Client-Centered Counseling

Client-Centered Counseling Using MI

Why are they important? Skills required to motivate clients to change behaviors vary by which stage they are at when they receive education.

Moving from pre-contemplation to contemplation requires awareness of the problem and potential consequences.

Moving from contemplation to determination requires identifying current behaviors that relate to the problem, understanding of desired behaviors, acknowledging the discrepancy between values and behaviors and developing a belief in one’s own ability to make changes.

Moving from determination to action requires identification of personal strengths, identification of potential barriers, vocalization of intent to change and development of plan for change.

Moving from action to maintenance requires sustained behavior change efforts, problem solving skills, frequent follow up and identification of a support system.

Characteristics of Highly Effective, Short-Term Counseling

Feedback o Provide feedback on any assessments done during visit o Provide feedback on changes made (and attempts) since last visit o Ask client to reflect on changes (or attempts) that have occurred

Responsibility o Emphasize client’s role in behavior change o “Personalize” ideas to the client’s situation

Advice o State clear outcomes and behavioral targets to assist with goal setting o Allow client to set intermediate goals to try to meet the target goal

Menu o Provide a variety of ideas for change to clients who cannot come up with personal goals o Continue to emphasize personal responsibility within the menu of choices

Empathy

1 o Elicit information from client to assist with goal setting o Reassure client that change is hard, but can be done

Self-efficacy o Promote client’s ability to identify and make changes o Praise all efforts no matter how successful – change is hard and just attempting to make a change is a positive step!

What is motivational interviewing?

A variety of strategies that elicit “change talk” and enhance motivation to change behavior - not a single strategy, but a “toolbox” of skills that can be used in client-centered counseling

Draws on values and goals of participants – Current, past and future behavior is linked to goals and values – Values and goals are assessed, not assumed

Ambivalence is acknowledged as “normal” and used to explore strategies for change – Ambivalence is opportunity, not barrier, to change

Uses open-ended questions to gather information and build rapport

Reflective listening is THE fundamental skill required

Builds and explores discrepancy between behavior and personal goals or values, as this is what leads to change - a way to help people “connect the dots” - helps clients see that what they are doing is not the best path to reaching a goal

Resistance signals the need to change current way of responding to a participant – #1 cause of resistance is when client at one stage of change but counselor at higher stage of change

The participant, not educator, is responsible for choosing to make specific changes

Minimizes guilt by acknowledging difficulty of changing and your commitment to assist client

Open ended questions

Open VS Closed

2 Tell me about how you…. Did You..?

Let’s talk about how often.. Will You..?

I’d like to hear why you think…. Can You..?

Help me understand….. Is it...?

Tell me about what happened when…

What else could you do when…

Examples of open ended questions Tell me why… …you think you need to change your medication. …you are surprised that your child is overweight.

Tell me about… …mealtime struggles to get your son to eat. …why you are hesitant to have your child vaccinated.

Tell me how you have... …tried to control your asthma. …tried to lose weight in the past.

I’m interesting in hearing why you… …think you have gained 16 poiunds over the past year. …are concerned that your daughter might have an eating disorder.

I’d like to hear your thoughts about… …how to improve your eating habits. …keeping firearms out of the house.

Explain… …what you might say the next time your friends encourage you to drink. …what you might do the next time your child refuses to eat his meal.

Give me some examples of… …ways that you have tried to control your asthma. …how you have tried to quit smoking.

Reflective Listening Follows an open-ended question

3 Makes no assumptions about the participant’s meaning – only reflects back what you heard the participant say to elicit more input

Encourages personal exploration

Conveys empathy to client and builds rapport

Is a statement, not a question.

Simplest way is to restate what client said – “You are unsure if you could lose weight”.

Deeper reflections try to draw out emotions or direct client toward positive change statements – “Fast food is just so good that it's too hard for you to resist, even though you are concerned about your weight”.

Examples of reflective statements

It sounds like you… …are really frustrated with your daughter’s picky eating. …have already tried to stop smoking.

It’s difficult/easy for you to… …imagine asking your boyfriend to use a condom. …resist the urge to drink when you are at a party.

You realize that… …your are spending too much time playing videogames and not enough time on homework. …your child’s weight can affect other areas of his health.

You’re having trouble/success with… …getting your children to try new foods. …remembering to carry your inhaler with you.

You understand that… …your son’s weight affects how he feels about himself and how others see him. … your parents are concerned about your weight loss and social isolation.

You feel that… …vaccines are more dangerous than protective. …you don’t have to worry about drinking if someone else is driving.

4 Prioritizing issues in reflective listening

When several issues or barriers are brought up, you will need to focus on one priority area

If reflection on a specific area of concern isn’t fruitful, try reflecting on another area

“Fishing expeditions” are one way to hit upon the most important issue of your client

Reflection #1: “You see a connection between breastfeeding and the health of your child”

Reflection #2 “You are scared that you might not be able to breastfeed or that it might be difficult”

Reflection #3 “Your are concerned that if you breastfeed you won’t be able to ask anyone else to watch your child or that it will be harder to find time for yourself”

Advanced reflective listening technique Shifting Focus Client: “I suppose you are going to tell me that in order to lose weight I can’t eat anything I like and that I have to get up at 6 a.m. to go running everyday.”

Counselor: “To be honest, it’s not up to me to decide what you will or won’t do to lose weight. My job is to help you figure out what YOU want to do and to help you succeed. What is it that you think you would like to do?”

Reframing Turning clients’ statements into more positive ideas Client: “I’ve been on so many diets and bought a half dozen exercise machines, but nothing has worked. I just end up gaining even more weight.”

Counselor: “The fact that you have tried diets and exercise in the past tells me that losing weight must be important to you. You are really motivated to make some changes.”

Use a double sided reflection to summarize session and ask about next step.

5 “You have mentioned some reasons why you don’t think you can eat more fruits and vegetables, such as cost and not knowing how to cook them so your family will eat them. On the other hand, you also talked about how eating more fruits and veggies might help you lose weight. Does that sound right?”

“In thinking about this, is there anything that I can do to help you?” Or,” What do you think is the next step?”

Using values to motivate clients

Values For Your Child Values for You Values for Your Family Be healthy Good Parent Pleasant mealtimes Be strong/athletic Responsible Healthy habits Have many friends Productive Getting along Fit in with peers Good Spouse Spending time together Get good grades Respected Respectful behavior Not being teased Feel good about self Following rules Not feeling left out Healthy Trust Fulfill her/his potential Fit in social group Have high self-esteem Feel good about body

Using and Interest & Confidence Ruler to evaluate Readiness to change

Interest On a scale of 0 to 10, with 10 being very interested, how interested are you to ...... (eat fast food less often, exercise with your child, watch less TV)?

0 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very

Confidence On a scale of 0 to 10, with 10 being very confident, assuming you decided to ...... (eat fast food less often, exercise with your child, watch less TV) how confident are you that you could succeed ?

0 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very

6 Providing Information

Using a Menu of ideas: Here are some things that have worked for other people – Idea 1 – Idea 2 – Idea 3 Which of these, if any, do you think might work for you? Where would you like to go from here?