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1 DEPARTMENT OF COUNSELING AND EDUCATIONAL PSYCHOLOGY COLLEGE OF EDUCATION 6300 Ocean drive, Unit 5834 Corpus Christi, Texas Facilitating Change: Combining Motivational Interviewing and Dialectical Behavior Therapy Robert L. Smith, Ph.D., NCC, FPPR Professor and Dep t Chair, TAMUCC Saumya Arora, M.A. Doctoral Student, Texas A&M Univ.-Corpus Christi Michelle H. Hollenbaugh, Ph.D., LPCS, Texas A&M Univ.- Corpus Christi

2 Motivational Interview Motivational Interviewing is a therapeutic method of helping individuals make change in their lives Builds on Carl Rogers humanistic approach emphasizing free choice and the process of self actualization Activates the capability for change

3 Motivational Interview It is a combination of: An engaged understanding of client s internal frame of reference A clear change focus Evoking client s own motivation for change It may also include a collaborative plan to implement this change

4 Key Concepts of MI Collaboration rather than confrontation Drawing out rather than imposing ideas with clients Autonomy rather than authority

5 Underlying Assumptions Presence of ambivalence as an obstacle to recovery Ambivalence in clients can be resolved by working with their intrinsic motivations and values Both the counselor and client bring important expertise to counseling sessions and that the alliance between the two can bring about change

6 Ambivalence Most individuals are aware of the dangers of abusing substances But most continue to use Most want to stop while at the same time not wanting to stop They enter treatment stating their problems are not serious

7 Ambivalence Understand and accept the client s ambivalence Ambivalence is often the central problem Ambivalence manifests itself through a lack of motivation It is a mistake to interpret ambivalence as denial or resistance

8 Evoking the client's motivation A client s balance of change talk and sustain talk predicts change, and is substantially influenced by the interviewer. Open ended questions eliciting change talk are an important tool Desire Questions Ability Questions Reason Questions Need Questions The Wrong Questions

9 Principles of MI Express empathy through reflective listening Bring out the discrepancy between the client s goals or values and their current behavior Avoid argument and direct confrontation Roll with resistance- use reflection Support self-efficacy- provide hope and a belief in change

10 Handling Discrepancy Goal-status discrepancy is tremendous source of motivation for change Change begins to occur when a person is able to perceive the discrepancy between important goals or values and the status quo Motivation is assisted when this discrepancy is significant to encourage than discourage or demoralize Explore goals and values for further clarity Honor Autonomy

11 Video of Miller Using MI in session

12 Dialectical Behavior Therapy Developed by Marsha Linehan (1993) A multifaceted, cognitive-behavioral approach that includes aspects of mindfulness meditation, behaviorism and dialectics. Created for clients with Borderline Personality Disorder Helps clients gain insight and skills to manage their thoughts, emotions, and behaviors

13 Dialectics A synthesis of opposites Many therapist strategies in DBT are dialectical Also help clients identify dichotomous thinking and how to find the dialectic in a given situation

14 DBT Treatment DBT training is intensive and focuses on how to conduct skills groups and individual therapy Two types of DBT treatment Individual Group Skills Training Homework and Diary Cards 24 hour phone coaching

15 DBT Treatment In this session, we will review a few techniques from group skills training

16 Biosocial Theory of BPD Biological Predisposition for Emotional Sensitivity/Reactivity Invalidating Environment Pervasive Emotion Dysregulation

17 DBT INTERVENES AVOIDANCE OR ESCAPE CUE EMOTION DYSREGULATION DBT teaches how to avoid or distract without problem behavior PROBLEM BEHAVIOR TEMPORARY RELIEF Teach skills on how to regulate emotions and reduce vulnerability to cues Teach how to stop the behavior; which stops reinforcement

18 Assumptions about BPD and Therapy Clients are doing the best they can Clients want to improve Clients need to do better, try harder, and be more motivated to change Clients may not have caused all of their problems, but they have to solve them anyway The lives of suicidal, borderline individuals are unbearable as they are currently being lived Clients must learn new behaviors in all relevant contexts Clients cannot fail therapy Therapists treating BPD need support

19 Group DBT Treatment Four Skills Training Modules Mindfulness Interpersonal Effectiveness Emotion Regulation Distress Tolerance

20 Mindfulness -States of Mind REASONABLE MIND WISE MIND EMOTIONAL MIND

21 MINDFULNESS Taking Hold of Your Mind: What Skills Observe Describe Participate Taking Hold of Your Mind: How Skills Non-Judgmentally One Mindfully Effectively

22 Mindfulness Practice o Notice one event or thought that you experienced today or yesterday, and contemplate that event or thought. o Observe thoughts, feelings, and sensations surrounding this event or thought. o Try to do this one-mindfully, non judgmentally, and effectively. o If you get distracted, just notice this, and bring yourself back to the thought or event.

23 Accepting Reality Distress Tolerance Radical Acceptance Freedom from suffering Being non-judgmental Accepting pain Turning the Mind Choice Commitment Willingness vs. Willfulness

24 DEAR MAN Interpersonal Effectiveness Objective Effectiveness Describe Express Assert Reinforce Mindfully Broken record Ignore Appear confident Negotiate Turn the table

25 Linehan Video

26 Combining DBT- MI Client Centered Importance of therapists speech on client Change Talk (Ambivalence and Dialecticism ) Two Phases of therapy with underlining concept of cultivation and expression of empathy: MI- DBT- Building Motivation for change Strengthening Commitment to change Validation Problem Solving

27 Combining DBT- MI Resistance is not challenged by both therapies, rather used a an opportunity to explore personal resources Therapist Behavior might lead to resistance Working towards improving client s protective factors Use clients intrinsic motivation towards achieving a goal Both theories can be used complementarily

28 References Miller, W.R., Rollnick, S. (2013). Motivational Interviewing: helping people change. The Guilford Press. NY Osborn, C. J. (2011). Bilingual Therapeutics: Integrating the Complementary Perspectives and Practices of Motivational Interviewing and Dialectical Behavior Therapy.(Report). Journal Of Contemporary Psychotherapy, (2), 81.