Counseling and Motivational Interviewing

 

Counseling and Motivational Interviewing By Dr Mwiya L. Imasiku

 

Part 1 Counselling

 

Definition of Counseling Therapeutic relationship between counsellor and client that leads to growth, change, healing, autonomy, and care for oneself and others

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CHALLENGES ! HEL"E#S 

Dealing with difficult clients

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Dealing with resistant clients

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Dealing with clients who think they know everything

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Dealing with clients in denial that they have a problem

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E!!EC$I%E NN&%E#BAL BEHA%I#S !HEL"E#S S' Squarely look at the client 

' aintain '  aintain an open posture

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L' Slightly lean toward the client  E' E' aintain  aintain an appropriate eye contact 

#' !ot #'  !ot being tensed but rela"ed  rela"ed 

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E!!EC$I%E A$ A$$ENDING S(ILLS ! HEL"E#S  !odding your head to indicate you are with the client 

Producing sounds# $m or $h etc  Silence # certain brief poses promote self e"ploration on the part of clients

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listening  %ctive listening  %ctive listening listening to the affect, affect, behavior behavior,, e"periences &verbal and none verbal behavior' of another person( % good listener does not interrupt

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listening  %ctive listening Concentrate on what is being said(  %ccurately hear the feelings of clients  %sk clarifying clarifying questions Paraphrasing shows you have listened well# e(g(, you said that((( ) heard you say that* what you are saying is that*

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+mpathy To feel inner world and underlying pain of another( +mpathy is listening for meaning( +mpathy is the bedrock of all skills Carl ogers defined empathy as an attempt to understand an internal framework of another person with accuracy( +mpathy is listening for meaning( 9

 

#o)ert Cra*ku++ devised a s*ale wit, +our  -evel 1 being slightly off track with what the client has levels o+ measuring em-at,y

said( 

-evel . being on track with what the client has said

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-evel / responses what has been saidreflects the meaning and feelings of 

-evel 0 responses reflects beyond the meaning and feelings of what has been said

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+mpathy makes clients understand a deep part of themselves

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  enuineness To be honest or authenti authentic c and self disclosure ) really want us to e"plore this so that ) can understand

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  enuineness To be honest or authentic and self disclosure e(g tell client 2) really want us to e"plore this so that ) can understand3

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  %cceptance Sometimes called unconditional positive regard( %ccepting %ccepting another without strings attached( e(g(, -et client know that you want to hear what he has to say( Show nonverbally that you are prepared to work with someone

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4pen indedness To be receptive to values of clients by suspending your own values and opinions +(g(, -et him know that you are going to be open to what he is going to say

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Psychological ad5ustment To be mentally healthy

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Cognitive Comple"ity 6eing reflective and willingness to e"amine a case from many perspectives(

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elationship building  %bility to develop develop a therapeutic therapeutic relationship or working alliance

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Competent 6eing willing to acquire knowledge and skills

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Part . otivational )nterviewing

 

#E!LEC$I%E S(ILLS ! H SCIAL #(E#S NEED $ #ES"ND $ CLIEN$S 

Ask *lari+ying /uestions. Does /uestions. Does not ask other kinds of questions(

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"ara-,rasing' is repeating the same meaning of what has been conveyed to you in a condensed form(  form(   Paraphrasing shows you have listened well# e(g(, you saying that,,, ) heard you say that* what you are saying is that* 7 if ) heard you right you are saying that*(

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%alidating *lients0 responses# *lients0 responses# acknowledging and praising the client for any observed positive progress made or view e"pressed(

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Definition of otivational )nterviewing otivational interviewing is a directive, client#centred style o+ intera*tion aimed intera*tion aimed at helping children and adolescents e"plore and resolve their  ambivalence about their negative behaviours which affect thier health and begin to make positive changes(

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)n other words* Some people engage in negative behaviour because they do not fully recognise that they have a problem

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)t seems surprising* That some children and adolescents don8t simply stop endulging in negative behaviour, considering that this creates so many problems for them and their families(

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9owever* children and adolescents that engage in negative behaviours which affect their health often say they want to stop, but they simply don8t know how, are unable to, or are not fully ready to stop(

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$nderstanding 9ow People Change: odels

 

Traditional approach ;1< The Stick

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Change is motivated by discomfort(

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)f you can make people feel bad enough, they will change(

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People have to 2hit bottom3 to be ready for change

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Corollary: People don8t change if they haven8t suffered enough

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Traditional approach ;.<  You  Y ou better! Or else!

I+ t,e sti*k is )ig enoug,1 t,ere is no need +or a *arrot.

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 %nother approa approach: ch: otivating otivating ;1< 

People are ambivalent about change

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People continue their drug use because of their ambivalence

The carrot

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 %nother approa approach: ch: otivating otivating ;1< 

otivation for change can be fostered by an accepting, empowering, and safe atmosphere

The carrot

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 %mbivalence  %mbivalence: =eeling =eeling two w ways ays about something(  %ll change contains contains an element of ambivalence(

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esolving ambivalence in the direction of change is a key element of motivational interviewing

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otivational )nterviewing

>hy don8t some children and adolescents change? 

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@ou would think ( ( ( that when an adolescent has a heart attack, it would be enough to persuade him to quit smoking, change his diet, exercise more, and take his medication.

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@ou would think ( ( ( that hangovers, damaged relationships,  A or even being pregnance  A would be enough to convince an adolescent girl to stop drinking excessively.

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 children and >hy don’t  children adolescents change?  

 

>hat is the problem? )t is !4T that*  they don8t want to see ;denial< 

they don8t care ;no motivation< They are 5ust early in the stages of change

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Stages of Change

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 %ctivity 1: eflection eflection Take some time to think about the most difficult change that you had to make in your live( 9ow much time did it take you to move from considering that change to actually taking action(

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Stages of Change ecognising the need to change and understanding how to change doesn8t happen all at once( )t usually takes time and patience(

Children and adolescents often go through a series of 2stages3 as they begin to recognise that they have a problem(

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9elping people change ;1< 9elping children and adolescents change involves increasing their awareness of their need to through change the andstages helpingofthem to start moving change( 

Start 2where the client is3

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Positive approaches are more effective than confrontation B particularly in an outpatient o utpatient setting(

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9elping children and adolescents change ;.< otivational interviewing is the process otivational of helping people moving through the stages of change(

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=irst Stage: Pre#contemplation Children and adolescents at this stage:  %re unaware of any problem related related to their behaviour 

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 %re unconcerned about about their negative negative

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behaviour  )gnore anyone else8s belief that they are doing something harmful

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Second Stage: Contemplation Children and adolescents at this stage are considering whether or not to change: 

They en5oy using drugs, but

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They are sometimes worried about the increasing difficulties the use is causing(

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They are constantly debating with themselves whether or not they have a problem(

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Third Stage: Determinationpreparation Children and adolescents at this stage are deciding how they are going to change 

ay be ready to change their behaviour 

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etting ready to make the change

m ove to the ne"t stage ;actionhen to use motivational strategies otivational interviewing can be used as:  %n assessment tool

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 %n intervention tool to help move the patient through the change process(

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 % way to facilitate the naturally occurring change process in patients

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 % method for helping the patient resolve ambivalence(

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)mportant considerat considerations ions The clinician8s counselling style is one of the most important aspects of motivational interviewing: interviewing: 

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$se reflective listening and empathy  %void confrontation confrontation >ork as a team against 2the problem3

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otivating for change otivating for change Maintenan*e A*tion Determination4 "re-aration

Contem-lation

"re&*ontem-lation

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Principles of otivational )nterviewing

 

Principles of otivational )nterviewing

otivational interviewing interviewing is founded on 0 basic principles: 

+"press empathy

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Develop discrepancy

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oll with resistance  Support self#efficacy

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Principle 1: +"press empathy 

The crucial attitude is one of acceptance

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Skilful reflective listening is fundamental to the patient8s feeling understood and cared about(

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Patient ambivalence is normal the clinician should demonstrate an understanding of the client8s perspective

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-abelling is unnecessary

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+"ample of e"pressing empathy

You drink wine to help you sleep.

So you are concerned about not having a job.

) am so tired that ) cannot even sleep* So ) drink some wine( *>hen ) wake up*) am too late for work already* @esterday @e sterday my boss fired me( (((but ) do not have a drinking problemE

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Principle .: Develop discrepancy 

Clarify important goals for the patient

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+"plore the consequences or potential consequences of the patient 8s current behaviours(

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Create and amplify in the patient8s mind a discrepancy between current behaviour and life goals

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+"ample of developing discrepancy ) only en5oy having some drinks with my friends*that8s all( Drinking helps me rela" and have fun*) think that ) So drinking has some good things for you* !ow tell me about the not#so#good things you have e"perienced

deserve that for a change*

because of drinking(

>ell*as ) said, ) lost my 5ob because of my drinking problem*

and ) often feel sick(  

Principle /: oll with resistance  %void resistance

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)f it arises, stop s top and find another way to proceed

 %void confrontation

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Shift perceptions

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)nvite, but do not impose, new perspectives  Falue the client as a resource for finding solutions to problems

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+"ample of !4T rolling with resistance resistance ) do not want to stop drinking*as ) said, ) do not have a drinking problem*) want to drink when ) feel like it(

6ut, %nna, ) think it is clear that drinking has caused you problems(

@ou do not have the right to 5udge me( @ou @ou don8t don 8t

understand me( 59  

+"ample of rolling with resistance

@ou do have a

) do not want to stop drinking*as ) said, ) do not have a drinking problem*) want to drink when ) feel like it(

drinking problem

4thers may think you have a problem, but you don8t(

That8s right, my mother thinks that ) have a problem, but she8s wrong(

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Principle 0: Support self#efficacy 

6elief in the ability to change ;self# efficacy< is an important motivator 

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The client is responsible for choosing and carrying out personal change

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There is hope in the range of alternative approaches available

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+"ample of supporting self#efficacy self#efficacy ) am wondering if you can help me( ) have failed many times( (  %nna, ) don8t think you have failed because you are still here, hoping things can be better( %s long as you are willing to stay in the process, ) will support you( @ou have been successful before and you will be again( ) hope things will be better this time( )8m willing to

give it a try( 62  

Part .: 9ow to $se otivational Skills in Clinical Settings

 

Training ob5ectives At t,e end o+ t,is -art1 you will )e a)le to'  

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2eflect3 proficiently Put into practise the 4%S strategies or micro#skills )ncrease your empathic abilities by working on personal issues and role#playing client issues(

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Techniques -earning the icro#Skills of  otivational )nterviewing

 

4%S $,e A#S are t,e skills t,at *an )e used )y interviewers to ,el- move *lients t,roug, t,e -ro*ess o+ *,ange.

pen#ended questions Affirmation #eflective listening

Summarising 66  

4%S: 4pen#ended questions -en&ended /uestions' 

 2>hat are the good things about your substance use?3 vs( 2%re there good things about using?3

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 2Tell me about the not#so#good things about using3 vs(  2Te 2%re there bad things about using?3

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 2@ou  2@o u seem to have some concerns about your substance use( Tell me more about them(3 vs( 2Do you have concerns about your substance use?3

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 2>hat most concerns you about that?3 vs( 2Do you worry a lot about using substances?3

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4%S: %ffirmation 

2Thanks for coming today(3 today(3

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2) appreciate that you are willing to talk to me about your substance use(3

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2@ou are obviously a resourceful person 2@o pers on to have coped with those difficulties(3

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 2That8s a good idea(3

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2)t8s hard to talk about(((() really appreciate your keeping on with this(3

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4%S: eflective listening eflective listening is used to: 

Check out whether you really understood the client

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9ighlight the client8s ambivalence about their substance use

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Steer the client towards a greater recognition of her

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or his problems and concerns, and einforce statements indicating indicating that the client is thinking about change(

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4%S: Summarise Summarising is an important way of gathering together what has already been said, making sure you understood the client correctly, and preparing the client to move on( Summarising is putting together a group of reflections(

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4%S: >hat is 2change talk3? C,ange talk' An indi*ation t,at you are su**ess+ully using motivational interviewing.

I+ you are using MI su**ess+ully you will ,ear statements t,at indi*ate t,e *lient' 1(

ecognises the disadvantages of staying the same

.( /(

ecognises the advantages of change +"presses optimism about change

0(

+"presses the intention to change 

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9elping to elicit 2change talk3 ;1<  %sk the patient to clarify their statements statements or elaborate:  

2Describe the last time this happened,3

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2ive me an e"ample of that,3 or 2Tell me more about that(3

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9elping to elicit 2change talk3 ;.<  %sk the patient to imagine the worst consequences of not changing and the best consequences of changing(

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9elping to elicit 2change talk3 ;/< +"plore the patient8s goals and values to identify discrepancies between the client8s values and their current substance use(  

 2>hat are the most important things in your life?3

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Part /:  %dditional otivational Strategies for Clinical Settings

 

Training ob5ectives At t,e end o+ t,is t ,is works,o-1 you will )e a)le to' 

$se the 2Pros and Cons3 =orm

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$se the 2>hat Does )t Cost?3 =orm

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)dentify a minimum of / situations to avoid when using motivational strategies

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The Pros and Cons* 4ften Children and adolescents can identify many advantages and disadvantages of their negative behaviour( They weigh these pros and cons iin n an effort to decide whether or not to continue or stop certain behaviors(

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Decision 6alance: Pros and Cons "ro)e t,e 5"ros and Cons6 by talking about the benefits of change and the costs of staying the same( 

+"plore pros and cons

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!ormalise ambivalence eintroduce feedback and information about the consequences

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e#e"plore values in relation to change

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Summarise concerns

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$se the 2Pros and Cons3 and 2>hat Does it Cost?3 forms

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Pros and Cons Bene+its o+ using drugs Bene+its o+ *,ange Costs o+ using drugs

Costs o+ *,ange

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 %ctivity G: Pros Pros and Cons Cons 

$sing the 2Pros and Cons3 and the 2>hat Does )t Cost?3 forms, observe the role# playing activity

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)ndicate the number of times that the client e"presses a desire to change, the ability to change, reasons to change, a need to

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change, or a commitment to change( !ote e"amples of these e"pressions of change that you hear from the client(

.H minutes 80  

>hat techniques should ) avoid? Techniques to avoid when motivating Children and adolescent patients: 

Confrontationdenial

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Closed questions

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6ecoming the 2e"pert3 problem#solver 

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-abelling

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oadblocks ;1< 4rdering, directing, or commanding  >arning or threatening  iving advice, making suggestions, providing solutions  Persuading with logic, arguing, lecturing  oraliIing, preaching, telling them their duty  Judging, criticising, disagreeing, blaming 

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oadblocks ;.<  %greeing, approving, approving, praising  Shaming, ridiculing, labeling, name# calling  )nterpreting, analysing  eassuring, sympathising, consoling  Kuestioning, probing  >ithdrawing >ithdrawing,, distracting, humouring, changing the sub5ect( 

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Thank you for your timeE The +nd