Rolling with Resistance : Using a Motivational Interviewing Approach Presented by Danette Heckathorn, M.S., L.P.C. 4/19/2017

Motivational Interviewing A Humanistic approach to counseling developed by Miller and Rollnick (1991, 2002). Motivational interviewing (MI) is not a theory. It is a tool to be used in conjunction with other theories. 4/19/2017

Agenda Motivation What this training will do for you Stages of Change Model Major goals of motivational interviewing How to address negative behavior Rolling with Resistance Practice 4/19/2017

Motivation What motivates? Is motivation enough? 4/19/2017

What will this training do for you? You will learn ways to use motivational interviewing as a tool to roll with client resistance. This training will give you a taste of MI and introduce you to some resources, but it cannot substitute for a 4-Day comprehensive MI training. 4/19/2017

Cycle of Change 4/19/2017 Precontemplation Contemplation Preparation Action Maintenance 4/19/2017

Stages of Change (Prochaska et. al., 1994) Precontemplation – either unaware of problems related to negative health behavior or lack the desire to change their negative behavior, and they do not report any intention to change their negative habit within the next 6 months. 4/19/2017

Contemplation Individuals recognize that some aspect of their negative behavior is a problem, and they plan to take action in the next 6 months. They are often seen as ambivalent because the perceived costs and benefits of the negative behavior are equivalent (Rollnick et. al., 1991). 4/19/2017

Preparation Action Maintenance Commitment to change has been made and they plan to take action in the near future. Action Begin to actively change behaviors and environmental conditions to overcome problem. Maintenance Changes have become a regular part of the individual’s lifestyle. 4/19/2017

Why Determine Stage of Change? Identifying a clients stage of change will help you determine the best approach to take with them. Change is the responsibility of the client but the caregiver is responsible for enhancing motivation to change. 4/19/2017

Ways to Determine Their Stage of Change I noticed (behavior) is this something that is creating a problem for you or something you would like to change? People differ in how ready they are to change their (behavior) habits. What about you? 4/19/2017

Precontemplative Client “I don’t have any problems with (behavior)” They may come across defensive Reluctant Resigned Rationalizing Rebellious No intention to change 4/19/2017

Comtemplative Client “I have been thinking about changing (behavior)” They have identified the behavior may be problematic More troubled about the behavior Ambivalent but may be weighing pros and cons Decisional balance exercise useful 4/19/2017

Preparation Stage and Client “How can I change (behavior)?” More committed Ready to start Sharing plans for change Change becomes a priority 4/19/2017

Action Stage and Client “Here I go” They decide on a change strategy and try it out Actively modify behavior including thoughts, feelings, and the environment Treatment and/or self-help Persistence and completion or drop-out 4/19/2017

Maintenance Stage and Client “I think this will work and I am going to continue” Trying to keep the ball rolling Preventing relapse – learning new coping skills Watching out for triggers Acknowledging self for changes made and taking credit Moving toward more balance 4/19/2017

Practice Identifying Stage of Change Quick Exercise We will come back to the stages of change after discussing motivational interviewing 4/19/2017

Motivational Interviewing Defined as “...a client-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25) Let’s break it down 4/19/2017

Four Main Principles of MI Express empathy Develop discrepancy Roll with resistance Support self-efficacy 4/19/2017

Strategies Used in MI Eliciting Change Talk – motivational statements from the client OARS Method Open-Ended Questions Affirming the client Reflective listening Summarizing 4/19/2017

Change Talk Client identifies that behavior might be problematic Client expresses concern about a behavior Client expresses a desire to change the behavior 4/19/2017

Reflective Listening What is it? How do you do it? Levels of reflective listening Optimal reflective listening Let’s Practice… 4/19/2017

Affirming the Client The idea here is to enhance self-efficacy Self-efficacy is our belief in our own ability to achieve a goal or accomplish a task Strengthen the relationship Enhance self-esteem 4/19/2017

Summarizing A technique to be used throughout the meeting Strategically repeat a client’s self-motivational statements Include reluctance/resistance Reflect optimism for change 4/19/2017

Knowing When a Client is Ready to Change What do you expect to hear when a client is ready to change? What do you not expect to hear? What will the client look like? What other indications might the client make? 4/19/2017

How to Elicit Change Talk Open-ended questions (handout) Ruler (handout) Pros/Cons exercise Looking forward Looking back Goals and values Open – ended questions Disadvantages – “in what ways does this concern you? Advantages to change – What would be a reason for making this changes? Optimism about change – What might excite you about making this change? What other problems have you tackled successfully? Intention to change – what might you do? What might the change look like? Conviction, confidence, readiness – ruler How convinced are you that you need to attend to this? How confident are you in your ability? How ready are you to do something different? Pros and Cons – help them tip the balance – what could help you make this change and what could get in the way? Looking forward – Look forward in your life and talk about what it might look like if you make this change, and if you don’t make this change. If you do make these changes, what advantages do you see for yourself in the future? What disadvantages? If you don’t make these changes, what do you see happening in your life in the near future? Looking back – before this concern was an issue, what was life like? As you look back in your life, how has this issue effected things for you? In what areas? Goals and values How do your goals in your life fit in with your current way of conducting your life?

Change Planning What changes? Why change? Goals – SMART Steps to take? First steps – concrete Help I will know it is working if Potential obstacles 4/19/2017

Resistance to Change 4 Categories Arguing Interrupting Denying Ignoring 4/19/2017

NO NO’s for Dealing with Resistance Arguing, disagreeing and challenging Judging, criticizing, blaming Warning of negative consequences Seeking to persuade with logic Analyzing Confronting with authority Sarcasm 4/19/2017

How to Respond to Resistance Simple reflection Amplified reflection Double-sided reflection Agreement with a twist Shifting focus Reframing Rolling with resistance 4/19/2017

Simple Reflection Stating what you here the client saying It is sometimes helpful for the client just to hear their own words 4/19/2017

Amplified Reflection Reflect with modification Client: I just don’t think that I have a problem with gambling. Caregiver: There is no cause for concern for you. Client: I don’t know how changing my eating habits could help me. Caregiver: You feel your eating habits are perfectly reasonable. 4/19/2017

Double-Sided Reflections Reflect back the statement but also use the other side of the client’s ambivalence Client: I can’t quit eating sweets. I look forward to having a nice desert each day. Caregiver: It sounds like you are going to miss eating deserts, but you also don’t want to take diabetic medication. What do you think would be the best way to resolve this situation? 4/19/2017

Agreement with a Twist and Shifting Focus Defuse resistance by shifting focus Add a slant or twist to the meaning when you reflect back to the client Client: I can’t imagine quitting drinking. All of my friends drink! Caregiver: It sounds like you’ll really miss the social interaction. And at the same time, it might provide an opportunity to expand your social network like you were wanting. Client: I can’t imagine quitting drinking. All of my friends drink! Caregiver: It’s hard to imagine giving up a lifestyle that you’re accustomed to. I’m wondering, what can you imagine? 4/19/2017

Reframing Placing something in a more positive light – (what are the benefits?) Client – It is really going to be hard for me to quit eating sweets. Caregiver: While it will be hard to quit eating sweets, you are determined to do it because it will allow you to control your diabetes without taking medication. 4/19/2017

Rolling with Resistance This is where you just want to validate what the client is telling you by letting them know you have heard their problem and understand their ambivalence It can be one of the most difficult techniques 4/19/2017

MI – The BASICS Let’s Practice… Don’t ignore the behavior – even if you simply say “Hey, (name) I noticed (behavior). Try to determine where they are with regards to stage of change. Let’s Practice… 4/19/2017

Summary The Basics of MI Can be used to address any negative behavior 4/19/2017

Feedback and/or Questions dheckat@uark.edu or (479) 601-2164 Thank you.