Motivational Interviewing: Helping the Difficult Client

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Motivational Interviewing counselling/coaching
the difficult ones

• Dr Douglas Kong
• Executive/business coach
• Optimal zone performance Pte Ltd

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What is motivational interviewing

• A technique for helping people change
• A collaborative, goal-oriented, client-centered
  counselling style for eliciting behavior change
  by helping clients to explore and resolve
  ambivalence
• Empirically validated approach for helping people
  with addictive behaviours and problematic
  behaviours
• First described by Drs Miller and Rollnick (1991)

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Motivational interviewing techniques

• Non-confrontational approach
• Strongly supported by empirical research
• Effective with different kinds of problems and
  high risk populations
• Produce good results even with brief sessions
• Non-specialist can learn and use it effectively

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Failures at attempts to change
Discouragements
Lonely and lost
Anger
Helplessnessess
Defensive
Criticisms
Hopelessnessess
Depression
Misunderstanding
Anxiety, fears
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Concepts in MI

• Stages of change
• Working with ambivalence
• Acceptance and empathy
• Providing support
• Integrate with his psychosocial environment

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Effectiveness of MI

• Alcoholism
• Drug addiction
• Smoking
• Obesity
• Procrastination
• Health behaviours eg diabetes, hypertension
• Anger management
• Violent tendency
• Sex addiction
• HIV patients to promote healthy behaviours

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What to avoid in MI

• Avoid the righting reflex
• Teach client a lesson
• Yes, but

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Reactions to Righting reflex

• Agitated and angry
• Oppositional
• Not heard
• Not understood
• Defensive
• Justifying
• Helpless, overwhelmed, trapped
• Procrastinated
• Rejected
• Disengaged and avoid it altogether

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Client listened to and understood

• Safe
• Empowered
• Comfortable
• Interested
• Understood
• Want to talk more
• Open and cooperative
• Accepted and respected
• Engaged. willing to change
• Like the counsellor
• Wanting to come back

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• It is better to have a NO said with sincerity,
  than a YES that is given to please and satisfy
  you. The pushback of the latter comes in subtle
  and hidden ways.
• How about a MAYBE

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Stages of change
---(from Proschaka and DiClemente)
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Precontemplation

• No consideration of change
• Happy user
• Learned helplessness
• Not consciously aware of any problem
• Previous attempts to change end in failure
• Change is perceived to be difficult
• Acceptance of the client most important
• Do not attempt to teach or advice the client

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Pre-contemplation behaviour

• Client is unaware, unwilling or too discouraged
  to change
• He is perceived by others as in denial,
  hopeless and argumentative
• People around him will want to convince thus
  provoking resistance
• Assess readiness to change on a scale of 1 to 10
• how important it is .
• How confident are you when you are ready
• What does it take to move you from X (lower no)
  to Y (higher no)

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Contemplation phase

• Thinking about change
• May be a long stay here in ambivalence
• Feeling of being STUCK
• Decisional balance
• Price of change vs price of maintenance
• Cognitive dissonance - torn between two opposing
  positions
• Sharpen the gap/distinction between A and B
• Shape the clients movement towards B

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Contemplation issues

• Why do you want to change
• Reasons for changing
• What is keeping you from changing
• What has helped in the past
• Reinforce change talk
• Decisional balance cost benefit analysis

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Matrix for Decisional balance sheet to change
or not to change
Status Quo or Staying in the Habit Change or Breaking from the habit
PROS 1 Benefits for me and for who else 4 Advantages of changing
CONS 2 Downside why it is bad for me 3 Downside of changing
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Preparation

• Decision made to change
• Ambivalence resolved firm plans
• May have try to change in recent past
• Menu of choices
• Setting of goals and objectives
• Support and praise decision to change
• Prioritize behaviour change opportunities
• Engage in problem solving
• Identify social supports

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Action

• Overt behaviour change
• Daily implementation and monitoring
• Risk of stopping, contingency management
• Stimulus control and counter conditioning
• Conscious effort for 6 to 18 months
• Goal is 90 in 90 days.

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maintenance

• Behaviour sustained over time
• Alternative behaviour has taken root
• New behaviour self-sustaining
• New behaviour now part of new nature
• Maintain at least 6 months until it is permanent
• Attention to relapse risk
• Repair and control when relapse occurs
• Empower by focusing on choices good and bad
  choices

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Transtheoretical Change Process HOW PEOPLE CHANGE
Precontemplation
Maintenance
Motivational Enhancement Strategies
Relapse Prevention and Management
Contemplation
Action
Treatment Strategies
Preparation/Planning
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GUIDE Ask, elicit clients response
DIRECT Advise, inform
FOLLOW listening to the client
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B
New status Desired situation or behaviour
Guide, Mentor Listener, Confidante
Purpose of MI Make A less desirable Make B more
desirable Equip client with skills to change
A
Current situation Problem behaviours, effects and
consequences
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Spirit of MI
Collaboration vs Confrontation Not the expert
Evocation Drawing out motivation and skills for
change

• Compassion
• The clients best interest in mind

Accepting clients autonomy Clients potential,
strengths and perspectives
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Principles of MI intervention

• Use of empathy
• Problem behaviour arises from a solution to a
  problem
• Supports self-efficacy
• Seeks to empower clients
• Rolls with ambivalence
• Engaging him at opposite poles
• Develop discrepancy
• Creating the gap that needs bridging
• Avoids argumentation
• You are caught in a win-lose bind

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How mi works from a laymans viewpoint

• Core components in laymans terms
• Try not to argue or be pushy
• Show client you understand his/her perspective
• Be optimistic, supportive and hopeful
• Explore inconsistencies between the the problem
  behaviours and the clients goals and values

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Skills to move the client forward

• Open ended questions
• Affirmations
• Reflective listening
• Summaries

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• My husband is getting more abusive, hes now even
  hitting my daughter, and I cant walk out of him
  because I dont even have a bank account in my
  name.
• Simple reflection he has hurt you but you dont
  know how to survive on your own
• Amplified reflection You feel trapped in a
  vicious cycle and you cant imagine yourself
  finding a way out
• Double sided reflection You do care about him,
  but now you are thinking perhaps you should now
  take care of yourself
• Shifting focus reflection You are trying hard to
  solve this problem of his abusive behaviour
  towards you and not being financially independent
  does make it really difficult

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Giving information to move forward

• ASK ----------gt ELICIT -----------gt ASK
  ----------? ELICIT
• Seeks information
• Its the clients choice
• When the client is ready, clarify goals
• When you are uncertain, ask the client to
  elaborate

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Find the Hook

• Collaborative vs confrontational
• Providing option
• hook is the behaviour related issue or problem
  that, if addressed, can promote quantum change

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B
New status Desired situation or behaviour
Change Talk
A
Sustain Talk
Current situation Problem behaviours, effects and
consequences
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Sustain talk

• Sustain Talk is talk about remaining in A
• Sustain Talk refers to the target behaviour
• Resistance refers to the relationship
• Sustain Talk is one side of the coin of
  Ambivalence
• Change Talk is the other side of the coin of
  Ambivalence
• Both are responsive to the Counsellors style
• We respond to sustain talk and resistance in
  similar ways

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Change talk vs sustain talk

• I should not drink so much beer
• Smoking is unhealthy
• Overweight can lead to health problems
• My angry outbursts can cost me my job
• Curbing my sex impulses will save my marriage
• I like to have that slim and energetic figure

• Beer is good and taste nice
• Smoking reduces my stress and make me to
  socialize better
• I have always enjoyed my food
• But letting off steam does make me feel nice
• Thats the only way I know to have fun
• Exercise always produce muscle pain

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Types of change talk d.a.r.n c.a.t
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Types of change talk

• Preparatory Change Talk
• Desires
• Abilities
• Reasons
• Needs
• Mobilizing Change Talk
• Commitment
• Action
• Taking Steps

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What kind of change talk?

• I want to be around to see the kids growing up.
• Smoking is not a problem for me, I can quit
  anytime I want
• I abstained from smoking 1 week now, but the
  cravings were horrible
• I am here not because I want to quit drugs, but
  because I was told I would lose my license if I
  did not come
• I dont know how long it will take, but I will
  keep on trying one day at a time, until I succeed

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MI one piece among many to help people change

• Contracting with patient for contingency
  management
• Social skills training
• Medical management
• Continuing care to handle relapse
• Bond with therapists therapeutic alliance
• Support group
• Sustain motivation

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What works in MI?

• Counsellors must be empathetic
• Counsellors must NOT be confrontational
• Clients Change Talk makes the difference
• Counsellors must be skilled in reinforcing Change
  Talk
• It is all in the relationship between counsellor
  and client
• Two most important factor RELATIONSHIP
• The other TECHNICAL

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Going forward

• Learning more about MI from books and videos
• Skills, you need guidance, and you need to
  practice for improvement
• Guided supervision and peer supervision
• Advantages confer by technology, audio, video and
  social media
• Online groups, webinars, live event online
• With manuals, videos, coaching, feedback
• Those with coaching, feedback or both produce the
  best therapeutic results