2/12/2019 Finding Ambivalence & 10 Other Things About MI Presented by Richard Choate, MA, CADC II February 13, 2019 1 Samson Teklemariam, MA, LPC, CPTM Director of Training and Professional Development NAADAC, the Association for Addiction Professionals www.naadac.org [email protected] 2 1 2/12/2019 Produced By NAADAC, the Association for Addiction Professionals www.naadac.org/webinars 3 www.naadac.org/webinars 4 2 2/12/2019 www.naadac.org/finding-ambivalence-MI-webinar 5 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. 6 3 2/12/2019 Using GoToWebinar – (Live Participants Only) . Control Panel . Asking Questions . Audio (phone preferred) . Polling Questions 7 Webinar Presenter Richard Choate 952-261-2604 FAX: 541-241-8074 [email protected] Juniper Behavior Consulting 8 4 2/12/2019 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 9 HOW ARE THEY CONNECTED? Motivational Interviewing is not the Stages of Change 10 5 2/12/2019 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. 11 The Stages Of Change Things do not change: We change. -- Henry David Thoreau, Walden 12 6 2/12/2019 Transtheoretical Change Process How People Change PRECONTEMPLATION 13 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 14 7 2/12/2019 Transtheoretical Change Process How People Change PRECONTEMPLATION CONTEMPLATION 15 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 16 8 2/12/2019 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 17 Transtheoretical Change Process How People Change PRECONTEMPLATION CONTEMPLATION PREPARATION/PLANNING 18 9 2/12/2019 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 19 Transtheoretical Change Process How People Change PRECONTEMPLATION ACTION CONTEMPLATION PREPARATION/PLANNING 20 10 2/12/2019 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 21 Transtheoretical Change Process How People Change MAINTENANCE PRECONTEMPLATION ACTION CONTEMPLATION PREPARATION/PLANNING 22 11 2/12/2019 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 23 Transtheoretical Change Process How People Change MAINTENANCE PRECONTEMPLATION ACTION CONTEMPLATION PREPARATION/PLANNING 24 12 2/12/2019 Transtheoretical Change Process How People Change Also identified 10 specific processes for change: • Experiential Processes • Behavioral Processes 25 Transtheoretical Change Process Experiential Change Processes • Consciousness Raising • Dramatic Relief • Self Reevaluation • Environmental Reevaluation • Social Liberation 26 13 2/12/2019 Transtheoretical Change Process Behavioral Change Processes • Stimulus Control • Counter Conditioning • Reinforcement Management • Self-Liberation • Helping Relationships 27 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 28 14 2/12/2019 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 29 Ambivalence and the Righting Reflex I WANT TO AND I DON’T WANT TO 30 15 2/12/2019 Conflict and Ambivalence • Decisional Balance • Paradoxical Responses • Readiness for What? 31 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 32 16 2/12/2019 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. 33 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. 34 17 2/12/2019 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 35 Motivational Interviewing What people really need is a good listening to. -- Mary Lou Casey 36 18 2/12/2019 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 37 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 38 19 2/12/2019 The Spirit of Motivational Interviewing 39 The Continuum of Styles Directing Guiding Following 40 20 2/12/2019 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