CLASS 2 Bio-Psycho-Social-Spiritual Approach to Health Care

Motivational Interviewing

Gary U. Behrman, PhD, MSW, M.Div., LCSW111 Prospect Ave. Suite 201 D

Kirkwood, MO [email protected]

314 456 1017

Fenelon: Spiritual Letters“Speak little, listen much. Think far more of

understanding hearts and of adapting yourself to their needs than of saying clever things to them. Show that you have an open mind and let everyone see by experience that there is safety and consolation in opening their story to you. Avoid extreme severity, and reprove, when necessary, with caution and gentleness. Never say more than what is needed but let whatever you say be said with entire frankness and kindness.”

•http://housechurch.org/spirituality/fenelon_letters.html

OBJECTIVESParticipants will Apply knowledge of the bio-psycho-social-

spiritual motivational model Observe the impact of cultural differences

when applying skills Practice motivational skills with variety of

clients

https://www.youtube.com/watch?v=W1EG_4IBzbA

What is your most valuable tool to motivate clients?

BUILDING RAPPORT

The most important tool for helping a client thru crisis is the “Strategic Use of Self

NOT: Do you care for this person?BUT: Why do you care?

“Are you motivated for change?”

How will you measure this?Will you give the client space to define

this?

Definition of Motivational Interviewing

‘A directive, patient-centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence.’ (Rollnick and Miller, 1995)

Patients may be hesitant to trust us We need to demonstrate our knowledge,

skills, kindness & empathy

Motivational Interviewing Evidence based: what are the facts?

Directive: you are a source of authority

Client Centered: client is also source of authority

Culturally Sensitive: what are the barriers facing this client?

6 Principles of Motivational Interviewing

Don’t tell clients what to do Listen Let the client tell you what she needs to

do to change Cognitive dissonance: what she knows she

must do & what she is hesitant to try Instill confidence Ambivalence is normal and needs to be

discussed

Motivational InterviewingThe practice to adopt when giving any piece

of information to the client is to: 1. Understand what the client already

knows, and what they would like to know, by asking him/her

2. Provide information in as clear a way as possible that is culturally sensitive

3. Check client’s understanding of what you have just said - “repeat to me the information I just provided”

5 A’s Protocol Address the issue: name the problem Assess the Problem: identify strengths &

barriers Advise the Client: educating client Assist the Client: create care plan w/

measureable goals Arrange for f/u: review progress

Motivating Clients “I’m finding that when I begin each session by asking my

clients how they are doing and how they are handling stressors in their lives, I see an enormous improvement in therapy results” Social Work Student

How do we motivate clients to follow tx. plans?• Patient must have a desire to achieve goals• Must claim ownership of tx. plan• Have resources to follow tx. plan• The tx plan must be meaningful to client• The client must have a reason to be healthy

Change Plan Worksheet

The changes I want to make are: The reasons why I want to make these

changes are: The steps I plan to take in changing are: The ways other people can help me are: I will know that my plan is working if: Some things that could interfere with my

plan are: What I will do if the plan isn’t working: http://www.motivationalinterviewing.org/sites/default/files/changeplan

.pdf

Communication Techniques Generate a list of possibilities with client

(You may add some suggestions, such as what other clients have tried)

Encourage client to evaluate the list

Client picks best option that is empirically sound and supported by best practices

Communication Approaches Get a conversation going - express

empathy through reflective listening

Develop discrepancy between clients' goals or values and their current behavior

Avoid argument & confrontation & adjust to resistance rather than opposing directly

Sample Questions

“So, are you saying that you’re thinking of changing soon, what may be stopping you today?

“Are you saying that this is not the best time for you to make these health changes? Why?”

What is motivating you to change your behavior?

Avoid Questions w/ Binary Responses

“Would you like to quit smoking pot?”rather “What might be the benefits if you quit

smoking pot?” “What are the benefits of continuing

smoking pot?”

Using Scales 1 = not at all 10= immensely “On a scale of 1 to 10, how important is it

for you to follow this care plan? “How confident are you that you can stay

the course?”

“Why did you answer this way?” “Where do you expect yourself to be on

this scale in 1 week? 1 month? 1 year?”

Open Ended QuestionsBIO: “Where do you experience the most pain?”PSYCHO: “What do you worry most about regarding

your situation?”SOCIAL: “Who are your main support systems?”SPIRITUAL: “What should I be aware of regarding your

religious or spiritual beliefs?”

Motivating Phrases “This is important. Please tell me more.” “I care about you and your family. Tell me

how I can help you with your care plan.” “You are very courageous to be facing

this. But you don’t have to face this alone” “You’ve accomplished a lot in a short time.

I am proud of you and privileged to be your P.A.”

“I can understand why you stopped taking your meds.”

Helping Client Own the Tx Plan

Problem recognition: “What can you do to help your recovery? “What can I do?” “What can others do?”

Values Clarification: “What is most important to you at this time?” “How has this changed during past year?”

Recommended Questions1. Tell me about you and what is most important

in your life?2. How does your condition affect you (bio-

psycho-socially-spiritually?3. What about your situation troubles you most?4. How will you handle this? Do you have the

resources?5. “This will be very demanding of you, but I am

here to help.” This technique is identified by the acronym BATHE

(background, affect, trouble, handling & empathy).http://www.aafp.org/dam/AAFP/documents/medical_education_residency/fmig/tips_relationships.pdf

Closing the Conversation “Here is what is most important to

remember.” “Can you repeat what I just said about

your care plan?” “We covered a lot of ground today. Do you

have any more questions or concerns?” “I am emailing you resources for your care

plan and I want you to visit these sites.” “How do you want me to communicate

with you outside of our sessions?”

Role of Provider your job is to ensure that there is an

honest discussion about the consequences of changing and not changing behaviors that impact health outcomes• Importance of motivation• Instilling confidence• Motivating the client

to adhere to tx.

ComplianceThe degree to which clients follow a tx plan Five factors to adherence:

1. Client baseline health2. SES & available resources3. Type of therapy/intervention4. Resources/Insurance coverage5. Providers communicating w/ each

other

Keys to Compliance If clients believe they can ultimately

succeed in their efforts How clients judge their abilities which

affect their compliance Level of compliance is correlated w/ their

self identity How do we instill confidence with

resources?

RESISTENT CLIENT There is no such person as a RESISTANT

CLIENT Often, we are missing what is most

important to our client OR We think we know what is best for our

client

Identity Theory

To the degree that a client’s identity is threatened, this will be the degree of trauma

Identity What roles do I assume responsibility for? What is most meaningful to me? How do I identify myself?

• Mother, nurse, wife, daughter, Muslim? What do I believe about myself? Life?

Trauma Trauma happens when our primary

beliefs about life, self and others are shattered and disrupted.

We reconstruct our schemas, seeking either to restore or create new beliefs

Trauma How we respond to a crisis event

depends upon our belief system• Consonance = Information and

experience matches our schema (beliefs)

• Dissonance = When we experience a crisis event and receive information that does not match our beliefs and we cannot make sense out of it

Assimilating & Accommodating

Assimilating the event: twisting the experience and the information to fit my schema (beliefs); distorting the event to fit my beliefs

Accommodating the event: try to create a new schema (belief system) to make meaning out of the experience

Dissonance Dissonance takes the form of dis-ease:

• Bio-somatic: physical ailments, (migraines, backaches, gastro-intestinal, cardiac disease)

• Psychological: anxiety attacks, depression; developmental digression

• Social: isolation, destructive and harmful behavior towards others

• Spiritual: lack of purpose and meaning with previous fulfilling roles, substance abuse & addictions

Strengths Based Approach

Identify and optimize client’s strengths What’s working for him/her today? Emphasize capacity building Take note of how he/she interacts with his/her

environment

Avoid looking only for what is wrong

Strengths-based definition:“All people must be seen in light of their capacities, talents, competencies, possibilities, vision, values and hope, however dashed and distorted these may have become through circumstance, oppression or trauma” https://www.youtube.com/watch?v=oag1Dfa1e_E

Looking into Client Hx.for Strengths

“What difficult goals have you achieved in the past?”

“What helped you get through this?”

“What might you draw upon at this time in your life that worked in the past?”

Client Resistancekey principles behind rolling with resistance

are: Don’t respond to resistance with

confrontation - no matter how frustrated you are!

Use empathy and reflective listening Reframe statements Acknowledge ambivalence as normal

Risk Factors Hx. of mental illness Substance abuse Poverty & lack of insurance Low social capital Lack of transportation

PROTECTIVE FACTORS:

Helping client achieve desired goals by modifying the environment

Gaining personal control by maximizing internal strengths

PIE

Which environment is HEALTHY for my client?

Asking or expecting a squirrel to excel in water does not produce great results

Partnering in Care

How do we motivate for change?How much change is Healthy?

Which environment builds Strengths?

Building Partnerships

From Care-Giving to Partnering in Care • Focusing & building on Strengths in your

client• Framing partnering as collaborating with

many sources of Strengths in his/her Environment

• Building relationships with family, teachers, work, coaches, pastors, classmates

Partnering in Care

• We cannot motivate alone• If we are lucky, we see our client for 50

minutes a week• Thus partnering in care is crucial• Providing Resources to build Strengths in

his/her Environment helps to motivate

Partnering in Care

Partnering in care is essential As partnering increases, motivation

increases As motivation increases, health increases

Creating Barriers w/ Client

Barriers:• Not relinquishing some power in the

relationship• Always knowing what is best for client• Not providing opportunities for client to

participate in tx. plan• Superficial assessment of client’s

emotional, social, spiritual contexts• Ignoring cultural differences

Enhancing Collaboration• Define client role and your role,• Acknowledge what client knows about

the problem & solution,• Identify client values & health habits• Surface resources to achieve goals• Create tx. plan with client

Remember:

This is a strength’s approach, not just fixing a problem

Be aware of our assumptions about healing and client’s capacity for change

We are NOT fixing their problems but assisting them in creating new meaning

Search for new ways to carry their trauma

Remember:

Motivation is a strength’s approach, not just fixing a problem

Be aware of our assumptions about healing and client’s capacity for change

We are NOT fixing their problems but assisting them in creating new meaning

Search for new ways to carry their trauma

How do we measure motivation?

That they listened to us?That they achieved their goals?Think about it…

Strategic Use of Self • How much to disclose about your own

hx of trauma• How to express genuine care• How to comfort & ease the pain thru

emotional cues• How to connect with client in meaningful

ways

Motivational Interviewing https://www.bing.com/videos/search?q=motivational+inter

viewing&view=detail&mid=5B3590BFEBDB37EDF6F35B3590BFEBDB37EDF6F3&FORM=VIRE

https://www.bing.com/videos/search?q=motivational+interviewing&view=detail&mid=F2C2050AC64F8998B8C6F2C2050AC64F8998B8C6&FORM=VIRE

https://www.youtube.com/watch?v=s3MCJZ7OGRk

https://www.youtube.com/watch?v=AjZ0KbJcav0

https://www.youtube.com/watch?v=skj-ALA1HFE

Role Play

Get in pairs of four Assign client & practitioner & observers Read scenarios Perform role play Observers give feedback –

• what went well; • what could be done differently?

Reflection

Client:What did practitioner do well?

Practitioner:What did you find challenging?What do you need to work on?

Everyone:How do you see the motivational approach working with your clients?

RESOURCES

Helpful Websites

Motivational interviewing• http://www.motivationalinterview.org/

Case Western U. Center for Evidence Based Practices• http://www.centerforebp.case.edu/practices/mi

You Tube• http://www.youtube.com/watch?v=s3MCJZ7OGRk

Guide to Motivational Interviewing

http://www.psychmap.org/uploads/Motivational%20Interviewing%20brief%20guide.pdf

Research indicates that 30%–50% of patients do not follow treatment plan

How do we understand actual and perceived obstacles?

Respect the dignity and autonomy of each client

How do we LISTEN to our clients?

Therapist AID Tools

Valuable Resources for treating trauma in adolescents Worksheets, interactive tools, interventions

• http://www.therapistaid.com/therapy-worksheet/thought-record/depression/adolescents

RESOURCES FOR MOTIVATION

Resilience Tools http://valueoptionsmarketing.com/resilience/site/tools/

Bounce Resiliencehttps://www.bounce-resilience-tools.eu/en

Roads to Resilience http://www.apa.org/helpcenter/road-resilience.aspx

Build Resiliencehttps://www.informationvine.com/index?qsrc=999&qo=semQuery&ad=semD&o=603071&l=sem&askid=eebb7a7d-6b12-4b75-a285-4568bef4870c-0-iv_gsb&q=build%20resilience&dqi=&am=broad&an=google_s

Complementary Approaches

NATIONAL CENTER for COMPLEMENTARY & INTEGRATIVE HEALTH

https://nccih.nih.gov/health/providers/digest/depression

MeditationModerate evidence suggests that meditation is useful for symptoms of anxiety and depression.

https://nccih.nih.gov/health/providers/digest/meditation-science

MOBILE APPS for Meditation http://mindfulnessforteens.com/resources/

Music & Aromatherapy https://www.adaa.org/finding-help/treatment/complementary-

alternative-treatment

Medications Before recommending medication, we

must determine the presence of any physical symptoms that may be related to medical problems.

APP for medications for social workers https://online.epocrates.com/drugs

APPS for Mental Health https://www.adaa.org/finding-help/mobile-apps http://www.psychiatryadvisor.com/top-10-mental-health-

apps/slideshow/2608/ http://www.refinery29.com/mental-health-apps http://blog.capterra.com/10-best-mental-health-apps-medical-

professionals/

Treating DepressionBest Practices CBT, DBT, IPT http://www.psychiatrictimes.com/adhd/treating-adolescent-

depression-psychotherapy-three-ts

Evidence based outcomes for CBT https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1540388/

Worksheets for treating depression http://www.therapistaid.com/therapy-

worksheets/depression/adolescents

Depression treatment options https://www.uptodate.com/contents/depression-treatment-

options-for-children-and-adolescents-beyond-the-basics http://effectivechildtherapy.fiu.edu/

WEBSITES https://motivationalinterviewing.org/

https://www.psychologytoday.com/us/therapy-types/motivational-interviewing

https://www.therapistaid.com/therapy-guide/motivational-interviewing

https://www.amazon.com/s?k=motivational+interviewing&hvadid=77996716818570&hvbmt=be&hvdev=c&hvqmt=e&tag=mh0b-20&ref=pd_sl_xvanr2vny_e