Motivational Interviewing (MI) With Clients Resistant to Change Mary T Motivational Interviewing (MI) With Clients Resistant to Change Mary T. Curtis, CAP Module IV 1

Agenda Explore Change…Motivation…Resistance Brief Overview of MI The Therapist’s Role in MI Strategies…Roll With Resistance

How Does Behavior Change? Behavior A Behavior B

Introspective Exercise Think of a behavior you’ve tried to change How much time elapsed between: The first time you engaged in the behavior, and The first time you recognized risk or consequences? Module IV 7

Introspective Exercise How much time elapsed between: The first time you recognized risk or negative consequences, and The first time you made an earnest attempt to change the behavior? Module IV 10

Introspective Exercise Did you ever experience some success in changing your behavior? What helped you achieve the success? Did you ever experience a resumption of or increase in the undesired behavior after experiencing some success? Module IV 12

Introspective Exercise What did you discover about change? Did motivation play a role in your change? Where did you find your motivation? Is motivation enough? Did you experience any resistance? Module IV 17

Stages of Change James Prochaska, PhD., and Carlo DiClemente, PhD. Precontemplation Contemplation Preparation Action Maintenance James Prochaska, PhD., and Carlo DiClemente, PhD.

Change Change is fluid Change is a process Change is influenced by motivation Module IV 17

Motivation Motivation is key to change Motivation is a dynamic & fluctuating state Motivation can be modified There are intrinsic and extrinsic motivators It can be influenced by relationships Module IV 17

Motivational Interviewing (MI) was developed in the late 1980’s by William Miller, PhD. and Stephen Rollnic, PhD. MI is now an established evidence-based practice in the treatment of individuals with substance use disorders. Module IV 1

Eight Stages in Learning MI 1. The spirit of MI 2. OARS – Client-centered counseling skills 3. Recognizing and reinforcing change talk 4. Eliciting and strengthening change talk 5. Rolling with resistance 6. Developing a change plan 7. Consolidating client commitment 8. Shifting flexibly between MI and other methods Miller, W. R., & Moyers, T. B. (in press). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions.

“…a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” (Miller & Rollnick, 2009) Module IV 1

Motivational Interviewing The Why: Enhance Motivation for Change The How: Identifying, exploring and resolving ambivalence about behavior change.

The Spirit of MI Autonomy...Collaboration…Evocation “…a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” Autonomy...Collaboration…Evocation Module IV 1

The Spirit of MI Guiding, more than directing Dancing, rather than wrestling Listening, as much as telling Collaborative conversation Evokes from a person what he/she already has Motivation is elicited from the person Honoring of a person’s autonomy Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care, 2008. The counselor is directive only in helping the person to examine and resolve ambivalence The relationship is collaborative more of partner rather than expert/recepient Meet the person where they are at

Principles of MI Express Empathy Support Self-Efficacy There are five distinct principles: Express Empathy Support Self-Efficacy Create Discrepancy Avoid Arguments Roll with Resistance Module IV 52

ACTIVITY...COLLABORATION Module IV 52

Therapeutic Alliance Module IV 52

There are necessary qualities a Therapist brings to a helping-relationship in order for it to be effective. Module IV 52

Necessary Qualities Skillset Be Present Effective Listener Skilled Communicator Emotionally Intelligent Skilled in MI concepts, principles and strategies.

Necessary Qualities Willing Accepting Committed Collaborative Mindset Willing Accepting Committed Collaborative Empathetic Compassionate

Therapists and Client Motivation Style/personality influence outcomes Empathic therapists have better outcomes Expectations influence outcomes Differences in drop-out rates Differences in outcome rates Simple actions decrease drop-out

The Professional’s Role “Therapists adopting a hostile-confrontational style tend to elicit more withdrawal, lower involvement, distancing, and resistance.” “For those (women) with low self-image, confrontational group therapy appeared to have a detrimental effect.” (Waltman,1995, Journal of Substance Abuse Treatment)

MI Strategies Module IV 17

OARS-Opening Strategy Open-ended questions Affirmations Reflections Summaries Module IV 54

Change Talk Client identifies that behavior might be problematic Client expresses concern about a behavior Client expresses a desire to change the behavior

Change Talk MI uses an acronym to identify types of “change-talk”. The acronym is DARN-C. Module IV 71

The Flow of Change Talk MI Desire Ability Reasons Need Commitment

Change Talk Preparatory Change Talk Desire (I want to change) Ability (I can change) Reason (It’s important to change) Need (I should change) Module IV 71

Change Talk Preparatory Change Talk Desire (I want to change) Ability (I can change) Reason (It’s important to change) Need (I should change) Module IV 71

Change Talk Implementing Change Talk Commitment (I will make changes.) Activation (I am ready, prepared, willing) Taking steps (I am taking actions to…) Module IV 71

Eliciting Change Talk Importance/Confidence Ruler Exploring problem Looking backward / Looking forward Exploring values and discrepancy with behavior Considering pros and cons (decisional balance) Exploring Extremes Planning and Committing Module IV 71

Resistance In Motivational Interviewing “Resistance” is defined as a misalliance in the counselor-client relationship and not an inherent “symptom” of addiction. Normal, natural and to be expected Module IV 71

Resistance Argue Deny a problem Accuse Interrupt Disagree Passively resist though minimal answers Overtly comply due to mandate Become angry Module IV 71

Resistance—Sustain Talk MI currently uses the term “sustain-talk” to describe client communication that indicates a desire, plan or commitment to staying the same. Module IV 71

Resistance—Sustain Talk “I don’t have a problem, it is all a mistake.” “You people are just out to make money on this.” “My wife thinks everyone has a problem because her father is an alcoholic.” “I know I need to cut down, but I can do it on my own.” “Coming to this program makes me feel worse, when do I get discharged?” Module IV 71

Resistance—Responding Roll with Resistance Module IV 71

Summary A style…a way of interacting with clients. The goal is to resolve the client’s ambivalence and guide them in the direction of making a positive change. Goal oriented and solution focused. Includes techniques to elicit “change talk” and “Sustain Talk.” Module IV 72

Resistance—Responding Reflective Techniques: Simple Reflection Double-sided Reflection Amplified Reflection Module IV 71

Simple Reflection A simple reflection, mirrors or reflects back to the client the content, feeling or meaning of his/her communication. Client: “I know I made a mistake but the hoops they are making me jump through here are getting ridiculous.” Therapist: “You are pretty upset about all this. It seems like everyone is overreacting to a mistake.” Module IV 71

Double-Sided Reflection Attempts to reflect back both sides of the ambivalence the client experiences so that the client hears back both the “sustain-talk” in his/her communication and the “change-talk.” An example is… Module IV 71

Double-Sided Reflection Client: “I know that I made a mistake, but the hoops they are making me jump through are ridiculous.” Counselor: “You made a mistake and it sounds like you feel badly about that, but you also think that people are asking you to do too much.” Module IV 71

Amplified Reflection Takes what the client said and increases the intensity of the “sustain-talk.” When hearing an amplification of what was communicated, a client will often reconsider what he/she said and clarify. An example is… Module IV 71

Amplified Reflection Client: “I know I made a mistake, but the hoops they are making me jump through are ridiculous.” Counselor: “You don’t agree with any of what they are making you do.” A client may respond to this, “No, I know I need to do some things to make this right but I am frustrated with this contract.” Module IV 71

Strategic Techniques Shifting Focus Coming Along Side Emphasizing Personal Choice and Control Reframe Agreement With a Twist Module IV 71

Shifting Focus Shifting focus attempts to get around a “stuck” point by simply side-stepping. An example, using the same client statement is: Client: “I know I made a mistake, but the hoops they are making me jump through are getting ridiculous.” Counselor: “You are upset by all of these hoops. Can you tell me more about the mistake you think you make? Module IV 71

Coming Alongside This technique is used to align with the client. An example of coming along side is: Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.” Counselor: “You may be at your limit and might not be able to keep up with all this.” Module IV 71

Emphasize Personal Choice & Control Clients ultimately always choose a course of action and this technique simply acknowledges this fact. Acknowledging this can sometimes help a client recognize that they are making a choice. An example is: Module IV 71

Emphasize Personal Choice and Control Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.” Counselor: “You don’t like what others are asking you to do, but so far you are choosing to follow-through with what they are asking. It takes a lot of fortitude to do that. Tell me what motivates you.” Module IV 71

Agreement With A Twist This is a complex technique that combines a reflection with a reframe. This gives the client confirmation that they were “heard” and then offers another perspective on their communication. It is similar to a reframe and an example is: Module IV 71

Agreement With A Twist Client: “I know that I made a mistake, but the hoops that they are making me jump through are getting ridiculous.” Counselor: “You are feeling frustrated with all these expectations. You are also anxious to be successful?” Module IV 71

Summary A style…a way of interacting with clients. The goal is to resolve the client’s ambivalence and guide them in the direction of making a positive change. Goal oriented and solution focused. Includes techniques to elicit “change talk” and “Sustain Talk.” Module IV 72

Strategies – Elicit Change Talk OARS Exploring the Problem Looking Backward Looking Forward Considering Importance Importance/Confidence Ruler Exploring Values Considering Pros and Cons Planning and Committing Module IV 72

Strategies – Decreasing Sustain-Talk Simple Reflection Double-sided Reflection Amplified Reflection Shifting Focus Coming Along-Side Emphasize Personal Choice and Control Reframe Agreement with a twist Module IV 72

Sources Center for Substance Abuse Treatment (1999). Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) 35. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Miller, W. R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. 2nd Edition. New York: Guilford Press. Miller, W.R. & Rollnick, S. (2010). What's new since MI-2? Presentation at the International Conference on Motivational Interviewing (ICMI). Stockholm, June 6, 2010. Accessed at http://www.fhi.se/Documents/ICMI/Dokumentation/June-6/Miller-and-Rollnick-june6-pre- conference-workshop.pdf Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Module IV 72

Why Motivational Interviewing? Evidence-based >120 clinical trials Relatively brief Grounded in testable theory With specifiable mechanisms of action Generalizable across problem areas Complementary to other treatment methods Verifiable – Is it being delivered properly? Can be delivered by non-specialists