Ambivalence - Motivational Interviewing

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MOTIVATIONAL
INTERVIEWING
in
CLINICAL
SUPERVISION
Ann D. Carden, Ph.D.
[email protected]
© Ann D. Carden, Ph.D. - 2006
1
Guiding Principle #1
Express Empathy
© Ann D. Carden, Ph.D. - 2006
2
Self-Regulation
Theory
© Ann D. Carden, Ph.D. - 2006
3
Intentional change
is grounded in awareness of
one’s core values and life goals
and the gap between those
values and goals and one’s
present behaviors
© Ann D. Carden, Ph.D. - 2006
4
“They say you can lead a horse to
water, but you cant’ make him
drink…but I say, you can salt the
oats.”
Madeline Hunter
© Ann D. Carden, Ph.D. - 2006
5
Guiding Principle #2
Develop Discrepancy
© Ann D. Carden, Ph.D. - 2006
6
Trans-theoretical
Stages of Change
Model
© Ann D. Carden, Ph.D. - 2006
7
Stages of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Termination
© Ann D. Carden, Ph.D. - 2006
8
•
Resources – internal & external
•
Risks – internal & external
•
Readiness ------> intervention
© Ann D. Carden, Ph.D. - 2006
9
Guiding Principle #3
Roll with Resistance
© Ann D. Carden, Ph.D. - 2006
10
Self-Perception
Theory
© Ann D. Carden, Ph.D. - 2006
11
Concern
Problem
Recognition
NEED
DESIRE
REASONS
Intention
COMMITMENT
Behavioral
Confidence
ABILITY
© Ann D. Carden, Ph.D. - 2006
12
The Flow of Change Talk
MI
Desire
Ability
Reasons
Need
Commitment
Change
© Ann D. Carden, Ph.D. - 2006
13
Guiding Principle #4
Support Self-efficacy
© Ann D. Carden, Ph.D. - 2006
14
Intentional Change is a
process, not an event!
© Ann D. Carden, Ph.D. - 2006
15
Intentional change is more likely to
occur when goals are






Small
Important to the goal-setter
Specific/Concrete/Measurable
Present-focused
Realistic/Practical
A presence rather than an
absence
© Ann D. Carden, Ph.D. - 2006
16
Three Phases in the
Intentional Change Process
© Ann D. Carden, Ph.D. - 2006
17
Common Barriers to SelfEnhancing Intentional Change










Cluelessness
Minimization
Projection of responsibility
Immediate gratification
Fear of failure
Skills deficits
Information gaps
Fear of the unknown
Lack of social / material supports
Competing stressors
© Ann D. Carden, Ph.D. - 2006
18
“Given a choice
between
changing and
proving that it is
not necessary,
most people get
busy with the
proof.”
© Ann D. Carden, Ph.D. - 2006
John Galbraith
19
It’s not so much that we’re afraid of
change or so in love with the old ways,
but it’s that place in between that we fear
…
It’s like being between trapezes …
It’s Linus when his blanket is in the drier.
There’s nothing to hold on to.
Marilyn Ferguson
© Ann D. Carden, Ph.D. - 2006
20
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.”
Miller & Rollnick
© Ann D. Carden, Ph.D. - 2006
21
Ambivalence
approach-approach
approach-avoidance
avoidance-avoidance
double approach avoidance
© Ann D. Carden, Ph.D. - 2006
22
Motivation
When the balance tips away from resistance and
toward commitment
Never completely free of ambivalence
and resistance
Requires on-going “buy in” at the
level of
thinking
feelings
actions
© Ann D. Carden, Ph.D. - 2006
23
Six Supervisor Guidelines
1. Adhere to the MI Guiding Principles
2. Avoid Traps / Roadblocks to progress
3. Teach / model the Philosophical Foundations
of MI
4. Maintain a clinical focus
5. Adapt to the Supervisee’s context
6. Assist supervisees to become proficient in MI
clinical skills
© Ann D. Carden, Ph.D. - 2006
24
Ongoing assessment of
client’s:




© Ann D. Carden, Ph.D. - 2006
stages
resources
risks
readiness
25
Ongoing assessment of
supervisee’s:




alliance with client
MI consistent interventions
goals for client
beliefs about outcomes
© Ann D. Carden, Ph.D. - 2006
26
Supervisory Responsibility
“Above all
do no harm”
© Ann D. Carden, Ph.D. - 2006
27
Six Supervisor Guidelines
1. Adhere to the MI Guiding Principles
2. Avoid Traps / Roadblocks to progress
3. Teach / model the Philosophical Foundations
of MI
4. Maintain a clinical focus
5. Adapt to the Supervisee’s context
6. Assist supervisees to become proficient in MI
clinical skills
© Ann D. Carden, Ph.D. - 2006
28
Cultural Diversity









Age
Socio-economic status
Gender / sexual orientation
Ethnicity / race
Geographic location
Religion
Educational level and type
Life roles
Disability / diagnosis
© Ann D. Carden, Ph.D. - 2006
29
Cultural effects ….









Values
Perspective
Meanings
Relationships
Independence
Current focus / life task
Time orientation / pacing
Communication and learning style
Client-counselor alliance
© Ann D. Carden, Ph.D. - 2006
30
Client-Related Stressors of
Direct Service Providers







Client resistance / supervisee’s
unrealistic expectations of client change
Boundary issues/ethical dilemmas
Client suicide/attempts
Client anger/hostility
Premature termination
Client violence toward others
Client death
© Ann D. Carden, Ph.D. - 2006
31
Job-Related Stressors of
Direct Service Providers








Isolation / insufficient supports
Productivity pressures / time crunches
Paperwork, paperwork, paperwork
Organizational politics
Low pay
Self-doubt
Perfectionism / compulsive
responsibility
Limited training opportunities
© Ann D. Carden, Ph.D. - 2006
32
Moving Toward
Melt-down/Freeze-up













Increased absenteeism
Over-reacting
Physical complaints
Chronic exhaustion
Low self-confidence
Depression / Anxiety
Procrastination
Boundary violations
Cynical attitude about job / clients
Social withdrawal
Hostility
Us-them mentality
Disorganized thinking / behavior
© Ann D. Carden, Ph.D. - 2006
33
Six Supervisor Guidelines
1. Adhere to the MI Guiding Principles
2. Avoid Traps / Roadblocks to progress
3. Teach / model the Philosophical Foundations
of MI
4. Maintain a clinical focus
5. Adapt to the Supervisee’s context
6. Assist supervisees to become proficient
in MI clinical skills
© Ann D. Carden, Ph.D. - 2006
34
Consolidate
Counter
Principles
Opening
MI
Spirit
Strategies
Traps
Sustain Talk
MI Core Skills
© Ann D. Carden, Ph.D. - 2006
Commitment
35
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