Finding Ambivalence & 10 Other Things About MI

2/12/2019

Presented by Richard Choate, MA, CADC II

February 13, 2019

Samson Teklemariam, MA, LPC, CPTM

Director of Training and Professional Development NAADAC, the Association for Addiction Professionals www.naadac.org [email protected]

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Produced By NAADAC, the Association for Addiction Professionals www.naadac.org/webinars

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www.naadac.org/finding-ambivalence-MI-webinar

CE Certificate Cost to Watch: Free To obtain a CE Certificate for the time you spent watching this CE Hours Available: webinar: 1.5 CEs 1. Watch and listen to this entire webinar. CE Certificate for 2. Pass the online CE quiz, which is posted at NAADAC Members: Free www.naadac.org/finding-ambivalence-MI-webinar

CE Certificate for 3. If applicable, submit payment for CE certificate or join Non-members: NAADAC. $20 4. A CE certificate will be emailed to you within 21 days of submitting the quiz.

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Using GoToWebinar – (Live Participants Only)

. Control Panel

. Asking Questions

. Audio (phone preferred)

. Polling Questions

Webinar Presenter

Richard Choate 952-261-2604 FAX: 541-241-8074 [email protected]

Juniper Behavior Consulting

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Webinar Learning Objectives

132

The participant will be The participant will be The participant will be able able to apply the theory able to demonstrate to synthesize motivational and methods of specific motivational interviewing techniques with motivational interviewing skills to other evidence-based interviewing to the respond to resistance approaches to improve therapeutic relationship and overcome patient outcomes with clients with co- obstacles to recovery occurring disorders

HOW ARE THEY CONNECTED?

Motivational Interviewing is not the Stages of Change

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References

Prochaska, James O., Norcross, John, & DiClemente, Carlo, (1994). Changing for Good: A Revolutionary Six- Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward, New York, Avon Books, Inc. Miller, William R., & Rollnick, Stephen, (2013). Motivational Interviewing, Third Edition: Helping People Change, New York, The Guilford Press.

The Stages Of Change Things do not change: We change. -- Henry David Thoreau, Walden

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Transtheoretical Change Process How People Change

PRECONTEMPLATION

Your Guide to the Stages of Change

PRECONTEMPLATION

I have no intention to change the behavior in the next six months

Length: Unknown

INFORMATION FEELINGS SOCIAL VALUING

Current Behavior Cons Pros

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Transtheoretical Change Process How People Change

PRECONTEMPLATION

CONTEMPLATION

Your Guide to the Stages of Change

CONTEMPLATION I am seriously considering changing the behavior in the next six months.

Length: Two weeks to several years

SELF-VALUING

Current Behavior Cons Pros

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Polling Question #1: When is the best time to use a Decisional Balance tool and explore pro’s and con’s of someone’s current behavior?

A. Precontemplation B. Contemplation

Transtheoretical Change Process How People Change

PRECONTEMPLATION

CONTEMPLATION

PREPARATION/PLANNING

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Your Guide to the Stages of Change

PREPARATION I am intending to change in the next month, and I have taken action unsuccessfully in the past year or have made some small behavioral change Length: Two hours to three months, but can last up to six months

COMMITMENT

Current Behavior Cons Pros

Transtheoretical Change Process How People Change

PRECONTEMPLATION

ACTION CONTEMPLATION

PREPARATION/PLANNING

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Your Guide to the Stages of Change

ACTION I have successfully altered my behavior, from one day to six months, in a way that places me at low risk for problems Length: From one day to six months SUBSTITUTE ALTERNATIVES OPEN UP TO OTHERS AVOID & COUNTER EXPECTED HIGH-RISK SITUATIONS REWARD YOURSELF New Behavior Cons Pros

Transtheoretical Change Process How People Change

MAINTENANCE PRECONTEMPLATION

ACTION CONTEMPLATION

PREPARATION/PLANNING

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Your Guide to the Stages of Change

MAINTENANCE I am remaining free of the behavior and/or I have been engaging in a new (incompatible) behavior for more than six months. Length: At least six months but frequently lasting years and even a lifetime SUBSTITUTE ALTERNATIVES (Still) AVOID & COUNTER UNEXPECTED HIGH-RISK SITUATIONS (Again) New Behavior Cons Pros

Transtheoretical Change Process How People Change

MAINTENANCE PRECONTEMPLATION

ACTION CONTEMPLATION

PREPARATION/PLANNING

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Transtheoretical Change Process How People Change Also identified 10 specific processes for change: • Experiential Processes • Behavioral Processes

Transtheoretical Change Process

Experiential Change Processes • Consciousness Raising • Dramatic Relief • Self Reevaluation • Environmental Reevaluation • Social Liberation

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Transtheoretical Change Process

Behavioral Change Processes • Stimulus Control • Counter Conditioning • Reinforcement Management • Self-Liberation • Helping Relationships

Transtheoretical Change Process Stage of change From pre‐ From contemplation From preparation to From action to Staying in contemplation to to preparation action maintenance maintenance contemplation

Most relevant change Consciousness processes raising Dramatic relief Self‐reevaluation Self‐reevaluation Environmental Environmental reevaluation reevaluation Decisional balance Decisional balance Self‐efficacy Self‐efficacy Self‐efficacy Self‐efficacy Self‐liberation Self‐liberation Self‐liberation Stimulus control Stimulus control Stimulus control Counter‐ Counter‐ Counter conditioning conditioning conditioning Reinforcement Reinforcement management management Helping Helping Helping Social relationships relationships relationships liberation Social liberation

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Polling Question #2: Which stage of change are most of your clients in now?

A. Precontemplation B. Contemplation C. Preparation/Planning D. Action E. Maintenance

Ambivalence and the Righting Reflex

I WANT TO AND I DON’T WANT TO

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Conflict and Ambivalence

• Decisional Balance • Paradoxical Responses • Readiness for What?

Decisional Balance A Decisional Balance Sheet

Continue to drink as before Abstain from alcohol

Benefits Costs Benefits Costs

Helps me relax Could lose my family Less family conflict I enjoy getting high

Enjoy drinking with friends Bad example for my children More time with my children What to do about my friends

Damaging my health Feel better physically How to deal with stress

Spending too much money Helps with money problems

Impairing my mental ability

Might lose my job

Wasting my time/life

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Paradoxical Responses

Increasing negative consequences as a deterrent? Psychological reactance An increase in the rate and attractiveness of a “problem” behavior if a person perceives that his or her personal freedom is being infringed or challenged. Secondary effects • Loss of a marriage – deprived of only social support to help deter unhealthy behavior = ever greater excess • If other sources of positive reinforcement are blocked, the person persists in the one remaining reward.

Readiness for What?

Why isn’t this person motivated? For what is this person motivated? Unwise to assume the cost and benefits of another person’s situation. Stomach problems Fines and imprisonment Highly valued to some maybe of little importance to others.

People are always motivated for something.

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Sources of Motivation

Intrinsic – behavior is motivated by personal desire or sense of need – intrinsic motivation may develop more slowly, but lead to greater persistence Extrinsic – behavior is motivated by situational reinforcement – extrinsic motivation may develop more quickly, but may fade quickly as well

Motivational Interviewing What people really need is a good listening to. -- Mary Lou Casey

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Four Fundamental Principles

Express Empathy • Acceptance facilitates change • Skillful reflective listening is fundamental • Reflect at least twice for every question • Ambivalence is normal (Transtheoretical Model of Change) Develop Discrepancy • Perceived consequences matter • Consequences that conflict with important goals favor a change • The client should present the arguments for change • Labeling is unnecessary

Four Fundamental Principles

Roll with Resistance • Avoid arguing for change • Perceptions can be shifted • New perspectives are invited but not imposed • The client is a valuable resource in finding solutions to problems Support Self-Efficacy • Belief in the possibility of change is an important motivator • The client is responsible for choosing and carrying out personal change • There is hope in the range of alternative approaches available • Therapist hope is a self-fulfilling prophecy

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The Spirit of Motivational Interviewing

The Continuum of Styles

Directing Guiding Following

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Some Verbs Associated with Each Communication Style

Directing Style Guiding Style Following style • Administer • Accompany • Allow • Authorize •Arouse • Attend • Command • Assist • Be responsive • Conduct • Awaken •Be with •Decide • Collaborate • Comprehend • Determine • Elicit • Go along with • Govern • Encourage •Grasp • Lead • Enlighten • Have faith in • Manage •Inspire •Listen •Order •Kindle • Observe • Prescribe • Lay before •Permit •Preside • Look after • Shadow •Rule • Motivate • Stay with • Steer •Offer • Stick to •Run • Point •Take in • Take charge •Show • Take an interest in • Take command • Support • Understand •Tell • Take along • Value

Spirit

Partnership Acceptance Absolute Truth Accurate Empathy Autonomy Support Affirmation Compassion Evocation Some Principles of Person-Centered Care

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Four Processes in Motivational Interviewing

Engaging Focusing Evoking Planning

Three Definitions of MI

Layperson’s definition Practitioner’s definition Technical definition

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Engaging

The Relational Foundation

Early Traps That Promote Disengagement

The Assessment Trap The Expert Trap The Premature Focus Trap The Labeling Trap The Blaming Trap The Chat Trap

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Factors that influence engagement

Desires or Goals Importance Positivity Expectations Hope

Listening

Understanding the Person’s Dilemma

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Thomas Gordon’s 12 Roadblocks

1. Ordering, directing or commanding 10. Reassuring, sympathizing, or 2. Warning, cautioning or threatening consoling 3. Giving advice, making suggestions or 11. Questioning or probing providing solutions 12. Withdrawing, distracting, humoring or 4. Persuading with logic, arguing, or changing the subject. lecturing 5. Telling people what they should do; moralizing 6. Disagreeing, judging, criticizing, or blaming 7. Agreeing, approving or praising 8. Shaming, ridiculing, or labeling 9. Interpreting or analyzing

Gordon’s Model of Listening

* Model from Thomas Gordon (Parent Effectiveness Training)

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Gordon’s Model of Listening

Communication can go wrong because: • The speaker does not say exactly what is meant • The listener does not hear the words correctly • The listener gives a different interpretation to what the words mean

Core Interviewing Skills (OARS)

Asking Open Questions Affirming Reflecting Summarizing

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Exploring Values and Goals

An Open-Ended Values Interview Structured Values Exploration Integrity Exploring Discrepancy

Focusing

The Strategic Direction

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Focusing in Motivational Interviewing

Agenda Three Sources of Focus The Client The Setting Clinical Expertise Three Styles of Focusing Directing Following Guiding

Counselor Issues That Can Arise in Focusing

Tolerating uncertainty Sharing control Searching for Strengths and Openings for Change Clear Direction Choices in Direction

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Agenda Mapping

Choosing a Change Topic Among Many Changing Direction Getting Unstuck Raising a Difficult Topic Fitting in an Assessment Clarifying your roles in tough circumstances

Some Ethical Guidelines for the Practice of Motivational Interviewing 1. The use of MI component processes is inappropriate when available scientific evidence indicates that doing so would be ineffective or harmful for the client 2. When you sense ethical discomfort or notice discord in your working relationship, clarify the person’s aspirations and your own. 3. When your opinion as to what is in the person’s best interest differs from what the person wants, reconsider and negotiate your agenda, making clear your own concerns and aspirations for the person. 4. The greater your personal investment in a particular client outcome, the more inappropriate it is to practice strategic evoking. It is clearly inappropriate when your personal investment may be dissonant with the client’s best interest. 5. When coercive power is combined with a personal investment in the person’s behavior and outcomes, the use of strategic evoking is inappropriate.

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Three Special Topics

Offering Advice • Engage first • Use sparingly • Ask permission • Emphasize personal choice • Offer a menu of options Self-Disclosure • Is it true? • Could it be harmful • Is there a clear reason why it would be helpful? Routine Assessment and Feedback • Practicalities of initial assessment • Sharing the outcome of assessment

Types of Ambivalence

Approach/Approach Avoidance/Avoidance Approach/Avoidance Double Approach/Avoidance

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Polling Question #3: Which of the following statements do you think is most true when it comes to resistance?

A. Resistance is 100% about the client’s behavior and attitude towards treatment. B. Resistance means the helper has failed. C. Resistance is about the helping relationship. D. Resistance means the helper should try a different approach.

Change and Resistance (Discord)

Opposite Sides of a Coin

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Consonance and Dissonance

• Dancing vs. Wrestling • It takes at least two people to not cooperate. • Client resistance behavior is a signal of dissonance in the counseling relationship.

Client Resistance Behavior

• Arguing – Minimizing – Challenging – Pessimism – Discounting – Reluctance – Hostility – Unwillingness to • Interrupting change – Talking over • Ignoring – Cutting off – Inattention • Negating – Nonanswer –Blaming – No response – Disagreeing – Side tracking –Excusing – Claiming impunity

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Counselor’s Role in Resistance

• Arguing for change • Assuming the expert role • Criticizing, shaming, or blaming • Labeling • Being in a hurry. • Claiming preeminence.

The Spirit of Motivational Interviewing

Fundamental approach of motivational Mirror-image opposite approach to counseling interviewing Collaboration. Counseling involves a partnership Confrontation. Counseling involves overriding the that honors the client’s expertise and client’s impaired perspectives by imposing perspectives. The counselor provides an awareness and acceptance of “reality” that the client atmosphere that is conducive rather than coercive cannot see or will not admit. to change.

Evocation. The resources and motivation for Education. The client is presumed to lack key change are presumed to reside within the client. knowledge, insight, and/or skills that are necessary Intrinsic motivation for change is enhanced by for change to occur. The counselor seeks to address drawing on the client’s own perceptions, goals, these deficits by providing the requisite and values. enlightenment.

Autonomy. The counselor affirms the client’s right Authority. The counselor tells the client what he or and capacity for self-direction and facilitates she must do. informed choice.

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Importance and Confidence

“How important would you say it is for you to ______? On a scale from 0 to 10, where 0 is not at all important and 10 is extremely important, where would you say you are?

012345678910

Not at all Extremely important important

“And how confident would you say you are, that if you decided to ______, you could do it? On the same scale from 0 to 10, where 0 is not at all confident and 10 is extremely confident, where would you say you are?”

Importance and Confidence

Group A: Low importance, low Group B: Low importance, high confidence confidence • These people neither see change • These people are confident that as important nor believe that they they could make the change if they could succeed in making such a thought it were important to do so change if they tried. but are not persuaded that they want to change.

Group C: High importance, Group D: High importance, low confidence high confidence • Here the problem is not in • These people see it is important to willingness to change, for these change and also believe that they people express desire to do so. could succeed. The problem is low confidence that they could succeed if they tried.

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Early Traps to Avoid

• The Assessment Trap (Q & A) • Trap of Taking Sides • The Expert Trap • The Labeling Trap • The Premature-Focus Trap • The Blaming Trap • The Chat Trap

Change Talk and Sustain Talk

Two sides of the same coin

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Change Talk

Phase I. Building Motivation for Change

Desire – I want to change Ability – I can change Reasons – It would help me if I changed Need – I need to change

Recapitulation Summary

Key Question: What is the next Step?

Ready to go forward Not ready to go forward I might change I’m not sure about changing

Change Talk

Key Question: What is the next Step?

Ready to go forward Not ready to go forward I might change I’m not sure about changing

Phase II. Strengthening Commitment

Commitment – I will change Taking Steps – I attempted change

CHANGE

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Change Talk

Preparatory •Desire • Ability • Reasons • Need Mobilizing • Commitment • Activating • Taking Steps

Sustain Talk

Desire “I just love smoking and how it makes me feel.” Ability “I’ve tried and I don’t think I can quit smoking.” Reason “Smoking helps me to relax” Need ”I have to smoke; I can’t get through the day without it.” Commitment “I’m going to keep on smoking.” Activation ”I’m prepared to accept the risks of smoking.” Taking Steps ”I went back to smoking this week.”

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Motivational Interviewing: What it’s not Counselor-centered or Non-directive Counselor-centered = What the counselor thinks, sees, hopes for, plans and influences the client to do are what is important Danger is tug of war Non-directive = Counselor follows client, does not try to influence Danger is going around in circles, lack of progress

Motivational Interviewing: What it is Client-centered AND Directive Client-centered = What the client thinks, sees, hopes for, plans and does are what is important Directive = Counselor guides conversation toward particular topics, explores client’s point of view and then increasingly focuses on certain aspects of the point of view – self- motivational statements or change talk

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10 Clarifications About Motivational Interviewing

#1: MI is not about the content

• Relational and Technical Components • Evidence • Happens with the client not to the client

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#2: Assessment of the client is not needed in order to use MI successfully. • MI focuses on an evoking process • Bring forward what they already know about what they would change • Assessment implies a tailored treatment plan • Client already know how and why to change – address ambivalence • Needs help resolving ambivalence about whether to change

#3: Giving information to the client may or may not be good practice in MI

• Knowledge rarely helps people change or address their ambivalence • Objective feedback may be useful to create ambivalence. • Does giving the information create discord?

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#4: MI is not the right thing for every client

• MI is most useful for clients who are ambivalent • Clinicians need a wide variety of skills • Clinicians want to keep the “spirit”

#5: MI is an empirically supported treatment but its efficacy is highly variable

• In some Randomized Control Trials (RCT) it works, in others it does not. • Active ingredients are not known • Better quality of the interventionist

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#6: MI can be learned, but not by everyone

• Four RCT’s directly address this • These covered more than 600 therapists • Outcomes varied by audio recordings • Rule of thirds 1/3 – get it easily 1/3 – get if if they work at it 1/3 – never get it

#7: Supervising MI requires direct observation of clinicians

• What they say happens has a very low correlation to what actually happens • Clinicians are not lying. What they don’t notice is often what is most important • Have to observe to help them learn

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#8: Client language during sessions might explain why MI works

• Change talk is client language. That emerges spontaneously in interpersonal interaction • Related to better outcomes • Hypothesis is that ambivalent clients decide they intend to change as they hear themselves voice arguments in favor of it • What does this mean about sustain talk?

#9: Clinicians have a lot to do with what clients say during interview

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#10: Sometimes the outcome of MI is that the client realizes that they don’t need you to change • MI emphasizes client autonomy • This means that clinicians must be willing to accept that clients may stop coming • Influence is earned and often depends on client characteristics

Thank You!

Richard Choate 952-261-2604 FAX: 541-241-8074 [email protected]

YourJuniper Behavior Consulting

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www.naadac.org/finding-ambivalence-MI-webinar

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