Study Cards 102 Lesson 4 PDF

TIP 35 ENHANCING MOTIVATION FOR CHANGE IN SUBSTANCE USE DISORDER TREATMENT Chapter 3—Motivational Interviewing as a Counseling Style Motivational interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change.” —Miller & Rollnick, 2013, p. 21 KEY MESSAGES The spirit of motivational interviewing (MI) is the foundation of the counseling skills required for enhancing clients’ motivation to change. Ambivalence about change is normal; resolving clients’ ambivalence about substance use is a key MI focus. Resistance to change is an expression of ambivalence about change, not a client trait or characteristic. Refective listening is fundamental to the four MI process (i.e., engaging, focusing, evoking, and planning) and core counseling strategies. Chapter 3 explores specifc MI strategies you can use to help clients who misuse substances or who have substance use disorders (SUDs) strengthen their motivation and commitment to change their substance use behaviors. This chapter examines what’s new in MI, the spirit of MI, the concept of ambivalence, core counseling skills, and the four processes of MI, as well as the effectiveness of MI in treating SUDs. Introduction to MI MI is a counseling style based on the following assumptions: Ambivalence about substance use and change is normal and is an important motivational barrier to substance use behavior change. Ambivalence can be resolved by exploring the client’s intrinsic motivations and values. Your alliance with the client is a collaborative partnership to which you each bring important expertise. An empathic, supportive counseling style provides conditions under which change can occur. You can use MI to effectively reduce or eliminate client substance use and other health-risk behaviors in many settings and across genders, ages, races, and ethnicities (DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017; Dillard, Zuniga, & Holstad, 2017; Lundahl et al., 2013). Analysis of more than 200 randomized clinical trials found signifcant effcacy of MI in the treatment of SUDs (Miller & Rollnick, 2014). The MI counseling style helps clients resolve ambivalence that keeps them from reaching personal goals. MI builds on Carl Rogers’ (1965) humanistic theories about people’s capacity for exercising free choice and self-determination. Rogers identifed the suffcient conditions for client change, which are now called “common factors” of therapy, including counselor empathy (Miller & Moyers, 2017). As a counselor, your main goals in MI are to express empathy and elicit clients’ reasons for and commitment to changing substance use behaviors (Miller & Rollnick, 2013). MI is particularly helpful when clients are in the Precontemplation and Contemplation stages of the Stages of Change (SOC), when readiness to change is low, but it can also be useful throughout the change cycle. 35 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment The Spirit of MI Use an MI counseling style to support partnership with clients. Collaborative counselor– client relationships are the essence of MI, without which MI counseling techniques are ineffective. Counselor MI spirit is associated with positive client engagement behaviors (e.g., self-disclosure, cooperation) (Romano & Peters, 2016) and positive client outcomes in health-related behaviors (e.g., exercise, medication adherence) similar to those in addiction treatment (Copeland, McNamara, Kelson, & Simpson, 2015). The spirit of MI (Miller & Rollnick, 2013) comprises the following elements: Partnership refers to an active collaboration between you and the client. A client is more willing to express concerns when you are empathetic and show genuine curiosity about the client’s perspective. In this partnership, you are infuential, but the client drives the conversation. Acceptance refers to your respect for and approval of the client. This doesn’t mean agreeing with everything the client says but is a demonstration of your intention to understand the client’s point of view and concerns. In the context of MI, there are four components of acceptance: - Absolute worth: Prizing the inherent worth and potential of the client - Accurate empathy: An active interest in, and an effort to understand, the client’s internal perspective refected by your genuine curiosity and refective listening - Autonomy support: Honoring and respecting a client’s right to and capacity for self-direction - Affrmation: Acknowledging the client’s values and strengths Compassion refers to your active promotion of the client’s welfare and prioritization of client needs. Evocation elicits and explores motivations, values, strengths, and resources the client already has. To remember the four elements, use the acronym PACE (Stinson & Clark, 2017). The specifc counseling strategies you use in your counseling approach should emphasize one or more of these elements. Principles of Person-Centered Counseling MI refects a longstanding tradition of humanistic counseling and the person-centered approach of Carl Rogers. It is theoretically linked to his theory of the “critical conditions for change,” which states that clients change when they are engaged in a therapeutic relationship in which the counselor is genuine and warm, expresses unconditional positive regard, and displays accurate empathy (Rogers, 1965). MI adds another dimension in your efforts to provide person-centered counseling. In MI, the counselor follows the principles of person-centered counseling but also guides the conversation toward a specifc, client-driven change goal. MI is more directive than purely person-centered counseling; it is guided by the following broad person-centered counseling principles (Miller & Rollnick, 2013): SUD treatment services exist to help recipients. The needs of the client take precedence over the counselor’s or organization’s needs or goals. The client engages in a process of self-change. You facilitate the client’s natural process of change. The client is the expert in his or her own life and has knowledge of what works and what doesn’t. As the counselor, you do not make change happen. People have their own motivation, strengths, and resources. Counselors help activate those resources. You are not responsible for coming up with all the good ideas about change, and you probably don’t have the best ideas for any particular client. Change requires a partnership and “collaboration of expertise.” You must understand the client’s perspectives on his or her problems and need to change. 36 Chapter 3 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style The counseling relationship is not a power struggle. Conversations about change should not become debates. Avoid arguing with or trying to persuade the client that your position is correct. Motivation for change is evoked from, not given to, the client. People make their own decisions about taking action. It is not a change goal until the client says so. The spirit of MI and client-centered counseling principles foster a sound therapeutic alliance. Research on person-centered counseling approaches consistent with MI in treating alcohol use disorder (AUD) found that several sessions improved client outcomes, including readiness to change and reductions in alcohol use (Barrio & Gual, 2016). What Is New in MI Much has changed in MI since Miller and Rollnick’s original (1991) and updated (2002) work. Exhibit 3.1 summarizes important changes to MI based on decades of research and clinical experience. EXHIBIT 3.1. A Comparison of Original and Updated Versions of MI ORIGINAL VERSION UPDATED VERSION Four principles as the basis for the MI approach: Four processes as the basis for the MI approach: 1. Express empathy: Demonstrate empathy 1. Engaging is the relational foundation. through refective listening. 2. Focusing identifes agenda and change goals. 2. Develop discrepancy: Guide conversations 3. Evoking uses MI core skills and strategies for to highlight the difference between clients’ moving toward a specifc change goal. goals or values and their current behavior. 4. Planning is the bridge to behavior change. 3. Roll with resistance: Avoid arguing against the status quo or arguing for change. The four processes replace Phase I and II stages in 4. Support self-effcacy: Support clients’ the original version of MI. Core skills and strategies beliefs that change is possible. of MI include asking open questions, affrming, using refective listening, and summarizing; all are Although these general principles are still integrated into the four processes. The original four helpful, the new emphasis in MI is on evoking principles have been folded into the four processes change talk and commitment to change as as refective listening or strategic responses to move primary principles. conversations along. Resistance is a characteristic of the client. Resistance is an expression of sustain talk and the status quo side of ambivalence, arising out of counselor–client discord. Rolling with resistance Strategies to lessen sustain talk and counselor–client discord Self-motivating statements Change talk Decisional balancing is a strategy to help clients move in one direction toward changing a behavior. Decisional balancing is used to help clients make a decision without favoring a specifc direction of change. It may be useful as a way to assess client readiness to change but also may increase ambivalence for clients who are contemplating change. Source: Miller & Rollnick, 1991, 2002, 2013; Miller & Rose, 2013. Chapter 3 37 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment Exhibit 3.2 presents common misconceptions about MI and provides clarifcation of MI’s underlying theoretical assumptions and counseling approach, which are described in the rest of this chapter. EXHIBIT 3.2. Misconceptions and Clarifcations About MI MISCONCEPTION CLARIFICATION MI is a form of MI shares many principles of the humanistic, person-centered approach nondirective, pioneered by Rogers, but it is not Rogerian therapy. Characteristics that Rogerian therapy. differentiate MI from Rogerian therapy include clearly identifed target behaviors and change goals and differential evoking and strengthening of clients’ motivation for changing target behavior. Unlike Rogerian therapy, MI has a strategic component that emphasizes helping clients move toward a specifc behavioral change goal. MI is a counseling technique. Although there are specifc MI counseling strategies, MI is not a counseling technique. It is a style of being with people that uses specifc clinical skills to foster motivation to change. MI is a “school” of counseling or psychotherapy. Some psychological theories underlie the spirit and style of MI, but it was not meant to be a theory of change with a comprehensive set of associated clinical skills. MI and the SOC MI and the SOC were developed around the same time, and people confuse the approach are the two approaches. MI is not the SOC. MI is not an essential part of the SOC and same. vice versa. They are compatible and complementary. MI is also compatible with counseling approaches like cognitive–behavioral therapy (CBT). MI always uses Assessment feedback delivered in the MI style was an adaptation of MI that assessment became motivational enhancement therapy (MET). Although personalized feedback. feedback may be helpful to enhance motivation with clients who are on the lower end of the readiness to change spectrum, it is not a necessary part of MI. Counselors can You cannot manufacture motivation that is not already in clients. MI does not motivate clients to motive clients to change or to move toward a predetermined treatment goal. It is change. a collaborative partnership between you and clients to discover their motivation to change. It respects client autonomy and self-determination about goals for behavior change. Sources: Miller & Rollnick, 2013, 2014; Moyers, 2014. Ambivalence A key concept in MI is ambivalence. It is normal for people to feels two ways about making an important change in their lives. Frequently, client ambivalence is a roadblock to change, not a lack of knowledge or skills about how to change (Forman & Moyers, 2019). Individuals with SUDs are often aware of the risks associated with their substance use but continue to use substances anyway. They may need to stop using substances, but they continue to use. The tension between these feelings is ambivalence. Ambivalence about changing substance use behaviors is natural. As clients move from Precontemplation to Contemplation, their feelings of confict about change increase. This Chapter 3 38 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style tension may help move people toward change, but often the tension of ambivalence leads people to avoid thinking about the problem. They may tell themselves things aren’t so bad (Miller & Rollnick, 2013). View ambivalence not as denial or resistance, but as a normal experience in the change process. If you interpret ambivalence as denial or resistance, you are likely to evoke discord between you and clients, which is counterproductive. Sustain Talk and Change Talk Recognizing sustain talk and change talk in clients will help you better explore and address their ambivalence. Sustain talk consists of client statements that support not changing a health-risk behavior, like substance misuse. Change talk consists of client statements that favor change (Miller & Rollnick, 2013). Sustain talk and change talk are expressions of both sides of ambivalence about change. Over time, MI has evolved in its understanding of what keeps clients stuck in ambivalence about change and what supports clients to move in the direction of changing substance use behaviors. Client stuck in ambivalence will engage in a lot of sustain talk, whereas clients who are more ready to change will engage in more change talk with stronger statements supporting change. Greater frequency of client sustain talk in sessions is linked to poorer substance use treatment outcomes (Lindqvist, Forsberg, Enebrink, Andersson, & Rosendahl, 2017; Magill et al., 2014; Rodriguez, Walters, Houck, Ortiz, & Taxman, 2017). Conversely, MI-consistent counselor behavior focused on eliciting and refecting change talk, more client change talk compared with sustain talk, and stronger commitment change talk are linked to better substance use outcomes (Barnett, Moyers, et al., 2014; Borsari et al., 2018; Houck, Manuel, & Moyers, 2018; Magill et al., 2014, 2018; Romano & Peters, 2016). Counselor empathy is also linked to eliciting client change talk (Pace et al., 2017). In MI, your main goal is to evoke change talk and minimize evoking or reinforcing sustain talk in counseling sessions. Another development in MI is the delineation of different kinds of change talk. The acronym for change talk in MI is DARN-CAT (Miller & Rollnick, 2013): Desire to change: This is expressed in statements about wanting something different— “I want to fnd an Alcoholics Anonymous (AA) meeting” or “I hope to start going to AA.” Ability to change: This is expressed in statements about self-perception of capability— “I could start going to AA.” Reasons to change: This is expressed as arguments for change—“I’d probably learn more about recovery if I went to AA” or “Going to AA would help me feel more supported.” Need to change: This is expressed in client statements about importance or urgency—“I have to stop drinking” or “I need to fnd a way to get my drinking under control.” Commitment: This is expressed as a promise to change—“I swear I will go to an AA meeting this year” or “I guarantee that I will start AA by next month.” Activation: This is expressed in statements showing movement toward action—“I’m ready to go to my frst AA meeting.” Taking steps: This is expressed in statements indicating that the client has already done something to change—“I went to an AA meeting” or “I avoided a party where friends would be doing drugs.” Chapter 3 39 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment Exhibit 3.3 depicts examples of change talk and sustain talk that correspond to DARN-CAT. EXHIBIT 3.3. Examples of Change Talk and Sustain Talk TYPE OF STATEMENT EXAMPLES OF CHANGE TALK Desire Ability Reasons Need Commitment Activation Taking steps “I want to cut down on my drinking.” “I could cut back to 1 drink with dinner on weekends.” “I’ll miss less time at work if I cut down.” “I have to cut down. My doctor told me that the amount I am drinking puts my health at risk.” EXAMPLES OF SUSTAIN TALK “I love how cocaine makes me feel.” “I can manage my life just fne without giving up the drug.” “Getting high helps me feel energized.” “I need to get high to keep me going every day.” “I promise to cut back this weekend.” “I am ready to do something about the drinking.” “I only had one drink with dinner on Saturday.” Source: Miller & Rollnick, 2013. To make the best use of clients’ change talk and sustain talk that arise in sessions, remember to: Recognize client expressions of change talk but “I am going to keep snorting cocaine.” “I am not ready to give up the cocaine.” “I am still snorting cocaine every day.” resistance as a pathological defense mechanism, MI views resistance as a normal part of ambivalence and a client’s reaction to the counselor’s approach in the moment (Miller & Rollnick, 2013). don’t worry about differentiating various kinds of change talk during a counseling session. Use refective listening to reinforce and help clients elaborate on change talk. Use DARN-CAT in conversations with clients. Recognize sustain talk and use MI strategies to lessen the impact of sustain talk on clients’ readiness to change (see discussion of responding to change talk and sustain talk in the next section). Be aware that both sides of ambivalence (change talk and sustain talk) will be present in your conversations with clients. A New Look at Resistance Understanding the role of resistance and how to respond to it can help you maintain good counselor-client rapport. Resistance in SUD treatment has historically been considered a problem centered in the client. As MI has developed over the years, its understanding of resistance has changed. Instead of emphasizing A client may express resistance in sustain talk that favors the “no change” side of ambivalence. The way you respond to sustain talk can contribute to the client becoming frmly planted in the status quo or help the client move toward contemplating change. For example, the client’s show of ambivalence about change and your arguments for change can create discord in your therapeutic relationship. Client sustain talk is often evoked by discord in the counseling relationship (Miller & Rollnick, 2013). Resistance is a two-way street. If discord arises in conversation, change direction or listen more carefully. This is an opportunity to respond in a new, perhaps surprising, way and to take advantage of the situation without being confrontational. This new way of looking at resistance is consistent with the principles of person-centered counseling described at the beginning of the chapter. Chapter 3 40 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style Core Skills of MI: OARS To remember the core counseling skills of MI, use the acronym OARS (Miller & Rollnick, 2013): Asking Open questions Affrming Refective listening Summarizing These core skills are consistent with the principles of person-centered counseling and can be used throughout your work with clients. If you use these skills, you will more likely have greater success in engaging clients and less incidence of discord within the counselor–client relationship. These core skills are described below. Asking Open Questions Use open questions to invite clients to tell their story rather than closed questions, which merely elicit brief information. Open questions are questions that invite clients to refect before answering and encourage them to elaborate. Asking open questions helps you understand their point of view. Open questions facilitate a dialog and do not require any particular response from you. They encourage clients to do most of the talking and keep the conversation moving forward. Closed questions evoke yes/no or short answers and sometimes make clients feel as if they have to come up with the right answer. One type of open question is actually a statement that begins with “Tell me about” or “Tell me more about.” The “Tell me about” statement invites clients to tell a story and serves as an open question. Exhibit 3.4 provides examples of closed and open questions. As you read these examples, imagine you are a client and notice the difference in how you might receive and respond to each kind of question. EXHIBIT 3.4. Closed and Open Questions CLOSED QUESTIONS OPEN QUESTIONS “So you are here because you are concerned about your use of alcohol, correct?” “What is it that brings you here today?” “How many children do you have?” “Tell me about your family.” “Do you agree that it would be a good idea for you to go through detoxifcation?” “What do you think about the possibility of going through detoxifcation?” “On a typical day, how much marijuana do you smoke?” “Tell me about your marijuana use on a typical day.” “Did your doctor tell you to quit smoking?” “What did your doctor tell you about the health risks of smoking?” “How has your drug use been this week compared with last week: more, less, or about the same?” “What has your drug use been like during the past week?” “Do you think you use amphetamines too often?” “In what ways are you concerned about your use of amphetamines?” “How long ago did you have your last drink?” “Tell me about the last time you drank.” “Are you sure that your probation offcer told you that it’s only cocaine he is concerned about in your urine screens?” “Tell me more about the conditions of your probation.” “When do you plan to quit drinking?” “What do you think you want to do about your drinking?” Chapter 3 41 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment There may be times when you must ask closed questions, for example, to gather information for a screening or assessment. However, if you use open questions—“Tell me about the last time you used methamphetamines”—you will often get the information you need and enhance the process of engagement. During assessment, avoid the question-and-answer trap, which can decrease rapport, become an obstacle to counselor–client engagement, and stall conversations. MI involves maintaining a balance between asking questions and refective listening (Miller & Rollnick, 2013). Ask one open question, and follow it with two or more refective listening responses. Afrming Affrming is a way to express your genuine appreciation and positive regard for clients (Miller & Rollnick, 2013). Affrming clients supports and promotes self-effcacy. By affrming, you are saying, “I see you, what you say matters, and I want to understand what you think and feel” (Miller & Rollnick, 2013). Affrming can boost clients’ confdence about taking action. Using affrmations in conversations with clients consistently predicts positive client outcomes (Romano & Peters, 2016). When affrming: Emphasize client strengths, past successes, and efforts to take steps, however small, to accomplish change goals. Do not confuse this type of feedback with praise, which can sometimes be a roadblock to effective listening (Gordon, 1970; see Exhibit 3.5 below in the section “Refective Listening”). Frame your affrming statements with “you” instead of “I.” For example, instead of saying “I am proud of you,” which focuses more on you than on the client, try “You have worked really hard to get to where you are now in your life,” which demonstrates your appreciation, but keeps the focus on the client (Miller & Rollnick, 2013). Use statements such as (Miller & Rollnick, 2013): - “You took a big step in coming here today.” - “You got discouraged last week but kept going to your AA meetings. You are persistent.” - “Although things didn’t turn out the way you hoped, you tried really hard, and that means a lot.” - “That’s a good idea for how you can avoid situations where you might be tempted to drink.” There may be ethnic, cultural, and even personal differences in how people respond to affrming statements. Be aware of verbal and nonverbal cues about how the client is reacting and be open to checking out the client’s reaction with an open question—“How was that for you to hear?” Strategies for forming affrmations that account for cultural and personal differences include (Rosengren, 2018): Focusing on specifc behaviors to affrm. Avoiding using “I.” Emphasizing descriptions instead of evaluations. Emphasizing positive developments instead of continuing problems. Affrming interesting qualities and strengths of clients. Holding an awareness of client strengths instead of defcits as you formulate affrmations. Refective Listening Refective listening is the key component of expressing empathy. Refective listening is fundamental to person-centered counseling in general and MI in particular (Miller & Rollnick, 2013). Refective listening (Miller & Rollnick, 2013): Communicates respect for and acceptance of clients. Establishes trust and invites clients to explore their own perceptions, values, and feelings. Encourages a nonjudgmental, collaborative relationship. Allows you to be supportive without agreeing with specifc client statements. 42 Chapter 3 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style Refective listening builds collaboration and a safe and open environment that is conducive to examining issues and eliciting the client’s reasons for change. It is both an expression of empathy and a way to selectively reinforce change talk (Romano & Peters, 2016). Refective listening demonstrates that you are genuinely interested in understanding the client’s unique perspective, feelings, and values. Expressions of counselor empathy predict better substance use outcomes (Moyers, Houck, Rice, Longabaugh, & Miller, 2016). Your attitude should be one of acceptance but not necessarily approval or agreement, recognizing that ambivalence about change is normal. Consider ethnic and cultural differences when expressing empathy through refective listening. These differences infuence how both you and the client interpret verbal and nonverbal communications. EXPERT COMMENT: EXPRESSING EMPATHY WITH AFRICAN AMERICAN CLIENTS One way I empathize with African American clients is, frst and foremost, to be a genuine person (not just a counselor). Clients may begin the relationship asking questions about you the person, not the professional, in an attempt to locate you in the world. It’s as if clients’ internal dialog says, “As you try to understand me, by what pathways, perspectives, life experiences, and values are you coming to that understanding of me?” Typical questions my African American clients have asked me are: “Are you Christian?” “Where are you from?” “What part of town do you live in?” “Who are your folks?” “Are you married?” All of these are reasonable questions that work to establish a real, not contrived, relationship with the counselor. As part of a democratic partnership, clients have a right and, in some instances, a cultural expectation to know about the helper. On another level, many African Americans are very spiritual people. This spirituality is expressed and practiced in ways that supersede religious affliations. Young people pat their chests and say, “I feel you,” as a way to describe this sense of empathy. Understanding and working with this can enhance the counselor’s expression of empathy. In other words, the therapeutic counselor‒client alliance can be deepened, permitting another level of empathic connection that some might call an intuitive understanding and others might call a spiritual connection to each client. What emerges is a therapeutic alliance—a spiritual connection—that goes beyond what mere words can say. The more counselors express that side of themselves, whether they call it intuition or spirituality, the more intense the empathic connection the African American client will feel. Cheryl Grills, Ph.D., Consensus Panel Member Chapter 3 43 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment EXPERT COMMENT: EXPRESSING EMPATHY WITH AMERICAN INDIAN/NATIVE AMERICAN CLIENTS For many traditional American Indian groups, expressing empathy begins with the introduction. Native Americans generally expect the counselor to be aware of and practice the culturally accepted norms for introducing oneself and showing respect. For example, during the frst meeting, the person often is expected to say his or her name, clan relationship or ethnic origin, and place of origin. Physical contact is kept to a minimum, except for a brief handshake, which may be no more than a soft touch of the palms. Ray Daw, Consensus Panel Member Refective listening is not as easy as it sounds. It is not simply a matter of being quiet while the client is speaking. Refective listening requires you to make a mental hypothesis about the underlying meaning or feeling of client statements and then refect that back to the client with your best guess about his or her meaning or feeling (Miller & Rollnick, 2013). Gordon (1970) called this “active listening” and identifed 12 kinds of responses that people often give to others that are not active listening and can actually derail a conversation. Exhibit 3.5 describes these roadblocks to listening. EXHIBIT 3.5. Gordon’s 12 Roadblocks to Active Listening 1. Ordering, directing, or commanding Direction is given with a voice of authority. The speaker may be in a position of power (e.g., parent, employer, counselor) or the words may simply be phrased and spoken in a way that communicates that the speaker is the expert. 2. Warning, cautioning, or threatening These statements carry an overt or covert threat of negative consequences. For example, “If you don’t stop drinking, you are going to die.” 3. Giving advice, making suggestions, or providing solutions prematurely or when unsolicited The message recommends a course of action based on your knowledge and personal experience. These recommendations often begin with phrases like “What I would do is.” 4. Persuading with logic, arguing, or lecturing The underlying assumption of these messages is that the client has not reasoned through the problem adequately and needs help to do so. Trying to persuade the client that your position is correct will most likely evoke a reaction and the client taking the opposite position. 5. Moralizing, preaching, or telling people what they should do These statements contain such words as “should” or “ought,” which imply or directly convey negative judgment. 6. Judging, criticizing, disagreeing, or blaming These messages imply that something is wrong with the client or with what the client has said. Even simple disagreement may be interpreted as critical. Continued on next page Chapter 3 44 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style Continued 7. Agreeing, approving, or praising Praise or approval can be an obstacle if the message sanctions or implies agreement with whatever the client has said or if the praise is given too often or in general terms, like “great job.” This can lessen the impact on the person or simply disrupt the fow of the conversation. 8. Shaming, ridiculing, or labeling These statements express disapproval and intent to correct a specifc behavior or attitude. They can damage self-esteem and cause major disruptions in the counseling alliance. 9. Interpreting or analyzing You may be tempted to impose your own interpretations on a client’s statement and to fnd some hidden, analytical meaning. Interpretive statements might imply you know what the client’s “real” problem is and puts you in a one-up position. 10. Reassuring, sympathizing, or consoling Counselors often want to console the client. It is human nature to want to reassure someone who is in pain; however, sympathy is not the same as empathy. Such reassurance can interrupt the fow of communication and interfere with careful listening. 11. Questioning or probing Do not mistake questioning for good listening. Although you may ask questions to learn more about the client, the underlying message is that you might fnd the right answer to all the client’s problems if enough questions are asked. In fact, intensive questioning can disrupt communication, and sometimes the client feels as if he or she is being interrogated. 12. Withdrawing, distracting, humoring, or changing the subject Although shifting the focus or using humor may be helpful at times, it can also be a distraction and disrupt the communication. Source: Gordon, 1970. If you engage in any of these 12 activities, you are talking and not listening. However well intentioned, these roadblocks to listening shift the focus of the conversation from the client to the counselor. They are not consistent with the principles of person-centered counseling. Types of refective listening In MI, there are several kinds of refective listening responses that range from simple (i.e., repeating or rephrasing a client statement) to complex (i.e., using different words to refect the underlying meaning or feeling of a client statement). Simple refections engage clients and let them know that you’re genuinely interested in understanding their perspective. Complex refections invite clients to deepen their self exploration (Miller & Rollnick, 2013). In MI, there are special complex refections that you can use in specifc counseling situations, like using a double-sided refection when clients are expressing ambivalence about changing a substance use behavior. Exhibit 3.6 provides examples of simple and complex refective listening responses to client statements about substance use. Chapter 3 45 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment EXHIBIT 3.6. Types of Refective Listening Responses TYPE CLIENT STATEMENT COUNSELOR RESPONSE PURPOSE SPECIAL CONSIDERATIONS Simple Repeat “My wife is nagging me about my drinking.” “Your wife is nagging you about your drinking.” Builds rapport. Expresses empathy. Avoid mimicking. Rephrase “My wife is nagging me about my drinking.” “Your wife is pressuring you about your drinking.” Expresses empathy. Highlights selected meaning or feeling. Move the conversation along, but more slowly than complex refections. Complex Feeling “I’d like to quit smoking marijuana so that the second hand pot smoke won’t worsen my daughter’s asthma.” “You’re afraid that your daughter’s asthma will get worse if you continue smoking marijuana.” Highlights selected feeling. Highlights discrepancy between values and current behavior. Selectively reinforce change talk. Avoid reinforcing sustain talk. Meaning “I’d like to quit smoking marijuana because I read that second-hand pot smoke can make asthma worse and I don’t want that to happen to my daughter.” “You want to protect your daughter from the possibility that her asthma will get worse if you continue smoking marijuana.” Highlights selected meaning. Highlights discrepancy between values and current behavior. Selectively reinforce change talk. Avoid reinforcing sustain talk. Double-“I know I should give “Giving up drinking Resolves Use “and” to join two sided up drinking, but I can’t imagine life without it.” would be hard, and you recognize that it’s time to stop.” ambivalence. Acknowledges sustain talk and emphasizes change talk. refections. Start with sustain talk refection and end with change talk refection. Amplifed “I think my cocaine use is just not a problem for me.” “There are absolutely no negative consequences of using cocaine.” Intensifes sustain talk to evoke change talk. Use sparingly. Avoid getting stuck in sustain talk. Source: Miller & Rollnick, 2013. Chapter 3 46 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style Forming complex refections Simple refections are fairly straightforward. You simply repeat or paraphrase what the client said. Complex refections are more challenging. A statement could have many meanings. The frst step in making a complex refection of meaning or feelings is to make a hypothesis in your mind about what the client is trying to say (Miller & Rollnick, 2013). Use these steps to form a mental hypothesis about meaning or feelings: 1. If the client says, “I drink because I am lonely,” think about the possible meanings of “lonely.” Perhaps the client is saying, “I lost my spouse” or “It is hard for me to make friends” or “I can’t think of anything to say when I am with my family.” 2. Consider the larger conversational context. Has the client noted not having much of a social life? 3. Make your best guess about the meaning of the client’s statement. 4. Offer a refective listening response—“You drink because it is hard for you to make friends.” 5. Wait for the client’s response. The client will tell you either verbally or nonverbally if your guess is correct. If the client continues to talk and expands on the initial statement, you are on target. 6. Be open to being wrong. If you are, use client feedback to make another hypothesis about the client’s meaning. Remember that refective listening is about refraining from making assumptions about the underlying message of client statements, making a hypothesis about the meaning or feeling of the statement, and then checking out your hypothesis by offering a refective statement and listening carefully to the client’s response (Miller & Rollnick, 2013). Refective listening is basic to all of four MI processes. Follow open questions with at least one refective listening response—but preferably two or three responses—before asking another question. A higher ratio of refections to questions consistently predicts positive client outcomes (Romano & Peters, 2016). It takes practice to become skillful, but the effort is worth it because careful refective listening builds a strong therapeutic alliance and facilitates the client’s self exploration—two essential components of person centered counseling (Miller & Rollnick, 2013). The key to expressing accurate empathy through refective listening is your ability to shift gears from being an expert who gives advice to being an individual supporting the client’s autonomy and expertise in making decisions about changing substance use behaviors (Moyers, 2014). Summarizing Summarizing is a form of refective listening that distills the essence of several client statements and refects them back to him or her. It is not simply a collection of statements. You intentionally select statements that may have particular meaning for the client and present them in a summary that paints a fuller picture of the client’s experience than simply using refections (Miller & Rollnick, 2013). There are several types of summarization in MI (Miller & Rollnick, 2013): Collecting summary: Recalls a series of related client statements, creating a narrative to refect on. Linking summary: Refects a client statement; links it to an earlier statement. Transitional summary: Wraps up a conversation or task; moves the client along the change process. Ambivalence summary: Gathers client statements of sustain talk and change talk during a session. This summary should acknowledge sustain talk but reinforce and highlight change talk. Recapitulation summary: Gathers all of the change talk of many conversations. It is useful during the transition from one stage to the next when making a change plan. At the end of a summary, ask the client whether you left anything out. This opportunity lets the client correct or add more to the summary and often leads to further discussion. Summarizing encourages client self-refection. Chapter 3 47 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment Summaries reinforce key statements of movement toward change. Clients hear change talk once when they make a statement, twice when the counselor refects it, and again when the counselor summarizes the discussion. Four Processes of MI MI has moved away from the idea of phases of change to overlapping processes that more accurately describe how MI works in clinical practice. This change is a shift away from a linear, rigid model of change to a circular, fuid model of change within the context of the counseling relationship. This section reviews these MI processes, summarizes counseling strategies appropriate for each process, and integrates the four principles of MI from previous versions. Engaging Engaging clients is the frst step in all counseling approaches. Specifc counseling strategies or techniques will not be effective if you and the client haven’t established a strong working relationship. MI is no exception to this. Miller and Rollnick (2013) defne engaging in MI “as the process of establishing a mutually trusting and respectful helping relationship” (p. 40). Research supports the link between your ability to develop this kind of helping relationship and positive treatment outcomes such as reduced drinking (Moyers et al., 2016; Romano & Peters, 2016). Opening strategies Opening strategies promote engagement in MI by emphasizing OARS in the following ways: Ask open questions instead of closed questions. Offer affrmations of client self-effcacy, hope, and confdence in the client’s ability to change. Emphasize refective listening. Summarize to reinforce that you are listening and genuinely interested in the client’s perspective. Determine the client’s readiness to change or and specifc stage in the SOC (see Chapters 1 and 2). Avoid prematurely focusing on taking action. Try not to identify the client’s treatment goals until you have suffciently explored the client’s readiness. Then you can address the client’s ambivalence. These opening strategies ensure support for the client and help the client explore ambivalence in a safe setting. In the following initial conversation, the counselor uses OARS to establish rapport and address the client’s drinking through refective listening and asking open questions: Counselor: Jerry, thanks for coming in. (Affrmation) What brings you here today? (Open question) Client: My wife thinks I drink too much. She says that’s why we argue all the time. She also thinks that my drinking is ruining my health. Counselor: So your wife has some concerns about your drinking interfering with your relationship and harming your health. (Refection) Client: Yeah, she worries a lot. Counselor: You wife worries a lot about the drinking. (Refection) What concerns you about it? (Open question) Client: I’m not sure I’m concerned about it, but I do wonder sometimes if I’m drinking too much. Counselor: You are wondering about the drinking. (Refection) Too much for…? (Open question that invites the client to complete the sentence) Client: For my own good, I guess. I mean it’s not like it’s really serious, but sometimes when I wake up in the morning, I feel really awful, and I can’t think straight most of the morning. Counselor: It messes up your thinking, your concentration. (Refection) Client: Yeah, and sometimes I have trouble remembering things. Counselor: And you wonder if these problems are related to drinking too much. (Refection) Client: Well, I know it is sometimes. Counselor: You’re certain that sometimes drinking too much hurts you. (Refection) Tell me what it’s like to lose concentration and have trouble remembering. (Open question in the form of a statement) 48 Chapter 3 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style Client: It’s kind of scary. I am way too young to have trouble with my memory. And now that I think about it, that’s what usually causes the arguments with my wife. She’ll ask me to pick up something from the store and when I forget to stop on my way home from work, she starts yelling at me. Counselor: You’re scared that drinking is starting to have some negative effects on what’s important to you like your ability to think clearly and good communication with your wife. (Refection) Client: Yeah. But I don’t think I’m an alcoholic or anything. Counselor: You don’t think you’re that bad off, but you do wonder if maybe you’re overdoing it and hurting yourself and your relationship with your wife. (Refection) Client: Yeah. Counselor: You know, Jerry, it takes courage to come talk to a stranger about something that’s scary to talk about. (Affrmation) What do you think? (Open question) Client: I never thought of it like that. I guess it is important to fgure out what to do about my drinking. Counselor: So, Jerry, let’s take a minute to review where we are today. Your wife is concerned about how much you drink. You have been having trouble concentrating and remembering things and are wondering if that has to do with how much you are drinking. You are now thinking that you need to fgure out what to do about the drinking. Did I miss anything? (Summary) Avoiding traps Identify and avoid traps to help preserve client engagement. The above conversation shows use of core MI skills to engage the client and help him feel heard, understood, and respected while moving the conversation toward change. The counselor avoids common traps that increase disengagement. Common traps to avoid include the following (Miller & Rollnick, 2013): The Expert Trap: People often see a professional, like primary care physician or nurse practitioner, to get answers to questions and to help them make important decisions. But relying on another person (even a professional) to have all the answers is contrary to the spirit of MI and the principles of person-centered care. Both you and the client have expertise. You have knowledge and skills in listening and interviewing; the client has knowledge based on his or her life experience. In your conversations with a client, remember that you do not have to have all the answers, and trust that the client has knowledge about what is important to him or her, what needs to change, and what steps need to be taken to make those changes. Avoid falling into the expert trap by: - Refraining from acting on the “righting refex,” the natural impulse to jump into action and direct the client toward a specifc change. Such a directive style is likely to produce sustain talk and discord in the counseling relationship. - Not arguing with the client. If you try to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for change. Chapter 3 49 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment The Labeling Trap: Diagnoses and labels like “alcoholic” or “addict” can evoke shame in clients. There is no evidence that forcing a client to accept a label is helpful; in fact, it usually evokes discord in the counseling relationship. In the conversation above, the counselor didn’t argue with Jerry about whether he is an “alcoholic.” If the counselor had done so, the outcome would likely have been different: - Client: But I don’t think I’m an alcoholic or anything. - Counselor: Well, based on what you’ve told me, I think we should do a comprehensive assessment to determine whether or not you are. - Client: Wait a minute. That’s not what I came for. I don’t think counseling is going to help me. The Question-and-Answer Trap: When your focus is on getting information from a client, particularly during an assessment, you and the client can easily fall into the question-and answer trap. This can feel like an interrogation rather than a conversation. In addition, a pattern of asking closed questions and giving short answers sets you up in the expert role, and the client becomes a passive recipient of the treatment intervention instead of an active partner in the process. Remember to ask open questions, and follow them with refective listening responses to avoid the question-and answer trap. The Premature Focus Trap: You can fall into this trap when you focus on an agenda for change before the client is ready—for example, jumping into solving problems before developing a strong working alliance. When you focus on an issue that is important to you (e.g., admission to an inpatient treatment program) but not to the client, discord will occur. Remember that your approach should match where the client is with regard to his or her readiness to change. The Blaming Trap: Clients often enter treatment focused on who is to blame for their substance use problem. They may feel guarded and defensive, expecting you to judge them harshly as family, friends, coworkers, or others may have. Avoid the blame trap by immediately reassuring clients that you are uninterested in blaming anyone and that your role is to listen to what troubles them. Focusing Once you have engaged the client, the next step in MI is to fnd a direction for the conversation and the counseling process as a whole. This is called focusing in MI. With the client, you develop a mutually agreed-on agenda that promotes change and then identify a specifc target behavior to discuss. Without a clear focus, conversations about change can be unwieldy and unproductive (Miller & Rollnick, 2013). Deciding on an agenda MI is essentially a conversation you and the client have about change. The direction of the conversation is infuenced by the client, the counselor, and the clinical setting (Miller & Rollnick, 2013). For example, a client walking through the door of an outpatient SUD treatment program understand that his or her use of alcohol and other drugs will be on the agenda. Clients, however, may be mandated to treatment and may not see their substance use as a problem, or they may have multiple issues (e.g., child care, relational, fnancial, legal problems) that interfere with recovery and that need to be addressed. When clients bring multiple problems to the table or are confused or uncertain about the direction of the conversation, you can engage in agenda mapping, which is a process consistent with MI that helps you and clients decide on the counseling focus. Exhibit 3.7 displays the components in an agenda map. 50 Chapter 3 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style EXHIBIT 3.7. Components in a Sample Agenda Map Source: Miller & Rollnick, 2013. To engage in agenda mapping (Miller & Rollnick, 2013): Have an empty agenda map handout handy, or draw 8 to 10 empty circles or shapes on a blank paper. Present the empty agenda map or the sheet of paper to the client by saying, “I know you were referred here to address [name the problem, such as drinking], but you may have other concerns you want to discuss. I’d like to take a few minutes and write down things you may want to talk about. That way, we’ll have a map we can look at to see whether we’re headed in the right direction. How does that sound?” Write a different concern or issue in each circle. Leave two or three circles blank so that you can add a new client concern or suggest a topic that may be important to discuss. If you suggest a topic, frame it in a way that asks permission and leaves the choice to the client: “You’ve mentioned a few different concerns that are important to discuss. Would it be okay to also talk about [name the problem, such as drug use] because that’s why you were referred to treatment?” Ask the client what the most pressing concern is: “You’ve mentioned several things you’d like to talk about. (Summarize) Where would you like to start?” Leave time to guide the client back to the substance use concern if not discussed during the session. Keep the map as a visual record, and refer back to it with the client as a reminder of the focus and direction of the counseling process. Add and delete topics as needed. Remember to use OARS throughout this process to move the conversation along. 51 Chapter 3 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment Identifying a target behavior Once you and the client agree on a general direction, focus on a specifc behavior the client is ready to discuss. Change talk links to a specifc behavior change target (Miller & Rollnick, 2010); you can’t evoke change talk until you identify a target behavior. For example, if the client is ready to discuss drinking, guide the conversation toward details specifc to that concern. A sample of such a conversation follows: Counselor: Marla, you said you’d like to talk about your drinking. It would help if you’d give me a sense of what your specifc concerns are about drinking. (Open question in the form of a statement) Client: Well, after work I go home to my apartment and I am so tired; I don’t want to do anything but watch TV, microwave a meal, and drink till I fall asleep. Then I wake up with a big hangover in the morning and have a hard time getting to work on time. My supervisor has given me a warning. Counselor: You’re worried that the amount you drink affects your sleep and ability to get to work on time. (Refection) What do you think you’d like to change about the drinking? (Open question) Client: I think I need to stop drinking completely for a while, so I can get into a healthy sleep pattern. Counselor: So I’d like to put stop drinking for a while on the map, is that okay? [Asks permission. Pauses. Waits for permission.] Let’s focus our conversations on that goal. Notice that this client is already expressing change talk about her alcohol use. By narrowing the focus from drinking as a general concern to stopping drinking as a possible target behavior, the counselor moved into the MI process of evoking. Evoking Evoking elicits client motivations for change. It shapes conversations in ways that encourage clients, not counselors, to argue for change. Evoking is the core of MI and differentiates it from other counseling methods (Miller & Rollnick, 2013). The following sections explore evoking change talk, responding to change talk and sustain talk, developing discrepancy, evoking hope and confdence to support self-effcacy, recognizing signs of readiness to change, and asking key questions. Evoking change talk Engaging the client in the process of change is the fundamental task of MI. Rather than identifying the problem and promoting ways to solve it, your task is to help clients recognize that their use of substances may be contributing to their distress and that they have a choice about how to move forward in life in ways that enhance their health and well-being. One signal that clients’ ambivalence about change is decreasing is when they start to express change talk. The frst step to evoking change talk is to ask open questions. There are seven kinds of change talk, refected in the DARN acronym. DARN questions can help you generate open questions that evoke change talk. Exhibit 3.8 provides examples of open questions that elicit change talk in preparation for taking steps to change. 52 Chapter 3 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style EXHIBIT 3.8. Examples of Open Questions to Evoke Change Talk Using DARN Desire “How would you like for things to change?” “What do you hope our work together will accomplish?” “What don’t you like about how things are now?” “What don’t you like about the effects of drinking or drug use?” “What do you wish for your relationship with __________?” “How do you want your life to be different a year from now?” “What are you looking for from this program?” Ability “If you decided to quit drinking, how could you do it?” “What do you think you might be able to change?” “What ideas do you have for how you could _________?” “What encourages you that you could change if you decided to?” “How confdent are you that you could _________ if you made up your mind?” “Of the different options you’ve considered, what seems most possible?” “How likely are you to be able to __________?” Reasons “What are some of the reasons you have for making this change?” “Why would you want to stop or cut back on your use of _____________?” “What’s the downside of the way things are now?” “What might be the good things about quitting _____________?” “What would make it worthwhile for you to _____________?” “What might be some of the advantages of _____________?” “What might be the three best reasons for _____________?” Need “What needs to happen?” “How important is it for you to __________?” “What makes you think that you might need to make a change?” “How serious or urgent does this feel to you?” “What do you think has to change?” Source: Miller & Rollnick, 2013. Motivational Interviewing: Helping People Change (3rd ed.), pp. 171‒173. Adapted with permission from Guilford Press. Chapter 3 53 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment Other strategies for evoking change talk (Miller & Rollnick, 2013) include: Eliciting importance of change. Ask an open question that elicits “Need” change talk (Exhibit 3.8): “How important is it for you to [name the change in the target behavior, such as cutting back on drinking]?” You can also use scaling questions such as those in the Importance Ruler in Exhibit 3.9 to help the client explore change talk about need more fully. EXHIBIT 3.9. The Importance Ruler Not Important Extremely Important Initial question: “On a scale of 0 to 10, how important is it for you to change [name the target behavior, like how much the client drinks] if you decided to?” Follow-up question 1: “How are you at a [fll in the number on the scale] instead of a [choose a lower number on the scale]?” When you use a lower number, you are inviting the client to refect on how he or she is already considering change. If you use a higher number, it will likely evoke sustain talk (Miller & Rollnick, 2013). Notice the difference in the following examples: Lower number -Counselor: You mention that you are at a 6 on the importance of quitting drinking. How are you at a 6 instead of a 3? -Client: I’m realizing that drinking causes more problems in my life now than when I was younger. Higher number -Counselor: You mention that you are at a 6 on the importance of quitting drinking. How are you at a 6 instead of a 9? -Client: Well, I am just not ready to quit right this second. In the higher number example, the counselor evokes sustain talk, but it is still useful information and can be the beginning of a deep conversation about the client’s readiness to change. Follow-up question 2: “What would help move from a [fll in the number on the scale] to a [choose a slightly higher number on the scale]?” This question invites the client to refect on reasons to increase readiness to change. Exploring extremes. Ask the client to identify the extremes of the problem; this enhances his or her motivation. For example: “What concerns you the most about [name the target behavior, like using cocaine]?” Looking back. To point out discrepancies and evoke change talk, ask the client about what it was like before experiencing substance use problems, and compare that response with what it is like now. For example: “What was it like before you started using heroin?” Looking forward. Ask the client to envision what he or she would like for the future. This can elicit change talk and identify goals to work toward. For example: “If you decided to [describe the change in target behavior, such as quit smoking], how do you think your life would be different a month, a year, or 5 years from now?” Chapter 3 54 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style Reinforce change talk by refecting it back verbally, nodding, or making approving facial expressions and affrming statements. Encourage the client to continue exploring the possibility of change by asking for elaboration, explicit examples, or details about remaining concerns. Questions that begin with “What else” effectively invite elaboration. Your task is to evoke change talk and selectively reinforce it via refective listening. The amount of change talk versus sustain talk is linked to client behavior change and positive substance use outcomes (Houck et al., 2018; Lindqvist et al., 2017; Magill et al., 2014). Responding to change talk and sustain talk Your focus should be on evoking change talk and minimizing sustain talk. Sustain talk expresses the side of ambivalence that favors continuing one’s pattern of substance use. Don’t argue with the client’s sustain talk, and don’t try to persuade the client to take the change side of ambivalence. There are many ways to respond to sustain talk that acknowledge it without getting stuck in it. You can use (Miller & Rollnick, 2013): Simple refections. Acknowledge sustain talk with a simple refective listening response. This validates what the client has said and sometimes elicits change talk. Give the client an opportunity to respond before moving on. - Client: I don’t plan to quit drinking anytime soon. - Counselor: You don’t think that abstinence would work for you right now. Amplifed refections. Accurately refect the client’s statement but with emphasis (and without sarcasm). An amplifed refection overstates the client’s point of view, which can nudge the client to take the other side of ambivalence (i.e., change talk). - Client: But I can’t quit smoking pot. All my friends smoke pot. - Counselor: So you really can’t quit because you’d be too different from your friends. Double-sided refections. A double-sided refection acknowledges sustain talk, then pairs it with change talk either in the same client statement or in a previous statement. It acknowledges the client’s ambivalence yet selectively reinforces change talk. Use “and” to join the two statements and make change talk the second statement (see Counselor Response in Exhibit 3.6). - Client: I know I should quit smoking now that I am pregnant. But I tried to go cold turkey before, and it was just too hard. - Counselor: You’re worried that you won’t be able to quit all at once, and you want your baby to be born healthy. Agreements with a twist. A subtle strategy is to agree, but with a slight twist or change of direction that moves the discussion forward. The twist should be said without emphasis or sarcasm. - Client: I can’t imagine what I would do if I stopped drinking. It’s part of who I am. How could I go to the bar and hang out with my friends? - Counselor: You just wouldn’t be you without drinking. You have to keep drinking no matter how it effects your health. Reframing. Reframing acknowledges the client’s experience yet suggests alternative meanings. It invites the client to consider a different perspective (Barnett, Spruijt-Metz, et al., 2014). Reframing is also a way to refocus the conversation from emphasizing sustain talk to eliciting change talk (Barnett, Spruijt-Metz, et al., 2014). - Client: My husband always nags me about my drinking and calls me an alcoholic. It bugs me. - Counselor: Although your husband expresses it in a way that frustrates you, he really cares and is concerned about the drinking. Chapter 3 55 TIP 35 Enhancing Motivation for Change in Substance Use Disorder Treatment A shift in focus. Defuse discord and tension by shifting the conversational focus.-Client: The way you’re talking, you think I’m an alcoholic, don’t you?-Counselor: Labels aren’t important to me. What I care about is how to best help you. Emphasis on personal autonomy. Emphasizing that people have choices (even if all the choices have a downside) reinforces personal autonomy and opens up the possibility for clients to choose change instead of the status quo. When you make these statements, remember to use a neutral, nonjudgmental tone, without sarcasm. A dismissive tone can evoke strong reactions from the client.-Client: I am really not interested in giving up drinking completely.-Counselor: It’s really up to you. No one can make that decision for you. All of these strategies have one thing in common: They are delivered in the spirit of MI. Developing discrepancy: A values conversation Developing discrepancy has been a key element of MI since its inception. It was originally one of the four principles of MI. In the current version, exploring the discrepancy between clients’ values and their substance use behavior has been folded into the evoking process. When clients recognize discrepancies in their values, goals, and hopes for the future, their motivation to change increases. Your task is to help clients focus on how their behavior conficts with their values and goals. The focus is on intrinsic motivation. MI doesn’t work if you focus only on how clients’ substance use behavior is in confict with external pressure (e.g., family, an employer, the court) (Miller & Rollnick, 2013). To facilitate discrepancy, have a values conversation to explore what is important to the client (e.g., good heath, positive relationships with family, being a responsible member of the community, preventing another hospitalization, staying out of jail), then highlight the confict the client feels between his or her substance use behaviors and those values. Client experience of discrepancy between values and substance use behavior is related to better client outcomes (Apodaca & Longabaugh, 2009). This process can raise uncomfortable feelings like guilt or shame. Frame the conversation by conveying acceptance, compassion, and affrmation. The paradox of acceptance is that it helps people tolerate more discrepancy and, instead of avoiding that tension, propels them toward change (Miller & Rollnick, 2013). However, too much discrepancy may overwhelm the client and cause him or her to think change is not possible (Miller & Rollnick, 2013). To help a client perceive discrepancy, you can use what is sometimes termed the “Columbo approach.” Initially developed by Kanfer & Schefft (1988), this approach remains a staple of MI and is particularly useful with a client who is in the Chapter 3 56 TIP 35 Chapter 3—Motivational Interviewing as a Counseling Style Precontemplation stage and needs to be in charge clarifcation of the client’s problem but appears of the conversation. Essentially, the counselor unable to perceive any solution. expresses understanding and continuously seeks EXPERT COMMENT: THE COLUMBO APPROACH Sometimes I use what I refer to as the Columbo approach to develop discrepancy with clients. In the old Columbo television series, Peter Falk played a detective named Columbo who had a sense of what had really occurred but used a somewhat bumbling, unassuming, Socratic style of querying his prime suspect, strategically posing questions and making refections to piece together a picture of what really happened. As the pieces began to fall into place, the object of Columbo’s investigation would often reveal the real story. The counselor plays the role of a detective who is trying to solve a mystery but is having a diffcult time because the clues don’t add up. The “Columbo counselor” engages the client in solving the mystery: Example #1: “Hmm. Help me fgure this out. You’ve told me that keeping custody of your daughter and being a good parent are the most important things to you now. How does your heroin use ft in with that?” Example #2: “So, sometimes when you drink during the week, you can’t get out of bed to get to work. Last month, you missed 5 days. But you enjoy your work, and doing well in your job is very important to you.” In both cases, the counselor expresses confusion, which allows the client to take over and explain how these conficting desires ft together. The value of the Columbo approach is that it forces the client, rather than the counselor, to grapple with discrepancies and attempt to resolve them. This approach reinforces the notion that the client is the expert on his or her behavior and values. The client is truly the only one who can resolve the discrepancy. If the counselor attempts to do this instead of the client, the counselor risks making the wrong interpretation, rushing to the client to conclusions rather than listening to the client’s perspective, and, perhaps most important, making the client a passive rather than an active participant in the process. Cheryl Grills, Ph.D., Consensus Panel Member Chapter 3 Asking Questions - To Open Up or Close Down? Asking questions (link to Learning counseling and problem-solving skills by Leslie E. Borck, Stephen B. Fawcett) - open and closed - is an important tool in the counseling kit. They can help a person open up or close them down. An open question is one that is used in order to gathering lots of information – you ask it with the intent of getting a long answer. A closed question is one used to gather specific information - it can normally be answered with either a single word or a short phrase. Good basic counsel skills to know! Open-Ended Questions (OEQs) have no correct answer and require an explanation of sorts. The who-what-where-why-when-how questions your English teacher taught you to ask? Little did she know you’d be using them for asking questions in counseling! Here are some good ones: What brought you in here today? Do you have an idea about why this keeps happening? What is your Plan B? How does that make you feel? You’ll notice that I didn’t use “why?” directly. This is because some people find it threatening and overwhelming. It implies judgment and it can be asking an unanswerable question. Open Ended Questions are great for: Starting the information gathering part of the session Keeping the client talking Closed Questions (CQs) are those that can easily be answered with a “yes” or a “no” or brief information. For example: What is your name and date of birth? Did you call the health practitioner to set up a physical? Where do you work? Occupation? Are you ready to stop doing that?! They sound a little harsh, but are needed: For getting necessary information To get bring a chatty client back on track or interrupt her/him. You’re going to take a few minutes right now and practice asking questions! Don’t worry, asking questions will soon be as natural as breathing. In Class Homework - Trying Out Open Ended Questions (OEQs) and Closed Questions (CQs): 10 minutes of questioning and 5 minutes of feedback Listener - Get ready to actively listen and get into your encouraging body language. Ask an OEQ like, “Was there anything particularly interesting that happened within the past few days?” You want them to go on at some length. Speaker - Talk away! After a few minutes, the listener can try to constrain or redirect conversation by asking a CQ such as “Does this make you feel good or bad?” You are looking for an either/or answer. Listener, ask another OEQ, followed by a CQ a few minutes later. Speaker, be helpful, ok? :) ***** Listener 1. How does it feel to be on the receiving end of an OEQ? 2. What impression did you have when asked a CQ? Speaker 1. Was it easy or difficult to ask OEQs? 2. How about CQs? You may have noticed that quiet people need lots of OEQs and chatty people need more CQs! ***** Out of Class Homework Be very conscious of asking questions - the kinds you ask and why you do so? Notice how you feel when asked an Open or Closed question? Motivational Interviewing - Good Example - Alan Lyme : well hi Miss Clark my name is Alan lime 0:02 I'm a social worker here at the Family 0:04 Health Center um Dr seal asked me if I 0:06 would spend some time with you today I'm 0:08 really glad that you're here I'm just 0:09 curious as to why he would send you to 0:11 me well I came to see Dr seal last week 0:14 because of increasing Stress and Anxiety 0:16 that's kind of getting the best of me 0:18 and in the course of um my appointment 0:20 with him um he was asking how I was 0:23 dealing with that stress and I mentioned 0:24 that my one or two glasses of wine a few 0:28 nights a week is turning into more 0:30 frequent in maybe three or four on some 0:33 nights and um he had some concerns about 0:37 that and and felt like maybe you could 0:40 help me with stress or something yeah so 0:44 so he um he also to see me because you 0:47 went to him for increased stress and 0:49 he's concerned that your alcohol 0:50 consumption may be a part of that 0:53 increase and prior to prescribing you 0:55 anything he wanted to make sure that you 0:56 at least had someone to talk to about 0:58 that I suppose okay I saw that you 1:00 filled in one of the pink sheets may I 1:01 take a look at that yeah he told me to 1:02 fill that out and bring it with me okay 1:04 thank you um so um you say here that you 1:08 have four or more drinks in one week um 1:12 you mentioned that you may be increasing 1:14 that a little bit as well um and that 1:16 you have one or two drinks in one 1:17 setting typically yeah and that maybe um 1:21 monthly you have have more than that um 1:24 what what's what kind of drinks do you 1:26 have what do you drink when you 1:27 typically drink um wine with my meals um 1:30 you know again one or two typically 1:34 and more frequently um three or four 1:39 since my stress is increased so it's 1:42 starting to increase you're starting to 1:43 drink a little more okay well based on 1:45 what you put here you it gives you six 1:47 points on this scale um scale ranges 1:50 from 0 to 40 so six points will put you 1:52 in what we would consider an at risk 1:54 Zone um so if it's okay with you I talk 1:58 a little bit about that okay okay 2:00 um so the at risk Zone say it run 0 to 2:02 40 uh it's not it's not a super high 2:04 risk but it certainly could be a risk 2:06 for maybe increasing stress maybe some 2:08 physical elements um related to alcohol 2:10 as well uh could could start to show up 2:13 if you were to increase your drinking 2:15 from there or even stay there um this is 2:17 a typical standard drink size over here 2:19 I'm not sure whether that fits your 2:21 description of a glass of wine or not I 2:24 fill the glass up so maybe a little more 2:26 than that yeah maybe than a little space 2:27 at the top so perhaps a drink drink and 2:28 a half each one so that also increase a 2:31 little bit more so perhaps maybe 2:32 drinking more than you indicated on here 2:35 and for woman healthy women your age um 2:37 no more than three drinks in one setting 2:39 is considered to be lower or no risk and 2:42 no more than seven in one week seven 2:44 total in one seven total in one week and 2:46 what you say here is that even on this 2:48 sheet you perhaps already drinking more 2:50 than that so what do you make of all 2:52 that um that it's news to me you know I 2:56 thought red wine with your meals is 2:58 supposed to be healthy and you know no 3:01 more than seven in a week that seems 3:03 kind of prohibitive yeah yeah it seems 3:05 seems a little less than perhaps you've 3:07 been drinking or the what you consider 3:08 to be healthy drinking and certainly 3:10 there's there conflicting information 3:12 out there about what's healthy and 3:13 what's not 3:15 healthy Imagine The increased stress is 3:17 what what concerned Dr seal um as your 3:20 stress increases and if he were to 3:22 prescribe you anything maybe some 3:24 interaction between the two that that 3:26 would also be a concern for him I I 3:28 would think um so if you would what is 3:30 it that you like about alcohol well you 3:33 know it it does at least in the moment 3:35 temporarily reduce my stress um and I 3:39 you know like a good glass of wine I 3:40 don't don't drink the cheap stuff I like 3:42 the expensive right so you like the 3:44 taste of it and it does help to lower 3:47 the stress even which is for that that 3:48 time you're drinking what are LS of good 3:50 things about alcohol for you um well you 3:54 know the nights that maybe I have a 3:57 couple more glasses than I should I wake 3:59 up feeling kind of yuck and um of course 4:03 part of my stress is finances and I 4:05 mentioned I like the good stuff and so 4:07 if I'm drinking more then I'm increasing 4:09 my financial burden yeah so so your 4:12 financial stress may be increased by the 4:15 fact that you're drinking yeah kind of 4:18 um defeating the purpose there 22 the 4:20 drinking to stress and increasing stress 4:22 at the same time so on the one hand it 4:24 lowers it and on the other hand it's 4:26 increasing it kind a sea TI effect there 4:30 um what do you make of of that given 4:32 that on one hand it lowers and the other 4:34 hand it increases and and now it's 4:35 increasing even more and maybe I need to 4:38 find some other way to deal with my 4:39 stress mhm yeah and have imagine you've 4:43 had some thoughts of that what have you 4:44 thought of 4:45 trying well I've exercised in the past 4:48 and that helps um right now my schedule 4:51 is kind of out of whack and um I just 4:54 really don't know what to do that's why 4:56 I came to see Dr seal I thought maybe he 4:57 could prescribe me something that would 4:59 to help me you know when I'm feeling 5:01 overwhelmed and he may be able to I'm 5:03 not saying that he cannot I'm just 5:05 imagine that he's concerned that if you 5:07 if you continue to drink on the level 5:09 that you are drinking whatever he 5:10 prescribes you there may be an 5:12 interaction with the two um I imagine 5:14 that's his concern I'm I'm not 5:16 completely sure um so you've had some 5:18 success in the past with change in 5:20 behaviors and if you were to decide to 5:22 to make any changes here it sounds like 5:24 you could draw on that to make those 5:26 changes how important would it be for 5:28 you um on a scale of 0 through 10 I have 5:30 a little kind of visual here with that 5:32 um if zero is is not important 10 is is 5:34 very important to do something about 5:36 your drinking right now mhm well I mean 5:38 if if it means that it's increasing my 5:42 stress and or he's not going to 5:44 prescribe me anything because of my 5:47 drinking then it's fairly important 5:49 maybe about a seven that's that's pretty 5:52 up there um why did you choose a seven 5:54 not a five or a 5:56 four well again I've got to get things 5:58 under control you know my kids are 6:00 dependent on me and um I've got to go to 6:05 work to help ease this financial stress 6:07 and so you know all those 6:10 responsibilities so there's a lot a lot 6:12 writing on your decision here on what to 6:14 do with this what if anything will bring 6:16 it up to an eight or nine on that 6:18 scale 6:20 um well the you know the risk that you 6:24 mentioned um about the drug interaction 6:26 I certainly can't afford to 6:30 you know have any more stress 6:33 so yeah so so you you choose to lower 6:36 your stress rather than increase it and 6:38 if lowering your drinking would would 6:40 have that effect there something you be 6:41 willing to do right how confident are 6:44 you that you could do something about 6:45 your 6:46 drinking um pretty confident you know 6:50 probably about a seven or an eight okay 6:51 so it's pretty H up there again and what 6:53 if what if anything would you choose to 6:55 do would it be to cut down would it be 6:56 to quit I'm just curious about well I 6:58 you know I like I said like a good glass 7:00 of wine I don't want to quit altogether 7:02 um I'd be willing to try cutting back 7:05 but now if it's going to if Dr seal 7:07 would agree to prescribe me something 7:09 for the anxiety and it meant that I had 7:12 to not drink at all I'd be willing to do 7:14 that at least for a period of time so 7:16 you'd be willing to to stop all together 7:18 that's what was indicated by The 7:19 Physician okay um so so based on that 7:23 how ready are you to do anything right 7:25 now whether it's to cut back whether 7:27 it's to quit well again you know if if I 7:30 can get something to help me manage if 7:32 maybe I can find some other way to deal 7:34 with the stress then then you know I I'd 7:38 be pretty ready i' again maybe about an 7:41 on that scale maybe an eight okay so 7:43 that's that's pretty high up there as 7:45 well um it sounds as though you're 7:47 pretty motivated to do something about 7:48 this right now giv your responsibilities 7:51 giv your children relying on you at this 7:53 point and just on on lowering your 7:55 anxiety in general it sounds that that's 7:57 one of your goals as well well I'm 7:59 confident that once you decide to do 8:01 whatever it is you decide to do you'll 8:03 be able to follow through that based on 8:05 your experience in the past of of making 8:06 Behavior changes I imagine there some 8:08 things that you can draw upon um what's 8:11 one thing that you could do I imagine 8:13 you thought of some things might help to 8:15 low your stress well I you know the the 8:18 exercise but again that that's kind of 8:20 difficult to fit in right now um hoping 8:24 that Dr seal will prescribe something 8:27 for me to take when I'm feeling 8:28 particularly overwhelmed 8:30 and um maybe just having somebody to 8:32 talk to to bounc some things off of one 8:35 of the things we can offer here is for 8:37 you to come in and talk to one of our 8:38 Behavioral Health Specialists may be 8:41 able to help you talk talk through this 8:43 this area of your life this area of 8:44 increased stress and sound like 8:46 responsibility there and we can make an 8:48 appointment for you if you like um 8:49 before you leave today to talk to 8:51 somebody that' be nice great they also 8:53 have some information here if you're 8:54 interested um some pamphlet on alcohol 8:58 and and how what healthy limits are and 9:00 how it may be affected by medications 9:02 that you take as well um and I I wish 9:05 you lots of luck it sounds as though 9:07 you're really committed to making this 9:08 shift and this change um and I imagine 9:11 Dr SE want to follow up with you and see 9:12 how you do with your with your change um 9:15 within a few weeks okay um and again I I 9:18 look forward to speaking to you in the 9:20 future all right thank you very much 9:21 you're very welcome

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