MI is about Helping People Change! Facilitating Change through Motivational Interviewing. And So, Why Do People Change?

Transcription

1 Facilitating Change through Motivational Interviewing Lindsay Hanna, M.S., CCC-SLP, LSLS Cert AVT Steven P. Wells, Ph.D., L.C.S.W. Darcy L. Stowe, M.S., CCC-SLP, LSLS Cert AVT Introduction to Motivational Interviewing Steven P. Wells, Ph.D., L.C.S.W. Clinical Associate Professor Anne and Henry Zarrow School of Social Work University of Oklahoma A Motivational Interviewing Prayer Guide me to be a patient companion, to listen with a heart as open as the sky. Grant me vision to see through her eyes and eager ears to hear her story. Create a safe and open mesa on which we may walk together. Make me a clear pool in which she may reflect. Guide me to find in her your beauty and wisdom, knowing your desire for her to be in harmony: healthy, loving and strong. Let me honor and respect her choosing of her own path, and bless her to walk it freely. May I know once again that although she and I are different, yet there is a peaceful place where we are one. Motivational Interviewing (MI) Can Be Defined As: A collaborative conversation style for strengthening a person s own motivation and commitment to change. MI is about Helping People Change! And So, Why Do People Change? One way to think about it is that people change when they are..... Ready: Willing: Able: Is it the right time? Is it important enough? Do I have what it takes? 1

2 Again, People Change When They Find: Readiness Confidence (Ability) Importance Maybe More Critical for Us Is: Why DON T People Change..... Even in the Face of: Pain Loss Threat Shame and Embarrassment But, Change may be more complex than we think. The Trans-Theoretical Model of Change (TTMC): Change Through STAGES The TTMC Spiral of Change Ambivalence Preparation Ambivalence Maintenance Action Pre-Contemplation Contemplation 10 Across the Stages, processes are at work that contribute to change. MI is about helping people have the right conversation, about the right process, at the right time. Processes of Change Gaining information, about ourselves (feedback) and about our environment (education). Release of emotions tied to the needed change. Finding and choosing new alternatives. Modifying individual response to our environment through planned activity or modifying the environment (when simply becoming conscious or having choice is 2

3 Stages of Change and the Processes Precontemplation Contemplation Preparation Action Maintenance Gaining Information Release of Emotions Choosing Motivational Interviewing (MI) Can Be Defined As: A collaborative conversation style for strengthening a person s own motivation and commitment to change. Modifying Individual Responses Modifying Environment Modifying Contingencies 13 The Spiral of Change MI Most Useful Here Pre-Contemplation Ambivalence Preparation Ambivalence Contemplation Maintenance Action Struggle With Change Thinking About the Importance of a Needed Change: People Arrive with Varied Capacities High Confidence High Importance High Confidence Low Importance Low Confidence High Importance Low Confidence Low Importance 15 Spirit of Motivational Interviewing : How a Helper Maximizes Being Helpful Partnership Acceptance Absolute Worth Accurate empathy Autonomy support Affirmation Compassion Evocation of Speaker Voice Maintaining the Spirit Means Being Open to... Suspending the authoritarian role. Working with clients rather than prescribing. Bringing forth client voice rather than installing our own values and ideas. Honoring client self-direction, capacity, strength, and experience. 17 3

4 Rogers on Empathy To what extent do we convey to our clients that we understand their experience (not necessarily agreeing with their cognitions, feelings, and behavior), and that our work with them is based upon as thorough a knowledge as possible. Ambivalence about Change is Not a Dirty Word! The natural tendency for a person to both want and not want to make change. It is normal to get stuck in ambivalence, sometimes for a long time. Life is a chronic, relapsing brain disease. The key to helping people make change is how we respond. When Advocating for Change is Contrary to Good Helping: Meeting Ambivalence with a RIGHTING RESPONSES Righting Responses Typically Produce RESISTANCE to Change Some Typical Responses That Advocate for Change Four Fundamental Processes of MI 1. Arguing for change 2. Assuming expert role 3. Criticizing, shaming, or blaming 4. Labeling 5. Being in a hurry for change. Focusing Evoking Planning Engaging 4

5 Core Communication Skills (OARS+): Building Engagement 1. Ask Open questions 2. Affirming 3. Reflective Listening 4. Summarization 5. + Informing and Advising Importance of Reflection: Two Levels Simple Stays Close 1. Repetition 2. Rephrase Complex Makes a Guess 1. Paraphrase: continuing the paragraph 2. Reflection of Feeling 25 Core Communication Skills (OARS+) 1. Ask Open questions 2. Affirming Change Talk and Sustain Talk: Opposites Sides of a Coin (The Process of Ambivalence) 3. Reflective Listening 4. Summarization 5. + Informing and Advising 27 Listening and Differential Response: Sustain Talk Listening and Differential Response: Change Talk (DARN CAT) Talk about sustaining the status quo. However, resistance may sound like sustain talk. But, it is likely a result from advocacy responses, or from inaccurate reflections about change Either way, it is best addressed by rolling with the resistance through using the following skills: Reflective Responses (Simple, Amplified, Double-Sided) Shifting Focus Reframing Agreeing with a Twist Emphasizing Personal Choice and Control Preparatory Change Talk Desire Ability Reasons Need Mobilizing Change Talk Commitment Activation Taking Steps 30 5

6 EXAMPLES OF PREPARATORY CHANGE TALK Desire to change: I wish things were different. I m hoping things will change This is not the person I want to be. Ability to Change: I know what I have to do I just need to do it. I can make a change: I just need to commit to it. I m going to prove everybody wrong. EXAMPLES OF PREPARATORY CHANGE TALK Reason(s) to change: My wife might get off my back if I didn t drink so much. Maybe I would have more energy if I watched my blood sugar better. It would be nice if I didn t have to worry about all this. Need to Change: I ve got to make things better. I need to get a handle on things. My blood sugars can t go on like this EXAMPLES OF MOBILIZING CHANGE TALK Commitment to change: I am going to... I will... I plan (or intent) to... I have already started to... EXAMPLES OF MOBILIZING CHANGE TALK Action or Taking Steps Toward : I went to the gym and worked out twice last week. I went to the store, bought vegetables, cleaned and cut them up, and have them in my fridge for snacks. I told my boyfriend he couldn t stay if he was drinking. I made an appointment to talk with someone about how I could manage my prescriptions better The Occurrence of Change Talk (Especially Mobilizing Change Talk ) is Directly Related to the Likelihood of Taking Steps Toward Change We can Respond to Change Talk or Elicit Change Talk

7 RESPONDING TO CHANGE TALK Reflect Elaborate Summarize Affirm Eliciting Change Talk Ask About the Disadvantages of the Status Quo Ask About the Advantages of change Ask About the Optimism for change Ask About the Intention to change 37 RESPONDING TO RESISTANCE Offer a... A Simple Reflection A Double Sided Reflection An Amplified Reflection An Agreement with a Twist An Emphasis on Personal Choice and Control Reframe When More Directness is Needed (or Allowed) Elicit Provide Elicit for Feedback 1. Elicit What the Person Wants to Know and What They Do Know 2. Provide Feedback Neutrally Just the information stay away from personal interpretation. Talk about what many clients experience. Avoiding you language. 3. Elicit What the Person Thinks About the Information What do you make of that? What does this mean to you? 39 Coaching Relationship Effectively using MI in AVT What the parent brings to the table What the practitioner brings to the table 7

8 Critical Conversations Initial diagnosis Responding to change talk Eliciting change talk Responding to resistance Initial Counseling Initial counseling: Where do you want your child to be (at 18)? AND How will you get there? (let them articulate) When providing test results: Don t discount science Listen to the client Provide opportunity for them to articulate their thoughts/feelings Summarize their feelings Responding to Change Talk Capitalize on ANY positive change talk REFLECT ELABORATE SUMMARIZE AFFIRM Eliciting Change Talk Ask about disadvantages of the Status Quo Ask about advantages of change Ask about optimism for change Ask about intention to change Eliciting Change Talk: Starting the Conversation What are your concerns about, how do you think he is doing? I hear you have some serious concerns, we would love to hear those concerns. Where do you want your child to be in 5 years? How would you like him/her to get there? Would you permit me to tell you how we can help your child? Eliciting Change Talk: Moving the Conversation Along We find that other families/children experience Here s what people who experience this have reported what do you think about that? We find that kids do this NOT If you do this, then your child will. Then ask, What do you think? Other parents have found it helpful to, what do you think about that? Is there one thing you could hear to help move you forward? This is surprising to you, what is the most surprising? What would you have to know to decide a CI/HA would be helpful for your child? 8

9 Eliciting Change Talk: Concluding the Conversation I really admire that you are willing to move forward even though you have doubts (acknowledge and affirm for making steps) Responding to Resistance Simple Reflection Double-Sided Reflection Amplified Reflection Agreement with a Twist Emphasizing Personal Choice and Control Reframing Responding to Resistance Elicit Provide Elicit for Feedback Responding to Resistance What I hear you saying is you never, ever want to hear about a CI again. Yes Here s my card, call me if you change your mind. It sounds like you know your mind. Sources: Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2008). Motivational Interviewing in the Treatment of Psychological Problems. New York: The Guildford Press. Miller, W. R. & Rollnick, S. (2012). Motivational Interviewing: Preparing People for Change (3 rd ed.). New York: The Guilford Press. (ISBN ) Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992) In search of how people change: Applications to Addictive Behaviors. American Psychologist, 47, No. 9, Prochaska, J.O. & Norcross, J. C. (2010). Systems of Psychotherapy: A Transtheoretical Analysis. Belmont, CA: Brooks/Cole Cengage Learning. Rosengren, D. B. (2009) Building Motivational Interviewing Skills. New York: The Guildford Press. Wells, S.P. & Stowe, D.L. (2013). Facilitating Change through Motivational Interviewing. Volta Voices, Volume 20, Issue 5, Darcy L. Stowe, M.S., CCC-SLP, LSLS Cert AVT dstowe@heartsforhearing.org Lindsay Hanna, M.S., CCC-SLP, LSLS Cert AVT lhanna@heartsforhearing.org Steven P. Wells, Ph.D. (LCSW) spwells@ou.edu 53 9