This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation, the five elements of motivational interventions and five principles of motivational interviewing. Now this is the first of two parts. Tomorrow we're going to go a little bit more in depth into motivational interviewing. If you have an interest in doing motivational interviewing or motivational enhancement therapy, this obviously is just a primer. It is not going to get you to where you have the skills to actually do it. This is more to get you to understand the philosophy, the techniques and the overview so you can say, ah, this is something I really want to learn more about or not so much. If you are interested in learning motivational interviewing, SAMHSA has a program called Mia Step M-I-A-S-T-E-P. It's a free training program. I linked to it actually in a couple of times during the supervision class that will walk you through the process, walk you through the training, give you the rubrics so you can score your, you know, record your sessions and score yourself to see how well you're developing those techniques. And with no further ado, we're going to learn how motivation is dynamic and I love talking about motivation. We'll explore reasons and methods for enhancing motivation, identify critical elements of motivation, the three elements of motivational approaches. We'll review the frames model, which is one of those elements, identify ways to deal with resistance and review how to use decisional balance exercises, another one of my super favorite interventions, which is also an element of motivational approaches. Now, motivation is dynamic. It's positive and a key to change. Now, what do I mean by positive? You know, obviously it's a good thing to have it, but motivation is something you have. It's not something you're eliminating. It's something you're putting into a behavior change.  So it's a positive generating sort of thing. It harnesses energy. It takes, you know, energy that you've got just floating around that you're using for miscellaneous tasks. It harnesses that energy and says, we're going to use the energy to do this. So, you know, I really like thinking about motivation, but we have to understand why people would want to take their energy away from all these other places and use it to accomplish whatever we hope they're going to accomplish. So thinking about your own motivation. When you're not motivated to clean, to exercise, to go to work, what happens? I know for me, if I'm not motivated to clean or to exercise, I may just sit on the couch and go, you know what, I'm just not feeling it today. And I may never get to it unless I increase my motivation for some reason, like reminding myself how much better I actually feel after I get to the gym. I'm more energized, less foggy-headed. I know this, but I have to remind myself in order to get the motivation to get my happy butt off the couch. So how do we increase this motivation? It's dynamic, so it's, you know, changing, but it's also multi-dimensional. You can have a lot of different types of motivation, and the more types of motivation we can enhance, the more motivated our clients are going to be and stay. Now, motivation, we're going to talk about it waxes and wanes. When the going gets tough, sometimes people get going. They're like, oh, this isn't so comfortable. I don't want to do this anymore. A lot of clients in substance abuse treatment, in residential, they'll be in there. Then when things start getting uncomfortable or when their cravings get too bad or something happens, they may decide, you know what, my problem is not that bad. I don't need to be here. So their motivation to stay in residential out the window. And it's up to, it was up to my clinicians to kind of bring them in and say, all right, let's think about this before you walk out against medical advice. So we need to help clients understand why they want to do something. And we need to understand why they want to do something, which sometimes means we're going to have slightly different goals. Like some of my clients in my first job, I was working in felony probation and parole and doing their drug counseling and assessments. And the clients that were coming to me were required to go through treatment. They were required to do between 10 and 16 sessions. And, you know, I was motivated to help them get clean and sober and develop a happy lifestyle and all this stuff. And they were looking at me like, whatever, I just want to get off papers and be done with you. Well, both of those goals can work together. They're not mutually exclusive because to get off papers, to get off probation and be done with me, they had to stay clean and sober. Now I couldn't force them to be happy.  What can we do, you know, to help you improve your life, you know, instead of just being miserable the whole time? Is there anything that you want to learn? Anything you could that I could help you improve time management, relationship skills, self-esteem, anything, you know, just, we kind of brainstorm. The other thing that I would do with them is clients who came every single session and participated actively, they couldn't just be a fly on the wall, would get credit. And if they came 10 sessions in a row and were actively participating and didn't have any dirty urine screens, then I would graduate them after 10 sessions. If they weren't doing some of those things, then they may have to stay longer. So they were able to, by kind of agreeing or consenting to my goals of them staying clean and sober and the court's goals, they were able to be done with me sooner, which satisfied a condition of their probation. So you can work with motivation a little bit, make it beneficial to them. If you do these things that I want you to do, what's in it for you? And that's really what it comes down to is the client is going, what's in it for me? So we want to look at the internal urges and desires felt by the client. What's going to make them happy? What is it that they want to do with those clients I was just talking about, getting off probation and not having to see my face, what's going to make them happy? Okay, so let's work to figure out how you can do that. Well, in order to do that, you need to stay clean and sober and come to 10 groups. Cool. All right. And then we can help them figure out what is going to help them feel better physically. Maybe they have chronic pain, maybe they've got low energy, maybe they're agitated, anxious, something like that. So these are the things that I would talk about with the clients.  How can I help you manage your pain or deal with your energy or maybe you've got a kid that's, you know, becoming delinquent. You know, what can we do to help you out here? We also want to help clients look at external pressures and goals that can influence their motivation or eliminate it. So they're social environment. If they are in an environment that is supportive of the change they're going to make, then that's going to enhance their motivation. When I was a personal trainer, you know, it was easier for me to stay in shape and eat more healthfully and stuff because I was around it all day long when I was working in the gym. So it wasn't as hard for me. Now when I'm not, when I was working in the clinic where we were doing paperwork and talking and the cafeteria ladies cooked very southern, very good, but very southern. And we were allowed to eat at the facility. It was preferred that we didn't leave the premises. So I would just go down there and get food from the cafeteria, which was almost always like fried and stuff. Not the best for my eating habits. So my motivation to eat healthfully and stuff wasn't as high because there wasn't the social pressure to, you know, be counting your macros and micros and stuff. So we want to help our clients look at what is your environment do for your motivation. If we're working with a client who's depressed and they're in a household where everybody's negative and there's a lot of stress and strife and that environment is not going to be real motivating for developing happiness and new coping skills and stuff as much. I mean, it might be a great place to use them, but that environment is not going to go here. Let's share in learning all this. But we can help them maybe through family therapy, develop an environment that's supportive of that. You know, helping them by maybe they go and they explain to their family one of the techniques that they learned each week and, you know, make some family exercises out of it to help improve the social environment. When I work with families sometimes and the youth, the teenager is the identified patient. You know, we're not always going to make a lot of headway with the teenager right away, especially if the environment is dysfunctional. So one of the things I may do in family education is teach the parents certain coping skills. And I'm like, okay, you have these new skills. Now, why don't you help practice these while you're at home so junior can see them and learn through observation. And you can also kind of teach them to junior as you go. So you can help junior learn distress tolerance skills or whatever. I don't work with little kids, but the same thing is really true. I've seen with a lot of the child therapists that I've worked with, they will teach the parents skills that they're hoping junior will learn. So you can bring it back and have the identified patient, if you will, share with the family in order to create a healthier social environment. If we're talking about substance abuse or something, if the person works at a bar and they're trying to stop drinking, probably not a motivating social environment. If they work at a doctor's office or a preschool or something, that may be more motivating. So we want to look at what are the social pressures. We want to look at their friends, the people you associate with, are they going to support your change or at least not detract from it? Or are they going to encourage you to stay the same? And they may not be ready to get rid of or step back from for a period. Friends, associates, family members who are going to encourage them to stay the same. Because if family therapy kind of says that there's a system going and it likes to maintain balance. So when one member changes, even if it's for the better, it puts stress on the system and the natural tendency is to try to pull them back in and get that homeostasis back. Doing what's always done, always been done. So we want to help clients really look and understand who in your environment is supporting this change. Who can you bring in? Maybe you can start going to support groups or volunteer activities where there are other people who will support this new change. Maybe you can take a cooking class if they're trying to eat more healthfully. Learn how to cook vegetarian or something in a way that's more healthful and where you can meet people who share similar goals. Environmentally, just looking around, guess what, the environment at home, at work, is that environment supportive of their goals? If it is a high stress, high conflict environment, it's going to be harder for somebody to learn to relax and be happy and do all those sorts of things. It's a burnout prone environment. If it is a relaxed environment, a comfortable environment, then that's going to be more supportive. You can't change an organization. We know this. However, you can change your little island in the organization or in the space. So if you live with roommates or you have a family and you can have one little bastion somewhere. I have a corner in my living room. I have a tapestry with the serenity prayer and I have a little chair and a shelf with books. That's my little quiet space. It stays clean. It stays the way I like it. I've got a little air freshener tart thing plugged into the wall. That's my happy, relaxing place. I can also go outside and work on the farm. I've shared with you before. My kids know the bigger the power tool, the worse mood I'm in. So if mama's got the chainsaw out, might as well just stay inside for a while. But that's my relaxing environment where there's no other stimulus except for the occasional rooster crow. Help clients figure out how can you address your environment to make it more supportive of your changes? Have them put things in their environment to remind them to make changes. If they're going to try to start having an attitude of gratitude so they're not focused as much on the negative, have them journal in the morning or keep that gratitude journal or list on their bathroom mirror somewhere where they're going to see it all the time. If they're trying to do something to get ready for their family coming or something like that. Maybe they can put a picture of the family or a calendar so they know how many days they've got until the family gets there. But you can set cues in the environment. If they're trying to stop emotional eating, stop stress eating or mindlessly eating, encourage them to put a food diary in the kitchen and fill out the food diary before they eat. So all of those things can help motivate them to stay on task and increase the likelihood that they'll stay motivated. Legal pressures can also help people stay motivated to change if they're in mental health court or drug court or if they're getting ready to go through a divorce or if they've got DUI charges. There's a lot of different reasons that the legal system, civil or criminal could come in that might say, you know what, it's in your best interest to stay involved in some sort of treatment. And work pressures or work motivation can also keep people going and motivated. If they want to get a promotion, that can help them stay motivated to continue on studying. Maybe they're working full-time and going to school and they're just starting to feel completely drained and exhausted. Well, we need to look at time management, but if they can see the reason they're doing it, they want to get this job or they want to switch careers or get a promotion, then it can help them stay motivated, help them keep their eye on the prize. The client's perceptions or cognitive appraisals about risks and drawbacks and benefits of change and staying the same are going to impact motivation. And we're going to talk about this more with decisional balance exercises. But the client's perceptions about the risks, if they think the risks, even maybe there's only one or two risks and there's 15 benefits, and you know, if you do them one for one, it looks like it's a no-brainer. But maybe there's 15 benefits, but the two risks are really huge risks and they're not willing to, that's too scary. That may undermine their motivation. So we really want to enhance the strength of the benefits and the client's appraisal and self-efficacy about the ability for change. Motivation is dynamic and fluctuating. It can fluctuate over time, you know, as, think about New Year's resolutions. January 1st, you're gung-ho. January 30th, you're still there. February 28th, other things have gotten in the way. It's not that anything got necessarily all that more difficult or all that much more difficult. You just kind of petered out. You know, there's little wind-up things that we used to have when we were little. We'd wind them up and they'd like bounce around and walk and they bounce, bounce, bounce, bounce, and then they start slowing down and then they peter out. That's how a lot of people's motivation is if they don't focus on it. Motivation is intentional. So people need to be reminded to look back at, like, every day or at least once a week at, why am I doing this? How far have I come? What are the benefits to me? What's, you know, what's in it for me? Motivation can also fluctuate in different situations. So you may be really motivated to go to the gym and do that kind of stuff during the summer when you're having to wear a swimsuit and all that kind of stuff, but not so motivated during the winter when you can put on three layers and be all, you know, stacked up. It can vacillate between conflicting objectives. You know, you've got your family over here and they like doing one thing and you want to do this other thing and it's really important for you, but your motivation kind of vacillates. Think about a kid who's going to school. Parents always thought he was going to go to school to be an engineer, but he decides, you know what? I want to be a cop. That's what I want to do. That's what I really love. That's what's important to me. So he's motivated to go to the police academy and become a police officer. But then he goes home for the holidays and his parents are like, you know, oh, we always thought you were going to be an engineer and you'll make so much more money as an engineer and it's so much safer. So his motivation may kind of wane a little bit from becoming a law enforcement officer and he might start toying with going to school to become an engineer again. So we need to help him kind of sort through what is important to you and how can you manage these seemingly conflicting objectives. You want to please your parents. You want to have a successful job, but you also want to be happy and this is this other thing you think is going to make you happier. It can differ between objectives. Somebody can say, you know what? I am tired of being depressed. I want to feel better. Well, that's wonderful. You know, we can work with that, but there's a lot of things that you may need to do. So we need to look at what's causing the depression. So they may be willing to start addressing their thinking patterns. They may be willing to come to counseling. They may be willing to, you know, start eating better and get a physical, but maybe they're not willing to start working on improving their sleep. Well, we know that sleep contributes in many, many ways to depression and stress. So the things that they're willing to work on, well, that's fabulous. Their motivation is there, but if there's a key factor to help them achieve their goals that they're not motivated to work on, we need to help them eventually increase their motivation to work on it by saying, you know, try doing it, try working on improving it for a week or two weeks and see if it helps. And if it doesn't, if I'm totally in the wrong ballpark, then we'll just drop it. And motivation can vary in intensity, faltering in response to doubts and increasing as doubts are resolved and goals are envisioned more clearly. So if they're doing something, think about when you've tried to lose weight or get in shape or stop smoking and you're going along and you just don't feel like you're making progress or you don't feel like you're making enough progress. Then your motivation may start to wane. You might start to go, is it really worth all this effort? I don't seem to be getting anywhere. So we want to help clients look at how far they've come, which is why baseline and logging and stuff is really helpful so they can see the incremental changes.   Where did your puppy hood go? Because we don't notice those incremental changes. Same thing in our behavior. We don't necessarily notice those incremental changes. It's helpful if there's another person in the household, if somebody's making changes to address depression or anxiety or something, if there's another person in the household that can help them by providing objective feedback. So, you know, if, for example, Sally's working on addressing her depression and her negativity and her husband starts to see that she's starting to get more negative and he knows that there's an impending depressive episode based on some of her behaviors, those changes are so small and gradual because generally, it's over a couple of weeks that she may not notice them, but he may notice them because he's not living in her skin. So it's important for him, if the relationship is such that he can, to say, you know what, I noticed that you're starting to not sleep as much and you're becoming more irritable with the animals and yadda yadda. So I'm wondering if you think you might have a depressive episode coming on and if there's something else you need to do. So having somebody else point out, you know, not only when there's problems, but also when there's incremental changes. If he can say, wow, I've noticed since you've been seeing therapists so and so that, you know, over the past month, you have been so much more relaxed and Sally may not have noticed and she may look back and go, you know what, you're right. I don't remember kind of losing my cool for a while now. So we can help people envision their progress, envision their goals and when they start to have doubts, we can help them really see how far they've come. Motivation can be modified and changed by working on those social influences implementing environmental pressures, you know, putting cues up, you know, that help the person remember what their goals are. It can be modified by distress levels. If they're in more distress, they're more likely to get more motivated because they don't want to feel that way for very long. Now we're not going to increase somebody's distress. But if they're starting to feel significantly less distressed, we can point that out.  So your distress has been alleviated. We can point that out and they can say, oh yeah, I'm going to keep doing that. Critical life events can also change motivation. Somebody may be working towards a promotion or training for a marathon or, you know, mental health stuff and then something catastrophic happens. You know, their kid goes into the hospital or they get laid off or something else happens and they just don't have time to focus as much on making this change right now. And with my clients, when that happens, thankfully it doesn't happen super often, my goal is to help them tread water, help them maintain what they've got, hold this plateau for right now. And then when you're ready, when you have the energy and the time to start working on it again, then we'll go back. I just don't want you to backslide. Motivation is influenced by our styles. So we want to be non-possessive and warm and friendly, genuine, respectful. We want to affirm what they're doing instead of constantly pointing out discrepancies. And we want to show empathy, you know, getting inside their head and understanding why it may be difficult to make this change instead of going, you're resistant, getting inside and going, I wonder why this old behavior is more rewarding than what I'm suggesting or than making a change because this person seems to be doing everything to sabotage themselves. What's the benefit to sabotaging themselves? Well, they may fear success. They may fear if they succeed, how far is that fall? How many people will they disappoint if they can't keep it up? Maybe they can't keep it up and that would be a ding to their own self-esteem. So if we get inside their head and we go, what is the benefit to sabotage? Then we can address that and eliminate the motivation to sabotage themselves and increase the motivation for change. Motivation is purposeful and intentional. We don't just like willy-nilly have motivation. You know, if you have motivation, it says you're going to get up and do something. So we want to help them figure out what are you motivated to do and what's the purpose? How is it going to benefit you to use acceptance and commitment therapy terms? How is it going to help you get closer to those people and things that are important in your life? So we enhance motivation to inspire change. We can enhance motivation in order to prepare clients to enter treatment because treatment's tough. It doesn't matter what kind of treatment. If they're coming in because they're struggling with depression or anxiety or they're getting ready to work on some trauma issues, either way, I tell my clients treatment is a full-time job. So while you are doing it, just don't expect as much out of yourself in some of the other areas of your life. You're not going to be pushing forward for that promotion and doing all this work because even when you're not in the office, you're going to be thinking about it. You're going to be trying to learn new tools. You're going to be doing activities to learn more about yourself. It's not just one hour a week. So remember that when you're trying to plan the rest of your life because, you know, it takes time. Now, is it worth the effort and all this time? Sure it is. Let's look at all the reasons why. And then we'll start looking at that. Enhancing motivation helps engage clients in treatment. When they come in, generally they're kind of going, I can't take it anymore. I need something to change. So they're kind of motivated. But we need to help them stay motivated by giving them small success, not giving them, helping them achieve small successes so they can see, okay, this is worth it. This is working. I can see the progress. And it'll help retain them in treatment when things get tough. We can stop, we can do a decisional balance exercise and help them see all the pros and cons and weigh it and figure out why staying the path really is worth the effort, even though it hurts right now. It increases participation and involvement because they've got buy-in. They see why it's important to them. And they've got all these other pressures, social pressures, environmental pressures, all those things going on out here that are going, you can do it. You can do it. You can do it. It improves treatment outcomes because if they are engaged and participatory and stay in treatment the whole time, then they're probably going to show more improvement. It encourages a rapid return to treatment if symptoms recur. If we are a cheering section, if we help them stay motivated, if it's a positive experience, and if when they leave, we leave the door open and say, you know what, if you ever need to come back to kind of tune up a little bit, I'm here. A lot of times they don't need another full course of therapy. They may need one or two tune up sessions and everybody does periodically or could benefit. And it creates a therapeutic partnership because we see and we're aligned along similar, if not the same goals. I see what the client's goals are and I want to help him or her achieve those goals and maybe achieve my goals in the process, but that's part substance abuse treatment. To help increase motivation, you can use the oars technique. Use open-ended questions, which respects the client's autonomy. Affirm their abilities to succeed by recognizing any co-occurring disorders and acknowledging how difficult it is.  It hurts to get out of bed sometimes. I hear where you're coming from.  We need to be empathetic. We need to acknowledge the difficulties and help them figure out how to overcome those difficulties instead of just saying, yeah, it really sucks right now. Okay, well, what do we do about that? How do you get yourself out of this cold, dark well so you can move on with your journey? And we affirm their abilities to succeed by using client-centered treatment. If we're focused on, what have you done in the past that's worked for you? Well, that starts out with me asking them, what have you done that's worked? How have you succeeded in the past so they're starting to hear, I can do this? Reflective listening uses empathy more than authority and validates the client's experience. We're going to use that. And summarize. Remember to regularly summarize, focusing on client's strengths, successes, and personal power. Try to reframe things instead of as failures as learning opportunities, instead of as struggles as opportunities for growth. And remember to acknowledge any small successes, even if it was just coming to treatment that day. You know, maybe things are not going so well, but they came, which tells me they still have hope and they still have the desire to get better. And then we'll look back over treatment and figure out periods where things have been going better and look at what was different then. You know, what changed? How might we be missing the boat, so to speak, right now? Which is, you know, causing you to relapse or not feel so good. And we'll start looking at that and it's a partnership. It's a we, not a, what are you doing differently? We can help clients recognize behavior that is not in their best interest. We can help them regard positive change to be in their best interest. A lot of times they may, we may have interventions or, you know, when I talk about sleep, a lot of times at first clients will look at me like I've got three heads. And then I educate them at how important sleep is to allowing the body to rest and rebalance, to reset the circadian rhythms, to turn off the threat response system. So they can have more available serotonin and, you know, a better balance of neurochemicals and feel better. And I don't get into the nitty gritty unless they're really interested. But if I educate them about why it's important, why this positive change is in their best interest and will help them achieve their goals, then they're going to be more motivated to at least try it. It helps them feel competent to change when we, are there cheering section, and we help them see why it's important. And we help them break it down into manageable increments so they can have successes. It helps them develop a plan for change because we're going along the way. We're saying, okay, there's 10 steps to this process, you know, we're going to be in counseling for 10 weeks. Right now, you're on the ground. You want to go up this flight of stairs. What's the first step? What's the first thing you need to do? All right. So you're going to do that this week. What's the next thing you need, you think you need to do? All right. Maybe you can do that next week. Sometimes I'll even do a graphic where I have a stair step and I have them put each of their objectives at each stair step. Depends on the client, whether they're visual or auditory learners. Motivation also helps them begin to take action because they're excited. When you're really motivated to do something, when you're looking forward to a vacation, you can't wait to get out the door and get started on your journey. Well, that's where I want them to be. And it helps them continue to use strategies that discourage a return to the old behavior. If we help them stay motivated to keep doing the next right thing, even though it may not be the most immediately rewarding, it will discourage them from returning to their old ways. Three critical elements of motivation. Ability, willingness, and readiness. So does the person have the ability? Do they have the knowledge and skills to do what we're asking them to do? If not, then we got to help them get those. Are they willing? Do they have any importance on this? Think about a track runner, somebody who's a sprinter. They may have the ability because they practiced for months. They may be willing. They got dressed out. They showed up at the track meet, so they're willing. But they also still need to get ready, which means putting all their ducks in a row for people that are getting ready for treatment. Maybe they have to cut back on some of their work hours or reschedule some things so they can make sure to make their appointment every week. Those are the things they need to do to get ready. A track runner would do something like stretching and warming up so they're ready when that pistol fires to go. But they have to be ready willing, which is motivated and ready. Ready, willing, and able. Elements of current motivational approaches include the frames approach, decisional balance exercises, helping clients identify discrepancies between personal goals and their current behavior, flexible pacing. They're going to ebb and flow some. Other things are going to come up in their life. They're going to need to slow down sometimes. Some tasks or steps are going to be more challenging than others so they may take some more time. Each step is not necessarily equal. So we need to be flexible with what the person needs and how well they're doing it, not just push them through and say, well, this is 10 weeks. You're in and you're out. And have personal contact with clients in treatment. So if somebody doesn't show up for an appointment, obviously following up with them, but sometimes just sending them a note in the interim saying, you know, you did some really good work last week. I can't wait to see what you bring next week. We'll help them feel like they are important to you, not just a number or client. So the frames approach, feedback regarding personal risk or impairment. Now it's hard to provide feedback sometimes without sounding like we're lecturing. So, you know, you want to use this delicately. A lot of times I do feedback by having clients keep a log, a baseline for a week of tell me how often this happens. So then they can get an idea about how much they're really drinking or how many times they really, you know, yell at people or whatever the baseline that we're looking at is, how much crying they do, whatever. So that gives them an idea about how bad their problem is or whatever. And then we can talk about it in comparison with, you know, the general population. The responsibility for change is placed on them. I am here to be a catalyst. I am here to help you as much as possible, but I can't make you do anything. So it's your, it's on you to make this change and I will do everything I can to facilitate it. Advice is clearly given to the client by the clinician in a non-judgmental manner.  Menus of self-directed change options and treatment alternatives are offered. So, you know, maybe we think this one thing is the way to go, but that might not be what works for the client or what they're ready to do right now. So we want to have multiple different options. You know, you might try some self-help support groups. There are these self-help books and then we've got a depression group that meets once a week if you don't want to go into individual counseling or maybe they don't want to do group and they would prefer individual. So we want to give them as many options as possible. If it's individual treatment, you know, maybe they're not, like I said, maybe they're not willing to work on their relationship right now, but they are wanting to work on their depression. Okay, so let's start there. You know, we have a lot of different ways we can go with this. Again, with the empathy and self-efficacy. If clients don't feel like they can do it, then they're not going to do it. If they feel like it's too much of a hurdle or it's too scary or too overwhelming. So we want to encourage their self-efficacy and make sure they realize that it's possible. It is so doable. Feedback should be straightforward, respectful, easy to understand and culturally appropriate. Not all clients respond to feedback in the same way. So for example, one person may be alarmed to find out that she drinks a whole lot more in a given week than her peers, but not concerned at all about the health risks. Another person may freak out about the health risks when they find out about that. So we need to find what's meaningful to them and tailor our feedback that way. Not lie, not omit, but make sure that we hit the salient points. Personalized feedback can be used throughout treatment to help them see how well they're improving. And feedback about improvements is especially valuable as a method for reinforcing progress. Feedback helps the client understand the information, interpret the meaning of, you know, what just happened or why am I doing this? You know, we want to provide feedback. If a client's doing a technique that we asked them to do, maybe their ABC worksheet for cognitive behavioral, we want to help them understand what they're doing and why they're doing it. And then when they bring it in, the filled out worksheets, we're going to give them feedback about them, about whether, you know, how they're doing it is helping to accomplish what it's supposed to accomplish. Feedback can help clients gain a new perspective about the personal impact of their behavior.   I just, I can't, and the withdrawals are awful. We can maybe help them gain a new perspective. Now, most likely they know that perspective, but consider changing is another reason that feedback can help. So we can help them see all the benefits of change and, you know, really weigh it out. And only focusing on the benefits of change is the quickest way to lose a client, because they're like, well, you're not looking at the big picture, because we're not. And so that's why, again, decisional balance will get there. And feedback can help them recognize a discrepancy or gap between future goals and current behavior. So if somebody wants to get into law school, but they are taking illicit drugs, that, you know, if they get caught, they may never be able to go to law school or they can maybe go to law school, but not get whatever licensed to be an attorney if they've got a felony conviction on their, on their record. So we want to help them see is what you're doing in conflict with the people and things that are important to you. We want to roll with resistance and avoid argument, which is so hard to do sometimes. We can do this through a simple reflection. That's the parroting back that we all did the first year we were, you know, working in our internship, probably. Amplified reflection reflects the client statements in an exaggerated form. So for example, the client might say, I don't know why my wife is so worried about this. All guys get angry sometimes. So the clinician would say, so your wife's just worried needlessly. So he's saying he doesn't understand and you're going. So it's really not a big deal. Double sided reflection acknowledges what the clients have said, but also states contrary things. So maybe the client says, maybe I should just stop caring about anything. Then, then I wouldn't worry at all. So my anxiety would be gone. And the clinician would say, so you can see that there are some real problems here, but stopping caring completely is clearly not what you want to do.  I can hear that, but you don't see how to start feeling any better. Shifting focus helps the client shift focus from obstacles and barriers. So if the client says, I can't take medication, I'm in recovery and can't take mind altering substances of any type, even psychotropics. The clinician can say something like, whoa, we are way ahead of me. We're exploring how your anxiety is impacting your relationship with your kids. We're not ready to talk about medication or anything yet. So that, you know, addresses their defensiveness and says, we're not there yet. You know, let's talk about this other thing over here. And then if we get to that point, then we'll cross that bridge. Agreement with the twist is the client may say, why are you and my wife so stuck on my drinking? What about all her problems? You'd drink too if your family was nagging you all the time. So the clinician can say something like, you've got a good point. There's a bigger picture here. It's not as simple as just one person drinking. I agree with you. We shouldn't be placing blame. Drinking problems involve the whole family. So it is the client feels like he's on the spot. He's on the hot seat. So the twist is to really open it up and go, it's not just you. I can see that there's a lot of other factors here. And reframing acknowledges the validity of the client's perception, but may offer a new meaning for consideration.  And, you know, normally I cost a whole lot more than free. So what can you get out of it? How can you use this time to your benefit? Is there anything you want to work on? And then they might kind of start working with me. Responsibility. Give individuals the responsibility and opportunity to decide when and whether they will change their behavior. It's up to them. Encourage them to choose their treatments and be responsible for changing. So I'm not just writing out a treatment plan for them and going here. Do this. I'm saying, okay, here are your options. What do you think is going to work best? And how can we make that work for you? We don't want to impose views or goals on clients. Because when clients are free to choose whether they change, they feel less need to resist or dismiss our ideas score. They feel empowered and more invested in treatment because they made that decision. And they may be more willing to negotiate common treatment goals with us. So if they're making the decision and they feel empowered, then they don't feel like they're being backed into a corner. The most appropriate time to give advice is when the client requests it. So we're not going to just be handing out unsolicited advice. As with feedback, the manner in which we advise clients determines how the advice is going to be used. If it sounds condescending or preachy, it's probably going to go in one ear and out the other. So we need to make sure to relate it to them and ask for their opinion on it. Suggesting also yields better results than telling clients what they should do. If a client requests direction, the clinician can first clarify what the client wants rather than immediately give advice. So if the client says, I need to know how to handle this situation with my coworker. Okay, well, you know, what exactly are you looking for here? And we can give simple advice that is matched to the client's level of understanding and readiness, the urgency of the situation, and the client's culture. So if they're not sure what they're going to do or how they're going to fix this problem, you know, maybe they've got a little time to think about it. So maybe we can suggest to them to take some time to weigh the pros and cons instead of pushing them and saying, you really need to get enrolled in treatment like tomorrow. When clients make independent decisions, they're likely to commit to them. So if we provide a menu of options and they can choose, then they're probably going to be more invested. Menus decrease dropout rates and resistors to treatment and often increase overall treatment effectiveness. But it's important that we provide accurate information about each option and a best guess about the implications of choosing a particular path. So if we say, you know, if you choose self-help workbooks and support group meetings, you know, that's great. Now, my experience or based on the assessment, I have concerns or I think that would work fine. You know, we want to make sure that we provide our educated to sense and they will take it or leave it. We want to elicit from the clients what they think would be effective or what's worked for them in the past and build off of that. If they love workbooks, well then let's start to want a workbook. It can be an adjunct to treatment. Instead of us having to come up with handouts, we'll just work through the workbook with them. Reinforce the client's ability to make informed choices. So think about the ways that your agency supports offering clients a menu of treatment options. Most agencies don't. Most agencies are pretty. This is what we offer, take it or leave it. Empathic counseling can be particularly effective with clients who are angry, resistant or defensive. So we can use empathy to explore the reasons why the client is angry about having to be here. You know, we probably would be angry too. So if we put ourselves in their shoes, it'll work a little bit better and we can establish more of a connection. Allow the client to do most of the talking in a safe environment. The client's process, change process will unfold at its own rate. So we don't need to direct it and we don't want to interrupt it when possible. Empathy communicates respect for and acceptance of clients and their feelings and encourages a non-judgmental collaborative relationship. Hopefully you got all that in intro to counseling. With self-efficacy, clients must believe they're capable of undertaking specific tasks and have the skills and confidence needed to change. We can help build this by reinforcing clients' beliefs in their capacities and capabilities. You can do this. Believing in clients' ability to change, we have, I mean, they can tell if we're just blowing smoke. We need to believe that they have the ability to change. Help clients identify how they've coped successfully with problems in the past and build on those successes, reinforce small steps and positive changes, foster hope and optimism, reframe past failures as partial successes. It's successful because you tried, you stepped outside your comfort zone and you learned what doesn't work. And use questions beginning with what else do you need to know? What else can I do to help you? So decisional balance exercises. Individuals naturally explore the pros and cons of any major life choices to make a decision. So decisional balance exercises are awesome. So you have to change whatever that is or to stay the same. And then you have the pros and the cons. And when I do it, I do it granularly like this. So we make sure to cover everything. And sometimes you're going to have overlap and that's okay. But first start where sometimes I start with staying the same. What are the benefits to staying the same? Not doing anything, just going home and pretending this didn't happen. How are you feeling right now emotionally? How are you thinking right now? Are you negative? Are you positive?  Can you concentrate? What about your physical health and wellness?  Or are you sleeping fine and you feel just ducky? Socially, the way things are right now, what's good about the way things are socially? What's good about your current environment and what's good at work? And so they go through all those things. And then it doesn't matter which way you go. You can go down to what are the drawbacks to staying the same?  You're feeling depressed right now. You've got foggy headedness, difficulty concentrating, physically you hurt. Generally this lower quadrant is why people come to treatment. They don't want to stay the same anymore. But we need to look at why they might want to stay the same or what the benefits were for that behavior. Because we're going to have to address those. When they change, we need to make sure that whatever their change, whatever change happens, meets their needs to the same extent. If they were smoking to deal with stress, well one of the benefits to staying the same is they still have some way to deal with stress. So if we're asking them to do something different instead of smoking, we have to make sure that it helps them deal with stress. Because that was the function of the old behavior. So then we go over to change and we start listing these things. What are the emotional benefits to change? How is it going to help you feel happier? What are the emotional benefits or the cognitive benefits, physical, social, environmental, occupational? We'll list all those. And then we want to look at the cons. What are the drawbacks to doing this? Therapy is expensive. That's true. It's going to take time and effort. That's true. Have them list all of the drawbacks to change. Because we're going to need to eliminate as many of those as possible. Once you have everything listed out, then I have clients go through with a highlighter and highlight the things in red that are of the most importance or the strongest motivators, either direction. So I can see the things that are most important to them. And we can kind of tip that decisional balance. So if down here under cons to change, they have finances. And that's highlighted like triple red. I might say, okay, so finances are really freaking you out right now. What can we do? Can we talk about payment plans? Or, you know, let's look at what your insurance covers or maybe you can go to groups instead of individual because that's less expensive. So we'll look at ways to make it more affordable for them. So we want to eliminate as many of the drawbacks to change and eliminate as many of the benefits to staying the same as possible and enhance the benefits of change and enhance or highlight the drawbacks to staying the same in order to tip that decisional balance. But you need to look at all four corners or all four quadrants to make sure we're not missing a reason that somebody might just not want to change or they might find once they start changing, you know, it's not worth this much effort. Flexible pacing and personal contact means meeting clients at their need at their levels. Use as much time as necessary with the essential tasks at each stage of change. And so they may be ready, but they may need a little bit more time to accomplish certain tasks. Personal contact through letters or phone calls is effective for clients to encourage clients to return for another clinical consultation, return to treatment following a missed appointment, stay involved in treatment, or adhere to a plan for change.  Obviously that's typically not HIPAA compliant, so you would need to get permission. So motivation is dynamic and influenced by multiple types of motivation, including emotional, cognitive, social, and environmental.  So we need to help them figure out how to enhance their motivation. Motivational interviewing increases client's hope and enhances treatment participation. The three critical elements of motivation are ability, willingness, and readiness. And the five elements of all motivational approaches include the frames approach, feedback, responsibility, advice, menu of options, empathy, and self-efficacy. The use of decisional balance exercises to increase the motivation, helping them identify discrepancies between their personal goals and their current behavior, flexible pacing, and personal contact. The ORS acronym stands for Open-Ended Questions, Affirmation, Reflective Listening, and Summarizing. And that's a neat acronym you can use and have your texts and maybe even your first-line intake staff learn in order to help clients start feeling motivated and accepted the minute they come to check in. We want to help clients identify ways to deal with resistance using reflection, amplified reflection, and reflection with a twist and use decisional balance exercises to highlight the benefits and drawback in number and value of change and staying the same. So just like we talked about, not only the number of pros to changing and the number of drawbacks to staying the same, but let's look at the intensity because if there's something that's really scaring the pants off them about changing, then we need to address that even if it's just one thing. Alrighty, thank you all for being here. Kind of a quiet group today. Is there anything you want to interject, anything you want to add? Have you had experience with this? If not, you can feel free to take your quiz and be gone. This Q&A section at the end is optional, as I said earlier. If you are needing or wanting particular topics covered, I am still working on the next set of approvals that I'm going to send out. That will be for the month of March. So please just send some in. Okay, everybody have a wonderful day and I'll see you tomorrow for Part 2 of motivational interviewing. Thank you.