kotkin mi 12-18-14

Introduction to Motivational Interviewing and Stages of

Change

…What the Non-Specialist Needs to KnowPt 2

By Elizabeth Kotkin, MA, LMFTProgram Director

YES Adolescent Skills Center-Manhattan

What makes behavior change so hard?What makes behavior change so hard?It works for usIt works for usIt often involves multiple behaviorsIt often involves multiple behaviors Knowledge about how to change isn’t always Knowledge about how to change isn’t always enoughenoughPeople are creatures of habitPeople are creatures of habit Health consequences are often delayedHealth consequences are often delayedBusy lifestyles require us to make time for self careBusy lifestyles require us to make time for self care

Motivational Interviewing

“A therapeutic style intended to help clinicians work with patients to address the patient’s fluctuation between opposing behaviors and thoughts.”

Source: Miller and Rollnick, Motivational Interviewing 1991.

What Is Motivational Interviewing?

It is designed to enhance the client’s own motivation to change using strategies that are empathic and non-confrontational

It can be defined as a patient-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

What Do Clients Really Want?

To be accepted

• Open-ended questioning

• Affirming

• Reflective listening

• Summarizing

Building Motivation usingOARS (the microskills)

Open-Ended Questions

Asking open-ended questions helps you to understand your clients' point of view and elicits their feelings about a given topic or situation.

Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response.

Affirm

When it is done sincerely, affirming your client supports and promotes self-efficacy.

Reflective Listening

Listen to both what the person says and to what the person means

Check out assumptions Create an environment of empathy (nonjudgmental) You do not have to agree Be aware of intonation (statement, not question)

Summarizing Summaries communicate interest, understanding and call

attention to important elements of the discussion Can be used to highlight both sides of the client’s

ambivalence about change in order to develop discrepancies

Draw together the client’s own perspective on change by linking together something the client just said with something said earlier.

Five Principles ofMotivational Interviewing(What you are actually doing)

1. Expressing empathy

2. Developing discrepancy

3. Avoiding argumentation

4.Roll with the Resistance

5.Supporting Supporting self-efficacy

1. Express Empathy•Empathy communicates acceptance, while supporting the process of change•Counselor is an ally to participant•Participant should feel heard

•Seek to build up, rather than tear down

•Skillful reflective listening is fundamental to expressing empathy

2. Develop Discrepancy

Motivation for change is enhanced when clients perceive differences between their current situation and their hopes for the future.

When a person says one thing and then in the next sentence says the opposite. These are signs of ambivalence.

Developing awareness of consequences helps clients examine their behavior.

A discrepancy between present behavior and important goals motivates change.

The client should present the arguments for change.

Understanding Ambivalence

Working with ambivalence is key

Ambivalence is normal, acceptable, understandable

Attachment to the behavior is part of ambivalence

Ambivalence tips back and forth

Using Discrepancy to Understand Ambivalence

Interventions: Use the following kinds of statements to help participants understand their ambivalence– “On the one hand…On the other hand…”– “So part of you wants…But another part of you

feels…”

Double-Sided Reflection Captures BOTH sides of the ambivalence

(both…..and…….) Double – sided reflection:

– I think I would feel so much better about myself if I were in better shape, but it’s so hard to stick to a workout plan.

– Counselor: On the one hand, trying to work out consistently is challenging, but on the other hand, you think your self-esteem would improve if you lost weight.

Other Ways to Explore Ambivalence

How Important Ruler

0 1 2 3 4 5 6 7 8 9 10Not At All Important Extremely Important

Ask participant: “How important is this change?” “Why Not Lower?”

3. Avoid Argumentation

•Resistance is signal to change strategies

•Labeling is unnecessary

•Shift perceptions

•Peoples’ attitudes shaped by their words,

not yours

Shifting Focus

You can defuse resistance by helping the client shift focus away from obstacles and barriers.

Focus is shifted towards what is do-able. This method offers an opportunity to affirm your

client's personal choice regarding the conduct of his own life.

4. Roll with Resistance Roll, rather than confront resistance. Confronting

resistance can cause participant to dig in. Strategies to help resolve resistance:

– Explore pros and cons of change– Use “Decisional Balance” tool– New perspectives are invited but not imposed– The client is a valuable resource for finding solutions to

problems Continued resistance equals a signal to change our

approach.

Simple reflection

The simplest approach to responding to resistance is with nonresistance, by repeating the patient's statement in a neutral form.

This acknowledges and validates what the patient has said and can elicit an opposite response.

Decisional Balance

Reframe

Acknowledge the validity of the client’s observation, but offer the possibility of new meanings for these observations.

5. Support Self-Efficacy

Belief that change is possible is important motivator

Person is responsible for choosing and carrying out actions to change

There is hope in the range of alternative approaches available

Harnessing Self-Efficacy: “I know I can do it!”

The belief in your ability to do something will mediate whether or not it is tried, how much effort goes into it, and how long you will persist in your efforts.

Explore with participant a time when they were successful at something (i.e. physical activity or healthy eating.)

One Way to Gain Self-Efficacy is Seeing Others Succeed:

Role Modeling:– “If they can do it, maybe I can too.”– Ask, “Who do you know who has been able to

accomplish this?” Group activities and workshops can help to inspire and motivate participants.

Borrowing Self-Efficacy Expressing faith in the participant helps

participant have faith in self. Participants can tap into other’s belief that

they can accomplish their goals. Ask, “Who in your family thinks you can

do this?”

Motivational Interviewing : Putting Responsibility for Change on the Client.

Simple Reflection Shifting Focus Rolling with Resistance Double-Sided Reflections Self-Efficacy

Open-ended Questions Listen Reflectively Expressing Empathy Develop Discrepancy Affirm

This third edition of the book, Motivational Interviewing, deals with changing health-related behaviors in general.

More resources are available at the MINT website, including training resources and recent research: http://www.motivationalinterviewing.org/

Motivational Interviewing, 3rd Edition. Miller and Rollnick