MOTIVATIONAL INTERVIEWING • Ready: Matter of priorities • “Quitting smoking is important to me… But it’s not the most important thing RIGHT now.” • Willing: Perceived importance • “I don’t really want to quit smoking.” • Able: • “I wish I could quit smoking… but I think I’ll fail if I try” • All contribute to ambivalence • Ambivalence is not pathological; Everyone is ambivalent sometimes • Because ambivalence is uncomfortable, it often leads to procrastination • Tempting to label ambivalence “resistance” • Ambivalence has to be resolved for change to occur • MI: turns ambivalence into motivation, STAGE OF CHANGE • Precontemplation: Not acknowledging there is a problem behavior that needs change • Contemplation: Acknowledging there is a problem, but not yet ready or sure of change (ambivalence) • Preparation: Getting ready to change (e.g., finding resources) • Action: Actually changing (practicing new behavior) • Maintenance: Sustaining behavior change • Relapse: Returning to old behaviors • MI can help with all stages
Stage of Change Precontemplation
Techniques Validate lack of readiness; clarify that the decision is theirs; gently encourage re evaluation of current behavior; encourage self exploration (NOT action); explain and personalize the risk
Validate lack of readiness; clarify that the decision is theirs; encourage evaluation of pros and cons of behavior change; identify and promote new, positive outcome
• What will happen if you don’t change?
• What makes you think you need to change?
• What would you like to see that’s different about your current situation?
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Identify obstacles, help problem solve, help client identify supports, develop necessary skills, encourage small initial steps
Focus on social support, restructuring cues, self efficacy, combat feelings of loss, reiterate long-term benefits
Plan for follow-up support, reinforce internal awards, discuss coping with relapse
Evaluate trigger for relapse, reassess motivation and barriers, plan stronger coping strategies
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• Elicit change talk • What would you like to see that’s different about your current situation? • What makes you think you need to change? • What will happen if you don’t change? • Provoke extremes: Suppose you don’t change, what is the WORST thing that could happen? How about the best? • Look forward: How would your life be different from what it is today? • Explore importance, readiness, and confidence (use numerical scales): How confident are you that you can change this behavior? What would it take to move from # to #? [Same with importance] • Open-ended questions to understand: What do you like about your behavior? What makes you think it might be time for a change? What’s different about quitting this time? • Reflective listening: “It sounds like…” “I hear you saying…” • Normalizing: “Many people have struggled with this…” “A lot of people are concerned about gaining weight when quitting.” • Decisional Balancing: What are some good things? Bad things? • Columbo approach: On one hand, I hear you telling me that… On the other, I hear… How do you reconcile these ideas?• Support self-efficacy (validation, encouragement): Last week you didn’t smoke at all! How did you do that? • Advice: Factual information (e.g., benefits of quitting smoking) “Do you mind if I provide feedback on…” • Summaries: selectively highlight change talk and ambivalence • Therapeutic paradox: “Maybe now is not the right time for you to make changes… Psychic Conflict Instinctual drive leads us to want things that we cannot have Why? What sorts of things keep us from following our drives? Social expectations, rules Contradictory desires Ambivalence and conflict Two opposite feelings toward the same thing Loving feelings and hateful feelings together One foot on the brake, one foot on the gas This is uncomfortable Defenses Unconscious techniques created by ego as an attempt to handle conflict. Healthy people use these too! Defenses are challenged through psychoanalysis Denial: This didn’t happen! Reject impulse Rationalization (making excuses): Convincing oneself no wrong has been done, through faulty reasoning – “convenient excuses” Splitting – Polarizing beliefs, actions, people into “good” or “bad” Repression – keep impulse in unconscious Reaction formation – do opposite of impulse Displacement – redirect impulse Sublimation – redirect impulse in a way toward a productive goal (healthy) Intellectualization – frame impulse in intellectual terms devoid of emotion (healthy) Humor: Impulses converted to jokes (healthy) Unique Themes in Psychodynamic Theory Content vs. Process Focus on affect and expression Exploration of attempts to avoid distressing thoughts and feelings Identification of recurrent themes and patterns Discussion of past experiences Focus on interpersonal relations Focus on the therapy relationship Exploration of fantasy life Evidence base for Psychodynamic therapy General symptom improvement Somatic Disorders Personality Disorders Intrapsychic changes exceeded those seen in Dialectical Behavior Therapy Bateman & Fonagy (2008) 87% (treatment as usual) vs. 13% (psychodynamic) retained BPD diagnosis at 5 yr follow-up Behavioral Observations Level of Consciousness • Vigilant • Alert • Drowsy • Lethargic • Stuporous • Asleep • Comatose • Confused • Fluctuating Speech and Language • Quantity: Talkative, spontaneous, expansive, paucity, poverty • Rate: Fast, slow, normal, pressured, halting • Volume (tone): Loud, soft, monotone, weak, strong • Fluency and rhythm: Slurred, clear, appropriate inflection, hesitant Mood and affect • What is mood? (Gloria: 4:00; Andy: 5:45) • Sustained inner feeling, reported by client • How are you doing today? How are your spirits? Have you been depressed lately? • What is affect (observed emotion)• Appropriate to situation, consistent with mood, congruent with thought content • Euthymic, dysthymic, angry • Fluctuations: Labile, even • Range: Broad, restricted Thought Process • Logical, relevant, organized • Linear, goal-directed • Loose associations: • Circumstantial: Unnecessary details, but returns to original question eventually • Tangential: Unnecessary details, does NOT return to original question • Incoherent, evasive, racing, blocking, perseveration • Neologisms, clang speech, word salad, echolalia • "I'm going to the park to ride the wallywhoop.“ • "He walked the dog eggnog, frog, clog, soggy” • “The sheep languished blue trains suffer” • How are you doing? Oing, oing, oing…