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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 TrainingApril 30th 2007

Tim Gearhart MSW

Alan McGuire MS


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Tentative Agenda

9am-noon

  • Spirit of MI

  • OARS

  • Elliciting Change Talk

  • Responding to Change Talk

  • Responding to Resistance

    1p-4p


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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


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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…


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Exercise

  • 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?


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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.


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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.


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  • 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.


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OARS

  • Open ended questions.

  • Affirmations.

  • Reflections.

  • Summaries.


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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?


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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?


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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.


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How to Elicit Change Talk

  • OARS

  • Asking Evocative Questions

  • Using the importance ruler

  • Exploring the decisional balance

  • Looking Back/Forward

  • Exploring Goals and Values



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Responding to Change Talk

  • Reflect it

  • Ask more about it

  • Affirm it

  • Summarize it (bouquet's)


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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


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Cont…

  • 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.


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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.


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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?


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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


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Cognitive-Behavior Techniques for IMR

Alan McGuire MS, Tim Gearhart MSW

ACT Center of Indiana


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Scope & Goals

  • CB Techniques vs. CBT-P

  • Why all the SZ?

  • Applied to IMR

  • A little hx/philosophy

  • Tools

  • Your goals



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Definition of CBT

  • A broad set of approaches to improving adaptive and emotional functioning based on theories of learning and behavior change.- Penn, 2006


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Brief History

  • Early Therapy Research

    • Psychoanalytic

    • Unsuccessful

  • Hiatus

  • Problem/Symptom focus


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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.


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Research Conclusions

  •  Positive & Negative Sx

    • Effects increase in follow-up

  •  Dropout Rates

  •  Time to Hos. Release

  • Subjects

    • Med Resistant

    • Acute Psychosis

    • Severity  Outcome


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Theoretical Foundations

  • Basic Learning Theory

  • Cognitive Theory


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Basic Learning Principles

  • Classical conditioning (learning by association)

  • Operant conditioning (learning by consequences)

  • Social learning (learning by observation)


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The Cognitive Model

  • Most people:

    • Actuating event Consequence

  • ABC Model

    • Actuating eventBelief Consequence

    • “ABC Model”



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“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


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Importance of Approach application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • “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)


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Basic Clinical Skills application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Active listening (exercise)

    • Non-verbals

  • Empathy statements (exercise)

    • You feel _____ because ____


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Targets of CBT application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Positive Sx

    • Hallucinations

    • Delusions

  • Negative Sx

  • Depression/Anxiety

  • Relapse Prevention


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Dealing with Sx application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Important to consumer?

    • Relevant to Goal

  • + Sx

    • Cognitive Flexibility

    •  Distress

    • ‘Work within’


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The Tools application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Reinforcement

  • Modeling/role-play

  • Relaxation Training

  • Cognitive Restructuring

  • Challenging Delusions*

  • Activity scheduling*

  • Shaping


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Reinforcement application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Positive Reinforcement

    • Examples?

  • Negative Reinforcement

    • Examples?

  • Why not extinction/punishment?


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Modeling application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Explain what your modeling

  • Model

  • Elicit feedback

  • Model Modeling


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Role-play application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Who uses? How?

  • Barriers to role-play?

  • Advantages?

  • Points to remember

    • Combine w/ Modeling

    • Positive feedback


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Relaxation Training application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Helps people learn techniques for reducing tension

  • Breathing

  • Progressive muscle relaxation

  • Guided imagery


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Relaxation Tips application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • 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


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Cognitive Restructuring application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Connection between thoughts and feelings (ABC)

  • Use for:

    • Affective Sx

    • Deal with psychotic Sx

  • Steps

    • Teach the idea

    • Assess connections

    • Change thoughts/beliefs


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Teaching the connection application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Explain ABC

  • Automatic thoughts


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Automatic thoughts application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • All or nothing thinking

  • “Must,” “should,” or “never” statements

  • Overgeneralization

  • Catastrophizing

  • Mind-reading

  • Emotional reasoning

  • Disqualifying the positive

  • Personalization


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Assessment application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Thought record

  • Mood record

  • Downward arrow


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Thought Record application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • SEE HANDOUT

  • 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)


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Mood Record application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Choose emotion

  • Track for week

    • ~3-4x per day

    • 1-10 on intensity

  • Review

    • Trends

    • What was going on then?


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Downward Arrow application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • 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.”


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Tips application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • FOCUS ON SPECIFIC SITUATIONS

  • Make it real

    • Imagery to recall event in detail

    • Role play

    • Assess change in session


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Delusions & Hallucinations application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Goal: increase doubt

  • Strategies

    • “Other possibilities?”

    • Weigh the evidence

    • Pie Chart Method

    • Experiment

  • Exercise


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Tips application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • Gentle and Non-confrontational

  • Choose your battles (cognitive flexibility)

  • If you can’t change, ‘work within’


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Behavioral Activation: application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”Rationale

  • Treatment for depression

  • Negative symptoms

  • Inactivity reinforces depression

  • Activity Scheduling

    • Work together to schedule activities


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Activity Scheduling: application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”Overview

  • Fill in current schedule

  • List “pleasurable” and “mastery” activities

  • Fill in w/ balance


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Wrap-up application of learning principles to help people acquire and use information and skills in Illness Management and Recovery.”

  • What did you learn?