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Slide 2 Created by Susan Sampl, Ph.D. Adapted by John P Thompson MA, CDP Slide 3 Primary Resource: Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. New York: Guilford Press Miller, W.R. and Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press An additional resource (free !): Enhancing Motivation for Change in Substance Abuse by Miller. Treatment Improvement Protocol Series (TIPS) # 35. Call 1(800) 729-6686; ask for BKD342 Slide 4 A style of intervention based on the premise that people are most likely to change when the motivation comes from themselves, rather than being imposed by the therapist Based on a trans-theoretical model: 1) stages of change theory 2) client-centered approaches 3) clinical research A strengths-based approach Slide 5 Developed by Prochaska & DiClemente, 1986 A sequence of stages through which people typically progress as they think about, initiate, & maintain new behaviors Both within & outside of therapeutic environment Applies to a variety of behavioral changes, including substance use, eating, parenting, exercise, and health behaviors. Slide 6 Precontemplation Contemplation Preparation Action Maintenance Relapse I need to do something about this problem. I need to change. Lets make a plan... figure out some steps & strategies. Ive changed a lot, and Id like to stay clean. Ive got more to learn. I dont have a problem You do Maybe I do have a problem Slide 7 Does not think has a problem, and does not consider change. May be more surprised than resistant when told has a problem. Rarely seeks treatment, unless compelled. Slide 8 Establish rapport & build trust Raise doubts by: Eliciting the clients perceptions of the problem Providing feedback Facilitating feedback of a significant other Avoid premature prescriptive advice Express concern & keep the door open Slide 9 Experiencing ambivalence (mixed feelings), which comes about with growing awareness of risks and problems associated with substance use. Both considers and rejects change. This ambivalence is considered normal. Common for people to come to treatment in this stage. Slide 10 Normalize ambivalence Help tip the decisional balance scales by: Eliciting pros and cons of use & change Emphasizing client choice & responsibility Elicit self-motivational statements, & summarize them Slide 11 Miller, Benefield, and Tonigan (1993) reported drinking outcomes at 12 months were strongly predicted by counselor style: the more the counselor confronted, the more the client drank. Random assignment to counseling styles also strongly predicted the degree of client resistance (higher with confrontation) expressed motivation for change (higher with MI). Slide 12 Argue with the client Impose a diagnostic label on the client Tell the client what he or she "must" do Seek to "break down" denial by direct confrontation Imply a client's "powerlessness" Slide 13 The Labeling Trap While some clients benefit from accepting a label like alcoholic or addict, this is not necessary for each clients success Pressuring clients to accept a label can reflect a power struggle in which therapist attempts to assert control Other buzzwords can elicit resistance, e.g., your problem The MI approach de-emphasizes labeling Slide 14 Adolescents are presenting as concrete (vs. abstract) thinkers with low problem recognition, and low readiness for change Therapist style is a powerful determinant of client motivation and change Change is more likely when the motivation comes from adolescent, rather than being imposed by the therapist, family, school, or court Need to show respect for the client and demonstrate understanding (vs. confrontation) Ambivalence about change is normal Change involves a process Slide 15 Therapist style is a powerful determinant of client motivation & change Show respect for the client Reflective listening is emphasized rather than confrontation Ambivalence about change is normal Slide 16 Feedback of personal risk or impairment Responsibility (Emphasis on personal RESPONSIBILITY for change) Advice to change Menus of alternative change options Empathy Self-Efficacy (Facilitation of client SELF-EFFICACY or optimism) Slide 17 Open-Ended Questions Affirm Reflective Listening Summarize Elicit Change Talk Slide 18 Closed-Ended Did you come here because of the court? Open-Ended What led to your coming to treatment? Slide 19 Closed-Ended How many times a week did you use cocaine when you first started? Open-Ended Tell me about your early experiences with cocaine. Slide 20 Closed-Ended You like smoking marijuana Open-Ended What do you like about smoking marijuana? Slide 21 The Question-Answer Trap Reinforces the client being in a passive role, waiting for the therapist to figure out the answer Encourages brief answers, without the additional info needed for MI Open-ended questions w/o reflective listening responses can have the same effect Generally, avoid asking 3 questions in a row Slide 22 Notice and comment on the clients strengths & efforts The extent of doing this depends on the context, including cultural issues Slide 23 A crucial skill for MET The clinician demonstrates through comments & gestures an understanding of what the client is communicating Improves with practice An alternative to the Question and Answer trap Slide 24 Slide 25 Warning or threatening Arguing or lecturing Shaming or ridiculing Humoring or withdrawing Moralizing, preaching, or should-ing Labeling Slide 26 CONFRONTATION: Yes you do! How can you sit there and tell me you don't have a problem when... QUESTION: What makes you think you don't have a problem? REFLECTION: So you can see some reasons for concern, but you really don't want to be labeled as "having a problem Slide 27 JUDGING: What's wrong with that? She probably has some good reasons for thinking so. QUESTION: Why does she think that? REFLECTION: And that really annoys you. Slide 28 ADVICE: I guess you'll have to get yourself some new ones. SUGGESTION: Well, you could just tell your friends that you don't use anymore, but you still want to see them. REFLECTION: It's hard for you to imagine living without drugs. Slide 29 In Groups of three... The purpose of this exercise is to demonstrate that sometimes we think we know what someone means, but that is not always true. Take turns being the Speaker: Speaker states an opinion about something that he/she has some feeling about, that is a bit of a complex topic. Listeners respond by asking yes or no questions, when you say _____, do you mean ______? Continue this with each speaker until you have a good sense of what they mean. Slide 30 In Groups of Three... 1) Speaker Something about myself that I would like to change is... 2) Listeners: Respond with reflective statements until the speaker feels understood. Then, switch to a new speaker. Reflective Statements So you... It seems to you that... It sounds like youre feeling... Slide 31 Reinforce what the client has been saying Demonstrate your attention to what the client has been saying Often provoke additional change talk 3 types of summaries: Collecting summaries A brief summary, Linking summaries Intended to help the client see connections Transitional summaries Marks & announces a shift from one focus to another Slide 32 Contrasted to traditional style in which counselor advocates for change, & client argues against Methods for Eliciting Change Talk Asking evocative questions Using the importance ruler Exploring the decisional balance Elaborating Querying extremes Looking back Looking forward Exploring goals & values Slide 33 1. Express Empathy 2. Develop Discrepancy 3. Avoid Argumentation 4. Roll with Resistance 5. Support Self-Efficacy Slide 34 Much of MET is listening rather than telling. Conveyed Non-verbally: eye contact body position facial expression Conveyed Verbally through reflections Slide 35 Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be. Thought to be the engine that drives change Help the client describe the discrepancy between how their life is when abusing substances how it was/could be without Slide 36 The Premature Focus Trap Trying too soon to focus in on substance abuse as the main issue may elicit much increased resistance Better to start with the clients concerns-likely to eventually lead back to the substance abuse issues Slide 37 Resistance is a cue to modify your approach Treat ambivalence (mixed feelings) as normal Use double-sided reflections It is the client and not the therapist who voices the arguments for change Slide 38 The Expert Trap MI as a collaboration, instead of counselor/therapist imparting wisdom Client is the expert on his/her situation Similar to the question-answer trap in placing the client in the passive role Avoid shifting prematurely to prescribing solutions, & doing problem-solving Slide 39 How the therapist handles client "resistance" is a crucial and defining characteristic of the MET approach. Dont get rattled when the client says something against change Best response is empathy, plus slightly hopeful comment Slide 40 Reflective Responses Simple Reflection Amplified Reflection Double-Sided Reflection Shifting Focus Reframing Agreement with a Twist Emphasizing Personal Choice Coming Alongside Slide 41 The Blaming Trap Client in early treatment may be very focused on figuring out who is to blame for the problem Useful to directly tell the client that therapy is not about figuring out whos to blame Slide 42 Reinforce any willingness: to hear information to acknowledge the problem to take steps toward change Make the connection between previous successful change & potential to change the current problem Slide 43 The Taking Sides Trap The most common trap Most important to avoid Increases the likelihood the client will argue for the other side of the ambivalence The more they hear themselves arguing against change, the more they reinforce their opinion that they dont have a problem Slide 44 1. being open to input about drug use and effects 2. acknowledging real or potential problems related to drug use 3. expressing a need, desire, or willingness to change 4. expressing optimism about the possibility of change. Slide 45 Remember to use open-ended questions Affirm the client Elicit self-motivational statements Offer feedback Use reframing Summarize