550111 Sect D E · Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency 3. Premature Focus Trap. When a counselor persists in talking about her own conception

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SECTION E: SupervisoryTeaching Tools

Topic Page

1. MI Style and Traps ......................................... 59

2. MI Assessment Sandwich ............................... 61

3. MI Principles ................................................. 62

4. Using Your OARs .......................................... 64

5. Stages of Change ............................................ 66

6. Reflections ..................................................... 68

7. Exploring Ambivalence .................................. 70

8. Eliciting Change Talk ..................................... 72

9. Assessing Readiness to Change ....................... 73

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58 Section E: Supervisory Teaching Tools

MIA:STEP Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency

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Section E: Supervisory Teaching Tools 59

Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency MIA:STEP

MI STYLE AND TRAPS

Motivational Interviewing is not a techniquebut rather a style, a facilitative way of beingwith people. MI is a client-centered,

empathetic and yet directive interaction designed toexplore and reduce inherent ambivalence andresistance, and to encourage self-motivation forpositive change in people presenting for substanceabuse treatment.

COLLABORATION - MI requires that the therapistrelate to the client in a non-judgmental,collaborative manner. The client’s experience andpersonal perspectives provide the context withinwhich change is facilitated rather than coerced.

EVOCATION - The interviewer’s tone is not one ofimparting wisdom, insight or reality, but rather ofeliciting the client’s internal viewpoint. Thecounselor draws out ideas, feelings, and wantsfrom the client. Drawing out motivation, findingintrinsic motivation for change and bringing it tothe surface for discussion is the essence of MI.

AUTONOMY - Responsibility for change is lefttotally with the client. Individual autonomy isrespected. MI style communicates safety andsupport, first through an absence of confrontationor persuasion and second, by acceptance of theclient.

ROLL WITH RESISTANCE - Opposing resistancegenerally reinforces it. Resistance, however, can beturned or reframed slightly to create a newmomentum toward change. The interviewer doesnot directly oppose resistance, but rather rolls andflows with it. Reluctance and ambivalence are notopposed but are acknowledged to be natural andunderstandable. The interviewer does not imposenew views or goals, but invites the client toconsider new information and offers newperspectives.

The interviewer does not feel obliged to answer aclient’s objection or resistance. In MI, theinterviewer commonly turns a question orproblem back to the person, and relies on theclient’s personal resources to find solutions to his/her own issues. Rolling with resistance includesinvolving the person actively in the process ofproblem solving. Resistance is a signal for theinterviewer to shift approach. How theinterviewer responds will influence whetherresistance increases or diminishes.

TRAPS - MI interviewers have discovered anumber of “traps” which prevent full use of MIstyle in working with substance abuse clients.Here are a few of the most common traps intowhich counselors can fall.

1. Question-Answer Trap. Setting theexpectation that the therapist will askquestions and the client will then answer,fosters client passivity. This trap can getsprung inadvertently when you ask manyspecific questions related to filling out formsearly in treatment. Consider having clients fillout questionnaires in advance, or wait untilthe end of the session to obtain the details youneed. Asking open-ended questions, lettingthe client talk, and using reflective listeningare several ways to avoid this trap.

2. Labeling Trap. Diagnostic and other labelsrepresent a common obstacle to change. Thereis no persuasive reason to use labels, andpositive change is not dependent uponacceptance of a diagnostic label. It is often bestto avoid “problem” labels, or refocus attention.For example, “Labels are not important. Youare important, and I’d like to hear moreabout…”

TeachingTool No. 1

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3. Premature Focus Trap. When a counselorpersists in talking about her own conceptionof “the problem” and the client has differentconcerns, the counselor gets trapped and losestouch with the client. The client becomesdefensive and engages in a struggle to beunderstood. To avoid getting trapped startwith the client’s concern, rather than yourown assessment of the problem. Later on, theclient’s concern may lead to your originaljudgment about the situation.

4. Taking Sides Trap. When you detect someinformation indicating the presence of aproblem and begin to tell the client abouthow serious it is and what to do about it, youhave taken sides. This may elicit oppositional“no problem here” arguments from the client.As you argue your view, the client may defendthe other side. In this situation you canliterally talk the client out of changing. Youwill want to avoid taking sides.

5. Blaming Trap. Some clients showdefensiveness by blaming others for theirsituation. It is useful to diffuse blaming byexplaining that the placing of blame is not apurpose of counseling. Using reflectivelistening and reframing, you might say, “Whois to blame is not as important as what yourconcerns are about the situation.”

6. Expert Trap. When you give the impressionthat you have all the answers, you draw theclient into a passive role. In MI the client isthe expert about his/her situation, values,goals, concerns, and skills. In MI stylecounseling you seek collaboration and giveyour clients the opportunity to explore andresolve ambivalence for themselves.

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MI ASSESSMENT SANDWICH

The MI Assessment protocol can beconceptualized as an “MI sandwich” in whicha more structured standard assessment process

(completion or review of completed instruments) issandwiched in-between two client-centered MIinterventions. This is designed as a single session thatstarts with a MI discussion using OARS (Step 1), thengently shifts to a more formalized assessment or reviewof already completed assessment instruments (Step 2),and then moves back to an MI discussion of change(Step 3).

MI ASSESSMENT “SANDWICH” CONCEPT:

STEP 1: Top of the MI sandwich involvesbuilding rapport and using the OARS micro-skills to elicit a discussion of the client’sperception of his/her problems. During thisstep, the counselor is likely to get an idea of theclient’s initial readiness for change and the kindsof resistance may emerge.

STEP 2: Middle of the MI sandwich involveseither some form of psychosocial assessment(ASI or standard clinic assessment) or the reviewof assessments already completed which can thenbe used to facilitate a feedback discussion of theeffects of substance use on different areas of theclient’s functioning. During the interview thecounselor will acquire more information aboutthe client’s concerns and what he/she wants fromtreatment. When finished, the counselor cansummarize the information obtained from the

instrument or go back to specific items to elicitfurther discussion using an MI style beforeproceeding to Step 3.

STEP 3: Bottom portion of sandwich focuseson strategies for eliciting change or managingresistance. The goal of Step 3 will depend verymuch on the readiness level of the client in termsof his or her perceived importance of the changeand confidence in being able to make a change.The ultimate goal is to develop a “change plan.”

Note to Supervisors and Mentors: You mayintroduce any portion of the “MI sandwich” in thementoring process. The idea is that you may want tostart by reviewing the initial portion (step 1) to assessand provide guidance on skill building with MI microskills, such as OARS, before moving on to the higherskill (step 3) of bringing together information toestablish a change plan. For more detailedinformation, see the more detailed description of theMI Assessment protocol.

TeachingTool No. 2

MI strategies during opening 20 mins

Agency intake assessment

MI strategies during closing 20 mins

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TeachingTool No. 3TeachingTool No. 3MI PRINCIPLES

In MI you provide low-key feedback, roll withresistance (e.g., avoiding arguments, shiftingfocus), and use a supportive, warm, non-

judgmental, collaborative approach. You conveyempathic sensitivity through words and tone of voice,and you demonstrate genuine concern and anawareness of the client’s experiences. You follow theclient’s lead in the discussion instead of structuringthe discussion according to your agenda. Fourprinciples paint the “big picture” of MI and underlieall aspects of the approach:

Express EmpathyDevelop DiscrepancyRoll with ResistanceSupport Self-Efficacy

One way to remember the principles is with thealliteration: EE – DD – RR – SS.

EXPRESS EMPATHY. Empathy has been called thedefining principle of MI. Empathy is a term looselyused in therapy circles, but what does it really mean?One definition (Webster’s) is: the capacity forparticipation in another’s feelings or ideas. Another wayof thinking about empathy comes from Carl Rogers whopopularized the term as one of the three essential pillarsof client-centered therapy. Empathy means acceptanceand understanding another’s perspective and feelingsneutrally, without judging or evaluating in any way.Neutrality is key because acceptance does not necessarilymean approval or agreement. Typically, the word“listening” is associated with empathy, because one hasto truly listen and hear another in order to be able tounderstand, accept, and empathize with him. Usingreflective listening and forming reflections are ways toconvey empathy using MI. For more information, seeReflections (Supervisory Tool No. 6) later in this section.

DEVELOP DISCREPANCY. Developing discrepancy iswhere MI departs from a straight client-centered orhumanistic approach because it is specificallydirective. The discrepancy a MI counselor wants to

build is that between the ways things currently areand the way a person would like things to be. One ofthe purposes of using an MI approach is to help aperson get “unstuck” from their ambivalent feelingsthat keeps them in the same behavior patterns. Bydeveloping the discrepancy between where a person isnow in their life and where s/he wants to be, thecounselor is helping the client determine howimportant a change could be. Ideally, a client will bemotivated by the perceived discrepancy between herpresent behavior and important goals or values that s/he holds.

Typically, it is most helpful if the client talks about thereasons for change rather than the counselor doing thetalking. Part of developing discrepancy is elicitingstatements from clients about the importance ofattaining future goals or making changes to the statusquo. When a current behavior is in conflict withoverall life goals such as being healthy, living aproductive existence, and providing for one’s family,focusing on the discrepancy can provide motivationfor change.

Although the number of ways to develop discrepancywith a client is probably only limited by one’screativity, some common methods used in MI are the“Decisional Balance” activity (in which the Pros/Consof current behavior and the Pros/Cons of changing arelisted by the client) and values clarification exercises.See Exploring Ambivalence (Supervisory Tool No. 7)later in this section for more information.

ROLL WITH RESISTANCE. Arguing for change with aclient will likely trigger the client to argue against it,which the counselor may feel (or think of ) as“resistance.” In MI, “resistance” is thought of as asignal, a red light, and a time to do something else.When you feel what has traditionally been calledresistance – the client sounds uninterested in orunmotivated or unprepared for change – in MI terms,you “roll” with it. Rolling means getting out of theway of resistance and not engaging it. A metaphor

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from Jay Haley and the strategic family therapists isfrequently borrowed to explain rolling with resistanceas “psychological judo.” In the martial art of judo, anattack by another is not met with direct opposition,but rather with using the attacker’s momentum toone’s own advantage. Instead of fighting against theattacker, one “rolls” with the other’s momentum orenergy and, in effect, gets out of harm’s way asresistance is reduced. For specific rolling strategies,see Rolling with Resistance (Supervisory Tool No. 10).

SUPPORT SELF-EFFICACY. Self-efficacy is a termpopularized by Albert Bandura in the 1980’s as acornerstone of his Social Learning Theory. It means aperson’s belief in his or her ability to carry out aspecific act or behavior. It is similar to self confidencebut is more specific and tied to a particular activity orbehavior. Self-efficacy is critical in MI because itreflects the “can do” or “can’t do” attitude that canmake or break an effort for change. If one feels thatmaking a change is very important but has no idea ofhow to go about making the change, one’s low self-efficacy for making the change is likely to jeopardizethe change attempt. One way to assess self-efficacy isby using the simple ruler described in AssessingReadiness for Change (Supervisory Tool No. 9).Instead of asking clients how ready they are to make achange, ask how confident they are on a scale of oneto 10 to make the specific change under discussion.

The “supporting” part of this principle refers in part tothe power of expectations. When a counselor believesin a client, and is able to convey this, the client is likelyto have more belief in his or her ability to make thechange. It works as a self-fulfilling prophecy. An MIcounselor supports and enhances a client’s belief insucceeding at making a change. It is not up to thecounselor to make the decision for change, but rather itis the client who is responsible for making and carryingout a decision. The counselor helps provide a contextconducive to change.

Another strategy for enhancing self-efficacy is toexplore a client’s past successes (around this behavioror other behaviors). The counselor encourages theclient to apply what worked to the current situation.For example, if a client has given up anothersubstance such as nicotine, a counselor can facilitate adiscussion around what steps the client took to besuccessful in changing that behavior. Another strategyis skill building. For example, if someone values usingcondoms but has low self-efficacy around negotiatingtheir use with her partner, working with her oncommunication and assertiveness strategies may buildher confidence in this behavior.

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USING YOUR OARS

Using OARS helps you navigate a client’sdiscussion through rapids of resistance andsteer your counseling into calmer waters of

change. Drs. William R. Miller and StephenRollnick, the developers of Motivational Interviewing,combined four basic MI methods to form theacronym, OARS. Using OARS can be especiallyhelpful early in the therapy process when firstbuilding rapport, and can be useful at other timesthroughout the course of counseling. Using OARSalso may help prevent rough waters or manageresistance. OARS stands for:

Open-ended questionsAffirmationsReflective listeningSummaries

Ask Open-Ended Questions: Asking open- versusclosed-ended questions helps clients get started talking.An open question is one that does not invite one-wordresponses but rather encourages the client to takecontrol of the direction of the reply, which can help theclient feel more safe and able to express oneself. Whena counselor starts off with several closed-ended ques-tions, it is likely to cause the client to answer in shortphrases and fall into a passive role waiting for thecounselor to ask for information. Instead, with open-ended questions, a counselor sets an interested, open,collaborative tone. A client is then likely to providemore information, explore issues of concern, and revealwhat is most important.

Open-ended examples:

What types of things would you like us to talkabout?How did you first get started drinking?What would change in your life if you stoppedusing?How do you think smoking pot is related to theproblems you talk about in your marriage?

Closed-ended examples not appropriate forcollaboration and inconsistent with MI:

Don’t you think your wife and kids have beenhurt enough by your using?Isn’t your friend’s idea that you should quit usingreally a good one?Have you ever thought about taking the stairsinstead of waiting in frustration for an elevator totake you up three floors?

Closed-ended examples which are relatively neutral:

Are there good things about your drug use?How long have you been concerned about yourdrug use?

Affirm the Client: In MI, affirmations are genuine,direct statements of support during the counselingsessions that are usually directed at something specificand change oriented that the client has done. Thesestatements demonstrate that the counselorunderstands and appreciates at least part of what theclient is dealing with and is supportive of the client asa person. For example:

I appreciate your honesty (if you know she isbeing honest).I can see that caring for your children is importantto you.It shows commitment to come back to therapy.You have good ideas.

The point of affirmations is to notice andacknowledge client effort and strength.

Listen Reflectively: Listening reflectively andforming reflections is one way to be empathic.Listening reflectively is about being quiet and activelylistening to the client, and then responding with astatement that reflects the essence of what the clientsaid, or what you think the client meant. SeePracticing Reflections Handout.

TeachingTool No. 3TeachingTool No. 4

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Provide Summaries: Summaries serve severalpurposes:

1. Communicate that you have tracked what theclient said and that you have an understanding ofthe big picture.

2. Help structure a session so that neither client norcounselor gets too far away from important issuesand can help you link what a client just said tosomething he offered earlier.3. Provide an opportunity to emphasize certain

elements of what the client has said. Forexample, providing summaries of the positivestatements a client has made about change(change talk) gives the client anotheropportunity to hear what she or he has said inthe context provided by the counselor.Summaries represent change talk statements

(statements that people make that are in thedirection of change) linked together bycounselor reflection. After several minutes ofusing OARS, a summary could serve as acheck to see if the counselor is “getting” whatthe client is trying to relay. For example:“So Sally, let me make sure I have got hisright. You care about your children verymuch, and you don’t want to chance havingsocial services intervene. You believe you needto change your relationships that involveusing, and aren’t quite sure how to do that. Isthat it?” Another possible ending may besaying “What else would you add?” Theclient will correct you if you are wrong andthen you could reflect back to affirm you arelistening and you got it.

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STAGES OF CHANGE

Researchers have found that people tend to gothrough a similar process when they makechanges and that this process can be

conceptualized in a series of steps or stages. TheStages of Change model, part of the TranstheoreticalModel of Change (Prochaska & DiClemente, 1984),depicts this process that people go through when theysuccessfully make changes in their lives. Because it isa model of how people change instead of a theory ofpsychopathology, it allows counselors with widelydiffering theoretical orientations to share a commonperspective.

BRIEF DEFINITIONS OF EACH STAGE OF

CHANGE

BASIC STAGE DEFINITION

1. PRECONTEMPLATION A person is not seeing aneed for a lifestyle orbehavior change

2. CONTEMPLATION A person is consideringmaking a change but hasnot decided yet

3. PREPARATION A person has decided tomake changes and isconsidering how to makethem

4 ACTION A person is actively doingsomething to change

5. MAINTENANCE A person is working tomaintain the change ornew lifestyle, possibly withsome temptations toreturn to the formerbehavior or small lapses.


MI and stages of change are complimentary when inthe context of understanding change. MI is used tohelp people change. Embedded in the spirit of MI isthe need to meet clients/supervisees where they are.The stages of change help to identify where a personis in the change process. A counselor will usedifferent MI strategies with clients in different stagesto assist them in moving toward change.

PRECONTEMPLATION

This graphic represents the stages as a circular wheelversus a linear stair-step model. The Stages of Changeare dynamic—a person may move through them onceor recycle through them several times before reachingsuccess and maintaining a behavior change over time.In addition, individuals may move back and forthbetween stages on any single issue or maysimultaneously be in different stages of changefor two or more behaviors.

ACTION

PREPARATION

CONTEMPLATION

MAINTENANCE

RELAPSE &RECYCLE

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KEY POINTS ABOUT THE USE OF MI WITH CLIENTS INTHE EARLY STAGES OF CHANGE:

Precontemplation and Contemplation:Application of MI in precontemplation is aresponse to resistance.The counselor follows the clients lead.The counselor stays with the client in whateverstage of change s/he might be in.Examples work well in the early stages asconcrete thinking may prevail.Estimates put 80% of people in eithercontemplation or precontemplation.

KEY POINTS ABOUT THE USE OF MI IN LATER STAGES

OF CHANGE:

Preparation, Action and Maintenance:Motivation to continue the change processfluctuates, as does ambivalenceMI is used to facilitate change talk in thepreparation, action and maintenance stages.MI is woven throughout the skill buildingprocess in order to maintain the client’s readinessto change.MI is used as clients transition through the stagesand embark on changing other addictivebehaviors.

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REFLECTIONS

REFLECTIVE LISTENING is listening respectfullyand actively to genuinely understand what theclient is trying to say. You can demonstrate

that you hear and understand another person bymaking REFLECTIVE STATEMENTS OR “REFLECTIONS.”Empathy can be felt when one is listened to reflectivelyand hears reflections.

The first step in using reflective listening is tolisten carefully and think reflectively. The key todoing this is to think in terms of hypotheses. Thismeans that when you hear someone say some-thing, you form a hypothesis or a best guess aboutwhat the client means.The second step is the action that results fromthe listening: forming reflections. You try outyour guess by reflecting back what you think youheard. It is like asking, “Do you mean….?”without putting your words in question form.

This requires differentiating a statement from aquestion. While asking questions has a large role intherapy, it is de-emphasized in reflective listeningand forming reflections. This means your voicegoes down at the end of the statement rather thanup as it would in a question. Think about thephrase: “You’re angry at your mother.” Say it outloud both ways: “You’re angry at your mother?”(voice up at the end as in a question), then “You’reangry at your mother.” (voice down at the end asin a statement). Consider the slight difference intone and meaning. It may feel odd to form astatement rather than a question when you arelistening to someone and want to try out a hypoth-esis. However, reflective statements work betterthan questions in conveying empathy and increasehow much a client talks. A question begs a re-sponse. When a client feels the need to answer aquestion, it has a slight distancing effect. A state-ment does not require a response. The speaker cango right on with his or her speech or can simply sitand think about what they have just had reflectedto them. Reflections can be used strategically toemphasize aspects of the client’s view, emotion,ambivalence, and change talk. When using a

reflection, the counselor is trying to get at what theperson means and reflect back. The client viewsthe counselor as listening carefully and empathic.

LEVEL OF REFLECTIONS

1. Repeating – The first or closest to the surface levelof reflection is simply repeating what someone hasjust said.

2. Rephrasing –The next level of reflection is to rephrasewhat a person has just said with a few word substitu-tions that may slightly change the emphasis.

3. Paraphrasing – Here you make a fairly major restate-ment of what the person has said. This typicallyinvolves the listener inferring the meaning of what wassaid and stating that back to the listener. It can bethought of as stating the next sentence the speaker islikely to say. This is not the same as finishingsomeone’s sentence.

4. Reflecting feeling – This is a special kind of paraphraseas it achieves the deepest level of reflection because youare not necessarily reflecting content, but the feeling oremotion underneath what the person is saying.

Typically, simpler reflections are used earlier in a meetingwith someone, and deeper reflections are tried as thecounselor gets a better understanding of the client’sperspective and feelings. Increasing the depth of thereflection is a sign of increasing proficiency.

TYPES OF REFLECTIVE STATEMENTS

1. Simple Reflection. This is the most basic acknow-ledgement of what a person has just said. It isrestating what the client said without addinganything additional. Sometimes, through use of asubtle change in words, a simple reflection canaccomplish a shift in emphasis.

CLIENT: She is driving me crazy trying to get meto quit.

COUNSELOR: Her methods are really bothering you.

CLIENT: I don’t have anything to say.

COUNSELOR: You’re not feeling talkative today.


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2. Amplified Reflection. With this type ofreflection, you reflect back what the person saidin a slightly amplified or exaggerated form.CAUTION: make sure to do it genuinelybecause any hint of sarcasm may elicit an angryreaction and be perceived as unempathic. Often,the amplified reflection will cause the client toclarify or elaborate on an important aspect ofwhat was said, especially when what wasamplified revealed resistance.

CLIENT: All my friends smoke weed and I don’tsee myself giving it up.

COUNSELOR: So, you’re likely to keep smokingforever.

A possible reaction might be: Well, no, I dothink I’ll give it up when I have a family. (Startsthe client thinking in the opposite direction)

CLIENT: I don’t know why everybody is makingsuch a big deal over my drinking. I don’t drinkthat much.

COUNSELOR: There’s no reason for any concern.A possible reaction might be: Well, sometimes Ido take it a little too far.

3. Double-Sided Reflection. The intent of adouble-sided reflection is to convey empathy.These statements are meant to capture both sidesof a person’s ambivalence. In using these, youcan reflect back both the pros and cons ofchange that the client has said or at least hinted.Typically, the two sides are joined by the phrase,“on the other hand.” Double-sided reflectionshave the bonus of summarizing as well asdemonstrating that you heard the client andprovide the opportunity to bring togetherdiscrepant statements.

CLIENT: It would stink to have to lose my jobover a dumb policy because I’ve been using, butno way do I want to quit partying just becausethat’s hanging over my head.

COUNSELOR: On the one hand, you value yourjob because it allows you to live comfortably, buton the other hand, you also enjoy using drugswith friends.

CLIENT: It would be so hard to stick to aworkout plan.

COUNSELOR: On the one hand, trying to stickto a specific workout plan seems daunting and,on the other hand, you think your self-esteemwould improve if you lost weight (second partwas heard earlier in the session).

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EXPLORING AMBIVALENCE

A key assumption in MI is that people do notusually come to therapy ready for change.This does not mean they do not want to

change but rather that they feel two ways about it: theywant to change and they want things to stay the same.Staying the same often represents comfort, familiarity,and certain pleasures. The reasons for change need to bestronger than the reasons for staying the same in order to“tip the balance” for change.

Pretend that the circle below represents ambivalence. Oneway of viewing it is that each side represents one way ofthinking about change. The left side represents the part ofa person that doesn’t want to change. The right siderepresents the part of a person that does want to change.

change; the stronger an ambivalent client will defend theopposing point or the argument not to change.INSTEAD, in MI it is important for the counselor to“come along side” the part of the person that doesn’t wantto change and join with or help protect that side of aperson’s ambivalence. However, it is imperative that theclient be given the freedom to talk about the side thatdoesn’t want to change.

For example: Tony said he loves smoking pot with hisfriends and would hate to give it up. He considers his usepart of his lifestyle. On the other hand, he is worried abouthis job. He has a good job that he likes with a strict drugtesting policy. If you encourage Tony to quit because heneeds to keep this job and it could be in jeopardy if hecontinues to use, he is likely to tell you all the reasons whyhe should continue to smoke pot. In contrast, if youexplore the status quo and acknowledge how much heenjoys smoking pot, he receives the message that you arelistening and are not rushing to change him. You learnmore about the thoughts and feelings that underlie hismarijuana use, which are strong forces in maintaining thebehavior. You have signaled that you are concerned withexploring his whole person. After talking about stayingthe same, he will feel the itch to talking about the otherhalf of the story, the reasons he wants to quit.

Ambivalence is not always a circle cut exactly in half. Forsomeone in precontemplation (who is not consideringchange), the part that doesn’t want to change might bemuch larger than the part that does want to change.However, both parts are still represented. At times, such aswhen a person is moving through the stages of change, theside that wants to change may get bigger and bigger. Itmay also shrink down again. This can happen fromsession to session or even minute to minute. The mostimportant point about ambivalence is that having it isnormal and fluctuation is normal.

DECISIONAL BALANCE

In MI, success in treatment is largely determined by theability of the counselor to help the client explore andresolve his or her ambivalence in favor of change.


What is likely to happen when you push orargue with the part of a client that wants tochange, encouraging him to change the behaviorand pointing out all the reasons for change?

Typically, the client will feel compelled to talk aboutthe other side—the side that does not want tochange.

WHY IS AMBIVALENCE COMMON?

This phenomenon happens because the client feels twoways about change. When trying to be convinced of allthe reasons to make a change, a client feels the need topresent the other side of the story because it is asimportant as the side being reflected by the counselor.The stronger the counselor argues his or her point for

PRO’S CON’S

+’S –‘SGOOD NOT SO

THINGS GOOD

THINGS

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A tool that can help a client explore and resolveambivalence is the Decisional Balance or Pro’s and Con’sworksheet. It is used as a means of exploring the good andnot-so-good things about the behavior in question. Ifused during a session, the counselor can facilitate theprocess by eliciting client responses. The responses wouldcorrespond with each of the four quadrants representingdiffering aspects of changing the behavior or making achange.

The counselor may use the decisional balance a numberof ways: as a homework assignment, as an activityduring the session, or as a virtual worksheet where thequadrants are filled in verbally. The counselor can askthe client to:

List all the good things about the current behavior.List all the not-so-good things about the behavior.List what would be good about changing.List what would not be so good about changing.

If the client fills out the worksheet as homework, it can bereviewed at the next session. It is important to review eachquadrant and explore the reasons behind each listing,eliciting the client’s thoughts and feelings about each item.Often the counselor needs to prompt client for the goodthings about the behavior. After discussing each quadrant,a counselor summarizes responses to the activity as a wholeand asks the client for any changes or additions. A wealthof information about the motivators of the behavior, thereasons for wanting to change the behavior and thebarriers to quitting are often revealed with this exercise.

DECISIONAL BALANCE WORKSHEET

(Fill in what you are considering changing)

Good things about behavior: Good things about changing behavior:

Not so good things about behavior: Not so good things about changing behavior:

Important to remember: The counselor does not suggest items that the client should put in quadrants,but instead lets the client determine from his or her perspective the pertinent issues.

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ELICITING CHANGE TALK

Eliciting change talk, or self motivationalstatements, is a crucial component andprimary goal when using a MI approach. It

differs from OARS in that it is more directive. UsingOARS will help keep you afloat and may help steer youin directions you and the client want to go, but it maynot get you to the final destination. Eliciting change talkis a strategy to help establish and resolve ambivalence andmove forward.

Change talk is the client making statements that are infavor of change, which suggests that the client is becomingmore ready, willing, and able to make a change. However,although a counselor may want to hear change talk, an MIcounselor avoids imposing it. The goal is to elicit it fromthe client in a collaborative fashion. Eliciting change talkhas to come about through a consensual, negotiatedprocess between the counselor and client.

Change talk can occur in several forms that make up theacronym DARN C.

D = Desire statements. Statements indicating a desireto make a change.

“I’d like to quit drinking if I could.”“I wish I could make my life better.”“I want to take better care of my kids.”“Getting in shape would make me feel so much betterabout myself.”

A = Ability statements. Statements that speak to theclient’s self-efficacy or belief in the ability to makechanges.

“I think I could do that.”“That might be possible.”“I’m thinking I might be able to cut back on cigarettes.”“If I just had someone to help me, I could probablyquit using.”

R = Reasons statements. Statements that reflect thereasons the client gives for considering a change.

“I have to quit smoking because of my asthma.”

“To keep my truck driving license, I should probablycut down on my drinking.”“My husband may leave me if I keep using.”“I don’t like my kids to see me like this.”

N = Need statements. Statements that indicate a needfor change. These can be similar to R statements, butthe emphasis is more affective or emotional than amore cognitive R statement.

“It’s really important to my health to change my diet.”“Something has to change or my marriage will break.”“I’ll die if I keep using like this.”

These DARN statements are important to recognizeand then emphasize through reflecting or directing theclient to further elaboration. These statements areavenues to the most important part of change talk, the“C” in the DARN C, Commitment language.Commitment language is the strength of change talk.For example, a person could say, “I might change”, or “Icould consider changing”, or “I’m planning to change”or “I will change”. The last two examples representauthentic commitment. The strength of the verb in thesentence corresponds with the strength of thecommitment language. An important counselor skill isaddressing client commitment to change over thecourse of the interview by recognizing and respondingto change talk. The goal is a strengthening of thecommitment level.

Amrhein and Miller (2003), a linguist and a psychologistrespectively, have shown that while all elements of changetalk can be important in building commitment language, itis the stronger commitment statements that predictpositive behavior outcomes. In other words, the more aclient is making strong commitment statements like “I willdo this” and “I am going to do that,” the more likely theclient’s behavior is going to change.

For more information about change talkand how to recognize it, see EnhancingMotivation for Change In SubstanceAbuse Treatment(CSAT TIP 35, 1998)


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ASSESSING READINESS TO

CHANGE

Readiness, or being ready to make a change, canbe thought of as a function of the relationshipbetween how important it is for a person to

make a change (how much the client values thechange) and how confident the person is in theirability to make the change.

Readiness is critical in the Stages of Change (Prochaska &DiClemente, 1992). Each stage in the model represents adifferent level of readiness to make a change. A fourth wayto assess readiness is to determine which stage a client is inregarding a specific behavior. Even within a stage, therecan be variation in readiness over time.

Readiness is voiced through self-motivating statementsor expressed reasons for change are forms of “ChangeTalk” and convey the strength of a commitment a clienthas to changing behaviors. A counselor using MIwants to draw change talk from the client.

Some statements will convey a high degree ofreadiness:

“I’ve decided that I’m going to stop smokingtoday.”

Others convey only a thread of readiness:“Someday I might want to cut back on mydrinking.”

Many statements are more in the middle:“I might be interested in quitting if I thought Icould do it.”

Importance, confidence and readiness can be assesseda number of ways:

Through a basic scaling ruler—either on paperor verballyThrough the clinical interview—listening forclues about readiness

Through specific inventories designed tomeasure readiness

1. READINESS RULERS- IMPORTANCE AND

CONFIDENCE. One simple assessment tool forassessing where the client is on differentdimensions of readiness is a two-part scaling ruler.

You can ask a client: “On the following line,make a mark at the point that best reflects howimportant it is to you to change behavior:”

... 1 ... 2 ... 3 ... 4 ... 5 ... 6 ...7 ...8 ...9 ... 10

Not at all Veryimportant important

Next, you can ask: “On the following line, make amark at the point that best reflects how confident youare that you can change behavior:”

... 1 ... 2 ... 3 ... 4 ... 5 ... 6 ...7 ...8 ...9 ... 10

Not at all Veryconfident confident

Another option: You can use the readiness ruler exerciseby verbally asking for a number between 0 and 10without using the printed ruler.

Follow-up questions:

Once the client gives you a “number,” you can follow-up my asking:

“You picked a 7, why not a 3?”Why wasn’t it a lower score?”

TeachingTool No. 9

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While this allows for the counselor to elicit changetalk, the client will impart his or her DARN (Desire,Ability, Reasons, Need) for change.

2. KEY QUESTIONS ON READINESS for use during aclinical interview session. The client’s responsewill help you gauge readiness. Responses mayinvolve change talk. Simply hearing oneselfmake such statements may help move the clientfurther along in the direction of change.

“What do you think you will do?”“What does this mean about your (habit)?’“What do you think has to change?”“What are your options?’“What’s the next step for you?”“What would be some of the good thingsabout making a change?”“Where does this leave you?”

If the client shows readiness to develop a plan foraction, you can brainstorm with (not for) him orher.

Many possible courses of action exist: “Let’s lookat some of the options together.”

Patient’s ideas supplemented by things thatyou know have worked for others“You will be best judge of what works foryou. Which one suits you the best?”Convey optimism and willingness to re-examine the client’s overall readinessthrough importance and confidence.

Remember successes (support self-efficacy),especially if confidence is low.

“What made your most recent successfulattempt different from previous efforts?”“What previous skills can be built into anew plan?”Break the plan into components and askwhich one patient feels most confidentabout.

3. INVENTORIES TO ASSESS READINESS. TheURICA and SOCRATES are two instrumentsused to more formally assess readiness. There areothers. For more information on these, seeEnhancing Motivation for Change in SubstanceAbuse Treatment (CSAT TIP 35, 1998).

The URICA is the University of Rhode IslandChange Assessment Scale (McConnaughy, et al.,1989), which is also referred to as the Stages ofChange (SOC) scale. The original versioncontains 32 5-point Likert questions thatmeasure 4 stages: precontemplation,contemplation, action and maintenance.

The SOCRATES is the Stage of ChangeReadiness and Treatment Eagerness Scale (Miller& Tonigan, 1996). Readiness is factored intothree dimensions: “Recognition,”“Ambivalence,” and “Taking Steps.” Twoseparate scales use items targeted towardproblematic alcohol or drug use. Both long (39items) and short (19 items) scales are available.

Documents

550111 Sect D E · Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency 3. Premature Focus Trap. When a counselor persists in talking about her own conception