the art of possibility in conversation: motivational conversations 101 presented by dee-dee stout,...
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The Art of Possibility in Conversation: Motivational Conversations 101
Presented by Dee-Dee Stout, MA, CADC-II;
Member of MINT; Advisor/Trainer, ICCE
for Lake County Health Services
Lakeport, CA
July 2010
MOTIVATIONAL INTERVIEWING
Teacher, clergy, parent, anyone!
Favorite Teacher/Positively Influential Person
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PLEASE, DO NOT REPRODUCE THIS SLIDE
Wednesday July 11, 2007
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Or What’s NOT MI
Bill’s Illustration of Persuasion
Persuasion (remember: this is NOT MI)
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Explain why your client should make this change
Give at least 3 specific benefits to them of making this change
Tell them how to changeEmphasize how important it is for them to
change, andTell them to “Just Do It!”
Taste of MI: The Speaker
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Topic: Something about yourself you..Want to changeNeed to changeShould/ought to changeHave been thinking about changing…
But you haven’t done yet (ambivalence!)
Taste of MI: The Listener, Part 1
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Listen intently with the goal of understanding your speaker’s circumstance & ambivalence
Give no adviceAsk these 4 open questions:
Why would you want to make this change now?How might you go about it, to be successful?What are your 3 best reasons to make this
change?On a scale of 1-10 (1 is low & 10 is high), how
important is it to make this change?How come you’re a ____ & not a 1?
Taste of MI: Listener, Part 2
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Give a short summary/reflection of the speaker’s motivations for changeDesire for changeAbility to changeReasons for changeNeed for change
Then ask: “So, what do you think you’ll do?” and just listen with interest
Could you see MI helping you work smarter? Would you like to know
more?
So, what did you think?
*8 Strategies to Learning MI (Miller & Moyers, 2007)
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SpiritOARS & client-
centered skillsRecognizing &
Reinforcing Change Talk
Eliciting & Strengthening Change Talk
Rolling with Resistance
Developing a Change Plan
Consolidating client Commitment
Switching btn MI & other counseling methods
My hope? Skills, Spirit, Strategies
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SpiritChange, Change Talk, & No Change Talk
(resistance/defensiveness)Skills & Strategies
OARSTrapsPrinciples
ReadinessDirectiveness: Complex Reflections!
So How Does MI Work?
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MI activates a client’s own motivation for change & adherence to tx (we think!)
Clients exposed to MI v traditional tx are generally more likely to:Enter tx & stay Complete tx moreParticipate in follow up apptsDecrease drug use
Great! Me, too, so let’s back up a second & talk about change for a
bit….
Excited??
About Change…
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Occurs naturally & is similar with or without treatment
Likelihood strongly influenced by interactions (“dancing”)
Very brief (5 mins or less) interventions can trigger change talk & other positive change effects!
And…
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Within treatment, most behavior change occurs in the first few sessions
Resist the “urge to right” – the “Righting Reflex” can be deadly (Cocoon Story?)
The Heroic ClientScott D. Miller, PhD
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“We should be humbled in the presence of our clients for they are the heroes of their lives.”
www.talkingcure.com
Alas, it is very hard to change and be different. It means passing through
the waters of oblivion.”
DH Lawrence, “Change” (1971)
“Do you think it’s easy to change?
increase or decrease motivation & resistance!
How we talk to folks can actually….
Defense Mechanisms (Bill Miller, 2009)
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The idea of "defense mechanisms" takes behavior & turns it into a trait. There is no evidence that people w/addictions truly have different (e.g., more immature) defense mechanisms than other people do, when these are directly evaluated via personality assessment. [And] with [defense mechanisms], you can double them or halve them [simply] by changing counselor style. A fourfold shift in "denial" within a matter of minutes doesn't exactly suggest a stable trait.
Walk-Away Skill #1: Ask, Tell, Ask
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Ask what the client knows about the topicTell the client the information (chunklets
please)Ask what their response is to this
information
Faith & Spirit RULE
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Resist the Righting ReflexRighting for others leads to dependency
Understand your client's motivationsIf time is short, try simply asking why your
client wants to make a change & how they might go about it (instead of that they should)
Faith & Spirit RULE
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Listen, listen, listen to clientsHard to do well; definitely improves w/practice
Empower Them!Those who talk about change – the how & why of change – are more likely to do it
Can’t give empowerment; can only get for oneself
The first is to be kind. The second is to be kind. And the third is to be
kind.”Henry James in Leon Edel’s
Henry James: A Life
Summary: “Three things in human life are
important:
The Spirit of MI
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CollaborationEvocationAutonomyPerceptionCuriosityEthics
MI treats resistance as thinking NOT as pathology
Graphic
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“Love with a Goal”Simple but not easy!
Motivational Interviewing is…
Motivational Interviewing IS NOT…
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A technique but rather a collection of skills & strategies
Learned in a 1 or 2- day workshop (but that’s a good start!)Practice makes better; coaching improves
Something you use all the time Use w/ambivalence & target behavior only
QUOTE
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“Treat people as if they are who they can be and you help them to become who they’re capable of being.”
-----Johann Wolfgang von GOETHE
MI: The Basics
Moving from Spirit to Strategy
Summary: Our ‘real’ job =
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Listen, listen, listenEnter the client/client’s worldAccept. Believe. Let Go!
No ‘plumbing’ practiced here!
4 Basic Principles of MI
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Express Empathy – “Fence-sitting is normal!”
Develop Discrepancy* – “Who do you want to be & what’s getting in your way?”
Avoid Argumentation/Roll with Resistance – “Turn into the Skid”
Support Self-Efficacy -“The Tinkerbelle Effect”
Ethics – Ask permission!
6 Traps to Avoid
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1. Asking Questions2. Being the Expert3. Taking Sides/Arguing for Change4. Labeling People5. Focusing Too Soon6. Getting Caught up in
Blame/Responsibility7. Being Attached to Specific Outcomes
(other than the client's!)
Summary of Key Concepts
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Ambivalence = “Fence-sitting”
Getting REAL Respect Empathy Affirm and Listen!
Develop Discrepancy = Behaviors v Values
Rolling with Resistance = Dancing or Wrestling?
Supporting Self-Efficacy = Whose recovery is this anyway?
Goals of Change = The client’s or mine/agency?
30 or 60?
Lunch!
Reflections are the key…and Teflon!
Skills!
Thinking in ReflectionsDyads/triads
“You mean that…”
“One thing I like about myself is…”
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Speaker: Discuss some quality you like about yourself or that is positive or quirky
Listener: Make your best guess re: what quality the speaker is describing to you by saying “You mean that …”
Speaker: Answer with “Yes” or “No”Continue until you get a solid “Yes!”
Everybody Loves Raymond(15)
Video
Walk-Away Skill #2: OARS
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Open-Ended QuestionsAffirmationsReflectionsSummaries
Getting Directional: 8 Ways to Show We’re Listening/ Options for Responding to No Change (Sustain)Talk
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Simple reflection (parroting)
Amplified reflection (take it up a notch)
Double-sided reflection (on the one hand…)
Reframe (get a new pair of glasses)
Emphasize individual choice (who’s recovery is this anyway?)
Change Focus (hit a wall, turn left)
Agreement with a twist (reframe & reflect)
Come alongside (paradox)
Reflections: Examples
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Simple Reflection: lets the client know that you understand what they said
Complex Reflection: adds more substantial meaning - oomph; reflect the emotion & the content of what the client has been describing.
Simple & Complex:
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Them: I’m not the one with the problem. If I don’t take my meds, it’s just because my kids need the money for food.
You: The real reason you don’t take your meds all the time has to do with problems getting your food stamps. (Simple)
You: You’re worried that this treatment isn’t really helping after all this effort. (Complex)
An opportunity!
Resistance is a key to successful treatment if you can recognize it for
what it is:
Rolling with Resistance:Instead of taking the bait, simply
“roll” the conversation back to the client (Teflon)
Client: “So, what am I supposed to do now anyway?”You: “This feels so hopeless, it’s
really frightening.”
Walk Away Skill #3: RWR
Dodge Ball!
Teflon Demonstration:
Round Robin
Practicing OARS
How do we MI-converse?
So what do we listen for?
Timing: OK, so I’m Ready…Recognizing Readiness to Change
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AcceptanceFeels finishedResolve
Questions about change
EnvisioningExperimenting
Change Talk!
DARN-CAT: The New Language
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Desire (I want to change)Ability (I can change)Reasons (It’s important to change)Need (I should change)=»Commitment (intention, decision,
readiness)Activate (ready, prepared, willing)Taking Steps
More No Change (Sustain) Talk & Resistance strategies
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Summarize what the client has said and even how you think he might be feeling
Give him some freedom to decide what to talk about or where to go next in the conversation
Check with her to see if you’ve offended her; remind her you’re not going to push her to make changes she doesn’t want to make
Apologize. A simple, non-dramatic apology can really be helpful
MI in a Nutshell
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Talk less than the client Offer 2-3x more reflections
(esp complex) than questions Ask 2x more open than
closed questions Listen empathetically through
(lots of) complex reflections
Keeping the Spirit Alive
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Collaboration v Confrontation(the old kind)
Evocation (eliciting) v Education (installing)
Autonomy (them) v Authority (us)
---Bill Miller, 2000
“MI is a way of being with people & that way must be of love. It is love & profound respect
that are the music in motivational interviewing, without which the words are empty.”
Please sort through these cards to find your top 10 professional values (there are some blank ones to write in your own, too). Be prepared to discuss them tomorrow. Thanks!
Homework: Value Cards Sort
Thanks all!www.motivationalinterview.orgwww.responsiblerecovery.org
End Day 1: Great work!!