1. Motivational Interviewing November 16, 2009 Nurse Practitioners Roundtable The Homestead, Hot Springs,VA Cecilia van Zyl-Knab, LCSW, MINT Motivation4Change

2. You would think... that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking

3. And yet so often it is not enough: What is the Key?

4. Client Motivation is a Key to Change Substance abuse treatment outcomes are predicted by: Pretreatment motivation measures Treatment attendance Treatment adherence/compliance Counselor ratings of motivation and prognosis That is, more “motivated” clients do better

5. And Client Motivation is Greatly Influenced by the Counselor: Clients’ motivation, retention and outcome vary with the particular counselor to whom they are assigned Counselor style strongly drives client resistance (confrontation drives it up, empathic listening brings it down) That is, the counselor is one of the biggest determinants of client motivation and change

6. Readiness for What? Rather than asking: “Why isn’t this person motivated?” Ask: “What is this person motivated for?” Potential Pitfall: Assuming you know.

7. Denial Research specifically has not found overuse of denial, or any other typical patterns of defensive styles among people with SUDs

8. If it’s not personality, then what behaviors cause counselors to perceive clients as being in “denial”? Disagreeing with the counselor Resisting a diagnosis/label Declining help Showing little distress Disavowing a need for counseling or change Being non-compliant with treatment prescriptions & Not changing

9. In contrast, counselors tend to perceive clients as being “motivated” when they: Agree with the counselor Accept the counselor’s diagnosis/label Express a desire for help Show distress Voice a need for the counselor/counseling Comply with the counselor’s treatment plan & Change

10. In other words, client motivation is evident in: Low resistance Openness and collaboration Expressing emotion Adhering to a change plan & Changing All of which are strongly influenced, for better or worse, by what the counselor does

11. Ambivalence The Dilemma of Change

12. Stages of Change Prochaska & DiClemente

13. Contemplation Stage It is easy to think that someone in this stage is ready to make a change. Work place smokers survey: 70-80% contemplation, but only 3-5% attracted to programs for change Some studies: Relationship between contemplation & higher levels of depression

14. Cognitive & Behavioral Change: Seems that cognitive and experiential processes of change more important in earlier stages (consciousness raising, self evaluation, environmental re- evaluation) Behavioral processes more important in later stages of change (efficacy)

15. The Righting Reflex

16. You take one side; I another When you strong argue one side, the ambivalent naturally argue the other The stronger the argument the less likely change occurs

17. Common Human Reactions to the Righting Reflex Angry, agitated Oppositional Discounting Defensive Justifying Not understood Not heard Procrastinate  Afraid  Helpless, overwhelmed  Ashamed  Trapped  Disengaged  Don’t come back – avoid  Uncomfortable  Resistant

18. Common Human Reactions to Being Listened to Understood Want to talk more Liking the counselor Open Accepted Respected Engaged Able to change Safe Empowered Hopeful Comfortable Interested Want to come back Cooperative

19. A Change of Role You don’t have to make change happen You can’t You don’t have to come up with all the answers You probably don’t have the best ones You’re not wrestling You’re dancing

20. Motivational Interviewing Definition: Motivational interviewing is a person-centered, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

21. The Spirit of Motivational Interviewing Collaboration Evocation Docere and Ducere Autonomy

22. Docere and Ducere Two Latin verbs regarding education Evoking vs. Imparting information Docere - lead / impart knowledge or info Ducere - to draw forth or evoke from within Spirit of MI: Ability to draw forth rather than pulling the client toward the goal

23. Thank You! Upcoming 2 Day Training: Richmond, VA January 14 & 15, 2010 for more info visit: Motivation4change.com

24. Reference List: Miller, W. R., Rollnick, S. (2002). Motivational Interviewing, Preparing People for Change. 2 nd Ed. Guilford Press.