Motivational 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 Change Client s Stage of Change Appropriate Motivational Strategies for the Clinician Establish rapport ask permission and build trust The client is not yet considering change or Raise doubts or is unwilling or unable to concerns in the client about substance using change patterns Express concern and keep the door open Precontemplation Client s Stage of Change Appropriate Motivational Strategies for the Clinician Normalize ambivalence Help the client tip the decisional balance scales toward change The client acknowledges concerns Elicit and summarize self motivational and is considering the statements of intent and possibility of change commitment from the but is ambivalent and client uncertain Elicit ideas regarding the client s perceived self efficacy and expectations regarding treatment Contemplation Client s Stage of Change Appropriate Motivational Strategies for the Clinician Preparation 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 The client is committed to and planning to make a change in the near future but is still considering what to do Client s Stage of Change Action Appropriate Motivational Strategies for the Clinician Engage the client in treatment and reinforce the importance of remaining in recovery The client is actively Acknowledge taking steps to difficulties for the client change but has not in early stages of yet reached a stable change Help the client identify state 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 Clinician Support lifestyle changes Affirm the client s The client has achieved initial resolve and selfgoals such as abstinence and efficacy is now working to maintain Help the client gains 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 Maintenance Client s Stage of Change Recurrence Appropriate Motivational Strategies for the Clinician Help the client reenter the change cycle and commend any willingness to reconsider The client has positive change experienced a recurrence of symptoms Explore the meaning and must now cope with and reality of the consequences and recurrence as a learning decide what to do next 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 selfefficacy and optimism Expressing Empathy Acceptance facilitates change Skillful reflective listening is fundamental to expressing empathy Ambivalence is normal Develop 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 life Responding 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 them Rolling With Resistance Momentum can be used to good advantage Perceptions can be shifted New perspectives are invited but not imposed The client is a valuable resource in finding solutions to problems Siding With the Negative One more strategy for adapting to client resistance is to side with the negative to take up the negative voice in the discussion If your client is ambivalent your taking the negative side of the argument evokes a Yes but from the client who then expresses the other positive side Avoiding Arguments Arguments are counterproductive Defending breeds defensiveness Resistance is a signal to change strategies Labeling is unnecessary Ask Open Ended Questions Asking open ended questions helps you understand your clients point of view and elicits their feelings about a given topic or situation Openended questions facilitate dialog they cannot be answered with a single word or phrase and do not require any particular response Listen Reflectively Reflective listening is a way of checking rather than assuming that you know what is meant Summarize Summaries reinforce what has been said show that you have been listening carefully and prepare the client to move on Affirm When it is done sincerely affirming your client supports and promotes self efficacy Four types of Motivational Statements Cognitive recognition of the problem e g I guess this is more serious than I thought Affective expression of concern about the perceived problem e g I m really worried about what is