Motivational InterviewingSlide 2Slide 4Slide 5Slide 6Slide 7SkillsExpressing EmpathyDevelop DiscrepancyFour Types of Client ResistanceResponding to ResistanceSlide 13Slide 14Rolling With ResistanceSiding With the NegativeAvoiding ArgumentsAsk Open-Ended QuestionsListen ReflectivelySummarizeAffirmFour types of Motivational StatementsBehavioral and CBT ApproachesBehavioral/Cognitive-Behavioral InterventionsAssumptions of these approachesAssumptionsBehavioral/CBT Etiology of DependenceSlide 28Behavioral/CBT AssessmentFunctional AnalysisBehavioral/CBT Treatment GoalsSlide 32Slide 33CBT ApproachesSlide 35Behavioral InterventionsSlide 37Behavioral InterventionsContingency ManagementContingency ManagementContingency ManagementEffectiveness of contingency management: Cocaine abuse Higgins et al., 1991Relapse Prevention OverviewSlide 44Slide 45Slide 46Relapse Prevention TheorySlide 48Relapse Prevention Theory of TreatmentRelapse Prevention TreatmentRelapse PreventionSlide 52Slide 53Slide 54Slide 55Slide 56Slide 57Slide 58Relapse Prevention LapseRelapse Prevention LapseSlide 61Relapse Prevention RelapseRelapse Prevention Dealing with a LapseSlide 64Slide 65Behavioral/CBTContinuing improvement after CBTSlide 68Behavioral/CBT Overall Strengths/weaknessesSlide 70Slide 71Motivational Interviewing•Motivational Interviewing:a therapeutic style intended to help clinicians work with clients to address the client’s continuous fluctuation between opposing behaviors and thoughts.Appropriate Motivational Strategies for Each Stage of ChangeClient's Stage of Change Appropriate Motivational Strategies for the ClinicianPrecontemplationThe client is not yet considering change or is unwilling or unable to change. •Establish rapport, ask permission, and build trust. •Raise doubts or concerns in the client about substance-using patterns •Express concern and keep the door open.Client's Stage of Change Appropriate Motivational Strategies for the ClinicianContemplationThe client acknowledges concerns and is considering the possibility of change but is ambivalent and uncertain. •Normalize ambivalence. •Help the client "tip the decisional balance scales" toward change.•Elicit and summarize self-motivational statements of intent and commitment from the client. •Elicit ideas regarding the client's perceived self-efficacy and expectations regarding treatment.Client's Stage of Change Appropriate Motivational Strategies for the ClinicianPreparationThe client is committed to and planning to make a change in the near future but is still considering what to do. •Explore treatment expectancies and the client's role. •Clarify the client's own goals. •Negotiate a change--or treatment--plan and behavior contract. •Consider and lower barriers to change. •Help the client enlist social support.Client's Stage of Change Appropriate Motivational Strategies for the ClinicianActionThe client is actively taking steps to change but has not yet reached a stable state. •Engage the client in treatment and reinforce the importance of remaining in recovery. •Acknowledge difficulties for the client in early stages of change. •Help the client identify high-risk situations through a functional analysis and develop appropriate coping strategies to overcome these.Client's Stage of Change Appropriate Motivational Strategies for the ClinicianMaintenanceThe client has achieved initial goals such as abstinence and is now working to maintain gains. •Support lifestyle changes. •Affirm the client's resolve and self-efficacy. •Help the client practice and use new coping strategies to avoid a return to use. •Develop a "fire escape" plan if the client resumes substance use. •Review long-term goals with the client.Client's Stage of Change Appropriate Motivational Strategies for the ClinicianRecurrenceThe client has experienced a recurrence of symptoms and must now cope with consequences and decide what to do next. •Help the client reenter the change cycle and commend any willingness to reconsider positive change. •Explore the meaning and reality of the recurrence as a learning opportunity. •Assist the client in finding alternative coping strategies. •Maintain supportive contact.Skills•Express EMPATHY through reflective listening.•Develop discrepancy or inconsistencies between client goals and current behavior.•Avoid argument and direct confrontation.•Adjust to client’s resistance rather than opposing it directly.•Support self-efficacy and optimism.Expressing Empathy •Acceptance facilitates change•Skillful reflective listening is fundamental to expressing empathy•Ambivalence is normalDevelop Discrepancy•Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes for the future.•Developing awareness of consequences helps clients examine their behavior. •The client should present the arguments for change.Four Types of Client Resistance •Arguing–The client contests the accuracy, expertise, or integrity of the clinician.•Interrupting –The client breaks in and interrupts the clinician in a defensive manner.•Denying–The client expresses unwillingness to recognize problems, cooperate, accept responsibility, or take advice. •Ignoring–The client shows evidence of ignoring and not following the clinician.Responding to Resistance•Simple Reflection–Repeating the client's statement in a neutral form–Acknowledges and validates what the client has said and can elicit an opposite response.•Amplified Reflection–Reflect the client's statement in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.Responding to Resistance•Double Sided Reflection–Acknowledging what the client has said but also stating contrary things she has said in the past•Shifting Focus–Help the client shift focus away from obstacles and barriers–Offers an opportunity to affirm your client's personal choice regarding the conduct of his own lifeResponding to Resistance•Agreement with a twist–Agree with the client, but with a slight twist or change of direction that propels the discussion forward.•Reframing–A good strategy to use when a client denies personal problems–Offer a new and positive interpretation of negative information provided by the client. –Reframing "acknowledges the validity of the client's raw observations, but offers a new meaning...for