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Copyright 2014, Glenn Duncan Do not reproduce any workshop
materials without express written consent. Motivational
Interviewing Glenn Duncan LPC, LCADC, CCS, ACS
2 Traits of an Effective Therapist Core Tasks of an Expert
Therapist - Working with Addicted Clients 1. Develop a Therapeutic
Alliance 2. Nurture Hope 3. Understand & Implement Best
Practices in Theory and Application knowledge of the main
therapeutic paradigms when working with addicted clients
individually, in group settings and with their families. Be able to
properly assess individual client problems and needs and tailor
theory and techniques that best suite individual client needs. 4.
Teach Skills emotional regulation, relaxation, problem-solving,
cognitive restructuring skills, interpersonal skills, tolerance and
acceptance skills. 5. Provide Ongoing Education to the Client the
ability to conduct accurate assessments, working with the client
towards individualized, behavioral treatment planning, having the
client engaged in self-monitoring of thoughts, feelings and
behaviors, enhance client awareness of the addition process.
3 Traits of an Effective Therapist Core Tasks of an Expert
Therapist - Working with Addicted Clients (continued) 6. Build in
Generalization and Maintenance Procedures understand the concept of
skill generalization to the target problem, involve significant
others as allies in obtaining generalization of targeted positive
behaviors, feelings and thoughts, and helping with the maintenance
of them. 7. Assess/Possibly Treat/Possibly Refer Co-occurring
Problems be able to look past substance specific issues to
accurately identify possible Co-occurring problems and treat (if
education ethically provides the ability to do so), or refer client
to have Co-occurring problems addressed. 8. Assess For &
Conduct Relapse Prevention assess and work with relapse triggers
and high risk situations that will occur for the client. 9. Ensure
Clients Take Credit and Ownership for Their Changes foster
independence and client ownership of the changes made. 10. Other
important clinician factors include: experience, personal
characteristics of the counselor and therapist, cultural
competence, and comfort with ambiguity.
4 Definition of Motivational Interviewing Motivational
interviewing is a collaborative conversation style for
strengthening a persons own motivation and commitment to change.
The overall style of MI is one of guiding style that is in the
middle of the continuum of styles: Directing Guiding Following A
skillful guide is a good listener and also offers expertise where
needed. MI lives in this middle ground of styles between directing
and following, often incorporating elements of both but doing too
much of either.
5 Definition of Motivational Interviewing Ambivalence
Ambivalence is a normal part of preparing for change and a place
where a person can remain stuck for some time. When a helper uses a
directing style and argues for change with a person who is
ambivalent, it naturally brings out the persons opposite reaction.
People are more likely to be persuaded by what they hear themselves
say.
6 Spirit of Motivational Interviewing Partnership MI is not
something done to a passive recipient by an expert. MI is not done
to or on someone, but is rather done for and with a person. MI is
an active collaboration between experts. When it comes to change,
the counselor cannot do it alone. The client has a vital expertise
that is complementary to the clinicians; the expertise of
themselves. Activation of that expertise is vital for change. The
interviewer seeks to create a positive interpersonal atmosphere
that is conducive to change but not coercive. The interpersonal
process of MI is a meeting of aspirations which may differ from
client to counselor. Honesty about aspirations is essential.
7 Spirit of Motivational Interviewing Acceptance MI is about an
attitude of profound acceptance of what the client brings. To
accept does not necessarily mean you approve of their actions or
acquiesce to the status quo. Acceptance has 4 aspects. Absolute
Worth acceptance of the person as an individual, respect for them
as having worth, and a belief that the person is fundamentally
trustworthy. Accurate Empathy an active interest in and effort to
understand the others internal perspective, to see the world
through their eyes. Autonomy Support the persons irrevocable right
and capacity of self-direction. Affirmation to seek and acknowledge
the persons strengths and efforts (more than just a private
experience of appreciation, but it is the search for what is right
with people).
8 Spirit of Motivational Interviewing Compassion New to MI when
describing the essence of MI To be compassionate is to actively
promote the others welfare, to give priority to the others needs.
This was added to MI because it was felt that many clinicians could
practice the principles of MI in the pursuit of self-interest.
Knowledge and techniques can be used to exploit, to pursue ones own
advantage and gain undeserved trust and compliance. To work with a
spirit of compassion is to have your heart in the right place so
that the trust you engender will be deserved.
9 Spirit of Motivational Interviewing Evocation Premise: People
already have within them much of what is needed, and your task is
to evoke it, to call it forth. The message is: You have what you
need, and together we will find it. Approach: To draw out: MI
perspective is the belief that there is a deep well of wisdom and
experience within the person from which the counselor can draw. MI
is about evoking that which is already present, not installing what
is missing. People who are ambivalent already have the pro-change
argument and the pro status-quo argument within them. The client
likely already has the pro-change arguments within them, and those
arguments are likely more persuasive than any you could make. Your
task, then, is to evoke and strengthen these change motivations
already present.
10 Spirit of Motivational Interviewing Evocation - Guard
Against The righting reflex. The righting reflex involves the
belief that you must convince or persuade the person to do the
right thing. Counselors not realizing they are in the midst of this
often think/feel: They just need to ask the right questions They
just need to find the proper arguments They need to provide the
client with critical information. The need to provoke the decisive
emotions to make change occur. They need to pursue the correct
logic to make the person see and change. This brand of counseling
was, and still sometimes is, rampant in substance use counseling.
It is the belief that clients had to have their pathological
defenses torn down before they could change. The formula goes as
follows: A. Confront the client. Louder = Better. B. Provide the
solution. The saltier the solutions was provided the cooler the
counselor. C. If you meet denial/resistance pump up the volume on A
and B. D. Rinse/repeat
11 Spirit of Motivational Interviewing Evocation Questions that
are the opposite of the righting reflex Some questions beginning
counselors using MI can ask, that do not incorporate the righting
reflex: 1. Why would you want to make this change? 2. How might you
go about it in order to succeed? 3. What are the three best reasons
for you to do it? 4. How important is it for you to make this
change, and why? 5. How confident do you feel about being able to
make this change, and why? 6. So what do you think youll do?
12 Definition of Motivational Interviewing Lay Persons
Definition Motivational interviewing is a collaborative
conversation style for strengthening a persons own motivation and
commitment to change. Practitioners Definition Motivational
interviewing is a person-centered counseling style for addressing
the common problem of ambivalence about change.
13 The Method of Motivational Interviewing Four Processes in
Motivation Interviewing Engaging engaging is the process by which
both parties establish a helpful connection and a working
relationship. Focusing process of engaging leads to a focus on a
particular agenda: what the person came to talk about. The provider
may also have an agenda, some of which may overlap with the client
and some of which may not. One or more change goals may emerge. The
focusing process helps clarify direction. Evoking evoking involves
eliciting the clients own motivation for change. Most simply put,
evolving is having the person voice the arguments for change.
Planning planning encompasses both the commitment to change and
formulating a specific plan of action.
14 Method of MI Questions to Ask Yourself Engaging 1. How
comfortable is this person in talking to me? 2. How supportive and
helpful am I being? 3. Do I understand this persons perspective and
concerns? 4. How comfortable do I feel in this conversation? 5.
Does this feel like a collaborative partnership?
15 Method of MI Questions to Ask Yourself Focusing 1. What
goals for change does this person really have? 2. Do I have
different aspirations for change for this person? 3. Are we working
together with a common purpose? 4. Does it feel like we are moving
together, not in different directions? 5. Do I have a clear sense
of where we are going? 6. Does this feel more like dance or
wrestling?
16 Method of MI Questions to Ask Yourself Evoking 1. What are
this persons own reasons for change? 2. Is the reluctance more
about confidence or importance of change? 3. What change talk am I
hearing? 4. Am I steering too far or too fast in a particular
direction? 5. Is the righting reflex pulling me to be the one
arguing the change?
17 Method of MI Questions to Ask Yourself Planning 1. What
would be a reasonable next step towards change? 2. What would help
this person to move forward? 3. Am I remembering to evoke rather
than prescribe a plan? 4. Am I offering needed information or
advice with permission? 5. Am I retaining a sense of quiet
curiosity about what will work best for this person?
18 The Skills of Motivational Interviewing Core Skills and the
Four Processes of MI Asking Open Questions open questions are those
that invite the person to reflect and elaborate. Open questions
help you understand the persons internal frame of reference. This
helps in engaging by strengthening a collaborative relationship and
finding a clear direction. Affirming The counselor in general
respects and honors the client as a person of worth. The counselor
also comments on the clients particular strengths, abilities, good
intentions, and efforts. Reflective Listening statements that make
a guess about the clients meaning which can deepen understanding by
clarifying the accuracy of the guess. Summarizing reflections that
collect what a person has been saying and offering it back. They
can be used to: 1) Pull together information; 2) suggest links
between present and past material; 3) used as a transition; 4)
promote understanding; 5) direct the flow of change talk or
discussion.
19 Definition of Motivational Interviewing Lay Persons
Definition Motivational interviewing is a collaborative
conversation style for strengthening a persons own motivation and
commitment to change. Practitioners Definition Motivational
interviewing is a person-centered counseling style for addressing
the common problem of ambivalence about change. Technical
Definition Motivational interviewing is a collaborative,
goal-oriented style of communication with particular attention to
the language of change. It is designed to strengthen personal
motivation and commitment to a specific goal by eliciting and
exploring the persons own reasons for change within an atmosphere
of acceptance and compassion.
Working Alliance The working alliance, or collaboration to
change is common in to all models of therapy, and common to the
supervisory relationship. It is composed of 3 elements: 1. The bond
between therapist and client. 2. The extent to which they agree on
goals. 3. The extent to which they agree on tasks to obtain the
goals. The real change in therapy occurs during the process of
weakening of the relationship and then repair of the
relationship.
Working Alliance Main Features There are 4 main features in
viewing the working alliance: 1. The therapist must possess certain
facilitating human qualities, the qualities of a good parent. 2.
These qualities permit the potential establishment of a power base
for the therapist, in which the therapist uses the clients desire
to please as leverage. 3. Within the context of the therapeutic
relationship, experiential learning occurs through the normal
developmental processes of imitation and identification. 4. The
success of this relationship-based learning experience depends on
preexisting client qualities that permit at least a beginning level
of trust and openness.
Working Alliance Goals Goals in the working alliance model are
defined (in part) as the expectations to the nature and quality of
the therapeutic relationship. For example one such goal would be to
ensure a constructive therapeutic environment, that fosters an
awareness of others, of oneself in terms of motivation,
self-efficacy. Foster two-way feedback with client. Expectations
can be defined as a persons anticipatory beliefs about the nature
(i.e., roles, behaviors, interactions, and tasks) or outcome of a
particular event. The congruence of expectations (i.e., shared
goals) between or among people in a relationship is at least as
important, and likely more important, than the expectations of any
one individual.
MI - Engagement Factors that can influence engagement and
disengagement: Desires or goals. What did you want or hope for in
going? What is it that youre looking for? Importance. How important
is what youre looking for? How much of a priority is it?
Positivity. Did you feel good about the experience? Did you feel
welcomed, valued, and respected? Were you treated in a warm and
friendly manner? Expectations. What did you think would happen? How
did the experience fit with what you expected? Did it live up to
(or even exceed) your expectations? Hope. Do you think that this
situation helps people like you to get what youre seeking? Do you
believe that it would help you?
MI - Listening Factors that can influence engagement and
disengagement: Desires or goals. What did you want or hope for in
going? What is it that youre looking for? Importance. How important
is what youre looking for? How much of a priority is it?
Positivity. Did you feel good about the experience? Did you feel
welcomed, valued, and respected? Were you treated in a warm and
friendly manner? Expectations. What did you think would happen? How
did the experience fit with what you expected? Did it live up to
(or even exceed) your expectations? Hope. Do you think that this
situation helps people like you to get what youre seeking? Do you
believe that it would help you?
MI Reflective Listening Using reflection to encourage continued
personal exploration broad goal of reflective listening.
Overshooting. Overstating the intensity of an emotion. The person
will tend to deny and minimize it. Undershooting. Slightly
understating the expressed intensity of an emotion, the person is
more likely to continue to explore and tell you about it. Length.
The reflection should not be longer than the statement. If longer,
then make it purposeful by placing emphasis on particular content.
Direction. Clients provide a variety of material even within a
short 5 minute time span. Reflection can therefore be used to shine
a light on certain aspects of what a person has said or to reframe
its meaning slightly.
26 Building Motivation for Change (cont) Listening Reflectively
a. The crucial element to reflective listening is how the counselor
responds to what the client says. What responses are not considered
to be listening: Ordering, directing, or commanding Warning or
threatening Persuading with logic, arguing, or lecturing Moralizing
preaching or telling clients what they should do Disagreeing,
judging, criticizing, or blaming Shaming, ridiculing, or labeling
Withdrawing or distracting b. Reflective listening isnt making a
statement that is a roadblock, but rather a guess about what the
person means.
27 Other Engagement Skills 1. Assess Motivation, which consists
of the following: - Importance the extent to which one wants,
desires, or wills change. - Readiness what is the priority level of
the presenting problem(s). - Confidence self-efficacy, or the
perceived ability to make a change. 2. Ask open ended questions to
the client in response to their answers during the assessment
period. - (e.g., What are some other ways marijuana has interfered
with other areas that are important to you? versus Is marijuana a
problem for you?) 1. Affirmation - To recognize and acknowledge
that which is good including their inherent worth. AFFIRMATION IS
NOT PRAISE - To accentuate the positive - To support and encourage.
Focus on the client, do not make affirmations self-focused.
28 Other Engagement Skills 4. Summarizing - Reflections that
pull together several thoughts or topics that that the client is
talking about. - They can be affirming (imply that youre listening,
remembering and putting together how things connect). - To support
and encourage. Focus on the client, do not make affirmations self
involved. Collecting Summary recalls a series of interrelated items
as they accumulate. Linking Summary reflecting what the person has
said and link it to something else you remember from prior
conversation Transitional Summary to wrap up a task or topic in
order to shift to either a new topic or to steer the direction
where you want the conversation to turn.
29 Empathic Communication Scale Level 1: Low-Level Empathic
Responding The practitioner communicates little or no awareness or
understanding of even the most obvious of the clients feelings. The
practitioners responses can be irrelevant, often abrasive,
hindering, rather than facilitating communication. Styles of
Communication: changing the subject, arguing, giving advice
prematurely, lecturing, or other ineffective styles that block
communication. Nonverbal responses are often not appropriate to the
mood and content of the clients statements. Client reaction: can
become confused, defensive, argumentative, withdrawing into
silence, begin discussing superficialities, change the subject.
RESULT: Clients energies are diverted from exploration and/or
working on the problems.
30 Empathic Communication Scale Level 2: Moderately Low-Level
Empathic Responding The practitioner responds to the surface
message of the client but erroneously omits feelings or factual
aspects of the message. The practitioner may also inappropriately
qualify client feelings (e.g., youre somewhat agitated about this
issue with your mother, isnt that a little bit exaggerated. The
practitioner may inaccurately interpret clients feelings (e.g.,
identifying hurt as anger, being tense for fear). Responses may
come from the practitioners own conceptual formulations about the
client, which may be diagnostically accurate, but which are not
empathically attuned to the clients expressions or attuned to the
clients phenomenological realities. RESULT: Level 2 reactions are
partially accurate, they do convey an effort to understand, thus do
not completely block clients communication.
31 Empathic Communication Scale Level 3: Interchangeable or
Reciprocal Level of Empathic Responding The practitioners verbal
and nonverbal responses at this level convey understanding and are
essentially interchangeable with the obvious expressions of the
client. The practitioner accurately reflects factual aspects of the
clients messages and surface feelings or state of being. These
responses do not add affect or reach beyond the surface feelings,
nor do they subtract from the feeling or the tone expressed.
Responses of this level facilitate further exploration and
problem-focused responses by the client. RESULT: Level 3 responses
are effective, working responses that should be sought by
practitioners as a base level of empathic responding.
32 Empathic Communication Scale Level 1 3 type of responses
Client statement: I dont trust you people. You do everything you
can to keep me from getting back my son. I have done everything I
am supposed to do and you people always come up with something
else. Level 3 response: Youre really angry about the slow progress
in your case and are wondering if your efforts are going to
succeed. Level 2 response: You feel angry because your case plan
has not been more successful to date. Maybe youre expecting too
much too soon; theres a lot of time yet. Level 1 response: Just
think what would have happened if you had devoted more energy in
the last year to carry out your case plan; you would have been
further along and less frustrated than you are now.
33 Empathic Communication Scale Level 4: Moderately High-Level
Empathic Responding Responses at this level are somewhat additive,
accurately identifying implicit underlying feelings and/or aspects
of the problem. The practitioners response highlights subtle or
veiled aspects of the clients message, enabling the client to get
in touch with somewhat deeper-level feelings and unexplored
meanings. Level 4 responses are aimed at enhancing clients
self-awareness.
34 Empathic Communication Scale Level 5: High-Level Empathic
Responding Responses at this level reflect each emotional nuance.
The practitioner accurately responds to the full range and
intensity of both surface and underlying feelings and meanings. The
practitioner may connect current feelings and experiencing, to
previous expressed experiences and feelings. Responses may also
identify goals embodied in the clients message, which enhance
self-awareness while paving the way for potential action. This type
of response facilitates the clients exploration of feelings and
problems in a much greater breadth and depth than at lower
levels.
35 Empathic Communication Scale Level 4 5 type of responses
Client statement: I dont trust you people. You do everything you
can to keep me from getting back my son. I have done everything I
am supposed to do and you people always come up with something
else. Level 4 Response: You feel very frustrated with the lack of
progress in getting your son back. You wonder if there is any hope
in working with a new worker and this system which you feel hasnt
been helping you. (additive reflecting the clients deeper feelings
of suspicion of institutional racism). Level 5 Response: Not
succeeding in getting custody of your son by now has angered and
frustrated you very much. Im sensing that youre unsure of whether
any efforts will succeed and maybe thinking the system is stacked
against me. You want to be able to trust that efforts are likely to
succeed and that I and this child welfare system will do all we can
do to assist you. (substantially additive to both institutional
suspicion and primal fear of never regaining son).
36 Empathic Communication Scale Exercise Client Statement Group
member: Its really hard for me to say what I want to say in this
group. When I do start to talk, I get tongue tied and my heart
starts beating faster. I feel like some of you are critical of me.
Group Leader/Member Responses What Level Response?: Yeah, I feel
that same way sometimes, too. What Level Response?: It is
frightening to you to try to share you feelings with the group.
Sounds like you find yourself at a loss for words and wonder what
others are thinking of you. What Level Response?: I know youre
timid, but I think its important that you make more of an effort to
talk in the group, just like youre doing now. Its actually one of
the responsibilities of being a group member. What Level Response?:
You get scared when you try to talk in the group.
37 Empathic Communication Scale Exercise Client Statement Group
member: Its really hard for me to say what I want to say in this
group. When I do start to talk, I get tongue tied and my heart
starts beating faster. I feel like some of you are critical of me.
Group Leader/Member Responses What Level Response?: I sense that
youre probably feeling pretty tense and tied up inside right now as
you talk about the fear youve had in expressing yourself. Although
youve been frightened of exposing yourself, I gather theres a part
of you that wants to overcome that fear and become more actively
involved with the rest of the group. What Level Response?: What
makes you think were critical of you? You come across a bit
self-conscious, but thats no big deal. What Level Response?: You
remind me of the way I felt the first time I was in a group. I was
so scared, I just looked at the floor most of the time. What Level
Response?: I wonder if weve done anything that came across as being
critical of you.
38 Empathic Communication Scale Exercise Client Statement Group
member: Its really hard for me to say what I want to say in this
group. When I do start to talk, I get tongue tied and my heart
starts beating faster. I feel like some of you are critical of me.
Group Leader/Member Responses Level 1 Response: Yeah, I feel that
same way sometimes, too. Level 4 Response: It is frightening to you
to try to share you feelings with the group. Sounds like you find
yourself at a loss for words and wonder what others are thinking of
you. Level 2 Response: I know youre timid, but I think its
important that you make more of an effort to talk in the group,
just like youre doing now. Its actually one of the responsibilities
of being a group member. Level 2 Response: You get scared when you
try to talk in the group.
39 Empathic Communication Scale Exercise Client Statement Group
member: Its really hard for me to say what I want to say in this
group. When I do start to talk, I get tongue tied and my heart
starts beating faster. I feel like some of you are critical of me.
Group Leader/Member Responses Level 5 Response: I sense that youre
probably feeling pretty tense and tied up inside right now as you
talk about the fear youve had in expressing yourself. Although
youve been frightened of exposing yourself, I gather theres a part
of you that wants to overcome that fear and become more actively
involved with the rest of the group. Level 1 Response: What makes
you think were critical of you? You come across a bit
self-conscious, but thats no big deal. Level 2 Response: You remind
me of the way I felt the first time I was in a group. I was so
scared, I just looked at the floor most of the time. Level 2
Response: I wonder if weve done anything that came across as being
critical of you.
40 Empathic Communication Scale Exercise Client Statement Male,
age 17, in a weekly visit to social work probation officer. I dont
see the sense in having to come here every lousy week. I havent
been in trouble now since I went to court 3 months ago. You should
know by now that you can trust me. Probation Officer Responses What
Level Response?: 3 months isnt very long you know, youre on
probation for at least 1 year. And how can I be sure youre staying
out of trouble? What Level Response?: I gather youd rather not have
to see me. I can understand that, but the judge ordered it and youd
be in trouble with him if you didnt meet the conditions of you
probation. What Level Response?: Has it been 3 months since we went
to court? I didnt think it had been that long. What Level
Response?: Youd prefer not coming here and feel youve earned my
trust.
41 Empathic Communication Scale Exercise Client Statement Male,
age 17, in a weekly visit to social work probation officer. I dont
see the sense in having to come here every lousy week. I havent
been in trouble now since I went to court 3 months ago. You should
know by now that you can trust me. Probation Officer Responses What
Level Response?: Having to come here each week gripes you, and I
gather youre irritated with me for encouraging you to follow the
judges order. What Level Response?: Lets take a look at who exactly
got themselves into this mess dont complain to me if you dont like
it. Maybe youd like to talk the Judge into changing her mind. What
Level Response?: It irritates you to have to come here each week.
Youd like to get me off your back. What Level Response?: Youre
confused about why you have to come here and wish you didnt have
to.
42 Empathic Communication Scale Exercise Client Statement Male,
age 17, in a weekly visit to social work probation officer. I dont
see the sense in having to come here every lousy week. I havent
been in trouble now since I went to court 3 months ago. You should
know by now that you can trust me. Probation Officer Responses
Level 1 Response: 3 months isnt very long you know, youre on
probation for at least 1 year. And how can I be sure youre staying
out of trouble? Level 2/3 Response: I gather youd rather not have
to see me. I can understand that, but the judge ordered it and youd
be in trouble with him if you didnt meet the conditions of you
probation. Level 1 Response?: Has it been 3 months since we went to
court? I didnt think it had been that long. Level 2 Response?: Youd
prefer not coming here and feel youve earned my trust.
43 Empathic Communication Scale Exercise Client Statement Male,
age 17, in a weekly visit to social work probation officer. I dont
see the sense in having to come here every lousy week. I havent
been in trouble now since I went to court 3 months ago. You should
know by now that you can trust me. Probation Officer Responses
Level 3 Response: Having to come here each week gripes you, and I
gather youre irritated with me for encouraging you to follow the
judges order. Level 1 Response: Lets take a look at who exactly got
themselves into this mess dont complain to me if you dont like it.
Maybe youd like to talk the Judge into changing her mind. Level 2/3
Response: It irritates you to have to come here each week. Youd
like to get me off your back. Level 2 Response: Youre confused
about why you have to come here and wish you didnt have to.
44 Constructing Reciprocal Responses To reach level 3 on the
empathic scale (the baseline of what you want to accomplish with
clients), you must be able to forumlate responses that accurately
capture the content and the surface feelings in the client message.
It is also important to frame the message so that you simply dont
restate the clients message. You can use the following to help
master the skill of empathic responding: You feel ______________
about (or because) ______________ (Accurately (Accurately
identifies describes situation feelings of client) or event
referred to by the client)
45 Multiple Uses of Empathic Communication 1. Establishing
relationships with clients in initial sessions (research shows that
empathic communication, along with respect and genuineness,
facilitate the development of the working relationship). 2. Staying
in touch with clients (meeting the client where theyre at). 3.
Accurately assessing client problems (evidence shows that the
levels of empathy offered by practitioners correlate with the
levels of exploration by clients). 4. Responding to the nonverbal
messages of clients. 5. Making confrontations more palatable (be
prudent when deciding when to use confrontation, however, empathic
responses attuned to client reactions immediately following
confrontation can be an effective tool.
46 Multiple Uses of Empathic Communication 6. Handling
obstacles presented by the client (What is often interpreted as
unconscious resistance may be a negative reaction to poor
interviewing and intervention techniques, or to client confusion
and misunderstanding. Empathic communication can be used to
carefully monitor client reactions and to deal directly and
sensitively to their feelings). 7. Managing anger and patterns of
violence (empathic communication can be an essential tool in
helping clients work through these feelings). 8. Utilizing empathic
responses to facilitate group discussions (facilitating discussion
by using empathic responses to reflect the observations of various
group members).
47 Focusing Focusing in MI is an ongoing process of seeking and
maintaining direction. The 3 sources of focus: 1. Client people
come through the door with presenting problems 2. Setting agencies
are funded to address specific issues and provide certain services
3. Clinical Expertise client coming with 1 goal in mind and the
clinical perceiving another goal need to be of focus. The challenge
is to explore the clients willingness to entertain this additional
focus. The 3 styles of focusing: 1. Directing this is where the
provider determines the focus, rooted in their own agenda or the
agenda of the agency. 2. Following the opposite where the focus
solely depends on client priorities. 3. Guiding the focus, momentum
and content are mutually forged utilizing client priorities,
constraints of the agency and setting, and expertise of the
clinician.
48 Focusing Issues that may arise 3 Common Focusing Scenarios
1. The focus is clear. 2. There are options to choose from. 3. The
focus is unclear. Issues regarding focus: 1. Tolerating Uncertainty
and Ambiguity resisting the righting reflex. 2. Sharing Control
sharing control of the flow of the interview/session. 3. Searching
for strengths and openings for change be careful not to over focus
on risks, problem management, and completion tasks and keep a focus
on a clients strengths or a small nugget of change talk that could
easily be overlooked by over- focusing on problems.
49 Focusing Issues that may arise When there are options to
choose from Agenda Mapping Agenda mapping is a tool to help you
focus faster, and with a more active client, to avoid unnecessary
confusion about direction. First make it clear what you are doing,
with a structuring statement such as would you mind if we consider
some topics that could discuss? Considering options 1. Allow
clients the space to reflect and express their preferences. 2.
Include information and support as appropriate. 3. Allow the client
to raise completely new ideas that havent been discussed yet. 4.
Use hypothetical language such as we might or you could gliding
over the landscape of options. 5. Include your own opinion, in a
modest way that acknowledges their autonomy.
50 Focusing Differing Goals & Ethics An ethical issue
within helping relationships is whether the clinician should
encourage resolution of ambivalence in a particular direction.
Ethical concerns arise particularly in situations where the
clinician or agency has an aspiration for change that the client
does not yet share. Four key ethical considerations in such
situations include nonmaleficence (do no harm), beneficence
(provide benefit), autonomy (self-determination) and justice
(fairness). It is inappropriate to use MI to influence choice when
the practitioner has a personal or institutional investment in a
certain outcome, especially when this is combined with coercive
power. MI should be adapted to clients needs, e.g., evoking may be
unnecessary with clients who have already decided to make a
change.
51 Focusing Information Exchange Elicit before providing
information. 1. Ask permission. 2. Explore clients prior knowledge.
3. Querrying interest in the information available. Provide the
information. 1. Prioritize. Focus on what the client most wants or
needs to know. 2. Clear and Manageable. Present clearly and in
manageable doses. 3. Support Autonomy. When the information has
implications for client change, you language needs to support their
autonomy. Self Disclosure 1. Is it true? Focus on being genuine
without selfish/inappropriate disclosure. 2. Could it be harmful?
3. Is there a clear reason why it would be helpful?
52 Principles of Motivational Interviewing The strategies of
Motivational Interviewing are more persuasive than coercive, more
supportive than argumentative. The counselor seeks to create a
positive atmosphere that is conducive to change. The overall goal
is to increase the clients intrinsic motivation, so that change
arises from within, rather than being imposed from without. There
are 5 general principles underlying motivational interviewing:
53 Principle Express Empathy Empathy is NOT an ability to
identify with a persons experiences. Empathy is a learnable skill
for understanding anothers meaning through reflective listening,
whether or not youve had similar experiences yourself. This is done
without judging, criticizing or blaming but with acceptance.
Empathic listening requires sharp attention to each new client
statement, and a continual generation of hypotheses as to the
underlying meaning. Your interpretation as to the meaning is
reflected back to the client, often adding to the content that was
overtly stated.
54 Principle Develop Discrepancy Create and amplify, in the
clients mind, a discrepancy between present behavior and broader
goals. Motivation for change is created when people perceive a
discrepancy between their present behavior and important personal
goals. MI Therapist wants to develop discrepancy, make use of it,
increase it, and amplify it until the discrepancy overrides
attachment to the present behavior. This change needs to occur
within the client (not external forces), the client should present
the arguments for change.
55 Principle Avoid Argumentation A key principle to MI is to
avoid arguments and head-to-head confrontations. One place that
arguments are very likely to emerge is in regard to the
applicability of a diagnostic label. Some counselors place great
importance on a clients willingness to admit to a label such as
alcoholic. AA the emphasis is more on self-recognition. We do not
like to pronounce any individual as alcoholic, but you can quickly
diagnose yourself. (Bill W.) Ambivalence and sustain talk is a
signal for the therapist to change strategies.
56 Principle - Roll with Ambivalence or Sustain Talk Reluctance
and ambivalence are not opposed, but are acknowledged by the
therapist to be natural and understandable. The therapist does not
impose new views or goals. Rather, the client is invited to
consider new information and is offered new perspectives. Rolling
with ambivalence includes involving the client actively in the
process of problem solving. The client is a valuable resource in
finding the solution to their problems.
57 Principle Support Self-Efficacy Self-efficacy is a persons
belief in his/her ability to carry out and succeed with a specific
task. General goal of MI is to increase the clients perceptions of
his/her capability to cope with obstacles and to succeed in change.
The client not only can, but must make this change for themselves.
There is hope in the range of alternative approaches available.
Thus a person who has failed in the past, may not have found the
right approach.
58 Common Therapist Traps The Confrontation Denial Trap The
Expert Trap The Labeling Trap The Premature Focus Trap The Blaming
Trap
59 Building Motivation for Change (cont) Elicit
Self-Motivational Statements This is the guiding strategy that
helps clients to resolve their ambivalence. Self-motivational
statements fall into four general categories: 1. Problem
recognition 2. Expression of concern 3. Intention to change 4.
Optimism about change These four kinds of statements reflect
cognitive (recognition, optimism), affective or emotional
(concern), and behavior (intention to act) dimensions of commitment
to change.
60 Eliciting Self-Motivational Statements Asking Evocative
Questions (e.g., problem recognition, asking areas of concern).
Exploring Pros and Cons Asking for Elaboration (tell you more about
it, give you an example of it, to talk you through one). Imagining
Extremes (best and worst things that could come out of making a
change like this).
61 Eliciting Self-Motivational Statements Looking Forward
(think ahead five years, where would you like to be and what would
you like your life to be like) Getting at a persons hopes and
desires. - What would it take for you to give up a certain
behavior? - If behavior changes, if behavior doesnt change, where
would your life be 5 years from now? Looking Backwards (contrast
present situation by looking back before the problem behavior(s)
were present. Case Example
62 Eight General Motivational Strategies What strategies can a
counselor use to enhance motivation for change? Giving Advice
Removing Barriers Providing Choice Decreasing Desirability
Practicing Empathy Providing Feedback Clarifying Goals Active
Helping
63 MI view of Confrontation Confrontational clinicians, groups,
and programs have been linked to poorer outcomes. Successful
outcomes have been linked to therapists showing high levels of
accurate empathy. The linguistic root of the verb to confront means
to come face to face. Thus we are trying to allow our clients to
come face to face with with a difficult and often times threatening
reality. In this light, confrontation is a goal of therapy. What is
the best way to achieve that goal?
64 MI View of Confrontation (cont.) Evidence is strong that
direct, forceful, aggressive approaches are perhaps the least
effective way to help people consider new information and change
their perceptions. Such confrontation increases the very phenomenon
it is supposed to overcome defensiveness and decreases the clients
likelihood of change. The goal of the MI therapist is to evoke from
the client statements of problem perception and the need for
change. This is the opposite of those strategies in which the
therapist is responsible for voicing these perspectives (e.g.,
Youre an alcoholic, and need to stop drinking.) and persuading the
client to the truth.
65 Client Ambivalence People struggling with addictive problems
usually enter counseling with fluctuating and conflicting
motivations. This conflict is known as ambivalence. Ambivalent
clients are often seen as abnormal or unacceptable, and having poor
motivation. In this thinking the client needs to be persuaded and
educated regarding the negative effects. This can lead to the
confrontation - denial trap. Ambivalence is normal, acceptable, and
understandable. Working with ambivalence is the heart of the
problem in MI.
66 Some Complications of Ambivalence 1. Values - Never assume
that the client will view a given cost or benefit the same way you
do. 2. Expectancies - People have certain expectancies regarding
the likely results of certain courses of actions. 3. Self-esteem -
Sometimes bolstering self-esteem is a necessary prerequisite to
motivation for change. 4. Social Context - A clients motivational
system cannot be understood outside the social context of family,
friends, and community. 5. Impaired Control - A person may persist
in a harmful behavior through a breakdown of normal self-regulation
(self-control) processes.
67 Dealing with Ambivalence and Sustain Talk MI has stopped
using the term resistance, but now focuses on ambivalence. Sustain
talk is a normal part of ambivalence. Sustain talk is that which
occurs in treatment, and shows that the client may be moving away
from the direction of change. Sustain Talk and Discord can be
determined by therapist style. Therefore, your style as a therapist
will determine how much ambivalence, sustain talk and discord is
elicited by the client. Discord signals dissonance in the working
alliance. An important goal of Motivational Interviewing is to
avoid eliciting or strengthening sustain talk.
68 Dealing with Ambivalence 4 Types 1. Arguing The client
contests the accuracy, expertise or integrity of the clinician. 2.
Interrupting The client breaks in and interrupts the clinician in a
defensive manner. 3. Denying The client expresses an unwillingness
to recognize problems, cooperate, accept responsibility, or take
advice. 4. Ignoring The client shows evidence of ignoring or not
following the clinical advice.
69 Strategies for Handling Ambivalence Simple Reflection This
is responding to ambivalence/sustain talk with non- resistance. A
simple acknowledgement of the clients disagreement, emotion, or
perception can permit further exploration rather than
defensiveness. Client: I dont think that anger is really my
problem. Counselor: You anger hasnt cause any real difficulties for
you. Client: Well, sure it has. Anyone who gets into scraps as much
as I do is about to have some consequences.
70 Strategies for Handling Ambivalence (cont.) Amplified
Reflection Reflecting back what the client has said in an
exaggerated form, to state it in an even more extreme form than the
client did. These responses must be straightforward and supportive,
not in a tone of sarcasm or impatience. Client: I think things are
just fine in our marriage the way they are. Counselor: Things
couldnt possibly be better in your marriage than they are right
now. Client: Im pretty satisfied, but I guess both of us
arent.
71 Strategies for Handling Ambivalence (cont.) Double-Sided
Reflection This is acknowledging what the client has said, and add
to it the other side of the clients ambivalence. This may require
material that the client has offered previously. CLIENT: OK, maybe
Ive got some problems with drinking, but Im not an alcoholic.
(minimizing) THERAPIST: You dont have any problem seeing that your
drinking is hurting you, but you surely dont want to be
labeled.
72 Strategies for Handling Ambivalence (cont.) Shifting Focus
This is shifting the clients attention away from what seems to be a
stumbling block standing in the way of progress. Such detouring can
be a good way to ambivalence/discord when encountering a
particularly difficult issue. Client: I know that you want me to
give up drugs completely, but Im not going to do that!
(unwillingness) Therapist: What is it that you would like out of
this. Client: I want that witch of a probation officer out of my
life. Therapist: So lets discuss that issue, what problems are you
experiencing with her?
73 Strategies for Handling Ambivalence (cont.) Emphasizing
Autonomy - Personal Choice and Control This works in working with
discord that comes from REACTANCE. When people think their freedom
of choice is being threatened, they tend to react by asserting
their liberty. Antidote for reactance is to assure the client it is
he/she who determines what happens. CLIENT: I know that you want me
to give up drugs completely, but Im not going to do that!
(unwillingness) THERAPIST: Nobody can change your drug usage for
you, its totally your choice to either stop using or continue
using.
74 Strategies for Handling Ambivalence (cont.) Reframing This
approach acknowledges the validity of the clients raw observations,
but offers a new meaning or interpretation for them. The clients
information is viewed in a new light that is more likely to be
helpful and to support change. Case Example: CLIENT: I can hold my
liquor just fine. Im still standing when everybody else is under
the table. THERAPIST: I hear you saying that you can drink a lot
more without looking or feeling drunk. When people start feeling
the effects of being drunk, they tend to curb their drinking.
Sometimes that built in warning system changes due and can result
in a higher tolerance for alcohol than existed previously.
75 Siding with the Negative This is where the Clinician
presents, or takes up, the negative voice in the discussion the
voice of precontemplation and status quo. This works well with
clients still in contemplation, and needing to elicit self-
motivational, change oriented statements but needs help doing so.
Taking the negative side can evoke a response of the positives for
change from the client, thus the client would be making your
argument for you. This is often times called a paradoxical
intervention or prescribing the problem. Therapist: From what Im
seeing, you dont have a problem, everything is functioning
perfectly well in your life, and there doesnt appear a need to
continue addressing this issue. Client: Well there have been some
problems, I do have 1 DWI, my wife has been complaining recently
because of my drinking away from home, and my kids have made
comments to me, so I wouldnt go so far to say there is no
problem.
77 MI is not based on: Stages of Readiness for Change Model
Precontemplation The client is not ready to change and
identification with the problem is marked with positive
associations. Goal is to get client to form some ambivalence
regarding problem. Contemplation Ambivalence exists with the client
regarding problem (the association with the identified problem are
now good and bad). Goal is to move the client into preparation
stage. Preparation Client has substantially resolved ambivalence
and prepares to commit to a change in the problem behavior. Goal is
to move the client into the action stage.
78 MI is not based on: Stages of Readiness for Change Model
Action The client has committed to specific actions intended to
bring about change, but needs help in maintaining this level of
change. Goal is to provide client with help in this area and work
client towards next stage. Maintenance The client enters the point
of being able to sustain the changes accomplished previously.
Replacing problem behaviors with new, healthy life-style.
Termination Person exits the cycle of change without fear of
relapsing to previous behavior. Much debate over whether certain
problems can be terminated. Relapse/Recycling Relapse to one of the
first three stages of change. Expectable setbacks and hopefully
learn from relapse before committing to a new cycle of action.
Multidimensional assessment to explore relapse reasons.
79 Defining Termination of a Problem How far and how long must
a client go before the problem can be considered to be terminated?
How can you distinguish the real signs of termination from the
rationalizations that will cause a client to return to the problem
behavior?
80 A New Self-Image If a significant revision in your attitude
and self-image takes place, there is a good chance a client will
approach termination. A feeling (understanding) that the change in
the problem is theirs. More than just the mastering of the problem
behavior(s), this is where a clients holds a new self-image , one
that is consistent with healthier behavior(s).
81 No temptation in Any Situation No temptation to return to
the problem behavior(s), regardless of the situation. No temptation
to return to the problem behavior(s), no matter how you are
feeling. These clients experience themselves in the same way as
individuals who have never experienced the problem.
82 Solid Self-efficacy Clients who transfer their center of
gravity from their problems to themselves. They look, act, and feel
with genuine confidence, not false bravado. In regards to addictive
behaviors, confidence peaks after one year after action begins, but
temptation does not bottom out until 2 or 3 years after action
begins.
83 A Healthier Lifestyle Life changes are essential for the
maintenance of a problematic behavior; however, a new lifestyle is
essential for termination. The difference is permanence of change.
In the maintenance stage, a client modifies parts of their life
(e.g., social contacts, daily schedules, behavior patterns), to
overcome their problem. In termination, clients institute a
healthier lifestyle as a means of preserving their gains and
promoting new growth.
84 MI - Planning There comes a time in therapy when the
emphasis shifts from building motivation to strengthening
commitment to change. Signs of Readiness for Change 1. Decreased
ambivalence 2. Decreased questions about the problem 3. Resolve 4.
Self-Motivational statements 5. Increase questions about change 6.
Envisioning or imagining aspects of change (good or bad) 7.
Experimenting
85 MI - Planning Recapitulation Summarizing clients current
situation. The time to move from evoking to planning is clinical
judgment call guided by signals of readiness from the client.
Developing a change plan usually involves moving from general
intention to a specific implementation plan 3 planning scenarios:
1. The Change plan is already clear 2. There are options among
which to choose in path mapping 3. The way forward is unclear and a
change plan needs to be developed from scratch.
86 MI - Planning Negotiating a Plan - Setting Goals (client
centered goals) - Considering Change Options (possible methods for
obtaining goals, what would happen with different courses of
change, client may not choose the correct option the first time
prepare clients for this). - Arriving at a Plan Endgame - Eliciting
Commitment to Action - Transition to the Action Phase
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