module 3: motivational interviewing
List the 4 tools that are used to put the principles of MI into practice. Identify when, in the counseling session, these tools are helpful.
"Spirit" of MI: - collaboration (build rapport) - evocation (address ambivalence) - autonomy Principles of MI: - express empathy - develop discrepancy - roll with resistance - support self-efficacy Tools to Express Empathy: - open-ended questions (how have things been going this month?; tell me about your food selections.) - reflective listening (so, you've been able to curb that mid-morning snacking at work but coming home still poses some problems for you; you're frustrated by when you do it yet realizing you are doing it is actually an improvement) Tools to Develop Discrepancy: - elicit (drawing out thoughts or concerns that might not have been shared) - selective reflection (paraphrasing something someone has said about their desire to change and possible reasons for making the change) Tools to Roll with Resistance: - accepting (an individual's beliefs and values) - autonomy (respecting) Tools to Support Self-Efficacy: - summarize - affirming (building confidence)
How can a client's language be an indicator of the degree to which they may be willing to make a change?
Behavior change is more likely if patients are able to verbalize their own arguments and reasons that favor a needed behavior. Specifically, the strength and commitment of change talk is predictive of behavior change. Eliciting change talk is especially important for patients who are ambivalent about change.
What is "Change Talk"? What are different types of Change Talk?
Change talk refers to statements that are made by clients that indicate they might be ready for behavior change. Individuals who engage in change talk are considered to be in the contemplation or preparation stage of change. At the contemplation stage, people are aware that a problem exists and are thinking about making changes but at this particular time they have not made any commitment to change. Those who are in the preparation stage recognize a problem exists, realize the need for change, and are actually preparing to make change. Characteristics of Change Talk: 1. Recognizes current behavior could or does pose a problem. 2. Correlates with a specific goal or behavior. 3. Focuses on tackling problems at the present time. 4. Comes from the patient. Preparatory change talk: occurs when the patient focuses on the advantages of making changes Desire (I want to try..., I hope things will change...) Ability (I could..., it's possible...) Reason (health, family, job; I might be able to enjoy playing outside with my children if I had more stamina) Need (if I don't..., I have to..., if I don't change I'll have to go on medication) Mobilization change talk: occurs when patients begin to focus on working through any ambivalence about making changes Commitment (I will make changes) Action (I am prepared to make changes) Taking Steps (I have made some changes)
How does "Eliciting" develop discrepancy?
Eliciting involves asking questions with the intent of drawing out thoughts or concerns that might not have otherwise been shared. This information can often be used to highlight discrepancies.
Identify techniques the counselor can use to elicit Change Talk?
Evocative Questions: Desire - why might you want to make the change? - what do you hope to see happen with the change? - what do you want your future to look like? Ability - what can you do to make this change? - what do you feel is possible? - what are you able to do as a first step? Reason - what are some benefits of making this change? - what problems would present by not making the change? - what risks would you like to decrease? Need - how important is it to you to make the change? - how does staying this way fit in with the goals you have for your family? Confidence Ruler: - on a scale of 1 to 10 (with 1 being not at all confident and 10 being extremely confident) how confident are you in making this change? - why did you choose that number and not a lower number? Pros/Cons (Extremes): - what are the drawbacks of making the change? - what are some good things that will happen if you make the change? Looking Forward/Back: - where will you start? - what do you intend to do? - if nothing changes, what do you see happening? - how have things been better in the past?
What are the different Stages of Change in the Transtheoretical Model? What are some techniques the counselor can use in each stage of change?
Pre-contemplation: not currently considering change Techniques: validate lack of readiness, clarify that the decision is theirs, encourage re-evaluation of current behavior, encourage self-exploration instead of action, explain and personalize the risk Contemplation: ambivalent about change, not considering change within the next month Techniques: validate lack of readiness, clarify that the decision is theirs, encourage evaluation of pros/cons of behavior change, identify and promote new positive outcome expectations Preparation: some experience with change and are trying to change, planning to act within one month Techniques: identify and assist in problem solving (obstacles), help patient identify social support, verify that the patient has underlying skills for behavior change, encourage small initial steps Action: practicing new behavior (3-6 months) Techniques: focus on restructuring cues and social support, bolster self-efficacy for dealing with obstacles, combat feelings of loss and reiterate long-term benefits Maintenance: continued commitment to sustaining new behavior (6 months to several years) Techniques: plan for follow-up support, reinforce internal rewards, discuss coping with relapse Relapse: resumption of old behaviors Techniques: evaluate trigger for relapse, reassess motivation and behaviors, plan stronger coping strategies
What does "Rolling with Resistance" look like? When is it used?
Rolling with resistance involves exploring a patient's resistance to change and inviting them to examine new points of view (resisting the righting reflex). It is done through accepting what an individual says and believes and respecting their autonomy. This acceptance takes place when the patient states their beliefs and the counselor listens without attempting to change them, judge them, or state objections to what they believe.
Several types of reflective listening can be used to further develop the client's story by assuring understanding, expressing empathy, and developing discrepancy. Identify 7 types of reflections and when they are used.
Simple reflection (repeat/rephrase): simply acknowledging the patient's resistance with a reflective listening statement can lead to further exploration and help you avoid the trap of taking sides Complex reflections: Amplified reflection: reflect back what the patient has said in an exaggerated or extreme way; do it with empathy in a matter of fact tone; this approach may encourage the patient to back off and explore the other side of ambivalence Double-sided reflection: acknowledge the resistance and add a reflective statement about the other side of the patient's ambivalence; be sure to use "and" rather than "but" to maintain balance of emphasis Coming alongside: when the patient argues against the status quo, sometimes it is useful to take sides with them; this approach can induce the patient to move away from resistance and towards change talk Shifting focus: when the conversation doesn't seem to be progressing because of resistance, shifting focus is a way to acknowledge this and redirects the conversation; this can be done using reflection, a question, or summarizing Reframing: acknowledge the validity of what the patient says and present them with new meaning or information that puts the situation in a different perspective; can be viewed as looking for something positive in the negative Agreeing with a twist: offer an initial agreement with a slight change of direction; can be seen as a reflection followed by a reframe and it helps maintain the collaborative relationship
What does it mean to 'support self-efficacy'? What are some ways a counselor can do this?
Supporting self-efficacy can be done by affirming the positive aspects of what the patient has already said and going on to summarize points of the patient's story that show actual movement toward change. Sometimes, this is done when the patient isn't even aware that they've said something that indicates they may be ready for change. Summarizing and affirming can be used to help build confidence.
What benefit(s) does the Confidence Ruler have for the client? For the practitioner?
The Confidence Ruler helps tell you how motivated the patient is to make a change. To get an honest answer, it is best used once you have established rapport with the patient and have a genuine interest in understanding and helping to motivate the patient.
