5 Elements of Motivational Interventions & 5 Principles of Motivational Interviewing

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you I'd like to welcome everybody today's presentation. We're going to be talking about the elements of motivational interventions and principles of motivational interviewing. Now, I know that sounds dreadfully dull, but I've tried to provide throughout the class different activities, kind of like we did in the last class, that you can use in order to enhance motivation and even teach motivation. And you might be thinking to yourself, well, why do we need to teach motivation? Because when clients come to treatment, theoretically they're motivated. And sometimes if you work with clients who are involuntary, they're not motivated. So we need to help them get motivated. But when we start making a change, client or not, think about your New Year's resolutions. When we start trying to make a change, there are going to be times when we are really motivated and there are going to be other days where we get up and we go, yeah, is this really worth it? Any change we do behavioral, emotional, whatever is the same way. So it's important for clients to know how to increase their own motivation so they can stay the course even after they quit counseling and all that kind of stuff. We're going to learn how motivation is dynamic, explore reasons and methods for enhancing motivation, identify critical elements, review the frames model, identify ways to deal with resistance, and review how to use decisional balance exercises. So why enhance motivation? Well, I kind of touched on that already. We want to inspire change. We want to inspire people to think, okay, I see this goal and I can actually get it. We want to prepare clients to enter treatment, engage and retain them, increase participation and involvement, improve treatment outcomes, and encourage a rapid return if symptoms recur and rapid return to treatment is ideal. But if they are making changes on their own, or if you're making a change and it's a New Year's resolution and you kind of flub up for one week, it's important to be able to make a rapid return to that course of action. Not necessarily treatment all the time. And motivational enhancement generally creates a therapeutic partnership because you're understanding what's making this person tick and you're helping them understand why it's important for them to do what they wanted to do. Motivation is positive and a key to change. So these are some of the characteristics we're going to talk about. Harnesses energy to accomplish a task. Some days yesterday I don't Know kind of what got into me, but I was motivated to rearrange the cabinets in my kitchen. Well, actually I was motivated because I couldn't find a lid that I needed and that frustrated me. So I was suddenly motivated to get everything back organized again. Whatever it takes to motivate you will help out. What happens when you're not motivated? You know, thinking about going to the gym, cleaning house, working, you kind of sit there, you dread it, you may drag your feet, think of any excuse. How do you get yourself motivated? And most of us have tricks to get ourselves motivated, but it just depends on who you are. And we're going to talk about some of those tricks as we go through. Motivation is multi dimensional. Emotional motivation helps people see how it can make them feel better. Mental motivation, those are the logical reasons that somebody, forgive the word, should do something. It makes sense that if they follow through, then they'll accomplish their goals. It's logical. Physical motivation going to make them feel physically better. It's going to help them reduce their. If they stop smoking, they may not be coughing as much, they may sleep better, they may have more energy. Physical motivation is, you know, definitely there because we want to feel relatively happy and healthy. Other physical motivation can be if you're trying to stop doing something in order to prevent getting something like COPD or cancer or whatever. Those can be physical motivations. Social motivation comes in two different forms. You have your social supporters, you have your battle buddies who want to do it with you, your New Year's resolution buddies, your gym buddies, whatever it is. But then you can also have social pressures. You can have society telling you that's not okay. You can have family members telling you that's not okay. And legal motivation. Not everybody has legal motivation. I don't have legal motivation to go to the gym. But sometimes we can look at it. We can go, what are the legal motivations for you? And remember, legal is not always criminal. Sometimes it is criminal. They don't want to go back to jail. Sometimes it's child custody, sometimes it is divorce proceedings, what have you. So there can be legal ramifications and financial motivation. How can this help me be more financially secure, stable, whatever? Those are questions you want clients to ask themselves. Now there's six identified motivations, which takes us to our cube. Activity on a large box. The first activity, get a large box. And most of us, because we use Amazon a lot, have large boxes. If you don't go to a grocery store, go to Walmart, go to somewhere and ask them when they typically are stocking their shelves. And you can generally get a large box. You don't have to pay money for them. And on each face of the box, you're going to identify reasons for not changing. You know, what are the emotional reasons for not changing? And you're probably thinking to yourself, well, what? Why would we do that? Because that is one of the most overlooked reasons that motivation fails. We look at all the reasons why we should want to change, but we forget all of the benefits of the current behavior. Going to the gym, for example. What's a reason, depending on where you want to put it, emotional or physical, that I wouldn't want to change? Well, because my couch is really comfy and I'm tired after a long day of work, so I don't have the energy to go, okay, well, that is one ding in motivation. So you would go through and all six faces, each face is a different dimension of motivation. You would write all the reasons that people don't want to make a particular change. If you are in a depression recovery group, have your group identify one change that they need to make. You know, that's pretty ubiquitous. If you're in substance abuse recovery, it's easy to start out with stopping using and talk about all the reasons they may not want to do that, and then discuss ways to eliminate those drawbacks. After you get the cube all filled out, then you want to talk about ways to eliminate or mitigate those drawbacks. I talked earlier about if the behavior that we're talking about I'm not motivated to do is go to the gym. Okay, well, one of the reasons is because I don't have energy after a long day and my couch is so comfortable. What can I do to mitigate those drawbacks? One, don't go home. If I go home after a day of work, I'm going to sit on that couch and my butt is going to go into that nice little butt print that I've got created and I'm probably not getting back up. Don't go home, go straight to the gym or go to the gym in the morning and I don't have enough energy. Well, then I need to do an assessment of where my energy is going. It could be that working out in the morning is more effective. It could be that I have other things like poor sleep or poor nutrition or what have you that are draining my energy. But I want to look at how can I increase my energy so I do have enough energy to go to the gym. And the third thing, just while we're on the gym Thing is, looking at how much energy I'm expecting to spend at the gym, you don't have to go and run five miles. You can go and walk for 20 minutes. Okay, so we talked about all the reasons you wouldn't want to change. So we're getting rid of all the yes buts and the excuses and what have you. The next activity is you use smallish boxes, and it depends on the person and how big they write. You can use little tiny boxes or, you know, maybe eight by eight boxes. It doesn't have to be a cube. It can be a rectangle there. It's going to have six sides anyway, and you're going to do the same thing that you just did, but you're going to do it for all the reasons that they do want to change. I generally recommend having the clients decorate the box ahead of time because this is something ideally they can keep. And they can put construction paper on it, paint it, whatever they want to do to make it pretty, and then write on top of that all of the reasons they want to change in each of the six dimensions. Another activity that you can do is a scale activity. And this can be kind of fun because it helps drive home the concept that every reason to change or not to change is not equally weighted. The reasons that I may want to do something, some of them are going to be, you know, a little bit important, and some of them are going to be super important. Prepare for this activity. Get at least 10 to 20 regular marbles and 10 shooter marbles or extra large marbles. You want something that is heavy, differences in weight, and then you can fashion a scale. And I have a link to how to do it. You use a clothes hanger, two paper cups, and string. It's really not that difficult. And one side of your scale is labeled change. The other side of your scale is labeled same. And you want to have them identify the reasons for change and the reasons for staying the same and write all those reasons on the whiteboard for your group. Once you have all those up there in a visual fashion, then you can talk about how some of the reasons carry more weight. You know, I may want to start exercising so I can lose some weight. Okay. I may want to start exercising so I reduce my risk of cancer. Well, for me, since I have a lot of people in my family who died of cancer, the second one is more of a big marble issue than a little marble issue. It's more important. You can have fewer motivations to change, but if they're more important, it may still tip the balance of that scale. And that's what we're trying to do with motivation. We're trying to help clients see how it's more important or to them to change. So then after you have the list of all the reasons to change and all the reasons to stay the same and you have your scale, then have clients assign a weight to each reason on the board and deposit the marble in the appropriate side. This is a reason to stay the same, the reason to change and help them, you know, really see it's about the total weight that tips the balance. Motivation is dynamic and fluctuating. It's a dynamic state that changes over time and in relation to different situations, rather than a static personal attribute. People are not motivated to do the same thing all the time. Every time. I am more motivated to clean house. For example, if I know I've got company coming over, I know I'm more motivated to get to work on time if I've got a meeting or an appointment versus if I don't. Motivation vacillates, and it's very specific. If I want to get healthy. Well, there's a lot of things that go into getting healthy. I may be really motivated to start exercising, not so motivated to change my diet, and not at all considering changing my sleep habits. We want to break it down incrementally and look at each change the person has to make. Motivation can vacillate between conflicting objectives. My motivation to go to the gym, my motivation to excel at work, I'm motivated to do both of them. And if I'm looking at, you know, I've got only so many hours in the day, which one am I going to choose? And those motivations can kind of tug at one another. Motivation varies in intensity, faltering in response to doubts, and increasing as doubts are resolved and goals are envisioned more clearly. We want to help people clearly envision what the end goal is for whatever change they're getting ready to make. So, for example, getting healthy people may have to change their nutrition. They may have to start exercising. They may have to make sure they're getting adequate quality sleep. Ask clients. You know, this is an easy one to do because it's very general. Ask clients what conditions would make you motivated to do these things and what conditions would undermine your motivation. So for nutrition, for example, most days a person may be really motivated to do them, but then they go out to dinner with friends, and it's really. They're not as motivated to stay on their nutritional plan because so much of the food Smells good and there's lots of fried food and what have you. Encouraging them to understand that motivation can fluctuate even on a daily or hourly basis and be cognizant of things that could undermine their motivation. To help them envision these goals, we want to help them set smart goals. Remember, specific, measurable, achievable, relevant, and time limited. You can have clients start out right on the whiteboard. You know, this is not one of those super fun activities. Get healthy to reduce my risk of cancer, for example. Okay, is that specific? Not really. Get healthy. How do we define that? What does healthy look like? Measurable? I don't know where I'm starting at yet. Achievable, maybe. Relevant, yes. Getting healthy can reduce your risk of cancer. And time limited. No, there is no time limited here. So we want to take that statement and rewrite it in a way that is more, that is smarter, if you will. So specific. I will start exercising at least 140 minutes per week in order to reduce my risk of cancer. Beginning tomorrow, that is, meets all of those goals. You can measure how many minutes a person exercised. Another goal that somebody may say is they want to lose weight to get their partner to pay attention to them. Okay, is it specific? No. Measurable, not yet achievable? Probably relevant. You might argue with that. There's probably a lot of reasons or maybe other reasons that their partner is not paying attention to them besides just their weight. So expecting that if they lose weight that all of a sudden all their relationship problems are going to go away is not a good thing. We don't want to set people up because then when they start losing weight and that doesn't happen, then they're going to lose all of their motivation. We need to help them identify the reasons they want to lose weight, how much they're going to lose, what time frame they're going to do it in, and the benefits to themselves. And if their goal instead is less about losing weight and more about getting their partner to pay attention to them, then we may need to look at other goals, other sub goals in order to make that happen. Out of the hat. That wasn't a creative title. I don't know what to call it. Write different goals on strips of paper and put them in a box. And these are goals that clients come in and they say, I want to get happier, I want to get rid of my depression, I want to improve my relationship. All of those things that clients say that are not smart goals. And then have clients draw a strip out of the hat. And restate the goal in specific measurable, achievable, relevant, and time limited terms. So if the strip says lose weight, okay, the client might say, I want to lose 10 pounds in two months so I'm more comfortable in my clothes. You know, when we wear clothes, they're too tight. It's just not happy. That's why I love all these pull on clothes right now. But I digress. If the strip says I don't want to be depressed anymore, okay, that's a good goal. But let's state it in more smarter terms. I want to increase my overall happiness to a rating of 4 out of 5 at least 5 days per week in the next 8 weeks. It's really helpful to teach clients how to use Likert scales because there's a lot of emotional stuff that we can't quantify. It's not, you can't weigh it, you can't measure it that way. But they can use a Likert scale, encouraging them to get used to using those Likert scales. And make sure to anchor your Likert scales one to five. You know, it's really hard to know what a three might be. They want to make sure to use language and or pictures to define one to five. So one would be depressed, two would be flat. You could say anhedonic, but that probably doesn't mean anything to clients. Three would be content, four would be happy, and five would be deliriously happy or something. But make it so it's very clear which one. So the client's not going, well, I don't know if I'm a 2 or a 3. Make it clear for them. Another strip might say, I want to improve my relationship. Well, that's a great goal. However, let's make it smarter. I want to reduce arguments with my partner to less than 2 per week. Spend at least 1 day per week together doing something enjoyable. Those are things that we can measure. We can say, yes, it got done or no, it didn't. Another characteristic of motivation is that is modifiable since hence what we've been talking about and it's modifiable by social media and social influences are when the Sports Illustrated swimsuit calendar used to come out. You know, that would be the talk of everybody back in the day. I don't know if it's still as prominent now. And that would be an influence, unfortunately, on people to want to start losing weight. When it comes down to spring break time, there are more social influences and a lot of body shaming and stuff, whole different classes. But there can be reasons that social reasons that people decide to make a change. And social influences can also be in the form of who you're doing it for. If you're trying to get healthier in order to prevent getting cancer so you can be there for your kids and see your grandkids, then those are things that, that those are social influences. And then we already talked about emotional, mental, physical, legal, financial. There's also environmental pressures. Sometimes a lot of people decided to quit smoking or it made it harder for them to smoke. When the laws were passed that made a lot of buildings non smoking buildings. Other environmental pressures may be custody and that could be legal issues too, depending on how you want to look at it. But there can be reasons why you want to change. A lot of apartments and hotels now don't talk about or don't allow you to smoke inside the building. So you have to go outside. And that's an environmental pressure because do you really want to go outside at 11 o' clock at night in a strange place? Distress levels can also modify motivation. And this is not one of those key things that we talked about raising the bottom is what we talk about in substance abuse counseling. But you can do it with a lot of things. For example, like I talked about earlier when you, if you want to lose weight, if you're wearing clothes, you know, you put on your old clothes, you can still get them zipped up but they are not super comfortable anymore. That can increase your motivation to stay the course. And there are. You just have to think about other ways to raise that bottom and make it more uncomfortable to stay the same. And critical life events can also modify motivation. People may be encouraged to start making positive changes in their life if they have a loved one that dies of cancer or dies in a car accident and they're hit with this notion of, you know, I may not be here tomorrow, I need to live every day like it's my last or what have you. Any of these things can increase motivation. Have clients use the same goals that you put in the hat in the goal setting exercise to identify ways to increase their motivation. So you've already, you went had the clients go through and set smart goals for each of those. Now they need to go back through and talk about all the ways that they could increase motivation for those things. Motivation is influenced by the clinician's style and I would argue also the client's style because we want them to stay motivated even when they're not in counseling. They need to, we need to express non possessive warmth and friendliness well, most of these, hopefully we're already doing genuineness, respect, validation and empathy. Okay, we'll just kind of go through those. Hopefully as clinicians, we're already doing that. But I want to encourage clients to do that for themselves, to be kind and compassionate to themselves, to be genuine and authentic with themselves when they're having a bad day. Go. You know, really not feeling this today. Okay, that's authentic. To respect themselves for the effort they're having to put in, for the progress that they've made, yada, yada, to validate themselves, validate their feelings, you know. Yeah, this really sucks that I've got to do this today, but I know that it will help me get closer to my larger goal. Okay, that's reasonable. Kind of goes with that. Radical acceptance and being empathetic with themselves, making sure that they are focusing on the successes as well as the challenges. Too often we, you know, as humans, focus on the things we did wrong or the mistakes we made instead of all of the days that went well. And finally, motivation is purposeful and intentional. And Brooke asked the question, has anyone dealt with clients who invalidate your validation? They say, you have to say that because you're my counselor or you have to say that because you're my mother. And yeah, it happens. And it's important for clients to also look at, okay, I said it. But who else might also say it? And looking externally and if they can't find anybody else, have them switch roles if you will, and say, if your best friend were in your shoes, would you validate him or her? So you can do. Sometimes you got to do some mental gymnastics. But it is important for them to learn how to self validate. Okay. Techniques we can use to increase motivation. Open ended questions. We want to respect the client's autonomy. Tell me what it is that you hope to accomplish in this activity today. Tell me what it is or how you see recovery looking like for you. I don't want to put words into their mouth. We want to affirm their ability to succeed. Recognizing co occurring issues and acknowledging difficulties and employing client centered treatment. Making sure clients recognize that they are different from one another. And obviously we're not going to be telling everybody in the group who has what diagnosis, but recognizing that not everybody in that room is starting from the same place. Some people are struggling with multiple disorders. Some people are struggling with other biopsychosocial issues. And it's important for them to recognize that and affirm their abilities to succeed. They may not be progressing as quickly as somebody else. In the group, but they're still progressing and that's what's important. We want to use reflective listening, using empathy more than authority and validating the client's experience. And regularly summarize focusing on clients strengths, successes and personal power so you can do the crave check in. I developed this when, you know, I was working in substance abuse. But it's a way to have clients do a check in when they come into group that encourages them to use the Auris technique on themselves, so to speak. Start with compassion. I am human, I am here is basically kind of where I want them to be. And have them report how the week went, acknowledge difficulties, any challenges they faced, validate how frustrating that must have been or how disappointed they are or whatever it is. Encourage them to validate that that's an okay feeling. And encourage group members to validate one another. And then have the client explain how they use their strengths and personal power to create successes, even if that success is just being here to try again tomorrow. I want them to identify their successes and that helps them see that it's not a total failure. Critical elements of motivation Change is war. If you want to go with that willingness, ability and readiness. So willingness involves the importance of a person places on changing and how much change is wanted or desired. Have you worked with clients that play the yes but game with you? You ask them to do something or you make a suggestion and every time you make a suggestion you get a yeah, I could do that, but well, okay, yes but tells me that there's some resistance. There is a reason why what I'm suggesting not motivating it is not as rewarding as the alternative. So instead of me just continually suggesting and getting shot down, let's switch it and have people start coming up with their own suggestions, which is where we start talking about using more Socratic interventions. However, you can do the yes but activity. Write a goal on the board that is common to most of the clients and have people think of as many yes buts for getting started on that goal as possible. And you can start with something that's very benign, like cleaning the house when you're finished. Discuss ways to deal with those objections so they can increase their motivation. Ability refers to the extent to which the person has the necessary skills, resources and conflicts to carry out a change. Again, going back to those goals, review the smart goals that you already created and discuss what skills and resources a person might need to accomplish the goal and how to acquire those. So getting healthy, that sounds easy. You know, I start eating Right. And exercising and I'll get healthy. But all of those are very vague. What does it mean to eat right? What does that look like? A lot of people don't have that knowledge. Only about 12% of people in the United States have a average or have an acceptable, as the CDC defines it, level of health literacy. 12% of people, so that means 88% are not health literate. That's kind of scary. It's important for them to be able to look at goals and go, yeah, I'm not sure how to do that. Where do I get that information? Readiness represents a final step in which the person decides to change a particular behavior. If you go through the prochaska stages of change, pre contemplation is when the person says, I ain't got a problem. Contemplation, okay, maybe this is a little more of a problem than I thought it was, but I've got it. Preparation is when the person starts to get ready to change and they're preparing to make that change. They've realized they need to get some resources and start doing something differently, maybe looking for a counselor, figuring out how they're going to pay for it, whatever, and then action. And that is when they're in this stage and they're ready to actually make a change. Five principles of motivational interviewing. And we've really kind of covered these already, but I'm going to sum them up. We want to express empathy through reflective listening. Develop discrepancy between the client's goals or values and their current behavior. Avoid argument and direct confrontation when a client is being resistant. Again, that means whatever you're suggesting is threatening in some way or not rewarding in some way. So let's just avoid that argument and confrontation and be more curious. Adjust the client resistance rather than opposing it directly. Support self efficacy and optimism. We can do a lot of this using the frames approach, decisional balance exercises, drawing those discrepancies, using flexible pacing, and making sure we have personal contact with clients in treatment. Now, the frames approach we're going to talk about in a minute. Decisional balance exercises are what we've really already been talking about. There is that balance that they need to figure out and they need to tip the scales so it's more worth their time to make the change than it is to stay the same. We want to help clients develop discrepancy between their goals and actions. You tell me you want to get healthier, but you are sitting in here eating, you know, donuts and drinking whatever those energy drinks are or Something is that helping you get healthier? Address the drawbacks to change. Again, we're looking at that decisional balance and address the benefits to staying the same. Helping them understand there is a reason for what you're doing right now. It's beneficial, it's rewarding in some way. And so you're doing what comes naturally. You're doing what seems feels most rewarding. One of the things we want to help them do is change their focus. Instead of focusing on immediate gratification, we want to help them see that long term goal, see that light at the end of the tunnel, if you will, so they can move toward that and that's where their reward is. Part of that means setting smart goals that are sufficiently time limited that they don't feel like they're never going to get the reward. Make sure those smart goals are broken down into, you know, what can you accomplish this week and then what can you accomplish this month and what can you accomplish in three months? So there are regular rewards for their efforts. Help clients feel competent to change. Highlight all the times that they've done similar things or things that were harder or times that they took on something they weren't sure about but they came out victorious. Develop a plan for change. Help them start to take action and encourage them to continue to use strategies that discourage a return to the old behavior. A lot of times people will go through counseling for anything and they make a lot of positive changes. They start sleeping better, eating better. They're using their cognitive behavioral tools to address distortions. They're more effectively communicating. They're not spending all their time at work. And then once they start feeling better, they slowly erode back into those old behaviors. It's important for us to encourage them to continue to stay mindful and use those strategies that will help them keep moving forward. A note about resistance. Resistance and yes buts are signs that what you're asking is either too threatening. You know, I think it would be a good idea for you to go into residential treatment. Yeah, but I've got kids and nowhere to. Nobody can watch them and. Yeah, but I've got a job. Yeah, but. Okay, it's not sufficiently rewarding. Well, somebody could have gone into treatment before and it didn't work or it only. They only stayed happy or clean and sober for 30, 30 days. They don't see how doing that again is going to be effective. And it could all. Whatever you're asking, they may already know it doesn't work for them. If you ask them to try meditation and you show them how to do a particular type of meditation and they've already tried that before. They may, yes, but you or resist you because they've tried it and it didn't work for them. On a side note, there are dozens of different types of meditation. So encouraging clients to explore and find something, even if it's just mindfulness based stress reduction, that can help them be more present centered as an activity. You can have clients identify things that they resist doing, like dieting, ending a relationship, taking their medication, entering treatment, whatever it is, and talk about the reasons it's hard to do that. Why is it hard and what are the benefits to staying the same. Frames stands for feedback, Responsibility, advice, menu of self directed change options, empathy and self efficacy. So let's talk about that. When we use a motivational approach, we are very. What's the word? Objective in presenting the information. We provide feedback regarding their personal risk or impairment or their status. This is what I see, this is what the results say and these are the possible reasons this might be happening. Just put it all out there for the client so they can do with it what they will. Responsibility for change is placed squarely and explicitly on the client. I'm not going to make you do anything. I can't make you do anything. What I am going to do is provide you information and advice and options so you can choose what you think is going to be most effective. When clients feel like they've got more power, they're not going to be told what to do or, you know, shoved into a little pigeonhole, then they tend to be more responsive. Advice is given clearly to the client by the clinician in a non judgmental manner. And I know we've always been taught not to give advice and I think they used the word advice as opposed to information because it just worked better with the, with the mnemonic. However, you're giving the client information about what the options are and you can potentially, as long as you own it, say, I think the best course of action would be this, that or the other. However, you know, you've been in your skin longer than I've known you, so you're the expert on you. We want to provide menus of self directed change options and treatment alternatives. You may think that you're working with a client with PTSD and EMDR is the thing and you want to refer them to an EMDR therapist and you are just, you know, gung ho about that. That may not be something the client wants to do. Providing them different options. These are all the different ways that we know work with treating ptsd. Let's talk about which one you think you want to try. Using empathy and engender self efficacy to encourage change. Help them see even if they failed at changing the same thing before, this time is different. Because every time you failed before you learned something, you learned something about what not to do, and you learned a little bit more about what you might need to do. Feedback should help the client understand the information, interpret it. You know, you don't want to just hand them a whole bunch of the SASE and the MBTI and whatever else and go, okay, here, here's all the information. Good luck. Help them interpret it. Help them gain a new perspective about the personal impact of their behavior, how what they're doing is counter to their goals. Feedback should help them consider changing. It should help kind of open their eyes to the fact that this is a problem. And in order to achieve their goals, they need to make a change and help them recognize a discrepancy or gap between future goals and current behavior. For responsibility, we want to give individuals the responsibility and opportunity to decide when and whether they will change their behavior. Unless you're working in a situation where clients are involuntary, and I've been there before, then generally clients have the option of whether they're going to pursue treatment or not. I worked in a as the liaison for felony probation and parole, as my first job out of graduate school. And those clients went through an assessment, but essentially it was a dog and pony show because they were required, regardless of the assessment, to attend between 10 and 16 weeks of counseling. Well, they didn't want to go. What kinds of options could I give them? And what kinds of changes was it incumbent upon me to encourage them to make? Well, one of the things with responsibility and the frames approach is coming to a mutually agreeable or a win win situation for those clients. They didn't want to be there, they didn't want to be in counseling, but they had to be. They wanted to get off probation. So instead of beating them over the head with, you know, using drugs is bad, we started looking at, let's talk in this group about changes that you might want to make. As long as you're being forced to be here, you know, pick my brain. Let me help you figure out how to start making some positive changes so you're happier at work or happier in your relationships and any questions you have. And we can talk about how to stay clean and sober so you can get off probation, because that was basically the crux of it. They couldn't test positive while they were on probation. So finding those win win situations, helping the client envision how certain behaviors or certain activities will help them achieve their goals and putting the responsibility on them. You know, they still didn't have to come to group. It was up to them. But most of them did Encourage clients to choose their treatment and be responsible for changing and don't impose views or goals on clients. Would I like them to get clean and sober forever and always? Sure, I would love that. But that's not for me to say. For me to say was, I need you to stay clean and sober for the duration of your probation. Once you're off papers, what you do is what you do. And that was refreshing for a lot of them because they had gone through the same process before in many cases, and they just heard that you've got to be clean and sober forever and ever. And that was overwhelming to them. So hearing you've got to be clean and sober for the next 18 months or however long they were on probation was less intimidating. They're like, okay, I can do that. And if they couldn't, then it started to highlight the fact that they may have more of a problem than they thought, but it gave them the, the control over the situation. When clients are free to choose whether they change, they feel less need to resist or dismiss the clinician's ideas. They feel empowered and more invested in treatment and may be more willing to negotiate common treatment goals with the clinician. Again, most of these people were not interested in stopping using. You know, that was not something that they envisioned. Okay. One of the treatment goal, though, one of the treatment goals they had to have was to stop using. So we negotiated that common treatment goal with the understanding that you need to do this during the period that you're on probation. And, you know, I would usually throw in there, if you can stay clean and sober after that, great. It'll save you a lot of money. But what we need to focus on for your treatment plan is just this time, limited goal advice. The most appropriate time to give advice is when a client requests it, when they say, what do you think I should do? And even then, responding with Socratic questioning is always better. Sometimes you want to give them a little bit of information because it can get annoying if they say, what do you think I should do? And you turn it around and go, well, what do you think you should do? It's like, no, that's not what I asked. So you do want to have some advice. When clients would ask me what do you think I should do? Should I go to residential or IOP or whatever? I would give them my honest opinion and put it out there about why I thought one was better over the other, but the choice was theirs. As with feedback, the manner in which the clinician advises clients determines how the advice will be used. If I said, well, my advice, you really need to do this because you know your life is ending, you're on probation, you're going to lose custody of your kids, yada, yada, yada, and sort of dismiss the rest of it, that's the person's going to feel kind of pushed. If I present both sides of IOP or residential, then the person feels like they've got options. They don't feel like they're being pushed. Suggesting yields better results than telling clients what they should do. And if a client requests direction, we can first clarify what the client wants and then give sample advice that is matched to the client's level of understanding and readiness, the urgency of the situation, and the client's culture. Sometimes the recommendations you have may not be culturally sensitive. It's important to keep all of these things in mind and a menu of options. When clients make independent decisions, they're likely to commit to them. So offer them a menu. It decreases dropout rates and resistance to treatment and increases overall treatment effectiveness. You can do groups, you can do individual, you can do some combination. You can do iop. Let's talk about the pros and cons of each one of them. Provide accurate information about each option and a best guess about the implications of choosing one particular path. Elicit from the client what they think would be effective or what has worked for them in the past and reinforce their ability to make informed choices. Empathic counseling can be particularly effective with clients who are angry, resistant, or defensive. Let's explore the reasons why they're angry, afraid, or resistant. A lot of times they've probably been in this same position before, and they felt condescended to, they felt judged, they felt pushed, they felt forced to do things. That's not what I want. I've told you guys before about the young woman who came in to see me for an assessment one day, and it was for substance abuse. And she sat down and the first thing she said to me was, I don't care what you say, I'm not going to those meetings, okay? And I can tell you for certain that is not the response that she would get or she got from other people at my agency. My response was, all right, I'm less concerned about what you're not going to do and more concerned about what you're going to do instead. So you're not going to go to those meetings, what you're going to do instead. And that started the assessment off on a much different tone than had I pushed her off and said, well, we'll talk about that later. That sounds like, yeah, you're going to those meetings, but we're going to address it later. I wanted to make sure she understood from the beginning, okay, you know, if that's not something required in your probation, then let's figure out what you're going to do instead and let's talk about the function that the meetings fulfill and how you can meet those needs in some other way. Allow the client to do most of the talking in a safe environment. Allow their process to unfold rather than directing or interrupting it. Empathy communicates respect for and acceptance of the clients and their feelings and encourages a non judgmental collaborative relationship. If you can be empathetic with a client, guess what, you're modeling empathy. And they may start learning how to be compassionate and empathetic towards themselves. Self efficacy. Clients must be able their cape be wow. Clients must believe they are capable of undertaking specific tasks. If you're asking them to do something that seems overly monumental, they're probably not going to be motivated. They're like, and I'm just doomed to fail that one. And they need to have the skills and confidence in order to change. We can help them do this by reinforcing their beliefs and their capacities and capabilities. We need to believe in their capacity for change because people are pretty perceptive generally and if you don't believe they can change, then they're not going to believe they can change. We want to help them identify how they've coped successfully with problems in the past and build on those successes. So when you were depressed last year and you worked on it and then you got your depressive symptoms into remission, what did you do and what did you do differently? What worked and what didn't. Reinforce small steps and positive changes. Foster hope and optimism, reminding them. And this is one of the best places that journals and logs can be super helpful because they can see incremental progress if they look back over their logs or they may not feel it if just in day to day living. You know, sometimes you look back and you're like, oh, wow, I actually have come pretty far. We want to reframe past failures as partial successes and use questions beginning with what else? What else can we do to Ensure your success. What else can I do to assist you? The failure activity. Failure is virtually inevitable. Sometimes it just, it happens. And whenever we step outside of our comfort zone, we risk failure. Start out by having people look up quotes about failure and there's a lot of them out there. And then you can have them each or as a group, create what I call a failure flag on each stripe. Write a sense that gives meaning to failure. So I failed or failure means to me that I took a risk, failure means to me that I grew as a person, failure means that I learned what not to do next time, failure means I got outside my comfort zone, etc. And this can be a really empowering thing for people to have around so they can keep looking back on it. Flexible pacing means meeting the client at their levels and using as much time as necessary with the essential tasks at each stage of change. Like I said, each person in your group has different things working for and against them. Some clients will progress really quickly, other clients may kind of creep along at a snail's pace, and some will even go backwards a little bit. That's okay. We need to pace it at a way that makes sense for them based on their unique strengths and challenges. And finally, personal contact. And I really like this activity. Letters or telephone calls are really important, especially from us. You know, hey, you missed your appointment, yada yada, that's important. But you can also encourage clients by having them do activities, have them write letters to themselves. And it works better with snail mail because, you know, everybody likes to get something in the mail and email just feels so impersonal, but that's me. You know, maybe younger people feel differently, but have them write letters to themselves to remind them to reflect on how far they've come, to reflect on what they've learned from themselves or each other, to encourage them to keep going, to remind them of all the reasons they wanted to make the change and to congratulate them on their progress. So have them create these letters ahead of time and then periodically send them out. This can be done as a group activity where group members write letters, you know, to one another saying, wow, you've come so far, yada yada, or I've learned so much from you. This is what I've learned, whatever. But that personal contact engenders connection to the group or to the process. And sometimes those letters come on the days that you just, you need them the most. Like I said, old fashioned mail can be really cool because you can decorate the letters and, you know, make them all pretty and shiny or whatever. Not everybody's into that. Whatever works for people. The key is to get regular way to go messages and regular encouragement encouragement messages coming from other than within ourselves at that very moment. So even a letter to yourself that you get a month later can be meaningful. Motivation is dynamic. It's influenced by multiple types of motivation, including emotional, cognitive, social, and environmental. Motivational interviewing increases clients hope and enhances treatment participation. Three critical elements of motivation remember war, willingness, ability and readiness and the five elements of motivational approaches that you need to remember the frames approach, decisional balance exercises, developing discrepancy between personal goals and current behavior, using flexible pacing and making sure that you have personal contact with clients in treatment. But if you're doing a group, it might be nice for them to have personal contact with one another and you can be the one that mails out the letters. So you're not giving each other's the clients aren't giving each other home addresses and everything. Are there any questions? Motivational interviewing exercises are a little bit more challenging to figure out how to do than some other activities. But one of the things that one of the reasons that I like doing it doing groups on it is to reinforcing clients to help them learn how to set those smart goals and develop the resources they need and learn how to encourage themselves and one another. Thank you, Kay Alrighty everybody. Have an absolutely fabulous weekend. I plan on planting my fall garden so I am super excited to get down in the dirt and I will see you on Tuesday. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend Therapy Notes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of TherapyNotes by just using the promo code CEU when you sign up for a free trial at therapynotes.com. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is at allce.com/podcastce. That's allce. Com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce. Com sponsor. Thank you.