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2013-08-19 18:44:43
Collaboration is a partnership between the therapist and the client, grounded
in the point of view and experiences of the client.
This contrasts with some other approaches to substance use disorders treatment,
which are based on the therapist assuming an 'expert' role, at times
confronting the client and imposing their perpective on the client's substance
use behavior and the appropriate course of treatment and outcome.
The MI approach is one of the therapist'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. No matter what reasons the therapist might offer to convince the client
of the need to change ge their behavior or how much they
might want the person to do so, lasting change is more likely to occur when the
client discovers their own reasons and determination to change. The therapist's
job is to "draw out" the person's own motivations and skills for change, not to
tell them what to do or why they should do.
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.
Counselors reinforce that there is no single "right way" to change and that
there are multiple ways that change can occur. In addition to deciding whether
they will make a change, clients are encouraged to take the lead in developing
a menu of options as to how to achieve the desired change.
The Principles of Motivational Interviewing
Building on and bringing to life the elements of the MI style , there are four
distinct principles
that guide the practice of MI. The therapist employing MI will hold true to
these principles
throughout treatment.
Express Empathy
Empathy involves seeing the world through the client's eyes, thinking about
things as the
client thinks about them, feeling things as the client feels them, sharing in
the client's
experiences. This approach provides the basis for clients to be heard and
understood, and
in turn, clients are more likely to honestly share their experiences in depth.
The process of
expressing empathy relies on the client s experiencing the counselor as able to
see the
world as they (the client) sees it.
Support Self- ‐Efficacy
MI is a strengths- ‐based approach that believes that clients have within
themselves the
capabilities to change successfully. A client's belief that change is possible
(self- ‐efficacy) is
needed to instill hope about making those difficult changes. Clients often have
previously
tried and been unable to achieve or maintain the desired change, creating doubt
about
their ability to succeed. In Motivational Interviewing, counselors support
self- ‐efficacy by
focusing on previous successes and highlighting skills and strengths that the
client already
has.
Roll with Resistance
From an MI perspective, resistance in treatment occurs when then the client
experiences a
conflict between their view of the problem or the solution and that of the
clinician or
when the client experiences their freedom or autonomy being impinged upon.
These
experiences are often based in the client s ambivalence about change. In MI,
counselors
avoid eliciting resistance by not confronting the client and when resistance
occurs, they
work to de- ‐escalate and avoid a negative interaction, instead "rolling with
it." Actions and
statements that demonstrate resistance remain unchallenged especially early in
the
counseling relationship. By rolling with resistance, it disrupts any struggle
that may occur
and the session does not resemble an argument or the client s playing "devil's
advocate" or
yes, but to the counselor's suggestions. The MI value on having the client
define the
problem and develop their own solutions leaves little for the client to resist.
A frequently
used metaphor is dancing rather than wrestling with the client. In
exploring client
concerns, counselors invite clients to examine new points of view, and are
careful not to
impose their own ways of thinking. A key concept is that counselor s avoid the
righting
reflex , a tendency born from concern, to ensure that the client understands
and agrees
with the need to change and to solve the problem for the client.
Develop Discrepancy
Motivation for change occurs when people perceive a mismatch between where
they are
and where they want to be , and a counselor practicing Motivational
Interviewing works to
develop this by helping clients examine the discrepancies between their current
circumstances/behavior and their values and future goals. When clients
recognize that
their current behaviors place them in conflict with their values or interfere
with
accomplishment of self- ‐identified goals, they are more likely to experience
increased
motivation to make important life changes. It is important that the counselor
using MI does
not use strategies to develop discrepancy at the expense of the other
principles, yet
gradually help clients to become aware of how current behaviors may lead them
away
from, rather than toward, their important goals.
Motivational Interviewing Skills and Strategies
The practice of Motivational Interviewing involves the skillful use of certain
techniques for
bringing to life the MI spirit , demonstrating the MI principles, and guiding
the process toward
eliciting client change talk and commitment for change. Change talk involves
statements or
non- ‐verbal communications indicating the client may be considering the
possibility of change.
OARS
Often called micro counseling skills, OARS is a brief way to remember the basic
approach used
in Motivational Interviewing. Open Ended Questions, Affirmations, Reflections,
and
Summaries are core counselor behaviors employed to move the process forward by
establishing a therapeutic alliance and eliciting discussion about change.
Open- ‐ended questions are those that are not easily answered with a "yes/no"
or short
answer containing only a specific, limited piece of information. Open- ‐ended
questions invite
elaboration and thinking more deeply about an issue. Although closed questions
have their
place and are at times valuable (e.g., when collecting specific information in
an assessment),
open- ‐ended questions create forward momentum used to help the client explore
the
reasons for and possibility of change.
Affirmations are statements that recognize client strengths. They assist in
building rapport
and in helping the client see themselves in a different, more positive light.
To be effective
they must be congruent and genuine. The use of affirmations can help clients
feel that
change is possible even when previous efforts have been unsuccessful.
Affirmations often
involve reframing behaviors or concerns as evidence of positive client
qualities. Affirmations
are a key element in facilitating the MI principle of Supporting Self-
‐efficacy.
Reflections or reflective listening is perhaps the most crucial skill in
Motivational
Interviewing. It has two primary purposes. First is to bring to life the
principle of Expressing
Empathy. By careful listening and reflective responses, the client comes to
feel that the
counselor understands the issues from their perspective. Beyond this, strategic
use
reflective listening is a core intervention toward guiding the client toward
change,
supporting the goal- ‐directed aspect of MI. In this use of reflections, the
therapist guides the
client towards resolving ambivalence by a focus on the negative aspects of the
status quo
and the positives of making change. There are several levels of reflection
ranging from
simple to more complex. Different types of reflections are skillfully used as
clients
demonstrate different levels of readiness for change. For example, some types
of
reflections are more helpful when the client seems resistant and others more
appropriate
when the client offers statements more indicative of commitment to change.
Summaries are a special type of reflection where the therapist recaps what
has occurred in
all or part of a counseling session(s). Summaries communicate interest,
understanding and
call attention to important elements of the discussion. They may be used to
shift attention
or direction and prepare the client to move on. Summaries can highlight both
sides of a
client s ambivalence about change and promote the development of discrepancy by
strategically selecting what information should be included and what can be
minimized or
excluded.
Change Talk
Change talk is defined as statements by the client revealing consideration of,
motivation for, or
commitment to change. In Motivational Interviewing, the therapist seeks to
guide the client to
expressions of change talk as the pathway to change. Research indicates a clear
correlation
between client statements about change and outcomes - ‐ client- ‐reported
levels of success in
changing a behavior. The more someone talks about change, the more likely they
are to
change. Different types of change talk can be described using the mnemonic
DARN- ‐CAT.
Preparatory Change Talk
Desire (I want to change)
Ability (I can change)
Reason (It s important to change)
Need (I should change)
And most predictive of positive outcome:
Implementing Change Talk
Commitment (I will make changes)
Activation (I am ready, prepared, willing to change)
Taking Steps (I am taking specific actions to change)
Strategies for Evoking Change Talk
There are specific therapeutic strategies that are likely to elicit and support
change talk in
Motivational Interviewing:
1. Ask Evocative Questions: Ask an open question, the answer to which is likely
to be change
talk.
2. Explore Decisional Balance: Ask for the pros and cons of both changing and
staying the
same.
3. Good Things/Not- ‐So- ‐Good Things: Ask about the positives and negatives of
the target
behavior.
4. Ask for Elaboration/Examples: When a change talk theme emerges, ask for more
details.
In what ways? Tell me more? What does that look like? When was the last
time that
happened?
5. Look Back: Ask about a time before the target behavior emerged. How were
things better,
different?
6. Look Forward: Ask what may happen if things continue as they are (status
quo). Try the
miracle question: If you were 100% successful in making the changes you want,
what would
be different? How would you like your life to be five years from now?
7. Query Extremes: What are the worst things that might happen if you don t
make this
change? What are the best things that might happen if you do make this change?
8. Use Change Rulers: Ask: On a scale from 1 to 10, how important is it to you
to change [the
specific target behavior] where 1 is not at all important, and a 10 is
extremely important?
Follow up: And why are you at ___and not _____ [a lower number than stated]?
What
might happen that could move you from ___ to [a higher number]?
Alternatively, you could also ask How confident are that you could make the
change if you
decided to do it?
9. Explore Goals and Values: Ask what the person s guiding values are. What do
they want in
life? Using a values card sort activity can be helpful here. Ask how the
continuation of target
behavior fits in with the person s goals or values. Does it help realize an
important goal or
value, interfere with it, or is it irrelevant?
10. Come Alongside: Explicitly side with the negative (status quo) side of
ambivalence.
Perhaps _______is so important to you that you won t give it up, no matter
what the cost.