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Motivational Interviewing- Trauma Informed Applications to Youth.pdf

  1. 1. Greg Merrill, LCSW MOTIVATIONAL INTERVIEWING: TRAUMA INFORMED APPLICATIONS TO YOUTH What people really need is a good listening to. Mary Lou Casey When we listen, they talk. When they talk, they discover. Unknown
  2. 2. Motivational interviewing is a person-centered and focused communication style plus methods that strategically responds to language about change, often accelerating resolution of ambivalence and increasing motivation and commitment to change. WHAT IT IS
  3. 3. COW AMBIVALENCE I’m not stuck. I’m thinking..
  5. 5. THE CHANGE TRIFECTA Readiness (the right time, the right way) Importance Confidence (willing) (able)
  6. 6. WHEN IT COMES TO LISTENIN’ STYLE MATTERS 75% of MI is NOT saying what everyone else does: NO FIXIN’
  7. 7. Listener Anxiety can lead to: Talking too much Offering advice or resources prematurely Rescuing Lecturing Pressuring Invalidating Fixin’ vs. Listenin’ “After all, when you seek advice from someone it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself.” --Terry Pratchett FIXIN’ AIN’T LISTENIN’
  10. 10. When we listen, they talk. When they talk, they discover.
  11. 11. OPENING STRATEGIES (OARS) Open Ended Questions (>50%) Affirm (at least 1x) Reflective Listening (2:1) Summarize (1-3x) Pause. Punctuation.
  12. 12. (WIDE) OPEN ENDED QUESTIONS Ask brief questions that do not invite brief answers, and more important, invite the person to tell their story. Common constructions: What . . .? How. . .? Tell me about . . . Followed by punctuation (?) and PAUSE.
  13. 13. Encouragers are short follow-up questions or prompts that help the person to answer the original, open-ended question more completely. What else? What example of that comes to mind? Say more. Wow! That’s really interesting! Go on. Mmm-hmmm. Really? ENCOURAGERS EXTEND
  14. 14. EXERCISE 1: Open Ended Question Formation The talker says: About a month ago, everything was blowing up, for real. I was getting a bunch of run around, everyone telling me: go here, do this, go there, do that. I’m doing cool now. I’m still alive. I’m going to school. A month ago, it was me and a hard time and no one helping me. Form 3 open questions using “what,” “how,” or “tell me about” that the talker is likely to answer: 1. 2. 3.
  15. 15.  Recognize effort (over success)  “The important part was that you tried so hard.”  Recognize strengths (reframe resistance)  “You are very persistent and strong-minded.”  Emphasize the talker’s personal choice, control, freedom, autonomy  “You are absolutely right. No one can make you do this.”  Express support  “Quitting smoking can be one of the hardest things to do in life.”  Express confidence  “If you decide to change this, I believe you can eventually succeed.” AFFIRMATION
  16. 16.  http://www.npr.org/2014/03/07/286921391/a-homeless- teen-finds-solace-in-a-teacher-and-a-recording STORYCORPS: AARON, A HOMELESS TEEN FINDS SOLACE IN AN (AFFIRMING) TEACHER Celeste Davis-Carr, a high school English teacher in Chicago, learned her student Aaron was homeless from a recording for the StoryCorpsU program.
  17. 17. “Every block of stone has a statue inside it and it is the task of the sculptor to discover it.” -Michelangelo
  18. 18.  A hypothesis as to what the talker is getting at said as a statement, not a question. Voice tone turns down at the end of the reflection, not up.  Integrate underlying feelings, values, and unsaid portions.  Brief: 10 words or less (variance here).  Period. Pause. Wait, Watch. REFLECTIVE LISTENING
  19. 19.  Simple Reflections: stays close to the person’s original speech  Repeating – simply repeats an element  Rephrase – substitutes synonyms  Complex Reflections: adds or enhances what the person said  Affective – emphasizes the emotional dimension  Values – emphasizes beliefs and principles  Understated/Overstated – minimizes or increases intensity  Continuing the paragraph – completes next sentence  Double-sided – states both sides  Uses images or metaphors – to increase perspective LEVELS OF REFLECTION
  23. 23. EXERCISE 2: Reflection Formation 2.1 The talker says: I’m not going to school. The principal and the teachers already hate me so I don’t see how that’s going to benefit me. Form 3 reflections 1. Simple: 2. Complex: 3. Use the word “you”: 2.2 The talker says: I don’t want to live with my grandmother anymore. She was a good grandmother but not a great parent. She does her best. There’s dust everywhere in her house. It’s gross and I have asthma. As soon as I turn 18, I’m just going to go live with my father. Form 3 reflections 1. Simple: 2. Complex: 3. Use the word “you”:
  24. 24. 2.3 The talker says: My dog is the only living thing I care about, and she loves me, too. People think that’s weird but I don’t care. She’s better than any human as far as I can tell. Form 3 reflections 1. Simple: 2. Complex: 3. Use the word “you:” 2.4 The talker says: I take my medications when I feel like it. I don’t need them every day. I don’t feel like myself on them. All everyone cares about is whether I take my medications. Form 3 reflections 1. Simple: 2. Complex: 3. Use the word “you”:
  25. 25. 2.5 The talker says: I’m not trying to get disappointed. I don’t want to hear about any disappointment or rejection. If I feel like I’m going to get a no, I’m just going to shut myself down. I’m not even going down that route. O-A-R All Together Now! 1. Open Question: 2. Affirmation: 3. Reflection:
  26. 26. Preface: “Let me try to summarize what you’ve been expressing . . .” Pearls of Wisdom: One, Two, or Three “Pearls” Ask for feedback: “What would you add or subtract?” “What did I miss?” “How accurate was that?” SUMMARIZING
  27. 27. EXERCISE 3: Summarize This Adolescent girl in an internship program she was excited about She says: Somebody told me the break was 30 minutes so I was like, all right cool. The supervisor dude was like, no way, you’ve got to finish before you go on break. I was like, “no, I can’t. I’m not doing it.” The other students all think the supervisor has anger issues with girls. One time I noticed he talked to me all crazy. He said something smart, just no need. I was like, OK, I’m going to let that slide. I’m going to let that pass. He just got at me wrong. I don’t have an issue with him even though he gets mad at me and raises his voice. I have no issue with him. I am still going to be there for him and give him a helping hand with the project. I have a right to be in this shop as a female. When he has an issue with somebody, he doesn’t tell them straight up. He talks about them to other people. That’s not right. That’s not professional.
  28. 28. I don’t like the way he deals with people. I want him to be direct but I don’t want to talk to him any kind of way. He can get mad easily and what he says can be seen as disrespectful. I don’t play that. I’m not taking that. If he talks to me crazy, I’m going to let him know that you can’t talk to me like that. It's nothing. He’s my co-worker. He just has issues. I don’t have an issue with him. I want to keep it in the past. It was an incident, just a misunderstanding. It’s nothing. I’m a professional. 1. What are the 2-3 of the talker’s most important points? 2. If you had to give the talker one piece of advice, what would it be? 3. If this talker had difficulties interacting with authority, which speech would you consider “sustain talk” and which speech would you consider “change talk”?
  29. 29. After all, when you seek advice from someone it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself. --Terry Pratchett
  30. 30. GIVING ADVICE: MI WAY ASK •Permission •What they already know OFFER •Information •Advice •Resources •Your concern •Your Perspective ASK •What they think •What they agree or disagree with SUPPORT AUTONOMY WHENEVER POSSIBLE
  31. 31. The concerns, the ideas, and/or the inspiration come directly from the talker whenever possible. Evocation is the opposite of “installing” or “instilling” from the outside in (i.e. the righting reflex). Evocation emphasizes “inviting out” the values, knowledge, skills, and hopes that are just inside waiting. . . EVOCATION (EXPLORATION)
  32. 32. CHANGE TALK  Any speech that favors the possibility for change related to a specific target  Examples:  Discomfort with the status quo  Confidence  Optimism or hopes for the future  Need to avoid negative consequences SUSTAIN TALK  Any speech that favors the status quo or no change position  Examples  Minimizing problems  Blaming others  Expressing pessimism about ability to change successfully CHANGE TALK AND SUSTAIN TALK
  33. 33. Preparatory Desire Ability Reason Need Commitment Commitment Action Taking Steps TYPES OF CHANGE TALK
  34. 34. Use Your: Elaboration or Example (Ask for) Affirm Reflect Summarize RECOGNIZING AND RESPONDING TO CHANGE TALK
  35. 35. Given what we’ve talked about today, what’s next? What else? NEXT STEP QUESTION
  36. 36. THEORY OF MI CHANGE MECHANISMS (Commitment Talk)
  37. 37.  EXPRESS EMPATHY: When people feel cared about and accurately understood, they open themselves up to questions of change and become more contemplative  DEVELOP DISCREPANCY: People who may be acting in a way that is against their own values or goals can benefit from realizing of their own accord that there is an internal (vs. external) conflict (trick: without triggering defensiveness or shame)  SUPPORT SELF-EFFICACY: When people feel that they – or people like them -- have a chance at success, they are more likely to try.  PROMOTE AUTONOMY: When people feel in charge of and responsible for making their own decisions and that their autonomy is respected, they are more likely to actively make decisions. FOUR META-METHODS
  38. 38.  When human beings feel accurately understood and unconditionally positively regarded, they can physiologically relax which, paradoxically, opens them up to challenge, growth, and self-reflection ACCURATE EMPATHY
  39. 39.  The mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs, ideas, or values at the same time, or is confronted by new information that conflicts with existing beliefs, ideas, or values.[1][2] When inconsistency (dissonance) is experienced, individuals tend to become psychologically uncomfortable and are motivated to attempt to either resolve the contradiction or avoid situations and information which are likely to increase it. COGNITIVE DISSONANCE (FESTINGER)
  40. 40. People with a strong sense of self-efficacy:  View challenging problems as tasks to be mastered  Develop deeper interest in the activities in which they participate  Form a stronger sense of commitment to their interests and activities  Recover quickly from setbacks and disappointments People with a weaker sense of self-efficacy:  Avoid challenging tasks  Believe that difficult tasks and situations are beyond their capabilities  Focus on personal failings and negative outcomes  Quickly lose confidence in personal abilities SELF EFFICACY: “THE BELIEF IN ONE’S CAPABILITIES TO ORGANIZE AND EXECUTE THE COURSES OF ACTION REQUIRED TO MANAGE PROSPECTIVE SITUATIONS” –BANDURA, 1977
  41. 41. PROMOTING AUTONOMY (SELF-DETERMINATION) Clinicians who promote autonomy:  Explicitly honors the person’s right not to change  Help the person recognize the choices or decisions in front of them  Express confidence about the person’s abilities particularly if they decide to change  markedly expand the person’s experience of his or her own sense of control and choice