fall 2013 motivating for change. ray caesar lpc, ladc-mh director of addiction specialty programs...

FALL 2013

MOTIVATING FOR CHANGE

MOTIVATING FOR CHANGE

• Ray Caesar LPC, LADC-MH• Director of Addiction Specialty Programs• Oklahoma Department of Mental Health &

Substance Abuse Services• (405)522-3870• rcaesar@odmhsas.org

OUTLINE

• Achievement Motivation Theory

• Self-Determination Theory

• Operant Conditioning

• Motivational Interviewing

MOTIVATING INDIVIDUALS

ROMAN LEGION

DECIMATION

BREAD AND WATER

AMERICAN MILITARY

FRENCH REVOLUTION

MOTIVATION

DEFINITION

• Motivation• The process of arousing and sustaining goal-

directed behaviors.

NEEDS DRIVES

DRIVES INCENTIVES

MOTIVATION

WHAT IS MOTIVATION?

External motivation

Internal motivation

WHY WE WORK

• Support ourselves and our families.• Pay bills.• Most people enjoy work.• Sense of purpose.• Social aspect of being with other people.

MOTIVATION

MOTIVATION IS NOT

Directly observableSynonymous with satisfaction

Always consciousDirectly controllable

STAGES OF CHANGE

ACHIEVMENT MOTIVATION THEORY

ACHIEVEMENT MOTIVATION THEORY

LOW ACHIEVEMENT MOTIVATION

HIGH ACHIEVEMENT MOTIVATION

ACHIEVEMENT MOTIVATION THEORY

LOW ACHIEVEMENT MOTIVATION

• Prefer very easy tasks• Failure is unlikely

• or very difficult tasks• Failure not embarrassing

ACHIEVEMENT MOTIVATION THEORY

HIGH ACHIEVEMENT MOTIVATION

• Prefer moderately difficult tasks• Success is attainable• Success is attributable to skill and effort

EXTRINSIC AND INTRINSIC MOTIVATION

MOTIVATION

EXTRENSIC AND INTRINIC MOVIVATION

Extrinsic motivationA desire to perform based on external

reward or threat of punishment

Intrinsic motivationA desire to perform a behavior based on internal (personal) reward or

punishment

MOTIVATION

EXTERNAL VERSUS INTERNAL

Better to have intrinsic motivation.

Behave not because you fear punishment or expect reward (external),

but because you want to behave in a certain way(intrinsic).

Motivation from within

COMPONENTS OF INTRINSIC MOTIVATION

Autonomy: self-governing

Competence: self-efficacy

Relatedness: support and affirmation from peers.

INTERNAL MOTIVATION

EXTRINSIC MOTIVATION

~ Needed when there are no intrinsic motivators. An example is paying taxes

~ Hopefully the behavior will alter to intrinsic motivation over time. An example is seat belt use.• At first extrinsic: avoid tickets, alarms, nagging

children• Over time this behavior becomes internalized

EXTRINSIC MOTIVATION

Environment controls behavior

External rewards and punishments

Praise increases the likelihood of participation

Criticism decreases the likelihood of participation

Principles of operant conditioning are at work*

MOTIVATION

• Exposure to commercial media prompt a focus on materialism which provides fleeting satisfactions.

• Individuals may seek extrinsic rewards in order to compensate for deficits in fulfilling basic psychological needs.

• Extrinsic rewards are insufficient and poor compensation.

• Ryan & Deci

MOTIVATION

MOVING FROM EXTERNAL TO INTERNAL MOTIVATION

WHY WE WORK

• Support ourselves and our families.• Pay bills.• Most people enjoy work.• Sense of purpose.• Social aspect of being with other people.

SAFER TO WEAR SEATBELTS.

• It is well-known that seatbelts save lives.• Compliance varies greatly.• 91% in California• 78% in Connecticut• 51% in Mass before law, now 76%.• Requirement and enforcement make a difference

PUNISHMENT AND REINFORCEMENT.

• “Click it or ticket”• Threat of punishment.• Random checks.• Cars come with warning buzzers that stop if you buckle up.

• Reinforces compliance

EVENTUALLY INTERNALIZED

• Starts extrinsic.• Not wearing seatbelt might lead to punishment.• Wearing reinforced by others and by vehicle.• Seat belt usage becomes a matter of habit.• Becomes intrinsic.

SELF DETERMINATION

THEORY

Ryan and Deci

SELF-DETERMINATION THEORY

A meta-theory of motivation incorporating multiple “mini-theories” into a unified whole.

• Self-Determination Theory addresses both intrinsic and extrinsic sources of motivation.

• Self-Determination Theory focuses on • Autonomy• Competence • Relatedness

COMPONENTS OF INTRINSIC MOTIVATION

Autonomy: self-governing

Competence: self-efficacy

Relatedness: support and affirmation from peers.

SELF-DETERMINATION THEORY

Self-Determination Theory proposes that the degree to which autonomy, competence or relatedness are supported and enhanced will have a significant positive effect on the individual within the specific context.

SELF-DETERMINATION THEORY

Self-Determination Theory proposes that the degree to which autonomy, competence or relatedness are unsupported or hindered will have a significant negative effect on the individual within the specific context.

SELF-DETERMINATION THEORY

Autonomy, competence and relatedness are recognized as basic psychological needs.

PSYCHOLOGICAL NEEDS

Not necessary for survival like biological needs.

People engage in all kinds of activities unrelated to basic needs.

Make life worth living.

MASLOW

SELF-DETERMINATION THEORY

THE FIVE MINI-THEORIES OF

SELF-DETERMINIATION THEORY

SELF-DETERMINATION THEORY

COGNITIVE EVALUATION THEORY

ORGANISMIC INTEGRATION THEORY

CAUSALITY ORIENTATIONS THEORY

BASIC PSYCHOLOGICAL NEEDS THEORY

GOAL CONTENTS THEORY

SELF-DETERMINATION THEORY

Cognitive Evaluation Theory

SELF-DETERMINATION THEORY

Cognitive Evaluation Theory

Intrinsic motivation

What are the effects of social contexts on intrinsic motivation?

Highlights competence and autonomy.

Explores reward, ego-involvement, controls

SELF-DETERMINATION THEORY

Organismic Integration Theory

SELF-DETERMINATION THEORY

Organismic Integration Theory

Extrinsic motivation

Explores the determinants, properties and consequences of extrinsic motivation

Identifies a continuum from external to

internal

Degree autonomy will be enhanced or hindered

SELF-DETERMINATION THEORY

Causality Orientations Theory

SELF-DETERMINATION THEORY

Causality Orientations Theory

Intrinsic/extrinsic motivation

Identifies how individual differences alter how the environment is perceived.

Identifies three orientations – autonomy, control (rewards) and impersonal (amotivational).

SELF-DETERMINATION THEORY

Basic Psychological Needs Theory

SELF-DETERMINATION THEORY

Basic Psychological Needs Theory

Intrinsic/extrinsic

Optimal well being is predicated on autonomy, competence and relatedness. All three are required.

Contexts that support or thwart these needs must be considered.

SELF-DETERMINATION THEORY

Goal Contents Theory

SELF-DETERMINATION THEORY

Goal Contents Theory

Intrinsic/extrinsic

Compares and contrasts the effects of internal and external motivators.

Goals have varying effects on need satisfaction.

SELF-DETERMINATION THEORY

LEVELS OFSELF-DETERMINATION

SELF-DETERMINATION THEORY

AMOTIVATION

The individual does not pursue a behavior as success is seen as unlikely or impossible – there is no point in trying

SELF-DETERMINATION THEORY

EXTERNAL REGULATION

The individual pursues a behavior for a reward (pay) or due to coercion.

SELF-DETERMINATION THEORY

INTROJECTED REGULATION

The individual pursues a behavior because of an internalized guilt or shame related sense of “ought to” or “should”.

SELF-DETERMINATION THEORY

IDENTIFIED REGULATION

The individual pursues a behavior because the outcomes are important to the individuals goals

SELF-DETERMINATION THEORY

INTEGRATED REGULATION

The individual pursues behaviors because they symbolize what is important to the person’s sense of worth.

SELF-DETERMINATION THEORY

TRUE INTRINSIC MOTIVATION

The individual pursues behaviors for the pleasure of accomplishing, knowing, or for the stimulation.

SELF-DETERMINATION THEORY

I TRUE INTRINSIC MOTIVATIONII INTEGRATED MOTIVATIONIII IDENTIFIED MOTIVATIONIV INTROJECTED MOTIVATIONV EXTERNAL REGULATIONVI AMOTIVATION

REGULATORY STYLES

AMOTIVATION

• Non-regulation• Don’t care about rewards and punishments.• Lack of control.• “They pretend to pay us and we pretend to

work.”

INTERNAL REGULATION

• Synthesis with self-congruence.• Agreement conforms to beliefs

• Goal is to get people to accept goals as their own.• Move from compliance to self-regulation.

FACILITATING INTERNALIZATION

• Relatedness• Desire to belong and feel connected.• Group projects, share tasks

• Self-efficacy• Improves chances of success• Work to avoid early failures

PSYCHOLOGICAL NEEDS

• Self-determination theory relates to psychological needs.• Extrinsic motivation is not strongly related

to well-being• Wealth, fame and image.

• Well-being not enhanced by achievement of extrinsic goals.

MASLOW

SELF ACTUALIZING

• Promotes autonomy and competence.

• Encourages natural potential for growth.

• Facilitates human achievement and well-being

• Provides the social environment to support growth.

STAGES OF CHANGE

OPERANT CONDITIONING

MOTIVATION

OPERANT CONDITIONINGAlso referred to as Instrumental Conditioning

EXTRINSIC MOTIVATION

Environment controls behaviorExternal rewards and punishmentsPraise increases the likelihood of

participationCriticism decreases the likelihood of

participationPrinciples of operant conditioning are at

work

EFFECTS ON BEHAVIOR

Reinforcement• Leads to an increase in behavior.Punishment• Leads to a decrease in behavior.

TYPES OF REINFORCEMENT

Positive reinforcement (reward): behavior leads to reward.

Negative reinforcement (reward): behavior removes pain or anxiety

The goal is to increase a wanted behavior

TYPES OF PUNISHMENT

Behavior leads to unpleasant outcome or takes away something pleasant.

The goal of punishment is a decrease in unwanted behavior.

MOTIVATION

REWARDS AND PUNISHMENTS

Add to Take away from

Pleasant

Unpleasant

REWARDS AND PUNISHMENTS

Add to Take away from

Pleasant Positive reinforcement

Negative punishment

Unpleasant Positive punishment

Negative reinforcement

PROBLEMS WITH PUNISHMENT

I Negative feelings towards person giving punishment.

II Physical or psychological pain.

III Escalate in severity.

INTRINSIC MOTIVATION

MOTIVATIONAL INTERVIEWING

Hope ExpectancyThe belief that one can change and will be successful at making changes.

15%

Therapeutic RelationshipThe degree to which counseling conveys a nonjudgmental, empathic, accepting, warm environment.

30%

Client TraitsStrengths, temperament, resources, and skills.

40%

Technique/Orientation The skills and counseling orientation.

15%

EVALUATING MI

Set goals Report &discuss Create planfindings

Evaluate ImplementChanges

Measure satisfaction Identify issues && assess Adjust componentsimplementation

MOTIVATIONAL INTERVIEWING

• Encourages a respectful counselor-client relationship.• Aids in resolving discrepancies in client

values & behaviors promoting homeostasis.• Emphasizes consultation not confrontation.• Honors the clients ability to use personal

strengths in recovery.• Engages client in the recovery process.

STAGES OF CHANGE

STAGES OF CHANGE

“I don’t have a problem.”

STAGES OF CHANGE

“I don’t have a problem.”

“I may have a problem.”

STAGES OF CHANGE

“I don’t have a problem.”

“I may have a problem.”

“I need to do something different.”

STAGES OF CHANGE

“I don’t have a problem.”

“I may have a problem.”

“I need to do something different.”

“I am taking action.”

STAGES OF CHANGE

“I don’t have a problem.”

“I may have a problem.”

“I need to do something different.”

“I am taking action.”

“I’m living differently.”

MOTIVATIONAL INTERVIEWING

Directive

MOTIVATIONAL INTERVIEWING

Directive

Client-Centered

MOTIVATIONAL INTERVIEWING

Directive

Client-Centered

Elicits positive behavior change

MOTIVATIONAL INTERVIEWING

Directive

Client-Centered

Elicits positive behavior change

Addresses client ambivalence

MOTIVATIONAL INTERVIEWING

Directive

Client-Centered

Elicits positive behavior change

Addresses client ambivalence

Respects Autonomy

MOTIVATIONAL INTERVIEWING

FUNDAMENTAL PRINCIPALS OF MI

Express empathy

MOTIVATIONAL INTERVIEWING

FUNDAMENTAL PRINCIPALS OF MI

Express empathy

Develop discrepancy

MOTIVATIONAL INTERVIEWING

FUNDAMENTAL PRINCIPALS OF MI

Express empathy

Develop discrepancy

Roll with resistance

MOTIVATIONAL INTERVIEWING

FUNDAMENTAL PRINCIPALS OF MI

Express empathy

Develop discrepancy

Roll with resistance

Support Self-efficacy

ASSESSING READINESS

MOTIVATIONAL INTERVIEWING

PHASE 1:

Building Motivation

PHASE 2:

Strengthening Commitment to Change

PHASE ONE

MI SKILLS AND STRATEGIES

PHASE I

• Open-Ended Questions

• Affirmations

• Reflective Listening

• Summarizing

• Eliciting Change Talk

MI SKILLS AND STRATEGIES

PHASE II

• Recognizing Readiness

• Transitional Summary

• Key Question(s)

• Information and Advice

• Negotiating Plans for Change

MI PHASE ONE STRATEGIES

OARS

Open-Ended Questions

Affirmation

Reflective Listening

Summary

MOTIVATIONAL INTERVIEWING

CLOSED vs OPEN QUESTIONS• Open• Requires more than a yes or no response• Eliciting—more person-centered• Aids individual cognitions

• Closed• Quick, easy, & efficient• Less client-centered• Less engaging

AFFIRMATIONS

• Compliments.

• Statements of appreciation.

•Highlights strengths.

• A form of Reflective Listening.

• Client-focused.

• Accurate.

ROADBLOCKS

• Order and, direct • Warn or threaten• Advise, suggest and

solve• Persuade, argue and

lecture• Moralize, preach -

“shoulds”• Disagree, judge and

blame

ROADBLOCKS

• Agree, approve and praise• Shame, ridicule or label• Interpret and analyze• Reassure, sympathize and

console• Question or probe• Withdraw or distract with

humor or change subject

COMMUNICATION MODEL

The words the The words the speaker listener hears says

What the speaker What the listenerreally means thinks the speaker means

Thomas Gordon

REFLECTIVE LISTENING

• Hearing the meaning behind client words

• Building hypothesis vs. making assumptions

• A non-judgmental, accepting environment

REFLECTIVE LISTENING

SimpleRepeat Rephrase

ComplexParaphraseReflection of FeelingsSummary, Metaphors

REFLECTIVE RESPONSES

•Simple

•Amplified

•Double-Sided

SUMMARIZING

• This is a special form of reflection.

• Counselor chooses what to include and emphasize.

• Include client’s concerns about change, problem recognition, optimism about change and ambivalence toward change.

• Let client know you are listening.

• Invite the client to respond to the summary.

CHANGE TALK

• What are the advantages of change

• What are the disadvantages of the status quo

• Stating optimism for change

• Stating an intention to change

• Stating a commitment

CHANGE TALK STRATEGIES

• Evocative QuestionsDesires, Ability, Reasons, Needs & Commitment for Change (DARN-C)

• Elaboration• Importance• Confidence Rulers

• Decisional Balance

• Looking Forward– Looking Back

• Exploring Goals and Values

MI CHANGE TALK STRATEGY PROCESS

ASK FOR ASSESS HEAR THE SEE THECOMMITMENT CHANGE

Desires Readiness Strong self-talk positive Abilities behaviorsReasonsNeeds

PHASE ONE TRAPS

• Question/Answer Trap

• Taking Sides

• Expert/Labeling

• Premature Focus

• Blaming

OARS AND CHANGE TALK

• Open-ended questions• Affirmation• Reflective

Listening• Summary• Eliciting change

talk

• Evocative question• Elaboration• Important

Confidence rulers• Decisional balance• Looking forward—

looking back• Exploring goals

and values

CLIENT RESISTANCEI N V O LV E S F E E L I N G S , A C T I O N S , A N D B E H AV I O R S O F A N I N T E R P E R S O N A L

N AT U R E W H E R E T H E R E I S A L A C K O F C O L L A B O R AT I O N .

RESISTANT BEHAVIORS

• Arguing

• Denying

• Blaming

• Interrupting

• Taking over

• Not responding

MOTIVATIONAL INTERVIEWING

FUNDAMENTAL PRINCIPALS OF MI

Express empathy

Develop discrepancy

Roll with resistance

Support Self-efficacy

STRATEGIC RESPONSES

• Shifting focus

• Agreement with a twist

• Emphasizing personal choice

• Reframing

• Siding with the negative

• Supporting self-efficacy

REFLECTIVE & STRATEGIC RESPONSES

TO RESISTANCE

• Shifting focus• Agreement with a

twist • Emphasizing personal

choice

• Reframing• Siding with the

negative• Support self-efficacy

Simple Amplified Double-Sided

PHASE TWO

PHASE 2 STRATEGIES

Recognizing Readiness

Transitional Summary

Key Questions

Information and Advice

Negotiating Plans for Change

CHANGE PLAN ELEMENTS

• Negotiating the plan• Identify the barriers to change• Implement the plan• Enlist support• Identify outcome measures• Measure success and revise the plan if

necessary

PHASE TWO HAZARDS

• Underestimating Ambivalence

• Over Prescription

• Insufficient Direction

MOTIVATING FOR CHANGE

• Ray Caesar LPC, LADC-MH• Director of Addiction Specialty Programs• Oklahoma Department of Mental Health &

Substance Abuse Services• (405)522-3870• rcaesar@odmhsas.org