Introduction to Stages of Change and Motivational Interviewing

1. Introduction to Stages of Change and Motivational Interviewing Charlotte Chapman, LPC May 6, 2009

2. Goals of Training • Increase knowledge of Stages of Change and discuss the change process. • Increase knowledge of Motivational Interviewing and the four principles. • Begin practice of Phase I skills in Motivational Interviewing.

3. Stages of Change • Write down a change in your own life you are thinking about making • How long have you been thinking about this change? How many attempts to make this change? Who or what gets in your way? • Reasons we make a change • Reasons we don’t make a change

4. Stages of Change Model Permanent Exit Pre-Contemplation Prochaska & DiClemente, 1992

5. Precontemplation • Entry point to the process of change • Person is not yet considering the possibility of change • Does not see themselves as having a problem although others might identify the problem • Often seen as resistant or “in denial”

6. Contemplation • Recognizes that there is some reason for concern • Characterized by ambivalence – both considers and rejects change • Seesaws between reasons to change and reasons to stay the same • May remain in this stage for a long time

7. Preparation • Characterized by accepting the need to change; to do something about the problem • May involve taking preliminary, tentative steps to change • At this point, either enters into action or slips back into contemplation

8. Action • The person is engaging in particular actions to bring about change (e.g., treatment). • The goal is to produce change in the problem areas.

9. Maintenance • Maintaining the changed behavior; avoiding the problem behavior. • The challenge is to sustain the change accomplished by previous action and to prevent relapse.

10. Relapse • A reversion back to problem behavior. • Normal, expected occurrences as a person seeks to change any long-standing pattern. • It MAY happen but not presented as something that DOES happen

11. Rulers • Group exercise: Importance and Confidence • Discuss your experience • One way of understanding where someone is with their change process • One way of eliciting change talk • Why would this be effective with clients? Not effective?

12. Benefits of Using Motivational Interviewing to Help Clients Change • Inspiring motivation to change • Preparing clients to enter a program • Engaging and retaining clients in a program • Increasing participation and involvement • Improving outcomes • Encouraging a rapid return for services if problems occur

13. Motivational Interviewing • A client-centered, goal oriented, collaborative process to help clients discuss and resolve ambivalence about change

14. Motivational Interviewing • Phase I Purpose: Build Motivation for Change • Opening Strategies • Decrease Resistance • Evoke Change Talk • Respond to Change Talk

15. Motivational Interviewing • Phase II Purpose: Strengthening Commitment to Change • Grand Summary • Ask Key Questions • Provide Information • Change Plan • Close the Deal

16. Four Principles of MI • Expressing Empathy • Developing Discrepancies • Rolling with Resistance • Supporting Self-efficacy

17. Four Principles: Empathy • “being empathetic is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto…it means to sense the hurt or the pleasure of another as he senses it…..” (Rogers)

18. Different Responses to Distress • Apathy • Antipathy • Sympathy • Empathy

19. Empathy • We need the skill and ability to experience empathy as well as the skill and ability to convey empathy to another • What gets in our way?

20. Empathy • Saying more than the clients says but not more than the client means • Counselor as expert says more than the client means: explaining the client rather than understanding the client (This will get resistant response) • Reflections are the best approach in demonstrating empathy

21. Four Principles: Develop Discrepancy • “It is discrepancy that underlies the perceived importance of change” (p. 22) • Discrepancy between how things are ( or how I am) and how I want them to be; the clients meaning/own value system about this is what is important in developing discrepancy • Open questions and complex reflections help develop discrepancy

22. Developing Discrepancy Client: “I don’t have a problem and I don’t need this program. I’m only doing it because my social services worker says they will take my children away if I don’t do something.” Counselor: “Even though you believe you don’t have a problem you are willing to do whatever it takes as a mother to keep your family together”

23. Four Principles: Roll with Resistance • Counselor accepts that ambivalence about change is normal, especially when the client perceives that outside forces are demanding the change • Explore the clients perception about this without arguing, advising, etc. • We will review specific strategies for dealing with resistance

24. Four Principles: Support Self-Efficacy • It is the client’s choice whether to change or not • Facilitate ways in which client feels empowered about this process • Facilitate confidence about making changes

25. Coding for Principles

26. Motivational Interviewing • Skills are similar to other approaches • Differences are the intention for using these skills and the four principles • The spirit of Motivational Interviewing is what differentiates this from other approaches however it blends well with other approaches

27. Quote from a student • “Often people come to us without a spark. They have lost creativity and they have really been beaten down either by others or themselves. Either way the end result is the same. Whether it be acceptance of their disability, too many No’s in trying to find a job, or just having a hard life, the MI spirit offers a glimpse of light to them and they can begin to recognize things on their own – and see the spark again.”

28. MI “Micro” Skills (OARS) • Open-ended questions • Affirmation • Reflective listening • Summarizing

29. Use Open-Ended Questions Closed-Ended “Did you come here because of the court?” Open-Ended “What led to your coming to treatment?”

30. Open Ended Questions • Response is more than one word or yes/no • What, How, Tell me • Respond to answer with a reflection before asking another question

31. Affirmations • Selective, non-judgmental reflections of clients’ strengths, resources, personal achievements • Aimed at: • Supporting client’s involvement in change • Acknowledging attempts at change • Client –centered not counselor centered

32. Affirmation Examples “You have courage to face these difficult problems” “This is hard work you’re doing” “You really care a lot about your family” “Your anger is understandable”

33. Practicing Affirmations Write down 3-4 affirmations for the following youth statement: “I'm sick of this, everything just keeps getting messed up. I do good for a week and then I have a fight with my mom and I just need to get high. I go to that program, I'm learning stuff but then something happens and I wind up using. My P.O. doesn't like me, I can't do anything right. My mom and step-dad are always on my case. I don't know what you all want from me. I'm just trying to make it until graduation and I can get out of this place.”

34. Reflective Listening • Listening not only to what the client says, but also for what the client means • Checking out assumptions • Creating an environment of unconditional positive regard and acceptance • Avoiding judging, criticizing or blaming • The client and counselor do not have to agree • Be aware of intonation

35. Reflective Listening Level One: Repeat Level Two: Rephrase Level Three: Paraphrase • Reflect feelings • Summary • Metaphors, similes • Continue the sentence/paragraph

36. Reflective Listening Practice • Dyads • Speaker and Listener: Speaker talks for 5 minutes: challenges of my work • Listener uses REFLECTIONS only in response • Switch • Group discussion

37. Reflective Listening with Affirmations • Dyads • Speaker and Listener: Speaker talks for 5 minutes about successes in my work • Listener uses reflections and affirmations in response • Switch • Debrief

38. Summarize • Reinforce what the client has been saying • Demonstrate your attention to what the client has been saying • Often provoke additional change talk • Ask for clients response to your summary • 3 types of summaries • Collecting summaries • A brief summary, “what else?” • Linking summaries • Intended to help the client see connections • Transitional summaries • Marks & announces a shift from one focus to another

39. Summarize Practice • Dyads: Speaker and listener • Speaker talks about something you are thinking about changing for 3 minutes • Listener’s task is to listen without speaking until time is called. Then give as exact a summary as possible. • Change roles and repeat

40. Summarize Practice 2 • Same dyads; Speaker and listener • Speaker talks about same issue for 3 minutes. Listener does not speak until time is called. Give a summary which now includes underlying meaning, values, and feelings in what you have heard. • Change roles and repeat • Debrief as large group

41. Quote from a student • “With MI, I am learning for the first time how to help someone change without lecturing or shaming them”

42. Resources • www.motivationalinterview.org • Miller and Rollnick (2002) Motivational Interviewing, 2nd edition • Wagner and McMahon (2004) Motivational Interviewing and Rehabilitation Counseling Practice Rehabilitation Counseling Bulletin, 47, 3, 152-161. • Charlotte Chapman charlotte@chapmantraining.com • www.chapmantraining.com