Chapter 6 — Motivational Interviewing & Self-Efficacy Flashcards
Define Autonomous Motivation vs. Controlled Motivation. Which of these does MI embrace?
Autonomous Motivation 78-79
Behaving with a full sense of volition, interest, and choice. People who are autonomously motivated control their choices and they act in ways they find interesting, important better, of deep value. — Deci, 2013
Autonomous Motivation is intrinsic. That is, it comes from within. We know that when behavior change is intrinsic, clients experience pleasure — It’s fun, challenging, and interesting. This kind of motivation can be present-focused or future focused.
♣ Present-focused intrinsic motivation. Example —Saver impact of the behavior change in the here and now and how good it feels to have made healthy choices at the end of the day.
♣ Future-focused intrinsic motivation. Example — the client knows that the change will lead to a better future. This energizes her to make the world a better place. The client steps closer to her “best self” Andrew realizes that the bigger reward comes after the behavior is sustained.
Controlled Motivation 78
This kind of motivation comes from an external source. Example —
♣ Motivations choices that are linked to external sources of motivation include/words that push, strongly encourage, or demand “compliance” in behavior change.
♣ Words most often connected with controlled motivation include: Should, must, and have to. These words imply an external standard or expectation that relates to self-respect and self-esteem. This leads to a form of internal compliance based on the notion that “I am a good or bad person depending on whether I do a behavior.”
How does a coach support a client in unleashing her own motivation without the use of force, faux, fear, or good old-fashioned cheerleading?
The coach assists the clients to make their own case for change (pro-change talk) and avoids triggering change-resistance talk.
With respect to Autonomous Motivation, what contributions do Dean Ornish, MD and Deci and Deci and Ryan (202) make?
Dean Ornish (2002) — “Fear of Dying” — Fear lasted as a motivator post heart attack for only a few weeks after the heart attack and out of fear. Once the client had passed out of the two week window — they stopped thinking about their mortality. Denial returned, and the clients return to their unhealthy lifestyles.
“Joy of Living” —Dean Ornish found that the joy of living was a more powerful motivator than fear. He supported his clients in considering a new vision that was focused on the joy of living.
My Conclusion: When clients focus on the joy of living (new vision), this increases positive emotions and acts as an intrinsic motivator for change. Autonomous Motivation is motivation that comes from within. It’s intrinsic.
Deci (2013) — the benefits to people who experience high autonomous motivation are huge. They include:
♣ New and positive behaviors persist longer.
♣ They are more flexible and creative.
♣ Performance improves
♣ People experience more enjoyment in making changes.
♣ People have better physical health and higher quality personal relationships.
Deci and Ryan (2002). — Autonomy is a core human drive. We are wired to dislike being told what to do. People assume responsibility for their health when they act autonomously. A top-down approach/hierarchical approach puts the healthcare provider in the driver’s seat and puts the client in the passenger seat; this deprives the patient of the opportunity to take charge and drill down to find a heartfelt source of motivation.
Deci and Ryan (2013) When there is an awareness of the importance of the need for autonomous motivation, positive results follow. Example —Smoking cessation study showed that when staff supported patients in becoming more autonomously motivated, the patients perceive themselves as more competent in their ability to quit smoking.
It is through undistracted listening and reflecting with an open, mindful, and curious mindset that clients connect with their own heartfelt desire for change —It’s not about the pounds on the scale, but rather it’s about unleashing clients desires to improve their health so they have the resources they need to live the lives they most want to live.
★Define each of the 4 Principles of MI. What are the 4 major principles/strategies of MI? 80
- Engaging: Developing growth-promoting relationship-building strategies that support the client’s autonomy. 80 - 81
♣ Rolling with Resistance
♣ Open-Ended Inquiry
♣ Perceptive Reflections - Focusing: Helping clients develop more clarity around their values and goals. 80 - 84
♣ Developing Discrepancy: The Decisional Balance and Richard Botelho (2004) uses a quantitative rating system (Fig 6.1 as a Tool for Developing Discrepancy.) 83
♣ Perceptive Reflections for Developing Discrepancy. - Simple Reflections
- Amplified
- Double-Sided Reflections
- Shifted-Focus Reflections
- Evoking: Generating a connection to the client’s autonomous motivations and drives.
♣ Role of Meaning in Motivation — One’s sense of purpose and meaning.
Wong (1987) found what having a sense of meaning, life purpose, and life control were predictors of psychological and physical health. 85
♣ Examining Motivation with Rulers — Willingness = Important, Confidence, and Readiness to Change Right Now - Planning: Designing action plans that support the building of self-efficacy.
MI Planning involves collaborating on an action plan supported by increasing self-efficacy.
Pneumonic/Visualization: Think of Engaging Executive Function. Start with Engaging → Move to get Focus → Evoke → Plan
Pneumonic/Visualization: Think of Engaging Executive Function. Start with Engaging the client using growth promoting relationship building strategies that support Autonomous Motivation by Rolling with Resistance, open-ended inquiry, and perceptive reflections. → Move to get Focus by helping clients develop clarity around their values and goals. The 2 tools for this are Developing Discrepancy and using perceptive reflections to develop discrepancy. → Evoke a Connection to the client’s autonomous motivations and drives. 1. Help them find meaning — their sense of purpose and meaning that are the foundations for change. 2. Use Rulers to Examine Motivation. This is where the Willingness = Importance, Confidence and Readiness to Change Rulers fit in the picture.→ Plan. Make realistic, well thought-out plans that consider barriers and challenges. Coach collaborates with the client to strengthen goal commitment and the possibility for mastery. See 91
If you are doi
If you are doing Importance, Confidence, and Commitment Rulers, how do you know when the person is ready to make a change? 86 - 87
It is important to remember that if a person thinks something is important and they have the confidence to do it, the person is not necessarily committed to making the change. It is the Commitment that drives the person across the line to change.
An important piece of making a commitment is to explore the values for change. When the person can connect the change to something that is really important in life, they are more able to make a change.
The values piece is the why I am going to go about all this work. Values are different than desire or commitment, but it reinforces both.
Example: Good health Be able to take care of grandchildren
What does it mean to “Roll with Resistance?” 80 - 82
Which MI Principle is this?
The point is that clients do not “resist change”. So, when we hear resistance talk, it is more about the Coach or a projection onto the Coach. Our job is to Roll with Resistance. We do this by centering ourselves and offer ourselves compassion. Then we explore the client’s underlying feelings, needs, and desires. We suspend our own judgment, agendas, assumptions, interpretations and evaluations.
This is one way to show support for client autonomy.
______________-
MI Principle 1: Engaging
♣ Rolling with Resistance
♣ Open-ended Questions/Inquiry
♣ Perceptive Reflections
What are the four principles of MI 80 - 86
- Engaging: Developing growth-promoting relationship-building strategies that support the client’s autonomy. 80 - 81
♣ Rolling with Resistance
♣ Open-Ended Inquiry
♣ Perceptive Reflections - Focusing: Helping clients develop more clarity around their values and goals. 80 - 84
♣ Developing Discrepancy: The Decisional Balance and Richard Botelho (2004) uses a quantitative rating system (Fig 6.1 as a Tool for Developing Discrepancy.) 83
♣ Perceptive Reflections for Developing Discrepancy. - Simple Reflections
- Amplified
- Double-Sided Reflections
- Shifted-Focus Reflections
- Evoking: Generating a connection to the client’s autonomous motivations and drives.
♣ Role of Meaning in Motivation
♣ Examining Motivation with Rulers — Willingness = Important, Confidence, and Readiness to Change Right Now - Planning: Designing action plans that support the building of self-efficacy.
MI Planning involves collaborating on an action plan supported by increasing self-efficacy.
Pneumonic/Visualization: Think of Engaging Executive Function. Start with Engaging → Move to get Focus → Evoke → Plan
What are the four general principles of MI?80 - 86
Principle 1: Engaging
Principle 2: Focusing
Principle 3: Evoking
Principle 4: Planning
Principle 1: Engaging 81 -82
The premise behind MI is that pro-change talk is facilitated by a calm, safe, judgment-free relational space in which people feel secure and honestly sharing their thoughts, feelings, needs, and desires without fear of judgment, ridicule, or pressure.
This is especially true when a client feels “stuck” and unable to move forward. Here it is more important to express empathy and to validate and appreciate the discomfort.
Tools: 82
1. OARS — Emphasis on Open-Ended Questions and Perceptive Reflections.
Reflective listening statements function like mirrors allowing people to see themselves in new ways. They improve motivation and capacity for change.
2. Empathy Reflections or “empathy guesses” are particularly valuable for expressing empathy. Level III Listening = Listen for the feelings they are expressing and the needs that are being met or not met. (Rosenberg, 2005) NVC Language.
Note: Level I Listening — Thinking about people’s words and listening how they connect to our theories. We are not with the client when we do this.
Principle 2: Focusing 82 - 84
This principle is a focused exploration of the discrepancies between the client stated values and goals and their current behaviors. Principle 2 is about more narrowly directing the focus on the gap between a clients present situation and their values and goals.
The purpose of the expiration of discrepancies between stated values and goals and current behaviors is to —promote change talk and increase motivation.
Tools:
♣ Decisional Balance —> Develop Discrepancy. We use open-ended questions and reflections that help clients thoroughly consider the pros and cons of changing. What are the costs and benefits of changing. The decisional balance discussion helps clients more fully appreciate the sources of their autonomous motivation and what is required to build confidence (finding possible strategies to deal with the benefits of not changing and the cost of changing.
Richard Bantelho (2004) = Figure 6.1 Tool for Developing Discrepancy. This is a quantitative rating system combined with decisional balance conversion. We can focus on one column at a time starting with reasons to stay the same and work our way through the table. Or, we can use mental contrasting where we alternate back and forth between reasons to stay the same and reasons to change. (Oettingen & Gollwitzer, 2010) 83 - 84
♣ Perceptive Reflections that Develop Discrepancy
These four powerful reflections are used to develop discrepancy between the desired future and current behaviors. Each type of reflection can be used with an NVC-style empathy reflection, addressing the client’s feelings and needs.
1. Simple —These reflections are like the images seen in a flat mirror.. A simple reflection paraphrases and restates what clients are saying, using their own words without exaggeration, interpretation, or distortion.
2. Amplified — These reflections are like the images seen in a convex or concave mirror. They maximize or minimize what clients say in order to evoke disagreement from them in the direction of change talk.
3. Double-Sided —these reflections are like the images seen in a trifle mirror. They reveal multiple perspectives at the same time. The intention is to help the client look at different facets to gain perspective and make different decisions as to how they want to move forward.
4. Shifted-Focus — These reflections are like the images we see in the periscope. They are used to redirect attention away from a resistance-provoking subject in order to focus on another area.
Note: Both amplified in empathy reflections or gases as to what will stimulate change talk and what feelings and needs may live behind a client’s words, body language, or tongue.
Principle 3: Evoking
Evoking Change Talk — This principle looks to uncover a client’s reasons for change. We encourage the client to explore their autonomous “why” behind a behavior change, especially with an orientation toward the future, as it can create the energy needed for a shift.
- The Role of Meaning in Motivation — We help clients
♣ Larger Value & Purpose: Examine the larger value and purpose behind any desired change,
♣ Past: Mining the past for lessons learned
♣ Present: Mining the present for what contributions the change could make to performance and life purpose
♣ Future: Potential contributions to causes beyond oneself. - Examining Motivation with Rulers
Ask: On a scale of 0 – 10, __________.
♣ Willingness Ruler: How important is it to you to change your _________ at this time?
♣ Confidence Ruler = Ability: How confident are you that you can change your ______ right now?
♣ Readiness Ruler: How ready are you to change your _ at this time?
For all 3 rulers, explore with the client:
♣ What led you to pick ____ and not a lower number?
♣ What would help you get to a higher number?
Ask open-ended questions followed by perceptive reflections.
Principle 4: Planning
Collaborating on an action plan supported by increasing self-efficacy.
Define empathy and discuss how to use it in coaching. 64 - 66
Empathy: The respectful understanding of another person’s experience, including his are her feelings, needs and desires.
Empathy is not a prelude to the work of coaching; it is the work of coaching.
Empathetic Statement.
“I respect your pain.”
“I celebrate your joy.”
How to use empathy in coaching:
MI Coaching: MI starts with the premise that change talk is facilitated by a calm, safe, judgment free relational space where people are free to honestly share their thoughts, feelings, needs and desires without the fear of judgment, ridicule, or pressure.
Coach with Client:
1. MI Principle 1: Express Empathy
♣ Acceptance facilitates change.
♣ Skillful reflective listening is fundamental.
♣ Ambivalence is normal.
Recognize health-risky behaviors as expressions of a client’s unmet needs.
A respectful and appreciative understanding of our clients’ experiences Helps to expand their awareness, create openness, and facilitate change.
Empathy requires level III listening: Full engagement and deep appreciation.
Necessitates both emotional and cognitive awareness to appreciate a client’s experience.
- NVC: 4 Step Communication Process
- Make observations not evaluations
- Express feelings not thoughts
- Identify needs not strategies
- Make requests, not demands.
Coach with Self:
- Awareness of: The client’s emotions and thoughts (cognitions) to connect respectfully and to give voice re: what people may be feeling, needing, and desiring.
- Full engagement
- Deep appreciation
- No hurry or judgment
- Safe, calm, no-fault zone where people can discover and develop their truths
- Treasures emotion as a guest
- Conscious engagement of emotional intelligence and the intuitive dance of dialogue
What does developing discrepancy mean? What tools can a coach used to develop discrepancy? Which MI Principle uses Developing Discrepancy? 82 - 84
Principle 2: Focusing — A focused exploration of the discrepancies between a client’s stated values and goals and their current behaviors.
Developing Discrepancy: This is Principle 2 : Focusing in MI. It is a focused exploration of the discrepancies between the client stated values and goals their current behavior. We narrowly focus on the gap between the client’s stated values and goals and their present situation.
We use the decisional balance tools to help a client think through whether they are ready, willing, and able to make a change.
Tools for Developing Discrepancy:
1. Decisional Balance Tools
♣ Decisional Balance Tool: Weigh pros of changing and cons of changing, pros of staying the same and cons of staying the same.
♣ Richard Botelho (2204)’s Tool for Developing Discrepancy. This tool combines a quantitative rating scale with a decisional balance.
2. Perceptive Reflections — Help tap into emotions and needs. They function like mirrors that allow people to see themselves in new ways and improve motivation and capacity for change.
♣ Simple
♣ Amplified
♣ Double-Sided
♣ Shifted Focus
We use these (above) reflections in conjunction with NVC-style-empathy reflection, addressing the client’s feelings and needs.
Name four types of reflections and give an example of each. 82,
See Perceptive Reflections for Developing Discrepancy 84 - 85
Empathy Reflections
- Simple
- Amplified
- Double-Sided
- Shifted-Focus
EMPATHY REFLECTION 62, 82
Feeling and Need/Longing
Listen for
1. The feeling that is being expressed and
2. The need/longing that is or is not being met
♣ Need is met. It sounds like you are feeling _____ because you have a need to ______.
♣ Need is not met. It sounds like you are feeling _____ because it is meeting your need(s) for ______.
♣ When you say ______, it sounds like you . . .
SIMPLE REFLECTION 84 Paraphrase and Restate Paraphrase and Restate What clients are saying in their own words without exaggeration, interpretation, or distortion. Like images in a flat mirror ♣ It seems that. . . ♣ I hear you saying . . .
AMPLIFIED REFLECTION 84
Minimize or Maximize
Maximize or Minimize
What the client says to evoke disagreement from them in the direction of change talk.
Use only in the service of client-generated goals.
Like images in a convex or concave mirror.
I hear you saying ______, and it feels ______.
Example
Client: I don’t have time to exercise. My friends and my spouse don’t either.
Coach: I hear you saying that you don’t know anyone close to you who has time to exercise and that it feels impossible to fit into your schedule.
SHIFTED-FOCUS REFLECTION 85
Re-Direct Attention
Re-direct Attention Away from a Resistance-Provoking Subject to Focus on Another Area.
Like images seen in a periscope.
This sounds challenging, so little time to exercise. I’m wondering about the dance class you started with your partner. You were doing pretty well with that; I remember you saying that you were enjoying the classes.
DOUBLE-SIDED REFLECTION 84
Compare and Contrast
Compare and Contrast the Resistant Statement to the Readiness Statement.
Purpose: Gain perspective to make a clearer decision on how to move forward.
Like images seen in trifold mirrors.
1. Encourage clients to look at different facets.
2. Compare two different statements.
I hear you saying that . . . . But, I’ve also heard you say that . . .
Define decisional balance and discuss how it is used in coaching. 82 - 83
The decisional balance is used in MI Principle 2 Focusing — A focused exploration of the discrepancies between a client’s stated values and goals and their current behaviors. We focus on the gap between their values and goals and current behavior.
We use both the _______ to help clients think through whether they are reading, willing, and able to make a change.
- Decisional balance Tools to help a client think through whether they are ready, willing, and able to make a change.
- The Rulers are used to: Help clients think out loud and quantify topics that are hard to pin down.
What are rulers? How are they used in coaching? 87
MI —Principle 2: Focusing — A focused exploration of the discrepancies between a client’s stated values and their current behaviors. It uses rulers to help a client think through whether they are ready, willing, and able to make a change.
The Rulers are used to: Help clients think out loud and quantify topics that are hard to pin down.
The
*
Examining Motivation with Rulers —
Ask: On a scale of 0 – 10, __________.
♣ Willingness Ruler: How important is it to you to change your _________ at this time?
♣ Confidence Ruler = Ability: How confident are you that you can change your ______ right now?
♣ Readiness Ruler: How ready are you to change your ________ at this time?
For all 3 rulers, explore with the client:
♣ What led you to pick ____ and not a lower number?
♣ What would help you get to a higher number?
Ask open-ended questions followed by perceptive reflections.
What is rolling with resistance? How can you decrease the likelihood of resistance talk? 80 - 82
The point is that clients do not “resist change”. So, when we hear resistance talk, it is more about the Coach or a projection onto the Coach. Our job is to Roll with Resistance. We do this by centering ourselves and offer ourselves compassion. Then we explore the client’s underlying feelings, needs, and desires. We suspend our own judgment, agendas, assumptions, interpretations and evaluations.
This is one way to show support for client autonomy.
Coaching Perspectives That are Useful for Rolling With Resistance:
1. From client resistance to an external desire to connection: Seek respectfully to understand the client’s experience - Client becomes more open.
2. From authoritative expert to inspiring confidence: Believe in the client’s ability to learn.
3. From causes to capacities: Collaborate with the client to search for capacities The change process becomes more engaging.
4. From counterforce to counterbalance: The more a coach counterbalances client ambivalence with appreciative awareness of the good reasons to not change, the more change talk is generated.
Use: To develop awareness of the gap from present behavior and important personal goals or values, use ________. Encourage the client to find the discrepancies for themselves.
♣ Open-ended questions
♣ Reflective listening statements
♣ Explore discrepancies with empathy and curiosity: - Clients become more open and motivated to change.
Questions that evoke change talk:
♣ What is the best experience you have had with your desired future behavior?
♣ What concerns do you have about your current behavior?
♣ What values do you seek to live by in your life?
♣ How might your desired future behavior lead to benefits in in the future?
♣ How might your current behavior lead to problems in the future?
♣ What changes would you like to make in your routine?
♣ Miller & Rollnick, 2012
Describe the differences and the similarities between AI and MI. 67 – 70, 80 - 87
AI
Defining What and How to Learn — Clarifying
What is the focus?
(Affirmative Topic Choice)
Discover the Best of What is —Appreciating
What gives life?
(The best of what is)
Dreaming of What Might Be —Envisioning
What might be question
(What the world is calling for)
Designing What Should Be — Co-Constructing
Destiny — Delivering What Will Be — Innovating
MI Engaging: Developing growth-promoting relationship-building strategies that support the client’s autonomy. ♣ Rolling with Resistance ♣ Open-Ended Inquiry ♣ Perceptive Reflections Focusing: Clarity around Values and Goals ♣ Developing Discrepancy: Decisional Balance and Mental Contrasting ♣ Perceptive Reflections Evoking: Connection to autonomous motivations and drives ♣ Role of Meaning in Motivation ♣ Examining Motivation with Rules — Willingness = Important, Confidence, and Readiness to Change Planning: Design action plans that support Self-Efficacy. Collaboration.
Similarities Between AI and MI ♣ Mindset ♣ Framework ♣ An inspirational way of being with people ♣ Preserve client autonomy ♣ Utilize collaborative partnerships
What is the impact of negative emotions on brain learning?
Physical disease/illness and mental/emotional illness
