ATI Exam 1

Cognitive Conceptual Model

(Early) Experience > Schemas/Core Beliefs> Assumptions/Expectations/Rules/Beliefs> Compensatory Strategies> Current Trigger/Situation> Assumptions etc (above)> Negative Automatic Thoughts> Emotions/Behaviors/Somatic Reactions

"Spirit of MI" 4 things

1. Collaboration between the practitioner and the client; Collaboration is a partnership between the practitioner and the client, grounded in the point of view and experiences of the client. 2. Evoking or drawing out the client's ideas about change; The MI approach is one of the practitioner's drawing out the individual's own thoughts and ideas, rather than imposing their opinions as motivation and commitment to change is most powerful and durable when it comes from the client. 3. Emphasizing the autonomy of the client. Unlike some other treatment models that emphasize the clinician as an authority figure, Motivational Interviewing recognizes that the true power for change rests within the client. Ultimately, it is up to the individual to follow through with making changes happen. This is empowering to the individual, but also gives them responsibility for their actions. 4. Practicing compassion in the process. Compassion is the ability to actively promote the other's welfare and give priority to the other's needs. It is a deliberate commitment to pursue the welfare and best interest of others.

Ways to Evoke a person's motivation (MI)*

1. Evocative questions 2. Ask for elaboration 3. Importance ruler 4. Querying extremes 5. Looking back 6. Looking forward 7. Explore goals and values

Approaches to identify an automatic thought

1. Recognizing when a belief is expressed as an automatic thought. 2. Providing the first part of an assumption. 3. Directly eliciting a rule or attitude. 4. Using the downward arrow technique. 5. Examining the patient's automatic thoughts and looking for common themes. 6. Ask the patient directly. 7. Reviewing a brief questionnaire complete by the patient.

Lay definition of MI*

A collaborative conversation style for strengthening a person's own motivation and commitment to change.

Technical Definition of MI*

A collaborative, goal-oriented style of communication with particular attention to the language of change, designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion.

Clinical Definition of MI*

A person-centered counseling style for addressing the common problem of ambivalence about change.

The Decatastrophising Question

A way of challenging thought What is the worst that could happen? If the worst happened, how would you cope? What is the best that could happen? What is the most realistic outcome?

The Alternative Explanation question

A way of challenging thoughts Is there an alternative explanation or viewpoint?

The "evidence" question (CBT)

A way of challenging thoughts What is the evidence that supports this idea? What is the evidence against this idea?

The Impact of Automatic Thoughts question (CBT)

A way of evaluating automatic thoughts What is the effect of your believing this automatic thought? What could be the effect of changing your thinking?

The problem-solving question (CBT)

A way of evaluating automatic thoughts What would you do? (if you were in that situation again).

The distancing question (CBT)

A way of evaluating automatic thoughts What would you tell _________ [a specific friend or family member] if he or she were in the same situation.

Four Aspects of Acceptance*

Affirmation Absolute worth Accurate empathy Autonomy

Agenda Mapping (focusing) Guidelines (MI)

Allow clients the space to reflect and express their preferences and concerns. Include affirmations and support when appropriate. Invite the client to raise completely new ideas that haven't been discussed yet. Use hypothetical language like "we might," "you could," and so on. Include your own opinions (with permission)

Types of Ambivalence

Approach/approach: person is torn between positive choices, win-win situation Avoidance/avoidance: choice is between two unpleasant alternatives, lesser of two evils Approach/avoidance: only one possible choice is being considered and it has significant positive and negative aspects Double approach/avoidance: most difficult, two options, each of which has both powerful positive and negative aspects

Types of Ambivalence (MI)*

Approach/approach: person is torn between positive choices, win-win situation Avoidance/avoidance: choice is between two unpleasant alternatives, lesser of two evils Approach/avoidance: only one possible choice is being considered and it has significant positive and negative aspects Double approach/avoidance: most difficult, two options, each of which has both powerful positive and negative aspects

How to elicit automatic thoughts*

Ask them what they were feeling and where on their body. Elicit a detailed description. Visualize the distressing situation. Role-Play the situation Elicit an image Supply opposite thoughts to those you hypothesize went through their mind. Ask for the meaning of the situation. Phrase the question differently.

Focusing on the problem (Mid Session; CBT)

Ask which problem to address first Collect data on the problem Conceptualize client's difficulties according to cognitive model Then collaboratively decide whether to (Work on solving the problem Evaluate the automatic though Reduce patient immediate distress Focus on behavioral change) Setting new homework

Six Common Disengagement Traps (MI)*

Assessment trap: if intakes are regarded as a prerequisite to rather than the beginning of treatment, clients may be alienated. Structure of intakes (question answer) places the client in a passive and one-down role. Additionally, the benefit of the questioning may be lost on the client. Ask open ended questions, reflect back what you are understanding Expert trap: asking a bunch of questions communicates that the therapist is in control and that at the end of questioning you'll have the answer. Know that you don't have the answers for clients without their collaboration and expertise Premature focus trap: focusing before engaging, trying to solve the problem before you have established a working collaboration and negotiated common goals. The trap is that you want to talk about a particular problem and the client is concerned about a different topic. Avoid focusing prematurely on issues that interest you but are of less concern to the person. Labeling trap: a specific form of the premature focus trap. You want to focus on a particular problem and you call it by a name (diagnostic label). Labeling can cause discord and descends into taking sides and hinders progress. Avoid getting into unproductive debates and struggles over labels. When diagnosis is required, collaboratively talk with the client about it Blaming trap: client's concern with and defensiveness about blaming. Can be dealt with by reflecting and reframing the persons concerns. Chat trap: insufficient direction to the conversation. Focus primary attention to the client's concerns and goals

Compensatory Mechanisms

Avoid negative emotions • Be perfect • Be responsible • Avoid intimacy • Receive recognition • Avoid confrontation • Control situations • Act childlike • Please others • Display high emotion/attract attention • Appear incompetent or helpless • Avoid responsibility • Seek inappropriate intimacy • Avoid attention • Provoke others • Give up control to others • Act in an authoritarian manner • Distance myself from others or try to please only oneself

Ten Principles of CPT*

CBT is based on an ever-evolving formulation of patients' problems and an individual conceptualization of each patient in cognitive terms. CBT requires a sound therapeutic alliance. CBT emphasizes collaboration and active participation. CBT is goal oriented and problem focused CBT initially emphasizes the present. CBT is educative, aims to teach the patient to be her/his own therapist, and emphasizes relapse prevention. CBT aims to be time limited CBT is structured. CBT teaches patients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs. CBT uses a variety of teaching techniques to change thinking, mood, and behavior.

What to do when experiencing discord (MI)*

Check yourself Find source of discord Discord in engagement Discord in focusing Discord in evoking Discord in planning

Mobilizing Change Talk (CAT; MI)*

Commitment Activation Taking Steps

Techniques for motivating change

Confidence ruler Giving information and advice Identifying and affirming strengths Reviewing past successes Brainstorming Reframing Hypothetical thinking Responding to confidence talk Radical change with multiple problems Asking permission, open-ended questions, eliciting/evoking change talk, reflective listening, affirmations, decisional balancing (what are some good things about, some bad things about), normalizing, advice/feedback (presented neutrally), readiness to change ruler, exploring importance and confidence, summaries, statements supporting self-efficacy

When to not use MI*

Conflict of Interest (Investment) Coercive Power If unlikely to benefit client

Types of Discord

Defending: it's not my fault Squaring off: you are perceived as an adversary rather than an advocate Interrupting: client talking over you may mean "you don't understand" Disengagement: inattentive or distracted Discord in engaging: labeling and blaming are likely to promote alienation. The client comes in feeling angry and defensive, making engagement difficult Discord in focusing: what is on the therapist's mind may not be the person's highest priority (premature focus trap) Discord in evoking: you'll notice that if you push the conversation in a direction or pace that the client is not ready for discord can emerge. Common consequence of the righting reflex Discord in planning: planning needs to be collaborative

Prepatory Change Talk (DARN; MI)*

Desire Ability Reasons Need

Initial part of a session (CBT)*

Do a mood check Set the agenda Obtain an update Review homework Prioritize agenda

Evocation in MI

Draw Motivation for change from the student

Focusing: Exchanging Information: Elicit-Provide-Elicit (MI)*

Elicit: ask permission, clarify information needs and gaps Provide: prioritize, be clear, support autonomy, don't prescribe the person's response Elicit: ask for the client's interpretation understanding or response.

Compassion in MI

Engage the individual, not the problem

What to do in the evaluation session (CBT)*

Formulate case & cognitive conceptualization Determine if you are an appropriate therapist Determine if you can provide an appropriate dose Determine whether adjunctive tx may be indicated Initiate therapeutic alliance with patient (and family) Introduce the structure and process of therapy Identify important problems & set goals

Considerations when determining whether to use CBT to moderate or challenging specific beliefs*

How much they believe it? How much does it affect their life? Should we work on it now? Is the patient likely to be able to evaluate it with sufficient objectivity? Do we have enough time to work on it in today's session?

MI vs. CBT

MI addresses problems of motivation, treatment readiness, ambivalence and resistance. MI: Not driven by theory or "model" Focuses on building client motivation Client primarily responsible for change Provider elicits, guides, and supports. No specific assumptions regarding course of treatment. Client-centered aspects (e.g. reflective listening, open-ended questions). Provider guides client toward change. Strengthen commitment to action plan CBT provides a variety of strategies for change in numerous clinical problems including depression, anxiety, low self esteem, anger, low resilience and more. These skills are used selectively to reinforce change talk and encourage clients to verbalize the advantages of change and then plan for it. CBT Process: Case conceptualization Time-limited and solution-focused. Structured and directive Individual and/or group format. Sound therapeutic relationship is essential. Educative and skill-building processes. Socratic method- Role play, rehearsal, shaping- Homework

Four Broad Ethical Values of MI*

Nonmaleficence: do no harm. It is possible for nonintervention to be harmful Beneficence: provide benefit. Autonomy: respect for human freedom and dignity Justice: equitable access to the benefits of treatment and protections against risks

OARS (MI)*

Open questions: invites the person to think before responding and provides space for different ways of answering. Typically, ask an open question and then reflect what the person says. Two reflections per question. Open questions yield more information, and invite conversation no a topic, focusing attention in a particular direction Affirming: to recognize and acknowledge that which is good including the individual inherent worth as a human being. To affirm is to support and encourage. It can increase retention in treatment and reduce defensiveness. You can affirm or you can ask the client to describe their own strengths and other self-affirming statements. Affirming notices, recognizes and acknowledges the positive about the person. Avoid affirmations with "I" in them. Summarizing: are affirming because they imply that you remember what they told you and want to understand how it fits together. A collecting summary recalls a series of interrelated items as they accumulate. A linking summary reflects what the person has said and links it to something else you remembered from prior conversation. Transitional summaries wrap up a task or session by pulling together what seems important or announces a shift to something new. Different from reflections because they pull together multiple elements whereas reflections are just what has been said directly prior

12 Roadblocks to active listening (MI)

Ordering, Directing, Commanding Warning or Threatening Giving Advice, Making Suggestions, Providing Solutions Persuading with Logic, Arguing, Lecturing Moralizing or Preaching Judging, Criticizing, Directing, Blaming Agreeing, Approving, Praising Shaming, Ridiculing, Name-Calling Interpreting or Analyzing Reassuring, Sympathizing, Consoling Questioning or Probing Withdrawing, Distracting, Humoring, Changing the Subject

Four Processes of MI

Planning Evoking Focusing Engaging

Cognitive and Behavioral Techniques

Problem Solving & Skills Training Making Decisions Refocusing Measuring Moods and behavior Using the Activity Chart. Relaxation and Mindfulness Graded Task Assignments Exposure Role-Play Using the "Pie" Technique Determining Responsibility Credit List

Use of Therapy Notes

Process Notes Therapists write down and recount issues identified in session: (+'s) - Less threatening to clinicians, Provides a more detailed recount of the session (compared with verbal report alone), Begins to identify therapist issues during session (process) recollection, transparency (-'s) Limited ability to monitor and provide feedback on the process of therapy, Subject to therapist focus and session along with their own personal reactions and feelings encountered in the session

Focusing on the problem (End Session; CBT)

Provide or elicit a summary Review new homework assignment Elicit Feedback

End of Session (CBT)*

Provide or elicit a summary Review new homework assignment Elicit Feedback

Identifying Core Beliefs*

Recognize when a belief is expressed as an automatic thought Provide the first part of an assumption Directly elicit a rule or attitude Use the downward arrow technique examine the patient's automatic thought and look for common themes ask the patient directly review a belief questionnaire completed by the patient

Considerations for balancing your client's autonomy and your ethics.

Reconsider or negotiate your agenda, making clear your own concerns and aspirations for the person Current goal of the client Yes No Your Yes A B Your No C D In cells A and D the client's and clinician's goals agree. Most practitioners spend most of their time working in A. Cell c contains client goals that you do not share. Cell B is where you have goals for the client that they do not currently share. MI was designed for Cell B (this is where ambivalence is found). When there is a situation where the therapist perceive a change that would be beneficial but the client does not see it. The book believes that when the clinician has a change aspiration that the client does not share and the clinician hopes to influence the client to want, choose, and pursue the change, the book believes that it does no violate the ethical principle of autonomy. This is because ultimately decisions about any personal change necessarily remain with the client. MI is not about persuading people to do something that is against their values, goals or best interest.

Cognitive Conceptualization Diagram Components (CPT)*

Relevant Childhood Data Core Beliefs Conditional Assumptions/Beliefs/Rules Compensatory Coping Strategies Situation (1,2,3) Automatic Thought (1,2,3) Meaning of AT (1,2,3, could lead back to Core Belief) Emotion Behavior

How to respond to discord

Responding to discord: reflection is a key tool for understanding and restoring a working alliance Apologizing Affirming Shifting focus to stop exacerbating the discord

Structure of the first therapy session (CBT)*

Set an agenda Discuss the patient's current mood & diagnosis Obtain Update from last session Set goals Outline the cognitive model Start working on a problem. Provide a summary Review homework assignments. Elicit feedback

Before trying to modify beliefs ask... (CBT)

Should you modify them? How strongly does the client believe it? If strongly, how broadly and how strongly does it affect the client's life? Should you work on it now? What may be the advantages & disadvantages to those beliefs? What belief/beliefs would be more functional for the client?

Reflections (MI)*

Simple Reflection Complex Reflection Should be most common response (2 per every question)

Modifying Core Beliefs*

Socratic Questioning Behavioral Experiments Cognitive continuum Intellectual-emotional role plays Using others as a reference point Acting "as if" Self-disclosure

Techniques for modifying automatic thoughts

Socratic questioning Behavioral experiments Cognitive continuum Intellectual-emotional role plays Using others as a reference point Acting "as if" Self-disclosure

Partnership/Collaboration, the "spirit" of MI*

Step out of expert role and position self alongside the student MI is done "for" and "with", not on or to Judo vs dancing technique Helper does less than ½ the talking Exploration, rather than exhortation

7 Ways to respond to change talk and discord (MI)*

Straight Reflection Amplified Reflection Double-Sided Reflection Emphasizing Autonomy Reframing Agreeing with a Twist Coming Alongside (agreement w/o a twist)

Acceptance in MI

Support autonomy and self-worth

Ambivalence: Change and Sustain Talk (MI)*

Taking Steps Commitment Activation Need Reasons Ability Desire

MI and CPT similarities

Talk therapies with "manuals" Share common elements of a therapeutic relationship- Empathy- Collaboration Emphasize client activity outside meetings Empirical support for efficacy Require training for provider competency

Educating Clients on core beliefs

That it is an idea, not necessarily a truth That they can believe it quite strongly, even "feel" it to be true, and yet it might be mostly or entirely untrue. That, as an idea, it can be tested. That it may be rooted in childhood events, and may or may not have been true at the time they first come to believe it. That it continues to be maintained through the operation of their schemas, in which they readily recognize data that support the core belief while ignoring or discounting data to the contrary. That you and they, working together, can use a variety of strategies over time to change this idea so that they can view themselves in a more realistic way.

Questions you might ask to a help client evaluate their automatic thoughts

The evidence question The alternative explanation question The decatastrophizing question The impact of automatic thought question The distancing question (What would you tell someone else in that situation?) The problem solving question (what to do if in that situation again?)

The Righting Reflex (MI)

The natural desire of helpers to set things right, to prevent harm and promote client welfare.

Ambivalence (MI)*

The simultaneous presence of competing motivations for and against change. The main goal of MI is to acknowledge ambivalence

How to Respond to change talk (MI)*

Use elaborations, affirmation, reflections and summarization (OARS) to recognize and strength CHANGE TALK

Therapy Report (CBT)*

What did we cover today that's important to you to remember? How much did you feel you could trust your therapist today? Was there anything that bothered you about therapy today? If so, what was it? How much homework had you done for therapy? How likely are you to do the new homework? What do you want to make sure to cover at the next session?

Affirmation (MI)

When the interviewer accentuates the positive, seeking and acknowledging a person's strengths and efforts.

Autonomy Support (MI)*

When the interviewer accepts and confirms the client's irrevocable right to self-determination and choice.

When and how to use neutrality (MI)

When you have no opinion yet about what direction would be best for the person or because you think you should not influence the choice one way or another Equipoise: leaving a choice wholly up to the client You do not have equipoise about a person, but rather a particular choice being contemplated It is different from your own opinion or aspiration It is a conscious intentional decision not to use one's professional presence and skills to influence a client toward making a specific choice or change Inform the client that you are choosing to remain neutral Avoid inadvertent guiding

Middle Part of Session (CBT)*

Work on specific problems, teach CBT Skills Follow up with relevant, collaboratively set HW assignment Work on second problem

Automatic Thoughts can be evaluated by...

validity and utility which can be: Distorted ("I am the worst person in the world.") Accurate, but the conclusion is distorted. ("I missed my kids play, he will never forgive me." Valid, but dysfunctional. ("I don't know if I will pass the EPPP.")