Making it Real, Making it Work

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Motivational Interviewing. A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Motivational Interviewing. Often brief; 1-2 sessionsStand alone, prelude, or in combination with other treatmentsCommonly combined with feedbackTra

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1. Making it Real, Making it Work Motivational Interviewing: From Conflict, to Compliance, to Commitment Terrence D. Walton, MSW, ICADC Director of Treatment District of Columbia Pretrial Services Agency

2. Motivational Interviewing A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence

3. Motivational Interviewing Often brief; 1-2 sessions Stand alone, prelude, or in combination with other treatments Commonly combined with feedback Training varies Diverse populations Across behavioral domains

4. What are we trying to change?

5. Targeted Change Must Be Behavioral and specific Measurable and achievable Universally positive Give examples of “positive change” which may be based on individual or cultural bias and is not universally positive

6. Why people change Willing Able Ready

7. Stages of Change Pre-contemplation Contemplation Preparation Action Maintenance

8. Pre-Contemplation Contemplation Preparation Action Maintenance Readiness to Change

9. Are there any drug programs that will let me take my kids with me? Pre-contemplation, Contemplation, Preparation, Action, Maintenance

10. I need to get to a meeting when I leave here because the thought of what might happen when I get sentenced tomorrow is messing with my head. Pre-contemplation, Contemplation, Preparation, Action, Maintenance

11. You cant order me not to drink. Drinking is not my problem. You all are my problem. Pre-contemplation, Contemplation, Preparation, Action, Maintenance

12. I don’t like to think of myself as an addict. I just like to party and sometimes I let it get out of hand. Pre-contemplation, Contemplation, Preparation, Action, Maintenance

13. I threw out my liquor and asked Jamal not to drink around me. Pre-contemplation, Contemplation, Preparation, Action, Maintenance

14. The Spirit of MI MI is an interpersonal style MI is more than just a group of techniques Motivation is elicited not imposed Direct persuasion is not effective in resolving ambivalence It is the client’s task to resolve ambivalence, not the helpers Readiness to change can be a product of interpersonal interaction

15. A Motivational Understanding of Change Natural versus Assisted Involuntary versus Intentional Faith/Hope Effects Helper Effects Conflict, Compliance, Commitment Change Talk Effects

16. The Righting Reflex Persuasion Confrontation

17. Ambivalence Understanding Accepting Exploring Resolving

18. Underlying Aspects Collaboration Evocation Autonomy

19. Phases of MI Phase I- Building Motivation for Change Phase 2- Strengthening Commitment to Change

20. GENERAL PRINCIPLES Develop Discrepancy Express Empathy Support Self-Efficacy Roll with Resistance

21. 4 Principles Discrepancy (Develop it) Empathy (Express it) Efficacy (Support it) Resistance (Roll with it)

22. Develop Discrepancy The client should present the arguments for change. Change is motivated by a perceived discrepancy Values and priorities What matters most? Current behavior/situation versus what matters most

23. Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal

24. Support Self-Efficacy A person’s belief in the possibility of change is an important motivator. The client is responsible for choosing and carrying out change. The case mangers belief in the person’s ability to change becomes a self-fulfilling prophecy May be hampered by lack of insight and ability

25. Roll with Resistance The defendant is the primary resource in finding answers and solutions. Resistance is not directly opposed. New perspectives are invited, but not imposed. Avoid arguing for change. Resistance is a signal to respond differently.

26. Categories of Resistance Arguing Challenging Accuracy, Discounting Expertise, Hostility Interrupting Negating Blaming, disagreeing, excusing, minimizing, pessimism Ignoring Agreeing

27. How to Roll with Resistance Simple Reflection Amplified Reflection (exaggeration) Double-Sided Reflection (reflecting both sides of ambivalence) Shifting Focus (temporarily shifting away from focus of resistance) Reframing Agreeing with a Twist (reflection, followed by a reframe) Emphasizing Choice and Control Coming Alongside (therapeutic paradox)

28. How Not to Respond to Resistance? Advocating Arguing for Change Assuming the Expert Role Criticizing, Shaming, or Blaming Labeling Being in a Hurry (justifying forcefulness) Claiming Preeminence

29. Phase I: Five Core Methods (OARS + E) Open Questions Affirm Reflective Listening Summarize Evoke Change Talk

30. Three Categories of In-Session Client Communication Resistance Sustain Talk Change Talk

31. Change Talk Evoking Change Talk Listening for Change Talk Responding to Change Talk

32. Types of Change Talk Desire Ability Reasons Need Commitment Activation Taking Steps

33. Evoke Change Talk Ask open questions that evoke change talk Why might you want to make this change? (Desire) How might you go about it? (ability) What are the three best reasons for you to do it? (reasons) How important is it for you to do this? (need) So what do you think you’ll do? (commitment)

34. Evoke Change Talk Using the Importance Ruler “How important would you say it is for you to _______? On a scale of 0 to 10, where 0 is not important at all and 10 is extremely important, where would you say you are?” Which question is better: Why are you at a ___ and not zero? Why are you at _____ and not 10?


36. Open Questions – 15% Allows client to create impetus for forward movement Cant be answered with “yes”, “no”, or other short answers Allows you opportunities to express empathy and listen for “what matters most” and ambivalence; as well as affirm, reflect, summarize, and respond to change talk

37. Open Ended Questions? What do you like about drinking? What brings you here today? Are you willing to try this for a week? What do you want to do about your anger: prevent it, lessen it, or understand it? What would you like to set as your quit date? Isn’t it important for you to have meaning in your life?

38. Affirm – 5% Emphasize a strength Notice and appreciate a positive action Should be genuine Express positive regard and caring Strengthen therapeutic relationship “You really worked hard on that.” “That’s a good suggestion.” “When you set your mind to something, you follow through”

39. Listen Reflectively – 75% Reflecting what the participant has expressed Selective Reflection Content versus Feelings Overstating versus Understating Question versus Statement

40. Listen Reflectively Repeating - simply repeats an element Rephrase - substitutes synonyms Paraphrase- infer meaning Reflect affect Reflect values Reflect ambivalence

41. Not Listening Reflectively Giving Advice, Making Suggestions, or Providing Solutions Ordering, Directing, or Commanding Warning, Cautioning, or Threatening Distracting, Humoring, Changing Subject Reassuring, Sympathizing, or Consoling Agreeing, Approving, or Praising Disagreeing, Judging, Criticizing, Moralizing Persuading with Logic, Arguing, or Lecturing Interpreting or Analyzing Questioning or Probing

42. Listen Reflectively Groups of Three “One thing I like about myself is….” Take turn saying sentence to each partner Each partners reflects Speaker responds “yes” or “no” if the person accurately reflect what you said, felt, believe, intended to say, etc.

43. Summarize – 5% Collecting Summary—”What else?” Linking Summary— Clarifying Ambivalence Use “And” instead of “But” “one the one hand…and on the other” “at the same time”

44. Responding to Change Talk Ask for elaboration Ask for more details or examples Affirm, Reflect, Summarize “What else?” “Say more about that” Don’t over-respond

45. Responding to Change Talk Elaborate Affirm Reflect Summarize

46. Early Session Goals Establish rapport Clarify of roles and responsibilities Encourage participant personal investment in complying with program requirements Search for mutual goals and next steps Set the tone for future work Review the intake results

47. Phase 2—Strengthening Commitment to Change Decreased Resistance Decreased Problem Discussion Resolve Change Talk Questions about Change Envisioning Experimenting

48. Phase 2 Hazards Underestimating Ambivalence Over-prescription Insufficient Direction

49. Initiating Phase 2 Recapitulate Key Question – “Where do we go from here?” Giving Information and Advice

50. Making it Real, Making it Work Motivational Interviewing: From Conflict to Compliance to Commitment

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