motivational interviewing: getting started with motivational counseling

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Powerpoint accompanying workshop session from the Homeless and Housing Coalition of Kentucky's 2013 conference. Presented by Patrick McKiernan Motivational interviewing is a technique that uses a dialogue between a counselor and a client who needs to change behaviors in his or her life. The purpose of this technique is to be non-confrontational, non-adversarial and non-judgmental, and uses open-ended questions and reflective listening to forge a relationship between counselor and client built on trust and empathy. This session will present basic information on how to help increase motivation to change with individuals considering but uncommitted to change. The discussion will include background, theory, and techniques related to the change process.



2. Overall Seminar Goal2 Provide a quick start to motivationalcounseling: Focus on practical clinical aspects TRY to limit theory and concepts Increase ability to implement MI Increase practice skills Increase supervision/evaluation skills Exposure to research that is changingmotivational interviewing practice 3. MI intervention overview (bigpicture) MI targeted behavior: Create and sustainengagement in an adherence changeplan. Follow Doctors recommendations Meditational: Different than actualtreatment adherence. Key point: MI is behavior specific 4. MI is highly strategic Advanced counselors are more strategic Strategic: More efficient (briefer) and effective Client state is continually assessed Navigational map Counselor utterance is a strategic response Few client states Relatively few MI strategies Memorize 5. Influences and References5 Client Centered Therapy (Carl Rogers): NonDirectional Motivational Interviewing (Miller & Rollnick):Directional Approach Self Determination Theory (Deci and Ryan):Psychological Needs & Quality of Motivation Transtheoretical Stages of Change (Prochaskaand DiClemente): Process of change Behavioral Economics (newly applied tochange): Time value and temporal effects ondecision making. 6. Rooted in Natural Change6 Self-actualization tendency (Rogers) Adaptive creatures Systems perspective Manipulate environment to meet their needsand desires Opening up a closed system Self Determination Theory: Human thriving Subtle nature of motivation behavior doesntfollow behavioral principles Better motivation is more value driven 7. RESEARCH ON MI: MetaAnalysisImportant distinction from Hettama (p. 108)MI does NOT communicateI have what you need.BUT RATHERYou have what you need, and together wewill find it. 8. Research on MI:Works as Standalone or Front End8 Phase I vs. Phase II Before and after commitment to change. MI works as a standalone intervention As a front end for some other interventionto increase treatment adherencePhase IMotivationalCounselingPhase II:Open ended menu of optionsPhase IMotivationalCounselingPhase II:Some prescribed treatmentemphasized (e.g., Lincoln Trail) 9. Meta Analysis: Summary The evidence base for MI is extremelystrong in addiction and growing in health.Evidence base is vast 72 target clinicaltrials spanning a range of target problems(Hettema, 2005) Current research is focused on findingwhy and how it works. Research on learning: Best learnedthrough practice. 10. Meta Analysis Works better than alternative approaches with with people from ethnic minority groups. angry and resistant, or less ready for changeclients. MI as preparation for any other treatment program High effect sizes are observed Improves tx adherence and retention The effect endures across time When MI is used as a standalone rapid impact of MI gradual de-crease of effect size across time Implications: Booster sessions Use as a stepped care program (followup built in) Used as fallback (followup built in) 11. What is motivation?How do we change it? 12. Miller & Rollnick on,What is motivation? Motivation: Mediates MI tx adherence Measurement: Recognition or action Ambivalence is difficult to measure Complex construct: Notfeeling, thought, behavior; rather, a drive / energy / fuel Dynamic / volatile across time andenvironment M&R: Ready (committed), willing(important), and able (self-efficacy /confidence) 13. SIMPLE NAVIGATIONAL MAP13WORKING ALLIANCE(red)Importanceof ChangeCommitment to ChangeChange Plan?? Temporal Effects ??ChangeConfidence 14. Major influences andtrendsWhat is MI? 15. Nature of Change Discussion15 Think of some non-trivial behavioral change thatyou or someone you know attempted? Smoking, diet / weight, exercise, etc. What important values or goals were the impetusfor change? Was it self change or aided change? Whathelped? What didnt help? Did education help? Describe pattern of change across a long periodof time. Lapse? 16. Application to yourself1. Think of one change you would like to make inyour life.2. How ready do you feel to make this change?3. Use a rating ruler to rate your readiness tochange:NOT READY TO CHANGE UNSURE READY TO CHANGE TAKING ACTION1 2 3 4 5 6 7 8 9 10 17. Phase I: Continual assessmentdetermines strategy (RICC)171. Relationship: How strong is myrelationship with this person?2. Importance: Is change important tohim/her? Is he or she ambivalent?3. Confidence: How confident are you that you can change if youtried? Will self efficacy support change plan?4. Commitment: What do you want to do?Note: All counselor strategies should be ideally directed at advancingone of the four RICC components. 18. Therapeutic Relationship (TR orworking alliance) Dilemma18 Strong TR is related to greater change. How will we know the level of TR? Will they tell us? Can we ask? If they do, can you rely on what theysay? Can you judge? Can only best be judged throughcounselor behaviors. Problem: Requires preventive effortsand hyper vigilance. 19. Therapeutic Relationship (TR)19 Rogers: Create an environment for self-actualization TR Synonym: Working alliance RULE: A TR is a requirement forfacilitating change. No TR / No change. What are risks to TR? 20. Developing & Maintaining TR20 Spirit of Motivational Interviewing Psychological needs (self-determinationtheory) Autonomy / internal locus of control Challenge / competency / self efficacy Relatedness All of the MI principles aid in increasing TR Express empathy --Support self efficacy Understand resistance --Developdiscrepancy 21. TR: Risk and Protective FactorsSupportive / Protective Accurateunderstanding(or empathy) Client talks>50% Support autonomy Conveycompetency Sponsor relatedness Affirm and accept(unconditional positiveregard) Understandresistance Discovergoals/values Ask permission for riskfactorsRisk factors* Observe / confront Give advice / fix it Educate / fix it Share opinion Take on authorityrole Debate / argue /defend Being rushed Fail to listen INACCURATE REFLECTIONS!!!*Avoid wheneverpossible. Askpermission whennecessary.21 22. Risk created by brevity22 Poor TR Blocks chance to help Avoid TR risk whenever possible Brevity: Need for balance Know when youare taking risk Calculate risk Mend fences Monitor client relationship Risk is minimized by asking permissionand tone in which you giveadvise, educate, or observe 23. 3 Strategies to improveimportance1. Assess importance and elicit most importantreasons for change with rulers2. Use decisional balance exercises to fullyassess, clarify, and organize ambivalence3. Life plan discovery: Explore past successesand future plans to achieve important goalsand values (desired or ideal) Raises discrepancy 24. Strategies to improve importance1) Use of the Importance Ruler Efficiently assesses importance Also discovers most important reasons forchange. How: On a scale of 1 to 10, how important ismaking a change? If client is high (8 or above) inimportance, summarize and move to assessment ofCONFIDENCE If client response is 7 or below, elicit most importantreasons for change with a ruler Why would you say a [stated value] compared to[stated value minus 3 or 4]. 25. Strategies to improve importance2) Decisional Balance Exercises Decisional balance Weighted list of pros/cons. Aids the client (and the counselor) in clarifying level ofambivalence vs. importance. What are the good things and not so good thinksabout recovery? List them. Pros/Benefits/Good things (the pros and change and cons of statusquo) Cons/Costs/Not so good things (cons of change and pros of statusquo) KEY Response: Reflect the underlying value. Every pro or con has an important value/goal attached to it. ORTHEY WOULDNT MENTION IT. Making that connections increases brings clarity. 26. TranstheoreticalStages of ChangeProchaska & DiClemente 27. Trans. Stages (process) of Change.Where does clinical purpose shift?Stage of Change Precontemplative Contemplative Preparation /Determination Action Maintenance RelapseClient Process Unaware Pre-crystallization Unwilling Discrepancy (conflict withimportant goals/values) Discouraged Support self efficacy Ambivalent Discrepancy tips scale Commit & prepareCollaborate on treatment plan. Carryout Tx plan / learn Relapse prevention / refine Overcome shame / regain confidence27 28. MI 2nd Edition: 2 Phases of Change1. Uncommitted to change: Resolve ambivalence in twoforms Important? Awareness of value incongruence. Confidence? Self-efficacywill it work? can I do it? Phase 2 shift marked by intent / commitment2. Committed: Collaborate on change plan Collaborate / menu of choices for action plan Continue to assess for importance / confidence Termination 29. MI Sandwhich MI Assessment sandwich concept: MI strategies during opening 20 mins Agency intake assessment MI strategies during closing 20 mins 30. MI emphasis on spirit30 Open ended question: Begin with how orwhat. Spirit (SDT research based version): Autonomy (emphasize client choice) Competency (they have what they need), Relatedness (peer relationship, no authority). Reflections Good: Simple (paraphrase) Complex: Reflect emotion or changemeaning 31. DISCOVERY: Achieving 2 Ends31 Interview for most important goals andvalues (ideal life) Achieves 2 ends People crave to be understood Initiates the process of raising importance. Focus on constructing a vision of theclients desired (or ideal) life. Value clarification Spirit: Use TR protective strategies andavoid TR risks. 32. Discovery: CommonValues/Goals32 Health Money / security Relationship with some romantic partner Wellbeing of children and family Psychological needs (SDT): Autonomy /competency / relatedness Will favor experiences that promote these Relatedness: Social support peer vs.authority. 33. TR Risk: Nuance33 Some people are harder than others Greater