Week 6

Week 6 Questions to Answer 1. What are the credentials of the writers to the document or chapter you are reading? 2. From your perspective -- what are the two or three most important points made in the reading? 3. How did the reading contribute to your learning? 4. How might the content influence your practice as a nurse in a helping relationship? Video  Bill Matulich who has a Ph.D and is a clinical psychologist and a motivational interviewer trainer.  Motivational interviewing is an effective way of talking with people about change  It’s evidence based  1200 publications and journals that cover motivational intervieweing in many different countries  Why is it necessary? o Shouldn’t ppl naturally change their behaviour o Common practice suggests o Counselors will give people advice and expect them to change o But change isn’t quick and easy sometimes slow and difficult  People face many decisions that require some part of change like children to do home  Later on difficult decisions like accepting help  It’s difficult to actual make the change  When change is hard it isn’t because of lack of information or laziness usually its because of ambivalence wanting and not wanting the change  Ambivalence is uncomfortable lead to anxiety which would cause procrastination  As person gets struck in ambivalence its mistaken for resistance  Natural condition of being unsure of change  When people get struck it could look like resistance  Motivational interewiving resolves ambivalence and helps client move towards change and helps elicit a percan to motivate to change  The spirit of mi o Partnership collabolarity between client and counsleor no expert role o Acceptance- respecting clients autonomy, potential, strengths and perspective o Compassion- keep the client’s best interest in mind o Evocation- the best ideas come from the client – client acts on  4 skils to do mi o OARS o Open question  Are you in pain?- closed question  How do you feel?

 What role does alcohol play in your life  What are the advantages that you see in moving?  Encourage client to talk about whats on your mind o Affirmations  Statements anything positive client notices about client  Awards, accomplishmenets  To build a sense of self-confidence o Reflections  Most important  Understanding what the client is thinking and feeling then saying it back to client  Reflection  - I’ve been this way for so long feel like its my personality  Reflection- you feel like this is a normal part of your life  This shows empathy and see world in clients eyes o Summaries  A long reflection of more than one client statement  o The four processes  Sequential in nature  Engaging  The process of establishing a trusting and mutually respectful relationship  Some connection with client before changing behaviour  Attuning  Aligning  Joining with  Therapeutic relationship  Anything that helps client feel welcome, comfortable, understand exceedind expections  Having mutual goals and  Client laves feeling hopeful  Pronounce name correctly   Dis-enganging  It’s important in motivitaional interviewing important to know what not to do  Don’t assess right away by asking a bunch of question  Don’t tell client how to fix problem  Cdont come across as authority figure  Don’t label client   Focusing

 Directing style has complementary roles for the recipient of direction such as obeying, adhering and complying o Examples of directing are a physician explaining the contingencies and consequences imposed by the court  Opposite end of the continuum is a following style o Good listeners take an interest in what the other person has to say, seek to understand and respectfully refrain ( at least emporarily) from inserting their own material o The implicit communication of a helper in a following style is “ I trust your own wisdom, will stay with you and will let you work this out in your own way” o Complementary roles to a following style are taking the lead, going ahead and exploring o There are times in most practices when following is appropriate simply to listen as a human companion for example with a dying patient for whom everything necessary has been done or a client who enters a session with strong emotion o In the middle is a guiding style  Skillful guide is a good listener and also offers expertise where needed  MI lives in this middle ground between directing and following, incorporating aspects of each  Helping a child to learn a new task involves guiding – not doing too much or too little to help  Righting Reflex o The desire to fix what seems wrong with people and to set them promoptly on a better course, relying in particular on directing  Ambivalence o People who want to change see both reasons to change and to not change o Normal part of change process o There are also some people who need to make a change but themselves see little or no reason to do so fro them developing ambivalence about change would be a step forward o The most common place to get stuck on the way to change is ambivalence o When a person is ambivalent 2 kinds of talk mixed together  Change talk  The person’s own statements that favor change  Called “self-motivational statements”  Sustain talk  The person’s own arguments for not changing, for sustaining the status quo  Ex I need to do something about my weight [change talk] but I’ve tried about everything and it never lasts [sustain talk]

o When ambivalent person meets helper with a right reflex is to take up the good side of the argument bu the person who needs help doesn’t realize they need to change o Client openness vs defensiveness change talk versus sustain talk is very much a product of the therapeutic relationship o Resistance and motivation occur in an interpersonal context o Counsel in a way that evokes defensiveness and counter argument and people are less likely to change o It also confirms the clinician’s belief that these people are difficult resistant and intractable o It is a self-fulffiling prophecy o Client should voice the reason for change o Client needs to be voicing the reasons for change o Righting reflex involves the belief that you must convince or persuade the person to do the right thing o You just need to ask the right questions, find the proper arguments, give the critical information, provoke tehd ecisive emotions or pursue the correct logic to make the person see and change o The perspective calls to confront the person with reality provide the solution and when you meet resistance turn up the volume o Clients tend to respond in the predictable way thus leading to the erroneous conclusion that all people with addications are characterologically immature, fiercely defenced and “in denial” o People tend to feel bad in response to the righting reflex and causing people to feel bad doesn’t help them to change o These questions for MI o “Why would you want to make this change?” 2. “How might you go about it in order to succeed?” 3. “What are the three best reasons for you to do it?” 4. “How important is it for you to make this change, and why?” o Then listens and gives short summary and asks o So what do you think you’ll do  So what is MI o Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change  MI is first and foremost, a conversation about change  It can be brief or prolonged and it may occur in many different contexts with individuals or groups but it is always a collaborative conversation, never a lecture or monologue  It is more a matter of guiding than directing  Also, as the name implies, in primary purpose is to strengthen motivation for change – the person’s own motivation  Key points

o Neither do we mean identification o Empathy is an ability to understand another’s frame of reference and the conviction tha tis worthwhile to do so  Autonomy support o Acceptance involves honoring and respecting each person’s autonomy, their irrevocable right and capacity of self- direction o Directly acknowledging a person’freedom of choice typically diminishes defensiveness and can facilitate change o  Affirmation o Seek and acknowledge the person’s strengths and efforts o Four person-centered conditions covey what we mean by “acceptance o One honours each person’s absolute worth and potential as a human being, recognizes and supports the person’s irrevocable autonomy to choose his or her own way, seeks though accurate empathy to understand the other’s perspective and affirms the peroson’s trengths and efforts o  Compassion  To be compassionate means to actively promote the other’s welfare to give priority ot the other’s needs   Evocation  Instead of trying to find what someone lacks and fixing that  Instead spirit of Mi is that person has what you need and together we will find it  When all 4 of these components intersect then the mi spirit emerges  Motivationall interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change  Change is fundamentally self0change  People are the expert on themselves no one knows more about them than they d  We don’t have to come up with all the good ideas  People have their own strengths, motivations and resources that are vital to activate in order for change to occur  Therefore change requires a partnership a collaboration of expertise  It is important to understand the person’s own perspective on the situation, what is needed and how to accomplish it  A conversation of change should feel like dancing not wrestling

 Motivation for chanfe is not installed but is evoked it’s already there and just needs to be called forth  Key points o MI is a person-centered counseling style for addressing the common problem of ambivalence about change o MI is done for or with someone not on or them o Four key aspects of the underlying spirit of MI are partnership, acceptance, compassion and evocation o Acceptance includes four aspects of absolute worth, accurate empathy, autonomy support and affirmation o MI is about evoking that which is already present, not installing what is missing  Four processes in motivational interviewing o Engaging  Every relationship begins with a period of engagement  When people come seeking consultation or services they wonder and often imagine what the provider will be like how she or he will treat them  Engaging is the process by which both parties establish a helpful connection and a working relationship  Therapeutic engagement is a prerequisite for everything that follows  Engagement involves more than just being friendly and nice to the client o Focusing  The process of engaging leads to a focus on particular agenda why the patient came to you in the first place  Provider may also have an agenda some of which overlap with the client’s whereas others may not  Focusing is the process by which you develop and maintain a specific direction in the conversation about change  In the course of helping relationships, a direction toward one or more change goals usually emerges  These may be formalized in a treatment plan although we prefer a broader change plan because treatment is often just one of many possible avenues toward change  Within MI, the focusing process helps to clarify direction, the horizon towards which one intends to move o Evoking  Understanding why the client wants to change and their own feelings about it  Personal change requires the individual’s active participation in the change process  Evoking is having the person voice the arguments for change  The righting reflex is to voice these arguments oneself which is counterproductive to do so

 General respects and honors the client as a person of worth, with the capability for growth and change as well as volitional choice about whether to do so  Interviewer also recognizes and comments on the client’s particular strengths, abilities good intentions and efforts  o Reflective listening  Fundamental skill in MI  Reflective statements that make a guess about the client’s meaning have the important function of deepening understanding by clarifying whether one’s guess is accurate  Allow people to hear again the thoughts and feelings they are expressing, perhaps in different words and ponder them  Keeps the person talking, exploring and considering  o Summarizing  Reflections that collect what a person has been saying offering it back as in a basket o Informing and Advising  Because of the person-centered foundation of MI, people sometimes mistakes  Mi one offers info or advice with permission  Second is not to just unload info on someone, but to understand their perspective and needs carefully and help them reach their own conclusions about the relevance of any info you provide o MI is a style of being with people an integration of particular clinical skills to foster motivation for change o MI is a collobaritve partnership that honors and respect the other’s autonomy seeking to understand the person’s interal frame of reference  Key points o Four key processes in MI are engaging, focusing, evoking and planning o Engaging is the process of establishing a helpful connection and working relationship o Focusing is the process by which you develop and maintain a specific direction in the conversation about change o Evoking involves eleiciting the client’s own motivations for change and lies at the heart of MI o Planning process encompasses both developing commitment to change and formulating a concrete plan of action o 5 key communication skills used throughout MI are asking open questions, affirming,reflecting, summarizing and providing info and advice with permission o