The Art of Possibility in Conversation: Motivational Conversations 101 Presented by Dee-Dee Stout, MA, CADC-II; Member of MINT; Advisor/Trainer, ICCE for.

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

XML

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!!