understanding

Elements of a Change Plan/Case Plan

Goals Reasons Steps Support Obstacles Signs of Progress

MI Skills (OARS)

Ask Open ended questions

Affirm

Reflective Listening

Summarizing

ReferencesBaer, J.S., Garrett .S.B., Beadnell, B,Wells E.A, & Peterson P.L.,

(2007). Brief Motivational Intervention With Homeless Adolescents: Evaluating Effects on Substance Use and Service Utilization, Psychology of Addictive Behaviors, 21, 582-586.

Burke B.L., Arkowitz. H & Menchola. M., (2003). The Efficacy of Motivational Interviewing: A Meta-Analysis of Controlled Clinical Trials Journal of Consulting and Clinical Psychology, 21, 843-861.

Miller, W. R., & Rollnick, S.,(1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.

Miller, W. R., & Rollnick, S., (2002). Motivational interviewing: Preparing people for change (2nd ed.) New York: Guilford Press.

Petrocellim, J.V., (2002). Process and change: counseling with the transtheoretical model of change, Journal of Counseling and Development, 80, 22-28.

Russell .C.R., Motivational Interviewing training for new trainers., (2002). The Motivational Interviewing Network of Trainers.

Wagner,C, .C,. Ingersoll. (2008). Beyond cognition: broadening the emotional, base of motivational Interviewing Journal of Psychotherapy. Integration and American Psychological Association 18, 191–206.

Wiles, M. (2005). Motivational interviewing: overcoming client resistance to change. Cross Country Education Inc.

Zuckoff, A., & Daley, D. C., (1999). Improving Treatment Compliance: Counseling & Systems Strategies for Substance Abuse & Dual Disorders.