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IMR Booster Training April 30 th 2007. Tim Gearhart MSW Alan McGuire MS. Tentative Agenda. 9am-noon Spirit of MI OARS Elliciting Change Talk Responding to Change Talk Responding to Resistance 1p-4p. Spirit of Motivational Interviewing. “Words without the music”.

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imr booster training april 30 th 2007

IMR Booster TrainingApril 30th 2007

Tim Gearhart MSW

Alan McGuire MS

tentative agenda
Tentative Agenda


  • Spirit of MI
  • OARS
  • Elliciting Change Talk
  • Responding to Change Talk
  • Responding to Resistance


spirit of motivational interviewing
Spirit of Motivational Interviewing
  • “Words without the music”.
    • Spirit + OARS = close but not quite MI
  • Docere – Expert
  • Ducere – Calling forth that which is already there.
  • Acceptance
    • “The curious paradox is that when I accept myself just as I am, then I can change.” Carl Rogers
what mi is not p 21
What MI is Not p. 21
  • Ask Questions: Why haven’t you made the change? What is in the way?
  • You should change because...
  • It’s important for you to change because…
  • If you don’t change…will happen.
  • You could make the change by…
  • I’m sure that you will make this change because…
Favorite Teaching Exercise
    • Why were they your favorite?
    • What characteristics did they have that you admired?
  • Rules: No giving advice. Just listen.
    • 1. Why would you want to make this change?
    • 2. If you decided to do it, how would you go about it?
    • 3. What are the 3 best reasons to make this change?
    • 4. From 0 – 10 how important is this to you? Why not 0?
    • 5. Provide a summary statement.
    • 6. So what do you think you’ll do?
thomas gordon
Thomas Gordon

2. What the speaker says.

3. Words the listener hears.

1. What the speaker means.

  • 4. What the listener thinks the speaker means.
Exercise 1: Hypothesis Testing 42
    • Cl: “One thing I like about myself is that…”
    • T: “Do you mean…”
    • Cl: “Yes/No”
types of reflective statements
Types of Reflective Statements
  • 1. Repeating: restating what the speaker said.
  • 2. Rephrasing: slightly rephrase what was offered.
  • 3. Paraphrasing: continuing the paragraph or inferring meaning.
  • 4. Reflection of feeling: a paraphrase that emphasizes the emotional dimension via metaphors.
Exercise 2: Forming Reflections
    • Cl: “One thing about myself I’d like to change…”
    • T: responds only with reflective statements. Questions are not allowed.
    • Cl: elaborates following the reflection.
  • Open ended questions.
  • Affirmations.
  • Reflections.
  • Summaries.
open or closed questions
Open or Closed Questions?
  • Is this an open or closed ended question?
  • Do you want to stay in the system forever?
  • What are the important reasons to make this change?
  • If you were less depressed how would life look differently?
  • In what way does this concern you?
change talk chapter 7 of 2 nd addition
Change TalkChapter 7 of 2nd addition
  • “It is the truth we ourselves speak rather than the treatment we receive that heals us.” O. Hobart Mowrer
  • The more one makes statements utilizing change talk, the more likely they will make a change (Amrhein et al)
    • Given this information, what should our goal be as clinicians?
types of change talk
Types of Change Talk
  • D – Desire (ex. “I’d really like to …”)
  • A – Ability (ex. “I think I could change if…”)
  • R – Reason (ex. “I should try because…”)
  • N – Need (ex. “I need to change because…”)
  • C – Commitment (“Do you take this woman to be your lawfully wedded bride?)
  • Change talk is preparatory language to commitment language.
how to elicit change talk
How to Elicit Change Talk
  • OARS
  • Asking Evocative Questions
  • Using the importance ruler
  • Exploring the decisional balance
  • Looking Back/Forward
  • Exploring Goals and Values
responding to change talk
Responding to Change Talk
  • Reflect it
  • Ask more about it
  • Affirm it
  • Summarize it (bouquet\'s)
responding to resistance
Responding to Resistance
  • Simple reflection: acknowledge the person’s disagreement, feeling, or perception.
  • Amplified reflection: reflect back in an exaggerated form
  • Double-sided reflection: acknowledgment + adds to the other side of ambivalence
  • Shifting focus: diverting the focus
  • Reframing: validate and build new meaning
  • Agreeing with a twist: (reflect/reframe)
  • Emphasize personal control
  • Coming alongside: (therapeutic paradox) recommend that they continue the behavior or even increase it. Need to be done non-manipulatively.
how does all of this relate to imr
How does all of this relate to IMR?
  • Lots of opportunity to explore interest/motivation in changing specific behaviors.
  • Assists in developing meaningful goals.
  • The Spirit of MI is consistent with the values of Recovery.
giving advice or going over material
Giving advice or going over material.
  • ASK: Prior to getting into the material you should make sure that you have the permission of the client.
  • TELL: Work through some material.
  • ASK: What do you think about that?
exercise roleplay cl didn t complete hmwk
Exercise RoleplayCl. Didn’t complete hmwk.?
  • Team Consult Role Play
    • Demographics
    • Life situation
    • Target Behaviors
    • Reasons to change
    • Agree to be a 5 on importance/confidence
cognitive behavior techniques for imr

Cognitive-Behavior Techniques for IMR

Alan McGuire MS, Tim Gearhart MSW

ACT Center of Indiana

scope goals
Scope & Goals
  • CB Techniques vs. CBT-P
  • Why all the SZ?
  • Applied to IMR
  • A little hx/philosophy
  • Tools
  • Your goals
definition of cbt
Definition of CBT
  • A broad set of approaches to improving adaptive and emotional functioning based on theories of learning and behavior change.- Penn, 2006
brief history
Brief History
  • Early Therapy Research
    • Psychoanalytic
    • Unsuccessful
  • Hiatus
  • Problem/Symptom focus
cbt p onslaught
CBT-P Onslaught!

Gould, R. A., et al., (2000). Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 48, 335-342.

Penn, D. L., Waldheter, E. J., Mueser, K. T., Perkins, D. O., & Lieberman, J. (2005). Psychosocial treatment for first episode schizophrenia: A research update. American Journal of Psychiatry, 162, 2220-2232.

Pilling, S. et al. (2002). Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763-782.

Rector, N. A., & Beck, A. T. (2001). Cognitive therapy of schizophrenia: A quantitative review. Journal of Nervous and Mental Disease, 189, 278-287.

Tarrier, N., & Wykes, T. (2004). Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale? Behaviour Research and Therapy, 42, 1377-1401.

Turkington, D., Kingdon, D., & Weiden, P. (2006). Cognitive behavioral therapy for schizophrenia. American Journal of Psychiatry, 163, 365-373.

Zimmermann et al. (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77, 1-9.

research conclusions
Research Conclusions
  •  Positive & Negative Sx
    • Effects increase in follow-up
  •  Dropout Rates
  •  Time to Hos. Release
  • Subjects
    • Med Resistant
    • Acute Psychosis
    • Severity  Outcome
theoretical foundations
Theoretical Foundations
  • Basic Learning Theory
  • Cognitive Theory
basic learning principles
Basic Learning Principles
  • Classical conditioning (learning by association)
  • Operant conditioning (learning by consequences)
  • Social learning (learning by observation)
the cognitive model
The Cognitive Model
  • Most people:
    • Actuating event Consequence
  • ABC Model
    • Actuating eventBelief Consequence
    • “ABC Model”
imr workbook

“Cognitive-behavioral techniques involve the systematic application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

-IMR Workbook

importance of approach
Importance of Approach
  • “The general approach is concerned with understanding and making sense, working to achieve collaboration between the person … and the therapist, rather than didactic, interpretative, or confrontational styles.”
  • -Garety, Fowler, and Kuipers (2000)
basic clinical skills
Basic Clinical Skills
  • Active listening (exercise)
    • Non-verbals
  • Empathy statements (exercise)
    • You feel _____ because ____
targets of cbt
Targets of CBT
  • Positive Sx
    • Hallucinations
    • Delusions
  • Negative Sx
  • Depression/Anxiety
  • Relapse Prevention
dealing with sx
Dealing with Sx
  • Important to consumer?
    • Relevant to Goal
  • + Sx
    • Cognitive Flexibility
    •  Distress
    • ‘Work within’
the tools
The Tools
  • Reinforcement
  • Modeling/role-play
  • Relaxation Training
  • Cognitive Restructuring
  • Challenging Delusions*
  • Activity scheduling*
  • Shaping
  • Positive Reinforcement
    • Examples?
  • Negative Reinforcement
    • Examples?
  • Why not extinction/punishment?
  • Explain what your modeling
  • Model
  • Elicit feedback
  • Model Modeling
role play
  • Who uses? How?
  • Barriers to role-play?
  • Advantages?
  • Points to remember
    • Combine w/ Modeling
    • Positive feedback
relaxation training
Relaxation Training
  • Helps people learn techniques for reducing tension
  • Breathing
  • Progressive muscle relaxation
  • Guided imagery
relaxation tips
Relaxation Tips
  • What does consumer use now?
  • Incorporate relaxation techniques into the daily routine
  • Make a relaxation tape
  • Practice, practice, practice
  • Help person set up a specific plan to practice
cognitive restructuring
Cognitive Restructuring
  • Connection between thoughts and feelings (ABC)
  • Use for:
    • Affective Sx
    • Deal with psychotic Sx
  • Steps
    • Teach the idea
    • Assess connections
    • Change thoughts/beliefs
teaching the connection
Teaching the connection
  • Explain ABC
  • Automatic thoughts
automatic thoughts
Automatic thoughts
  • All or nothing thinking
  • “Must,” “should,” or “never” statements
  • Overgeneralization
  • Catastrophizing
  • Mind-reading
  • Emotional reasoning
  • Disqualifying the positive
  • Personalization
  • Thought record
  • Mood record
  • Downward arrow
thought record
Thought Record
  • This requires the client to record:
    • The event
    • Emotions (type and degree [1-100])
    • ATs (type and belief [1-100])
    • Rational Response (type and belief [1- 100])
    • Outcome (Re-rate belief in ATs and emotion)
mood record
Mood Record
  • Choose emotion
  • Track for week
    • ~3-4x per day
    • 1-10 on intensity
  • Review
    • Trends
    • What was going on then?
downward arrow
Downward Arrow
  • Start w/ thought
  • “What would that mean?”

“I’ll screw up this interview.”

“I won’t get this job.”

“I won’t get any job.”

“I’m worthless.”

  • Make it real
    • Imagery to recall event in detail
    • Role play
    • Assess change in session
delusions hallucinations
Delusions & Hallucinations
  • Goal: increase doubt
  • Strategies
    • “Other possibilities?”
    • Weigh the evidence
    • Pie Chart Method
    • Experiment
  • Exercise
  • Gentle and Non-confrontational
  • Choose your battles (cognitive flexibility)
  • If you can’t change, ‘work within’
behavioral activation rationale
Behavioral Activation:Rationale
  • Treatment for depression
  • Negative symptoms
  • Inactivity reinforces depression
  • Activity Scheduling
    • Work together to schedule activities
activity scheduling overview
Activity Scheduling:Overview
  • Fill in current schedule
  • List “pleasurable” and “mastery” activities
  • Fill in w/ balance
wrap up
  • What did you learn?