Motivational Interviewing & Goal Attainment Scaling - CogComm

What is motivational interviewing (MI)?

"a directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence"

You want to elicit "change-talk" from them, that means they're going to initiate behavior change

Strategies: OARS - What is its purpose?

"to ask clients to share their concerns, listen to how they respond and help them discover what will make their lives better"

What does OARS stand for?

Open ended questions

Affirmations

Reflections

Summaries

Why is MI necessary?

- When client's functional abilities don't change, the lack of progress may be due to a lack of motivation

- BUT sometimes the px hasn't had time to think about what they want to change and set goals for themselves

- Very few clients are not motivated; our interactions can influence their desire to change

What does MI entail?

- Therapy is collaborative!

- Clinician becomes their partner/coach

--> Help them find functional goals

- Shared decision-making, but the ultimate decision falls on the client

What is an important part of collaboration?

Acceptance

- client's autonomy is respected; they explore therapeutic options

- client's responsibility to select and implement strategies

- clinician guides in an empathetic, compassionate and non-judgemental manner on how to make changes that will translate to functional goals

- client will ultimately decide what to do

What is the compassion part of collaboration?

Place the best interests and welfare of the client before your own

What is the evocation part of collaboration?

- Based on idea that client has the resources to achieve his or her goals and the clinician is there to help him or her "find" them

- Conversations during counseling evoke change talk from the client

- Change talk will ideally lead (slowly and delicately) to talk about engagement in actions that facilitate change

What is change-talk?

These are statements about desire, reasons or need for change

What is the principle in MI of RULE?

R: Resist the righting reflex

U: Understand the clients motivations

L: Listen to your client

E: Empower the client

What is resisting the righting reflex?

- Therapy is a partnership and client/clinician communicate on a peer level

--> Don't be patronizing or condescending

- RESIST the tendency to correct the client's self-selected approach to improving

- With TBI, client may need to undergo the process of trial and error with strategies

--> So they realize that they may not be functioning at their pre-injury level (unless it's driving or something that could impact or harm others if they do)

What is understanding the client's motivation?

- What motivates your specific client to change/not change?

--> Work, parenting, school, socializing

- Understand their own concerns and values and what the keys to motivating change might be

--> ex: A special relationship or experience they might want to work towards

What do we want to find out in conversations when understanding their motivation?

1) what clients want to change

2) why they want to change

3) how they might best go about to effect that change

What should we be doing with our client?

LISTENING

- Signals respect, empathy and a caring attitude

- This will help channel the client's desire for change into an effective therapy plan

How do we empower our client?

- Clients must ALWAYS know they have the freedom to choose the course of therapy and that the clinician will not tell them what to do

- If you need to educate the client, first ask for permission to share the information rather than taking a directive approach

What are our tools for interview?

1. Asking

2. Listening

3. Evoke change

What are broad open-ended questions we can ask?

For those who don't need help elaborating!

What would you like to be doing that you aren't doing right now?

How can I help you do you think?

What do you want to happen?*

Why might you want to make a change to improve your ability to concentrate/ remember?*

What are the advantages/benefits of not changing?*

What are the disadvantages/costs of not changing or staying where you are?*

What are specific open-ended questions we can ask?

Use for those who don't talk as much!

What happens when you read?

What happens at work?

What could you do to ___________?

What have you done before to __________?

If you were able to _________ better, how would things be different for you?

Why would you want to ____________?

What are you doing right now to ________?

What are negative questions we shouldn't ask?

Why aren't you __________?

Why don't you do____?

What is the reflection part of listening?

- Reflections are not questions; they are statements relevant to what the client has said. Reflections let the client know that you are listening and hearing what they are saying

- If the clinician's hypothesis is correct, it furthers the discussion in ways that reveal what most concerns the client. If the clinician's hypothesis is wrong, the client is free to say so and hopefully elaborate on why it's wrong, providing additional information

Slide 18 - example of a reflection discourse about homework

What are summaries?

- They are used to gather and connect related information within the interview. Summaries convey to clients that the clinician has been listening and understanding what they have said.

- More importantly, summaries can be used to highlight and focus specific information that can set the stage for informing clients about available strategies and developing specific goals associated with the strategies they select

Slide 19 - example of a summary

Clinician relays generally what the client said after a long conversation

What is the evoking change part?

- Once the client has expressed readiness and commitment to a specific change, then you will move to the planning/action stage of treatment

- The goal setting and goal attainment literature suggests that outcomes are better when the client participates in goal planning.

--> A study found that those who participated in formulating task strategies performed significantly better and had higher self-efficacy than those who did not

Goal Attainment Scaling

-2 most unfavorable

-1 less than expected

0 expected outcome

+1 more than expected

+2 most favorable

What is the primary advantage of GAS?

being able to scale and measure progress on individualized goals that are important and meaningful to the client

What was GAS originally proposed for?

- to evaluate mental health programs

- a collaborative process that allows clinicians to develop and monitor progress on individualized goals, that are personally relevant to the client

What type of measure is GAS?

- a criterion-referenced measure

- GAS serves as an evaluative assessment, allowing clinicians to measure longitudinal change in an individual

What does GAS allow clinicians and clients to do?

clearly define a range of most to least favored outcomes

Because GAS is client-centric, GAS allows clinicians to do what?

embrace the diversity in patient needs and accommodate differences in performance

--> as opposed to global measures of disability that serve as a "population-centric" measure and fail to reflect the heterogeneity in patient characteristics

What is the validity of GAS?

VALIDITY: The responsiveness of GAS has been compared to standardized measures such as the Functional Independence Measure, Barthel Index and Instrumental Activities of Daily Living, and has been found to be a more responsive measure of functional improvement in the rural, geriatric population

It is also responsive to clinically important change in patients undergoing cognitive rehabilitation and was more responsive compared to other criterion-referenced measures such as the Cognitive-Linguistic Quick Test

What is the reliability of GAS?

The inter-rater reliability of follow-up GAS scores has been found to be particularly high when GAS was utilized as an outcome measure in rehabilitation settings with adults

The test-retest reliability has not been extensively studied, however, there has been a study that supports this reliability for GAS with persons undergoing neurological rehabilitation

What are the components of GAS?

Planning

Monitoring

Evaluation

What is the planning component of GAS?

Goal setting and identification of levels of goal attainment

Selecting treatment approach

What is the monitoring component of GAS?

Evaluate progress

Adjust intervention

What is the evaluation component of GAS?

Documenting outcome

Determining intervention effectiveness

How should the levels of GAS look?

- Measurable and quantifiable (timeframe for target behavior)

- Roughly equidistant

- Should be discrete

The GAS functional domain should be meaningful to the patient

The GAS functional domain should be directly related to the type of therapy approach and/or cognitive domain being provided

What can we do as clinicians to help clients?

Be the voice of reason!

We can help them be calm and reduce anxiety by pointing out what is actually going well and that everything's not on fire