Motivational Interview Slides (4 MB) - National Health Care for the

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Welcome

Motivational Interviewing: an overview and application in outreach

August 17, 2011

We will begin promptly @ 2PM EDT

Event Host Victoria Raschke, MA Director, Technical Assistance and Training National Health Care for the Homeless Council

This presentation is supported through a National Cooperative Agreement with the Health Resources and Services Administration.

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Health Care & Housing Are Human Rights

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Presenters

Kevin Kelley, LMFT •  Clinical Director, Integrated Treatment Program for CoOccurring Disorders, Homeless Health Care Los Angeles •  Clinical Program Supervisor, Comprehensive Neurobehavioral Specialists

John Petroskas •  Outreach worker, Catholic Charities Housing First, Minneapolis, MN • Previously worked with HUD, Amherst Wilder Foundation and Metro-wide Engagement on Shelter and Housing

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Overview of Today’s Presentation Overview of Motivational Interviewing, including the stages of change and components of Motivational Interviewing Presentation of an example of how Motivational Interviewing can be used in outreach to persons experiencing homelessness Q &A

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Motivational Interviewing 
 A Basic Overview#

Kevin Kelley, LMFT !

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Clinical Director ! Integrated Treatment Program! for Co-Occurring Disorders! Homeless Health Care Los Angeles#

Learning Objectives By the end of the presentation you will be able to:

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Discuss the Spirit of Motivational Interviewing Define Motivation Describe the Stages of Change Discuss core Motivational Interviewing Components

Motivational Interviewing “A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002)

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Spirit of Motivational Interviewing “Motivational Interviewing is not a series of techniques for doing therapy but instead is a way of being with patients.” William Miller, Ph.D.

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Spirit of Motivational Interviewing Also Known As… “Helping people talk themselves into changing”

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Spirit of Motivational Interviewing •  Collaborative - a partnership that honors a client’s expertise and their perspectives •  Evocative - resources and motivation presumed to reside within the client •  Empowering - affirming of client’s right and capacity for self-direction, facilitates informed choice 10

Spirit of Motivational Interviewing •  Hospitality - “safe place” •  Story - “everyone has a story to tell” •  Care - “empathy not sympathy” •  Entering the Shadows - “exploring areas never explored” 11

Four Principles of Motivational Interviewing Express Empathy" Develop Discrepancy" Roll With Resistance" Support Self-Efficacy

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1. Express Empathy Acceptance facilitates change! Skillful reflective listening is fundamental! Ambivalence is normal

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2. Develop Discrepancy Client rather than clinician should present arguments for change.! Change is motivated by perceived discrepancy between present behavior and important personal goals/values.

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3. Roll with Resistance Avoid arguing for change! Resistance is not directly opposed New perspectives are offered, but not imposed Client is primary resource in finding answers and solutions! Resistance is a signal to respond differently 15

4. Support Self-Efficacy Belief in the possibility of change is an important motivator! Client, not the counselor, is responsible for choosing and implementing change! Provider’s own belief in the person’s ability to change becomes a self-fulfilling prophecy 16

Motivational Interviewing “A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002)

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“INTER - VIEWING”

BETWEEN - LOOKING AT

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Client - Centered Here and now approach Genuine, accepting, empathic Assumes strengths reside within client Assumes resources reside within client Goal oriented Client determines focus and pace Egalitarian therapeutic relationship Collaborative Freedom of choice 19

Directive “Serving to direct, indicate, or guide…”

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Method a way of doing something, especially a systematic way; implies an orderly logical arrangement (usually in steps) 21

Motivation Motivation is the tipping point for making change happen

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Motivation Motivation comes from: External Factors Intrinsic Factors

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Motivation Key to change" •  Multidimensional" •  Dynamic and fluctuates " •  Influenced by social interactions" •  Influenced by clinician's style" •  Can be elicited and enhanced

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Three Critical Components of Motivation Ready - a matter of priorities Willing - importance of change Able - confidence to change

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Stages of Change •  Precontemplation - person does not consider the possibility for change •  Contemplation - person is ambivalent and considers change versus no change •  Preparation - person considers various strategies for change •  Action - person initiates change •  Maintenance - person continues to maintain change 27

Precontemplation DO - Motivational Responses" •  raise doubt (explore pros and cons)" •  increase perception of risks and problems" •  develop discrepancy

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DON’T •  nag, push into action •  give advice •  cover for or make excuses for person •  give up

Contemplation DO - Motivational Responses" •  provide empathy" •  explore ambivalence (pros and cons)" •  evoke client’s reasons to change" •  strengthen hope, self-efficacy DON’T" •  take sides (push your personal view) •  create an action plan 29

Preparation DO - Motivational Responses" •  explore client’s options for change •  help to set acceptable goals" •  develop effective and achievable action steps DON’T •  push client too fast/hard •  decide for client which option to take 30

Action DO - Motivational Responses" •  help build needed skills and coping strategies! •  assist with accessing resources (family and social support) DON’T •  give up •  push client to take on too much 31

Maintenance DO - Motivational Responses •  maintain supportive contact with client •  facilitate support for short/long-term change! •  develop relapse prevention supports - “fire escape plan” DON’T •  give up •  push client too hard 32

Assumptions About Change •  Motivation is a state, not a trait.! •  Ambivalence is normal, positive! •  Resistance happens, not a force to overcome! •  The other person is an ally, not an adversary! •  Recovery, change, growth are intrinsic to the human experience 33

Ambivalence

“I want to, but I don’t want to” •  Natural phase in process of change! •  Problems persist when people “get stuck” in ambivalence! •  Normal aspect of human nature, not pathological! •  Ambivalence is key issue to resolve for change to occur 34

Ambivalence “People often get stuck, not because they fail to appreciate the down side of their situation, but because they feel at least two ways about it.”

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Resistance •  •  •  • 

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Resistance happens" Not a force to overcome" A signal, information" Influenced by clinician responses

Traps to Avoid •  •  •  •  •  • 

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Question - Answer" Taking Sides" Expert" Labeling" Premature Focus or Pacing" Blaming

OARS: Tools of Motivational Interviewing •  Open-Ended Questions" •  Affirmations" •  Reflective Listening" •  Summaries “Motivational Interviewing is not a series of techniques for doing therapy but instead is a way of being with patients.” William Miller, Ph.D. 39

OARS: Open-Ended Questions •  •  •  •  •  •  •  •  40

Can you tell me more about that situation? What have you noticed about your ____? What concerns you most? When would you be most likely to share needles with others?" How would you like things to be different?" What will you lose if you give up drinking?" What have you tried before?" What do you want to do next?

OARS: Affirmations •  Statements of recognition of a client’s strengths" •  Build confidence in a client’s ability to change" •  Must be congruent and genuine

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OARS: Reflective Listening “Reflective listening is the key to this work. The best motivational advice we can give you is to listen carefully to your clients. They will tell you what has worked and what hasn't. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen.” (Miller & Rollnick, 2002) 42

Levels of Reflection Reflection 1.  Simple – repeating, rephrasing; staying close to the content 2.  Amplified – paraphrasing, double-sided reflection; testing the meaning/what’s going on below the surface 3.  Feelings – emphasizing the emotional aspect of communication; deepest form

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OARS: Summarizing “Let me see if I understand thus far…”

•  •  •  •  •  • 

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Special form of reflective listening" Ensures clear communication" Use at transitions in conversation" Be concise" Reflect ambivalence" Accentuate “change talk”

General Practice Guidelines •  Talk less than your client does" •  Offer 2 or 3 reflections for every question you ask a client " •  Ask twice as many open-ended questions as closed questions " •  When listening empathically, more than half of your reflections should go beyond simple reflection 45

Eliciting Change Statements •  •  •  • 

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Disadvantages of status quo" Advantages of change" Optimism about change" Intention to change

Exploring Importance (Willing)

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•  Assess: On a scale of 1-10, how important is it now for you to (change)?" •  Explore: “Why did you give it a __ and not a __ ?” “What would have to happen to raise that score from a __ to a __?” “How can I help you with that?” 47

Exploring Confidence (Able)

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•  Assess: “On a scale of 1-10, how confident are you now that you could make that change, if you decided to make it?”" •  Explore: “Why did you give it a __ and not a ___?”“What would have to happen to raise your confidence?” “How can I help you with that?” 48

Strengthening Commitment to Change •  •  •  •  •  •  49

Recognizing signs of readiness" Beware of hazards" Summarizing" Asking key questions" Giving information and advice" Negotiating a change plan

Giving Advice •  •  •  •  •  • 

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Ask permission to discuss concerns" State concerns non-judgmentally" Affirm decision is client’s to make" Inquire what client thinks" Help evaluate options" Provide affirmations and hope

MAY I GIVE SOME ADVICE?

When in doubt…

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LISTEN!

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References •  J.O. Prochaska and C.C. DiClemente. “ In search of how people change: applications to addictive behaviors” in American Psychologist, 47: 1102-1114 (1992) •  William R. Miller and Stephen Rollnick. Motivational interviewing: preparing people to change addictive behavior. (1991) •  Rollnick, S, Mason P, & Butler, C. Churchill Livingstone, Health Behavior Change. (1999)

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References •  Stanton Peele and Archie Brodsky. The truth about addiction and recovery. (1991) •  CSAT. TIP # 35 - Enhancing Motivation for Change in Substance Abuse Treatment. (1999) 1-800-729-6686 •  Website: www.motivationalinterview.org

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Motivational Interviewing in Outreach Settings

John Petroskas Catholic Charities Twin Cities, Housing First

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Secure Waiting Space

1000 Currie Avenue, Minneapolis

Year-round overnight shelter for 251 men

125 in free “secure waiting” space

- mats on the floor

126 in “pay for stay” program, $6 per night

- bunk, linens, lockers

Opened in 1996

No limit on length of stay

Funded largely by Hennepin County

Operated by Catholic Charities

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Do we try to “sell” things people aren’t ready to buy?   Housing

  Services   Appointments   Treatment  “Case

Managers”  “Disability”   CHANGE!! 64

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Why MI is great  We

don’t have anything to sell, except our support

 It

can be used effectively in brief encounters or in-depth conversations

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 It

is client-centered

 It

takes the pressure off

 It

helps build relationships

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Why MI is difficult  We

want to fix things

 We

have seen what worked for others

 We

know people can change

 We

have expectations

 Others  It

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have expectations of us

requires patience

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Case Study: “Richard”  Elderly  Living  Has

veteran, long time shelter user

with schizophrenia

an apartment, but has returned to shelter

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Motivational Interviewing allows us to: Build & sustain client-centered relationships, based on trust, in which we help people achieve their goals over time.

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John Petroskas Outreach Worker Catholic Charities Housing First Program 612-204-8318 (office) 612-490-3634 (cell) [email protected]

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Q & A

Kevin Kelley, LMFT •  Clinical Director, Integrated Treatment Program for CoOccurring Disorders, Homeless Health Care Los Angeles •  Clinical Program Supervisor, Comprehensive Neurobehavioral Specialists

John Petroskas •  Outreach worker, Catholic Charities Housing First, Minneapolis, MN • Previously worked with HUD, Amherst Wilder Foundation and Metro-wide Engagement on Shelter and Housing

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More Information



The National Health Care for the Homeless Council is a membership

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organization for those who work to improve the health of homeless people and who seek housing, health care, and adequate incomes for everyone. Our site: www.nhchc.org

NHCHC offers

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Detroit Regional Training, free training event, September 19 & 20, 2011 register: http://www.nhchc.org/regionaltraining/detroit091911.html

Upcoming webinars:

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free individual memberships at: http://www.nhchc.org/council.html#membership

organizational memberships which support our policy and advocacy work at: http://www.nhchc.org/councilmembershipform.html

no-cost training and technical assistance to HCH grantees, request at: http://www.nhchc.org/TArequest.html

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HCH & Community Mental Health Provider Partnerships: September 22 | 12:30PM EDT

Chronic Pain Management in HCH: Monday, September 29, 2011, 1PM EDT

Thank you for your participation. Upon exiting you will be prompted to complete a short online survey. Please take a minute to complete the +survey to evaluate this webinar production.

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Motivational Interview Slides (4 MB) - National Health Care for the

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