Charlotte Chapman, LPCMay 6, 2009

Goals of TrainingIncrease 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.

Stages of ChangeWrite down a change in your own life you are

thinking about makingHow 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

Stages of Change Model

Contemplation

Relapse

Preparation

Action

Maintenance

Prochaska & DiClemente, 1992

Pre-Contemplation

PermanentExit

– 5

PrecontemplationEntry point to the process of changePerson 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

ContemplationRecognizes that there is some reason for

concernCharacterized by ambivalence – both

considers and rejects changeSeesaws between reasons to change and

reasons to stay the sameMay remain in this stage for a long time

– 7

PreparationCharacterized 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

ActionThe person is engaging in particular actions

to bring about change (e.g., treatment). The goal is to produce change in the problem

areas.

– 9

MaintenanceMaintaining the changed behavior; avoiding

the problem behavior. The challenge is to sustain the change

accomplished by previous action and to prevent relapse.

– 10

RelapseA 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

RulersGroup exercise: Importance and ConfidenceDiscuss your experienceOne way of understanding where someone is

with their change processOne way of eliciting change talkWhy would this be effective with clients? Not

effective?

Inspiring motivation to changePreparing clients to enter a programEngaging and retaining clients in a programIncreasing participation and involvementImproving outcomes Encouraging a rapid return for services if

problems occur

– 12

Benefits of Using Motivational Interviewing to Help Clients Change

Motivational InterviewingA client-centered, goal oriented, collaborative

process to help clients discuss and resolve ambivalence about change

Motivational InterviewingPhase I Purpose: Build Motivation for Change

Opening StrategiesDecrease ResistanceEvoke Change TalkRespond to Change Talk

Motivational InterviewingPhase IIPurpose: Strengthening Commitment to

ChangeGrand SummaryAsk Key QuestionsProvide InformationChange PlanClose the Deal

Four Principles of MIExpressing

EmpathyDeveloping

DiscrepanciesRolling with

ResistanceSupporting Self-

efficacy

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)

Different Responses to DistressApathy

Antipathy

Sympathy

Empathy

EmpathyWe 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?

Empathy Saying more than the clients says but not

more than the client meansCounselor 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

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 DiscrepancyClient: “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”

Four Principles: Roll with ResistanceCounselor 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

Four Principles: Support Self-EfficacyIt 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

Coding for Coding for PrinciplesPrinciples

Motivational InterviewingSkills 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

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.”

MI “Micro” Skills (OARS)Open-ended questions

Affirmation

Reflective listening

Summarizing

Use Open-Ended QuestionsClosed-Ended

“Did you come here because of the court?”

Open-Ended“What led to

your coming to treatment?”

Open Ended QuestionsResponse is more than one word or yes/no

What, How, Tell me

Respond to answer with a reflection before asking another question

AffirmationsSelective, non-judgmental reflections of

clients’ strengths, resources, personal

achievementsAimed at:

Supporting client’s involvement in changeAcknowledging attempts at changeClient –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 AffirmationsWrite 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.”

Reflective ListeningListening not only to what the client says,

but also for what the client meansChecking out assumptionsCreating an environment of unconditional

positive regard and acceptanceAvoiding judging, criticizing or blamingThe client and counselor do not have to

agreeBe aware of intonation

Reflective ListeningLevel One: RepeatLevel Two: RephraseLevel Three: Paraphrase

Reflect feelingsSummaryMetaphors, similesContinue the sentence/paragraph

Reflective Listening PracticeDyadsSpeaker and Listener: Speaker talks for 5

minutes: challenges of my work Listener uses REFLECTIONS only in

responseSwitchGroup discussion

Reflective Listening with AffirmationsDyadsSpeaker and Listener: Speaker talks for 5

minutes about successes in my workListener uses reflections and affirmations in

responseSwitchDebrief

SummarizeReinforce what the client has been sayingDemonstrate your attention to what the client has

been sayingOften provoke additional change talkAsk for clients response to your summary3 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

Summarize PracticeDyads: Speaker and listenerSpeaker talks about something you are

thinking about changing for 3 minutesListener’s task is to listen without speaking

until time is called. Then give as exact a summary as possible.

Change roles and repeat

Summarize Practice 2Same dyads; Speaker and listenerSpeaker 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 repeatDebrief as large group

Quote from a student“With MI, I am learning for the first time how

to help someone change without lecturing or shaming them”

Resourceswww.motivationalinterview.orgMiller and Rollnick (2002) Motivational

Interviewing, 2nd editionWagner and McMahon (2004) Motivational

Interviewing and Rehabilitation Counseling Practice

Rehabilitation Counseling Bulletin, 47, 3, 152-161.

Charlotte Chapman charlotte@chapmantraining.com

www.chapmantraining.com