1
Q
Three central concepts of MI
A
- readiness
- ambivalence
- resistance
2
Q
Readiness
A
Conceptualised in stages of change:
framework that indicated that people often have different needs, depending on their stage of change, & that simply moving stages during counselling might be beneficial
- stages if change model: gives contract “readiness to change” which proves proves useful for understanding & conduct of MI session
Conceptualised as a continuum
- highlights the need to maintain congruent with the client’s readiness on an ongoing basis in counselling
- oversimplifies, no reference being made to circular process
Motivation can be views as a state of readiness to change
- fluctuates & can be influenced by others
3
Q
Readiness & MI
A
- counsellor awareness of shifting readiness is invaluable for the skilful use of MI
- in MI the counsellor always walks beside the client, in step with its readiness to change
Issue: not only is the client usually cautious, but the counsellor often with limited time for the journey, may run ahead of clients readiness
- sensitivity to readiness may enable resistance behaviours of client ti be kept to minimum & for rapport to be sustained through difficult passages
4
Q
Readiness & Resistance
A
big mistake of counsellor to assume bigger readiness to change of client than there is
–> resistance
5
Q
Ambivalence
A
- feeling two ways about something
- all changes contain an element of ambivalence
- discomfort as a result of change or choice situations if the consequences are uncertain
6
Q
MI & ambivalence
A
- ML helps to reduce it
- resolving ambivalence in direction of change key element
- MI helps to explore clients ambivalence about change without experiencing the process as hostile & insensitive
- places at center of description if MI bc provided counsellors with a conceptual anchor for dealing with the uncertainty about behaviour change that pervades so many counselling sessions
- inter-relationship of ambivalence about change and clients goals ans core values is substance of MI
7
Q
Ambivalence & behaviour change
A
- change may be effortful & enervating
demanding to reconfigure beliefs concerning the role of the behaviour
8
Q
Resistance
A
- observable behaviour that arises when the counsellor loses demonstrable congruence with client
- often consequence of counsellor behaviour & amenable to change
may be:
- a general reluctance to make progress
- opposition to counsellor or what counsellor thinks is best
- the client’s expectation as to the posture of the agency the counsellor represents
denial
May defend:
- self-esteem
- personal values
- articulating of a particular important opinion (e.g. a core belief)
Responding constructively to rapport damaged by miscommunication & confusion is especially important in early stages of counselling
9
Q
Principles of MI
A
- express empathy
- develop discrepancy
- roll with resistance
- Support self-efficacy
10
Q
Express empathy
A
fundamental principle
- ensures counsellor remains in step with needs & aspirations of client
- client needs to know you g have cognitive & emotional understanding
- show acceptance towards client, so client feels accepted
reflective listening
- rephrase what they are saying (not in clinical terms)
- try to move gently to next level
- show understanding for clients ambivalence
- no labelling, stay neutral & open in the beginning
- use labels at later stages when
client ready & willing to self-label
11
Q
Develop discrepancy
A
Why?
- so client can look at own situation & release that is not good & realise that this is where change is coming from
- in exploration of client’s personal values & aspirations fir future, a particular state of discomfort, termed discrepancy, can arise from contrast between what person wants from life & self-destructive nature of addition problem
Goal
- clarify important goals for the client
- explore if client is aware of he consequences or potential consequences of the client’s current behaviour
- create & amplify the client’s mind a discrepancy between current behaviour & life goals
> find a way to put those two things together
> this means working with ambivalence, not fighting it
12
Q
Roll with Resistance
A
Why?
- if client is not following you, you need to make different move such that you are not blocking their behaviour but are gently showing an alternative direction
Goal
- avoid resistance
- if arises, stop & find another way to proceed (step back & look at situation again)
- avoid confrontations
- shift perceptions
- invite, but not impose new perspectives
- value the client as a resource for finding solutions to problems
13
Q
Types of Resistance
A
Arguing
- client contests the accuracy, expertise, integrity of the clinician/expert
Interrupting
- client breaks in & interrupts clinician/expert in a defensive manner
Denying
- client expresses unwillingness to recognise problems, cooperate, accepts responsibility, take advice
Ignoring
- client shows evidence of ignoring or not following clinician/expert
14
Q
Support Self-efficacy
A
Why?
- give them tools, vocabulary, behaviour to help them develop so they are able to do it
- -> here STD comes in
- belief in ability to change (self-efficacy) is important motivator
- research supports importance of self-efficacy as a predictor of success in changing behaviour
- client is responsible for choosing and carrying out personal change (also furnish them with the understanding/the belief they can do it)
- there is hope in the range of alternative approaches available (show client there is not only one way, try out one if not helping next one)
15
Q
OARS
A
are the skills that can be used by interviewers to help move clients through the process of change
- Open-ended questions (use 50-70% of time)
- Affirmation (use at least 1x)
- Reflective listening (ratio 2:1)
- Summarising (1-2x)
- -> amount of usage is minimum but no clear rule
Ask:
- permission
- open-questions
- closed questions
Tell:
- inform
- give feedback
- advise
Listen:
- appreciate
- reflect
- summarise
16
Q
Open-ended Questions
A
evokes client’s arguments for change
- avoid yes-no questions
- should use specific labelling (stay neutral)
- should invite them to give you info to work with
Guideline:
- need to spell these out in your guideline for counsellors so that they have ready made questions that they can use
Keep in mind:
- this is harder/more complex than it seems
17
Q
open question: asking permission
A
- needed when dicing into sensitive topic
- communicates respect for client
- major value in MI with patients
- allows clients to feel human, helps maintain eye-level between client & you
- gives opportunity to discuss patient’s behaviour when not presenting problem
> giving opportunity to present problem but ask “do you want to talk about it” - allows conversation to continue even if patient not thinking of changing
- respectful
18
Q
Affirmations
A
Goal: affirm patient
- often forgotten
- can be big, important thing for patient
- supports self-efficacy
- increases their confidence
Affirmations need to be done:
- respectfully
- genuiely
- need to be pitched at a level that fits with the patient themselves
- useful to make them situational or behaviourally specific
19
Q
Reflective listening
A
- used to checkout whether you really understood client
- highlights their ambivalence of behaviour
- steers client towards greater recognition of problem
reinforce statements indicating that the client is thinking about change
–> helps to find out where client is on change trajectory
Simple reflective listening: can ensure that client feels understood in often confusing discussion (empathy)
- use reflective statements to help people to keep thinking about their perspective on change and their ambivalence, and moving towards change
- use a lot of conditionals & question techniques while at same time repeating a lot of info you got from client
Reflect on:
- what person says
- how they feel
- what things mean to them
reflective listening is difficult
- do not put words in their mouth
- the more thoughtful & understanding the practitioner, the more likely client hets contemplative & by that makes new connections
- paraphrasing after clients comment
20
Q
Normalising
A
in reflective listening
- communicates to the patient that difficulty in changing not uncommon
- don’t use negative label
- takes pressure/focus away from individual
21
Q
Levels of reflection
A
- reflection on own behaviour often avoided
- engagement in reflection is 1st step towards change
simple reflection
complex reflection
22
Q
Simple reflection
A
- repeating
- rephrase
–> swing back to person what they said to you
23
Q
Complex reflection
A
- Affective - emphasised the emotional dimension
- Values - emphasised beliefs & principles
- Over/understanding - changes in intensity
- Continuing the paragraph - completes next sentence
- Double-sided - states both sides
- Uses images or metaphors - to increase perspectives
- -> quite difficult, lot of training needed
- -> try to arrive at a hypothesis or hunch of what the person is feeling or what they mean & offer that back to them
24
Q
Summarising
A
is an important way of gathering together what has already been said, making sure you understood the client correctly, and preparing client to more on
- show where we are
- putting together a group of reflections
- every now & then summarising the client’s own perspective of change and offering it back to them
- can be linked to “advice giving”
25
Advice giving
Key MI strategy
- patients often little or misinformation about their behaviours
Advice or Information
- presented in neutral, non-judgemental manner can help patients make better more informed decisions about changing
Focus on:
- positives if possible (& NOT what could go wrong or what they should focus on otherwise)
- giving advise is NOT telling "this is what you need tot do"
Giving advise IS saying "this is what has worked for others, would you be willing to explore this yourself?"
- research shows effectiveness is very limited
> bc ppl don't like being told what to do
> they don't understand it
26
MI alternatives to simple advise
- offers relevant new info in neutral, nonjudgemental sensitive manner
- ask permission
- ask what does client know about how Behaviour effects health (or other domains)?
27
Change Talk
an indication that you are successfully using MI
instead of presenting arguments for change, counsellor elects these from client
Eliciting change talk:
- needed to make MI work
If MI used successfully, client will make statements that indicate that client
1. recognises disadvantage of staying the same
2. recognise the advantages of change
3. expresses optimism about change
4. express the intention to change
- -> change talk
28
8 Methods to facilitate change talk
1. asking evokative questions
- disadvanatage of status quo
- advantage of change
- optimism
- change intention
2. Using the importance ruler
3. Exploring the decisional balance (4 field matrix)
- consequences of changing and not changing
4. Elaborating
5. Quering extremes
- what would be the worst outcome of you continue
6. Looking back
- have there been successes in the past?
7. Looking forward
- where do you want to be?
8. Exploring goals & values
29
Readiness Ruler
"Where are you on the Ruler"
- helps them see that they haven't changed, went backwards or have changed
- helps especially with clients that not so cognitively gifted
Values of using ruler:
- patients at different levels of readiness to change
- assess patients readiness to change
- helps practitioners recognise and deal with ambivalence
- allows patients to give voice to changing
e.g. "on a scale from 1 (def. not ready to change)-10 (def. ready to change) what best reflects how ready you are at present time to change?
where were you 6 months ago?
30
Eliciting confidence talk
- to boost self-efficacy in clients, so that they feel able & furnished with right means to make changes possible that they want to attain
- very important
- to build confidence in client that they think they can do it
8 simple methods to facilitate confidence talk
1. evokative questions
2. confidence ruler
3. reviewing past success
4. personal strength & support
5. brainstorming
6. giving information & advice
7. refraiming
8. hypothetical change
31
Limitations of MI
- MI is about change
- not the only approach that can/needs to be taken
- -> NOT only tool for everything
Choosing MI based on
- characteristics of client &case
- position of client in the therapeutical trajectory
- useful in contexts where clients are not willing ti change, ambivalence, need to make decisions to change themselves
Research:
- little known about what elements of method particularly effective
32
Self-Determination Theory
- theory of personality development & self-motivated behaviour change
- fundamental to theory is that ppl have innate organisational tendency toward growth, integration of self, resolution of psychological inconsistency
--> could be underlying model for MI
> propose that adopting an SDT perspective could help furthering our understanding of the psychological processes involved in MI
33
Similarities MI & SDT
both based on assumption that
- humans have innate tendency for personal growth towards psychological integration
--> MI provides social environment facilitating factors suggested by SDT to promote this tendency
- common element in both is emphasis on having motivation for change emerging from within rather than attempting to coerce person to change
34
SDT & MI
- SDT can provide theoretical framework for understanding how change occurs in MI
- MI can foster self-motivated behaviour change by promoting internalisation & integration of regulation of new behaviour so that it is engaged in more willingly & more accord with person's broader goals, values, sense of self
--> process facilitated by style of MI & specific strategies that provide ambient supports for needs for competence, autonomy & relatedness
35
MI & autonomy
autonomy support inherent in all principles of MI
Autonomy Is promoted by:
- avoiding confrontation& coercion
- exploring behavioural options
- developing the discrepancy between the client's current behaviour & how they would like to be so that they present the arguments for change themselves
- encouraging clients to choose their preferred courses of action
36
MI & competence
need for competence in MI
- for provision of clear info about behaviour-outcome contingencies
- by helping the client to embrace realistic expectations & to set appropriate self-selected goals
- by giving positive, non-judgemental feedback
37
MI & relatedness
Need for relatedness is facilitated in MI by
- genuine interest& warmth demonstrated by counsellor
- expression of empathy, non contingent support
- avoidance of criticism or blame
38
MI & beliefs/behaviours/attitudes
MI as a process of movement toward integration & internal harmony whereby the client's behaviour, attitudes, beliefs become consistent with those values that are core to their personal identity
39
Stages of Change Model
recognises that the need to change & understanding how to change doesn't happen all at once
--> usually takes time & practice
- people usually go through stages as they begin to recognise that they have a problem
Stages:
- Pre-contemplation
- contemplation
- Preparation
- Action
- Maintenance
- Relapse
Helping ppl change involves increasing their awareness of their need to change & helping them to start moving through the stages change
- start where client is
- positive approaches are more effective than confrontation particularly in an outpatient setting
40
MI & Stages of change
MI is the process of helping ppl move through the stages of change
- dealing with pre contemplation phase, prepare & support them for action, pick them up when they relapse
41
Stage 1: Pre-contemplation
People at this stage:
- are unaware of any problem related to their problematic behaviour
- are unconcerned about their problematic behaviour or even enjoy it
- ignore anyone else's belief that they are doing something harmful
42
Stage 2: Contemplation
People at this stage are considering whether or not to change
- enjoy their problematic Behaviour BUT
- are sometimes worried about the increasing difficulties it is causing
- they are constantly debating with themselves whether to not they have a problem
43
Stage 3: Determination/preparation
at this stage ppl are deciding who they are going to change
- may be ready ti change
- getting ready to make change
it may take a long time to move to next stage (action)
- willing to change, are positive
44
Stage 4: Action
- ppl have begun process of changing
| - need help identifying realistic steps, high-risk situations, ans new coping strategies
45
Step 5: Maintenance
- ppl have made a change and
- are working on maintaining the change
need to figure out how to fight off temptations
46
Relapse (Stages of Change)
people have reinitiated in identified behaviour
- people usually make several attempts to quit before being successful
- process of change rarely same in subsequent attempts
- each attempt involves new information gained from previous attempt
- relapse not bad, its natural --> NOT a failure
- part of recovery process
- tis part most crucial, bc client can either stop processes or can go back to stage 1
47
Why don't people change
It is NOT that:
- they not want to see (denial) or not willing to do it
- they don't care (no motivation)
- they are to lazy (no energy)
- they want to anger counsellor (evil)
Is that
- they are just early in the stages of change
- therefore denial, lack of motivation can sneak back
--> can be dressed by MI
48
Traps to avoid
Question-answer trap
- ping-pong back & forth
Confrontation-denial trap
- denial will win
Expert trap
- I know better, this is why you need to do this"
Labeling trap
- if you label condition/negative terms may not lead to a lot of change
- -> risk that client labels themselves as victim of external condition, not in my control --> think cannot do anything
Premature focus trap
- going into conversation with client, if they are nor ready yet & you are at step 2-3
- not acknowledging that client needs more time to get to step 2-or 3
Blaming trap
- blaming issue on someone outside of self
- -> think is outside of their control
Lack of time trap
- therapist has limited amount of time with clients
- need to rush
- -> overlook that client needs more time to be ready for change
49
The notion of truth & MI
if notion of objective truth, MI not needed, you know what is right & everyone follows that
e.g. medical service providers haver very high status in society all over the world, "the doctor knows"
--> does this work? What if don't want to follow objective truth? --> MI
50
Traditional Approach
"the stick" --> this is what you need to do
change
- motivated by discomfort
- if you can make ppl feel bad enough, they will change
- people habe to "hit bottom" to be ready to change
Corollary
- people don't change if they haven't suffered enough
