MOTIVATIONAL INTERVIEWING SOW 4341 MICRO LEVEL ROLES INTERVENTIONS

MOTIVATIONAL INTERVIEWING SOW 4341: MICRO LEVEL ROLES & INTERVENTIONS (WEEK 7) RESHAWNA CHAPPLE, PHD, LCSW ASSOCIATE PROFESSOR SCHOOL OF SOCIAL WORK RCHAPPLE@UCF. EDU

“Client – centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25) WHAT IS MOTIVATIONA L INTERVIEWING (MI)? Helps clients clarify goals and make commitment to change (on their terms) Explores reasons for and against change Reduces ambivalence about change MI is a style of being with people, an integration of clinical skills to foster motivation for change (not a technique) (p. 35)

Layperson’s definition MOTIVATIONA L INTERVIEWIN G DEFINITIONS • A collaborative conversation style for strengthening a person’s own motivation & commitment to change Practitioner’s definition • A person-centered counseling style for addressing the common problem of ambivalence about change

TECHNIC AL DEFINITI ON – HOW DOES MI WORK? MI IS A COLLABORATIVE, GOALORIENTED STYLE OF COMMUNICATION WITH PARTICULAR ATTENTION TO THE LANGUAGE OF CHANGE. IT IS DESIGNED TO STRENGTHEN PERSONAL MOTIVATION FOR AND COMMITMENT TO A SPECIFIC GOAL BY ELICITING AND EXPLORING THE PERSON’S OWN REASONS FOR CHANGE WITHIN AN ATMOSPHERE OF ACCEPTANCE AND COMPASSION. (MILLER & ROLLNICK, 2013) HTTP: //WWW. YOUTUBE. COM/WATCH? V=67 I 6 G 1 I 7 ZAO

INSTEAD OF PHASES AND PRINCIPLES OF MI, NOW THE APPROACH COMPRISES OF FOUR BROAD PROCESSES: • ENGAGING THE SPIRIT OF MI • FOCUSING • EVOKING • PLANNING THE “SPIRIT” INVOLVES A COLLABORATIVE PARTNERSHIP WITH CLIENTS, A RESPECTFUL EVOKING OF THEIR OWN MOTIVATION AND WISDOM, A RADICAL ACCEPTANCE RECOGNIZING WHETHER CHANGE HAPPENS IS EACH PERSON’S OWN CHOICE (AUTONOMY) (MILLER & ROLLNICK, 2013)

MI SPIRIT Collaboration compassi on Acceptan ce Evocation

PREPARING FOR CHANGE TRANS-THEORETICAL MODEL STAGES OF CHANGE 1. PRE-CONTEMPLATION 2. CONTEMPLATION 3. PREPARATION 4. ACTION 5. BEHAVIOR MAINTENANCE 6. RECYCLING

PRE-CONTEMPLATION STAGES OF CHANGE Ø MINIMIZE AND RATIONALIZE PROBLEMS – NO INTENTION TO CHANGE IN THE FORESEEABLE FUTURE; MAY BE UNAWARE OR UNDER-AWARE OF PROBLEMS Ø SHOW SUPPORT FOR CLIENT’S ANXIETY ABOUT CHANGE

STAGES OF CHANGE CONTEMPLATION Ø BECOMING AWARE THAT A PROBLEM EXISTS AND OF NEED FOR CHANGE Ø THINKING SERIOUSLY ABOUT OVER-COMING IT, BUT NO COMMITMENT TO TAKE ACTION YET Ø WEIGHING PROS AND CONS OF THE PROBLEM AND ITS SOLUTION

PREPARATION STAGES OF CHANG E Ø COMBINES INTENTION AND BEHAVIOR – ACTION IS PLANNED WITHIN THE NEXT MONTH, HAS BEEN UNSUCCESSFUL WITHIN THE LAST YEAR Ø DETERMINES PROBLEM AND MAKES A DECISION TO CHANGE Ø SOME REDUCTIONS HAVE BEEN MADE IN PROBLEM BEHAVIORS, BUT A CRITERION FOR EFFECTIVE ACTION HAS NOT BEEN REACHED

ACTION STAGES OF CHANGE Ø BEHAVIOR, EXPERIENCES, OR ENVIRONMENT ARE MODIFIED TO OVERCOME THE PROBLEM Ø TAKES STEPS TO CHANGE BEHAVIOR OR DEAL WITH ISSUE Ø KEEP STEPS SMALL AND MANAGEABLE Ø TEMPTATION TO RETURN TO OLD HABITS IS NORMAL

TREATMENT IN STAGES PRE-CONTEMPLATION (ENGAGEMENT) • ASSERTIVE OUTREACH, PRACTICAL HELP (HOUSING, ENTITLEMENTS, OTHER), AND AN INTRODUCTION TO INDIVIDUAL, FAMILY, GROUP, AND SELF-HELP TREATMENT FORMATS CONTEMPLATION OR PREPARATION (PERSUASION) • EDUCATION, GOAL SETTING, AND BUILDING AWARENESS OF PROBLEM THROUGH MOTIVATIONAL COUNSELING

TREATMENT IN STAGES ACTION (ACTIVE TREATMENT) COUNSELING AND TREATMENT BASED ON COGNITIVE-BEHAVIORAL TECHNIQUES, SKILLS TRAINING, AND SUPPORT FROM FAMILIES AND SELF-HELP GROUPS MAINTENANCE (RELAPSE PREVENTION) CONTINUED COUNSELING AND TREATMENT BASED ON RELAPSE PREVENTION TECHNIQUES, SKILL BUILDING, AND ONGOING SUPPORT TO PROMOTE RECOVERY

BEHAVIOR MAINTENANCE Ø BECOMES MORE COMFORTABLE WITH NEW SELF, BUT MUST PERSIST BECAUSE RELAPSE IS ALWAYS A POSSIBILITY Ø REMAINING FREE FROM ADDICTIVE BEHAVIOR AND ENGAGING CONSISTENTLY IN A NEW INCOMPATIBLE BEHAVIOR FOR MORE THAN 6 MONTHS Ø MAKE CHANGES IN ENVIRONMENT Ø REVIEW REASONS WHY CLIENT MADE THE CHANGE

Precontemplation Maintenanc e Action Contemplation Preparation

CONTINUUM OF COMMUNICATION STYLES Directin g Guiding Followin g

AMBIVALENCE • AMBIVALENCE IS “SIMULTANEOUSLY WANTING AND NOT WANTING SOMETHING, OR WANTING BOTH OF TWO INCOMPATIBLE THINGS”. (MILLER & ROLLNICK, P. 6) • CLIENTS GET STUCK ON THEIR WAY TO CHANGING SECONDARY TO AMBIVALENCE • “PATH OUT OF AMBIVALENCE IS TO CHOOSE A DIRECTION & FOLLOW IT, TO KEEP MOVING IN THE CHOSEN DIRECTION” (P. 7)

KEY COMPONENTS • ACCEPTANCE INVOLVES THE INHERENT WORTH AND POTENTIAL, UNCONDITIONAL POSITIVE REGARD • AWARENESS OF CLIENT’S UNIQUE INDIVIDUALITY • RESPECT • AFFIRMATION • AUTONOMY • EMPATHY • WORTH • COLLABORATION • EVOCATION • COMPASSION (NEW) – PROMOTE THE OTHER’S WELFARE, GIVE PRIORITY TO OTHER’S NEEDS

FOUR ASPECTS OF ACCEPTANCE Absolute Worth Affirmatio n Acceptan ce Accurate Empathy Autonomy

ACCEPTANCE • TAKEN TOGETHER, THESE FOUR PERSON-CENTERED CONDITIONS CONVEY WHAT WE MEAN BY “ACCEPTANCE”. • “ONE HONORS EACH PERSON’S ABSOLUTE WORTH AND POTENTIAL AS A HUMAN BEING, RECOGNIZES AND SUPPORTS THE PERSON’S AUTONOMY TO CHOOSE HIS OR HER OWN WAY, SEEKS THROUGH ACCURATE EMPATHY TO UNDERSTAND THE OTHER’S PERSPECTIVE, AND AFFIRMS THE PERSON’S STRENGTHS AND EFFORTS. ” (P. 19)

MOTIVATIONAL INTERVIEWING (MI) • KEY COMPONENTS • COLLABORATION – PARTNERSHIP BETWEEN SOCIAL WORKER AND CLIENT • PARTNERSHIP THAT HONORS THE CLIENT’S EXPERTISE AND PERSPECTIVES; AVOIDS AN AUTHORITARIAN ONE-UP STANCE, INSTEAD COMMUNICATING A PARTNER-LIKE RELATIONSHIP • FOCUS IS ON MOTIVATIONAL STRUGGLES, ISSUES OF CHANGE FOR WHICH A PERSON IS NOT READY OR IS AMBIVALENT

KEY COMPONENTS OF MI • EVOCATION – THE INTERVIEWER’S TONE IS NOT ONE OF IMPARTING THINGS (SUCH AS WISDOM, INSIGHT) BUT RATHER ELICITING, OF FINDING THESE THINGS WITHIN AND DRAWING THEM OUT FROM THE PERSON. • THE SOCIAL WORKER’S TASK IS TO “EVOKE” THE CHANGE • ASSUMPTION IS PEOPLE HAVE WHAT THEY NEED, “TOGETHER WE WILL FIND IT” (STRENGTHS-BASED)

KEY COMPONENTS OF MI • AUTONOMY - AFFIRM THE CLIENT’S RIGHT TO SELFDETERMINATION AND FACILITATE INFORMED CHOICE • RESPONSIBILITY FOR CHANGE IS LEFT UP TO THE CLIENT • OVERALL GOAL IS TO INCREASE INTRINSIC MOTIVATION, SO THAT CHANGE ARISES FROM WITHIN RATHER THAN BEING IMPOSED FROM WITHOUT AND SO THE CHANGE SERVES THE PERSON’S OWN GOALS AND VALUES • IT IS THE CLIENT RATHER THAN THE COUNSELOR WHO PRESENTS THE ARGUMENTS FOR CHANGE (MILLER & ROLLNICK, 2013, P. )

FOUR PROCESSES IN MI (QUESTIONS REGARDING MI PROCESSES, P. 32) Evoking Engagin g Focusin g Plannin g

Core Communications Skills (OARS) Open-ended questions Affirmations (or validation) Reflective listening Summarizati on

CORE COMMUNICATION SKILLS (OARS) • ASKING OPEN QUESTIONS INVITES A PERSON TO REFLECT, EXPLORE, AND ELABORATE • AFFIRMING OF CLIENT’S OWN PERSONAL STRENGTHS, RESOURCES, EFFORTS • REFLECTIVE LISTENING ASSISTS IN DEEPENING UNDERSTANDING OF WHAT THE CLIENT IS SHARING • SUMMARIZING • INFORMING & ADVISING WITH PERMISSION

• STATING WHAT YOU THINK THE CLIENT IS SAYING: • STATE THE PROBLEM AS THE CLIENT SEES IT WITHOUT EMOTIONAL WORDS. REFLECTI VE LISTENING • FOCUS ON THE ISSUE TO PROMOTE DISCUSSION ON THE CLIENT’S FEELINGS AND/OR CIRCUMSTANCES. • DON’T GIVE ADVICE, DON’T DEFEND YOURSELF, DON’T REASSURE. • DON’T MAKE IT RIGHT FOR THE CLIENT. • KEEP THE RESPONSIBILITY ON THE CLIENT.

REFLECTIVE LISTENING POSSIBLE PHRASES WHEN YOU THINK PERCEPTIONS ARE ACCURATE PHRASES WHEN YOU HAVE DIFFICULTY UNDERSTANDING • I SEE THE SITUATION AS… • COULD IT BE… • I WONDER IF… • FROM WHERE YOU STAND… • DOES IT SOUND REASONABLE THAT YOU… • AS I HEAR IT. YOU… • YOU FEEL… • I REALLY HEARING YOU SAYING… • I’M PICKING UP THAT… • YOU THINK… • THIS IS WHAT I THINK I HEAR YOU SAYING… • LET ME SEE IF I UNDERSTAND YOU; YOU… • I’M NOT CERTAIN I UNDERSTAND; YOU’RE FEELING…

ETHICAL VALUES WITH MI • PROFESSIONAL RELATIONSHIPS INVOLVE UNEVEN POWER AND THEREBY INCUR SPECIAL RESPONSIBILITIES. • SOCIAL WORK HAS ITS OWN SET OF ETHICAL STANDARDS FOR PRACTICE, WHICH TENDS TO REFLECT A COMMON SET OF VALUES. • THE NATIONAL RESEARCH COUNCIL IDENTIFIED FOUR BROAD ETHICAL PRINCIPLES:

ETHICAL PRINCIPLES • NON-MALEFICIENCE – “DO NO HARM” • BENEFICENCE – CLINICAL INTERVENTIONS ARE MEANT TO PROVIDE BENEFIT (OFFER EVIDENCE-BASED TREATMENTS) • AUTONOMY – RESPECT FOR HUMAN FREEDOM AND DIGNITY • JUSTICE – FAIRNESS WITH EQUITABLE ACCESS TO THE BENEFITS OF TREATMENT AND PROTECTIONS AGAINST RISK • SW – DIGNITY & WORTH OF THE PERSON; IMPORTANCE OF HUMAN RELATIONSHIPS; COMPETENCE; SOCIAL

STRENGTHS-BASED VALUES • BY SPECIFYING THE PROCESS OF CREATING DISCREPANCY AND ESTABLISHING VIABLE GOALS, MOTIVATIONAL INTERVIEWING OPERATIONALIZES STRENGTHS-BASED VALUES • THE GOAL IS FOR CLIENTS TO TALK THEMSELVES INTO CHANGING, IF IT IS COMPATIBLE WITH THEIR OWN VALUES AND ASPIRATIONS!

MI • SUPPORT SELF-EFFICACY – REFERS TO A PERSON’S BELIEF IN HIS OR HER ABILITY TO CARRY OUT AND SUCCEED WITH A SPECIFIC TASK • A PERSON’S BELIEF IN THE POSSIBILITY OF CHANGE IS AN IMPORTANT MOTIVATOR • THE CLIENT, NOT THE COUNSELOR, IS RESPONSIBLE FOR CHOOSING AND CARRYING OUT CHANGE • THE COUNSELOR’S OWN BELIEF IN THE PERSON’S ABILITY TO CHANGE BECOMES A SELF-FULFILLING PROPHECY

IN THE BEGINNING…ASK PERMISSION • DO YOU MIND IF WE TALK ABOUT YOUR… • WHAT HAVE YOU NOTICED ABOUT YOUR DRINKING? • TELL ME A LITTLE MORE ABOUT YOUR…CONCERNS ABOUT BLACK-OUTS, ETC. • WOULD YOU BE INTERESTED IN LEARNING MORE ABOUT THE HEALTH EFFECTS OF YOUR DRINKING? • MAY I MAKE A SUGGESTION? • WOULD IT BE ALRIGHT IF I TELL YOU ONE CONCERN I HAVE ABOUT THIS PLAN?

MI: STRATEGIES & TACTICS • PRACTITIONERS CAN ELICIT SELF-MOTIVATIONAL STATEMENT IN SEVERAL WAYS: • DIRECT QUESTIONS • “WHAT DO YOU THINK WILL HAPPEN WITH YOUR (HEALTH) IF YOU CONTINUE TO (DO) AS YOU HAVE BEEN DOING? ” • DEVELOP DISCREPANCY – WHAT DO CLIENTS LIKE OR DON’T LIKE ABOUT THEIR CURRENT BEHAVIOR • CLIENT-CENTERED INTERVIEW STRATEGIES LIKE REFLECTIVE LISTENING TO ENCOURAGE THEM TO EXPAND ON THEIR CONCERNS BY TAKING A “WHAT ELSE” OR “TELL ME MORE” APPROACH TO HELP THEM EXAMINE AND CLARIFY AREAS OF AMBIVALENT CONFLICT

SIMPLE REFLECTIONS CASE SAMPLE • CLIENT: “ALL MY FRIENDS DRINK AND I FEEL LIKE THEY WOULD LOOK AT ME DIFFERENTLY IF I QUIT…LIKE I WOULDN’T BELONG ANYMORE. ” • INSTEAD OF: “WOULD YOU RATHER DIE FROM LIVER DISEASE? ” • TRY: “DRINKING HELPS YOU FIT IN. ”

SIMPLE REFLECTIONS CASE SAMPLE • CLIENT: “IT’S IMPOSSIBLE TO GET THROUGH THE DAY IF I CAN’T LOOK FORWARD TO A LITTLE BREAK AND A BEER. I HAVE 3 KIDS AND A FULL-TIME JOB. I’M EXHAUSTED!” • INSTEAD OF: “LOOK, IF YOU DON’T CARE ABOUT YOURSELF, THINK OF THE KIDS. IT IS REALLY IMPORTANT FOR YOU TO QUIT DRINKING BEFORE SOMETHING REALLY SERIOUS HAPPENS. ” • TRY: “YOU HAVE A LOT OF RESPONSIBILITIES RIGHT NOW. ”

SIMPLE REFLECTIONS CASE STUDY • SERENA IS A FEISTY 17 Y/O WHOSE MOTHER INSISTED SHE COME TO SEE YOU AFTER BEING CAUGHT SMOKING MARIJUANA IN A CAR WITH A FEW OF HER HIGH SCHOOL FRIENDS. • SERENA: “WHO ARE YOU TO BE GIVING ME ADVICE? WHAT DO YOU KNOW ABOUT HAVING A GOOD TIME WITH YOUR FRIENDS? YOU’VE PROBABLY SPENT ALL YOUR TIME STUDYING AND NEVER EVEN SMOKED A JOINT!” • SW: “IT’S HARD TO IMAGINE HOW I COULD POSSIBLY UNDERSTAND. ”