Motivational Interviewing

Mary Dugan, Ph.D., LCSW

Amanda Anderson

Shelly Evans &

Jennifer Bartlett

Marla Gamble

Objectives

MI Definitions Processes of MI OARS Change Talk Resistance Learning to use MI

MI: A way to talk about behavior change

Person-centered Directional method Enhances internal motivation for

change Explores and resolves ambivalence Empirically supported

Motivational Interviewing . .

. . . is a clinical method that overlaps humanistic and cognitive therapies

. . . is not behavior therapy although there is some use of reinforcement to elicit and shape client speech

. . . Has a strong focus on acceptance and commitment as interpersonal transactions

MI is an Evidence Based Practice

On the federal NREPP list Being vetted by American Psychological Association Strongest evidence in alcohol and drug abuse Good outcomes for alcohol, drugs, hypertension,

bulimia, and compliance in diabetes Support for smoking, physical activity, and adherence

with hyperlipidemia treatment AMIs (Adaptations of MI) were superior to placebo

controls and equal to active treatments. Noonan and Moyers (1997); Dunn (2003)

Broader than Behavior Change Decision – to make a choice

– Forgiveness, Leaving or staying

Attitude - to become a different person– To be more Compassionate, Assertive etc.

Resolution - Acceptance– Complicated grief

– Finding peace regarding a decision

– Tolerance for anxiety, uncertainty etc.

Three Essential Elements in any Definition of MI

1. MI is a particular kind of conversation about change (counseling, therapy, consultation, method of

communication)

2. MI is collaborative (person-centered, partnership, honors autonomy, not expert-recipient)

3. MI is evocative, seeks to call forth the person’s own motivation and commitment

DEFINITIONS OF MI

Three levels of definition (of increasing specificity)

1. A layperson’s definition

(What’s it for?)

2. A pragmatic practitioner’s definition (Why would I use it?)

3. A technical therapeutic definition

(How does it work?)

1. A layperson’s definition(What’s it for?)

Motivational interviewing is a collaborative conversation to

strengthen a person’s own motivation for and commitment to change

2. A pragmatic practitioner’s definition (Why would I use it?)

Motivational interviewing is a person-centered counseling method for

addressing the common problem of ambivalence about change

3. A technical therapeutic definition (How does it work?)

Motivational interviewing is a collaborative, goal-oriented method of communication with

particular attention to the language of change. It is designed to strengthen an individual’s

motivation for and movement toward a specific goal by eliciting and exploring the person’s own

arguments for change

Four Fundamental Processes in

MI

Relational Motivational Foundation Interviewing

1. Engaging

2. Focusing

3. Evoking

4. Planning

4 Fundamental Processes in MI

1. Engaging – The Relational Foundation

Person-centered style

Listen – understand dilemma and values

OARS core skills

Learn this first

4 Fundamental Processes in MI

1. Engaging – The Relational Foundation2. Focusing – Strategic Centering

Agenda settingFinding a focus

Information & advice

4 Fundamental Processes in MI

1. Engaging – The Relational Foundation

2. Focusing – Strategic Centering

3. Evoking – The Transition to MI

Selective eliciting

Selective responding

Selective summaries

4 Fundamental Processes in MI

1. Engaging – The Relational Foundation

2. Focusing – Strategic Centering

3. Evoking – The Transition to MI

4. Planning – The Bridge to Change

Replacing prior Phase I and Phase II

Negotiating a change plan

Consolidating commitment

Is it MI Yet?

Can it be MI without . . .

Engaging ?

Focusing ?

Evoking ?

Planning ?

NoNoNoYes

So it’s MI when . .

1. The communication style and spirit involve person-centered, empathic listening (Engage)

AND

2. There is a particular identified target for change that is the topic of conversation (Focus)

AND

3. The interviewer is evoking the person’s own motivations for change (Evoke)

The 4 processes are somewhat linear ... .

Engaging necessarily comes first Focusing (identifying a change goal) is a

prerequisite for Evoking Planning is logically a later step

Engage Focus Evoke Plan

. . . . and yet also recursive

Engaging skills (and re-engaging) continue throughout MI

Focusing is not a one-time event; re-focusing is needed, and focus may change

Evoking can begin very early “Testing the water” on planning may indicate a need

for more of the above

Four Foundational Processes

Planning

Evoking

Focusing

Engaging

Engaging – The Relational Foundation

Best Developed Process Person-centered style Listen – understand dilemma and values

MI SPIRIT

OARS core skills

Exercise

The “Spirit” of Motivational Interviewing

Collaboration Evocation Autonomy Compassion

The Underlying Spirit of MI

How do we help people solve problems?

Steve Rollnick (Sophia, Bulgaria 2007)

manage, prescribe, lead, tell, manage, prescribe, lead, tell, show the way, take charge of, show the way, take charge of, preside, govern, rule, have preside, govern, rule, have authority, exert authority, authority, exert authority, reign, take the reins, take reign, take the reins, take command, point towards; command, point towards; conduct, determine, steer one’s conduct, determine, steer one’s course, pull the stroke oar.course, pull the stroke oar.

DirectDirect

Go along with, allow, Go along with, allow, permit, be responsive, have permit, be responsive, have faith in, go after, attend, faith in, go after, attend, take in, shadow, take in, shadow, understand, observe.understand, observe.

FollowFollow

A widespread dichotomyDirectDirect

Manage Manage PrescribPrescribeeLead Lead TellTell

FollowFollowPermitPermitLet beLet beAllowAllowGo alongGo along

Enlighten, shepherd, Enlighten, shepherd, encourage, motivate, encourage, motivate, support, lay before, look support, lay before, look after, support, take along, after, support, take along, accompany, awaken, accompany, awaken, promote autonomy, elicit promote autonomy, elicit solutionssolutions

GuideGuide

Guiding: a neglected style

DirectDirectManage Manage PrescribPrescribeeLeadLead

GuideGuideShepherdShepherdEncouragEncourageeMotivateMotivate

FollowFollowPermitPermitLet beLet beAllowAllow

Fundamental MI skills

Open QuestionsAffirmationReflective ListeningSummarizingElicit

Questions can’t be answered yes or no

Questions that can’t be answered with one or two words

Questions that are not rhetorical

What does open-ended mean?

Open-Ended QuestionsProbe widely for informationHelp uncover the individual’s

priorities and valuesAvoid socially desirable

responsesDraw people out

Some Guidelines with Questions

Ask fewer questions! No more than three questions in a

row Ask MORE OPEN than closed

questions TWO REFLECTIONS for each

question

Open Ended Questions Video

Affirm a person’s struggles, achievements, values, and feelings

Emphasize a strength Notice and appreciate a positive action Should be genuine Express positive regard and caring Examples

– “It takes courage to face such difficult problems”– “This is hard work you’re doing”– “You really care a lot about your family”– “Your anger is understandable”

Affirmations

Affirmations Video

The Function of Reflection

What thespeaker means

1 What the listener hears

3

What the speaker says

2

What the listenerthinks the speaker means

4

Bridge the gap by reflection

Reflective ListeningA critical MI skillMirrors what the individual saysIs non-threateningDeepens the conversationHelps people understand

themselves

MI Listening Method

Reflective listening encourages disclosure and exploration.

Listen carefully Generate hypothesis about content, meaning,

emotion Put your hypothesis in form of a statement Keep voice inflection neutral/down at end Listen to individual’s clarification Restate hypothesis of the clarified

content

Reflective listening stems

So you feel like.. It sounds like you…. You’re wondering if… In other words you’re

saying…. Let me see if I heard you

correctly…. What I hear you saying…

Ask for clarification- I want to understand, help me to understand what you’re saying

You’re feeling. . . It seems that you …. So you….

Reflections

First, train yourself to think reflectively What does this person really mean? How does this fit with cultural

competence? Reflective listening is a way to check in

with the patient. Can be a guess about what they really meant.

Reflections Video

“What you’ve said is important.” “I value what you say.” “Here are the salient points.” “Did I hear you correctly?” “We covered that well. Now let's

talk about ...”

Summarization

After a minimum of 3 reflections Good for moving the conversation or

transitioning to the next topic

Using Summaries

Summaries Video

Practice Exercises

Workbook OARS Practice sheet Virginia Reel

Focusing – Strategic Centering

Developing a clear direction and goal(s) Sometimes the change goal is clear, but

often it’s not Most often, from the client’s agenda;

Sometimes prescribed by the context

Agenda Setting

Eliciting the client’s agenda– “Miracle question”

Offering a menu– What are the options?

Asking permission to discuss your agenda– I’d also like to talk a bit about ? and you can decide if that

would be helpful

Finding a Focus What is the focus, the “change goal” for MI? Most often, it is from the client’s agenda Sometimes prescribed by the context What if you have your own goal(s)

that the client does not

currently share?

Evoking – The Transition to MI

A clear focus is a prerequisite Eliciting change talk

– Selective eliciting

– Selective responding

– Selective summaries

Change Talk

• Change talk is any client speech that favors movement in the direction of change

• Previously called “self-motivational statements” (Miller & Rollnick, 1991)

• Change talk is by definitionlinked to a particular behavior changegoal

DARN CATs

Preparatory Change TalkFour Examples

DARNDESIRE to change (want, like, wish . . )

ABILITY to change (can, could . . )

REASONS to change (if . . then)

NEED to change (need, have to . .)

Mobilizing Change TalkReflects resolution of ambivalence

CATs COMMITMENT (intention, decision,

promise) ACTIVATION (willing, ready, preparing) TAKING STEPS

Yet another metaphor

MI Hill

Prepara

tory Change Talk Mobilizing Change Talk

Contemplation Preparation Action(Pre-)

Responding to Change Talk

Responding to Change TalkAll EARS

E: Elaborating: Asking for elaboration, more detail, in what ways, an example, etc.

A: Affirming – commenting positively on the person’s statement

R: Reflecting, continuing the paragraph, etc. S: Summarizing – collecting bouquets of

change talk

MI Flow Chart

OARS

Does change-talk

occur naturallywithout explicit

elicitation?

yes

no

Develop a plan, etc

Apply Techniques For ElicitingChange-Talk

Respond with• Elaboration Qs• Reflection• Affirmation &or• Summarization

https://adept.missouri.edu/

DESIRES

StrengthenClient

CommitmentTalk

ABILITIES

REASONS

NEEDS

Client Behavior

alChange

   Seeing Behavior Change

      

  

 

Asking for Clients

Assessing

Hearing Strong Commitment Talk

MI Change Talk Strategy Process

Change Talk and Sustain Talk

Opposite Sides of a Coin

Examples of Sustain Talk

Desire for status quo Inability to change Reasons for sustaining status quo Need for status quo Commitment to status quo

Sustain TalkThe other side of ambivalence

I really like marijuana (D) I don’t see how I could give up pot (A) I have to smoke to be creative (R) I don’t think I need to quit (N) I intend to keep smoking and (C) nobody can

stop me I’m not ready to quit (A) I went back to smoking this week (T)

Change Talk Video

Evoking Change Talk!

Giving goal-oriented or target behavior- oriented direction…

Previously, we learned that change talk can flow naturally by simply using OARS

In this lesson, we will learn strategies for eliciting change-talk when it does NOT naturally occur

We will list, define, and discuss 7 strategies for eliciting change talk

Eliciting change talk

Ask Evocative Questions (Assumes a problem)- What

happened the last time you used? How did your

little sister react the last time you and your mom

fought?

Explore Decisional Balance – Weighing Costs &

benefits. *Consider short & long term consequences

(+/-)

How to Evoke Change Talk!(How MI becomes directive)

Ask for Elaboration or Examples – What else do you

think is going on with that? Tell me a little more

about your situation at school… Tell me about the

last time you got in a fight….

Looking Back – Think back to a time when things were

OK [you weren’t using]? What things did you do to

keep you on track?

More Strategies…

Looking forward – How would you like your life to look

a year form now? What will be different in a year if

you stop using?

Query Extremes - what is the worst that could happen if

you [quit behavior]? What is your worst fear? What

is the best thing that could happen if you [quit

behavior]?

More Strategies….

Use Change Rulers – On a scale of 1-10, how important

is it for you to get through treatment? What would it

take for you to go even higher on the scale?

Explore Goals & Values – What’s most important to

you? Where would YOU like to start? Which of these

3 areas would you like to work on first?

More Strategies….

Come Alongside – Explicitly side with the negative (or

status quo) side of ambivalence. This may be so

important to you that changing is out of the

questions, no matter what the cost.

More Strategies….

Change talk: I wouldn’t have a hangover. Open Question: What might be some advantages of

quitting?

Change talk: I suppose I could go with a buddy. Open Question: What might make it easier for you to

get to the program?

Change Talk Jeopardy: Examples

Recognizing and Attending to Commitment

High Commitment Strength

Medium Commitment Strength

I will

I definitely will

I promise

I swear

I guarantee

I know I will

I intend to

I am ready to

I am going to

I plan to

I think I will

I expect to

Planning – The Bridge to Change

Replacing prior Phase I and Phase II Negotiating a change plan &

Consolidating commitment

It’s time for the Planning Process when:

There is sufficient engagement

AND A clear shared goal

AND Sufficient client motivation for change

Often a “testing the water” strategy such as recapitulation and key question

Planning: A Continuum

Clear Plan Menu of Options Unclear

What is the client/patient role in planning?

How does the interviewer influence planning?

What are the key elements of MI-guided planning?

Ambivalence: A Central Concept Simultaneous motivations leading in

different directions – Desire to gain medication benefits and avoid side-effects

– Desire to be strong and healthy and to relax and eat enjoyable foods

– Desire to be in greater control/feel on top of things, desire to let go and escape

– Hope for change / fear of failure

Role of Ambivalence Ambivalence is a

normal component of psychological problems

Acknowledge and protect the side that doesn’t want to change

Explore pros and cons of change (decisional balance)

Specifics are unique to each person--try not to assume

What is Resistance? Behavior (a state not a “trait”) Interpersonal (It takes two to resist) A signal of dissonance Predictive of (non) change Highly responsive to practitioner style

Psychological reactance Individuals will defend their freedom when it

is threatened, especially when the threat is perceived as unfair. – Restricted behaviors may increase in attractiveness

(forbidden fruit) – Person may become aggressive or assert other freedoms

Therapeutic relationship (advising, addressing problems) may induce reactance(Brehm, 1966)

Status Quo or Option A

Change or Option B

Advantages

+

Good things about Status Quo or Option A

CON

Good things about Change or Option B

PRO

Disadvantages

-

Less-good things about Status Quo or Option A

PRO

Less-good things about Change or Option B

CON

2 x 2 Decisional Balance GridPROs and CONs of Change

Rolling with Resistance

Don’t push back Avoid arguments Reflect Remind the person (and

yourself) about autonomy

What do you feel when the individual resist?

Sustain Talk and Resistance Sustain Talk is about the target behavior

– I really don’t want to stop smoking

– I have to have my pills to make it through the day Resistance is about your relationship

– You can’t make me quit

– You don’t understand how hard it is for me Both are highly responsive to practitioner’s style

Traps to Avoid

Question/Answer

Premature Focus

Taking SidesExpert Role Blaming

Another Trap: The Righting Reflex

Born of concern and caring There’s a problem? Let’s fix it! Fails to consider ambivalence in change

process May engender resistance

Possible contraindications for MI

Clients who are already ready for change or appear to be at the action stage

Clients who are low in anger or resistance Clients making a decision we should not be

involved with!

When, in MI, do you give information and advice?

Three kinds of permission:

The person asks for advice

You ask permission to give advice:

“Can I make a suggestion?” “Would you be interested in some resources?” “Would you like to know what has worked for some other

people?”)

You qualify your advice to emphasize autonomy:“A lot of people find that _____works well, but I don’t

know if that’s something that interests you.”

Giving information & Advice

• Get Permission (sometimes best to ask permission to

listen & learn more before giving advice!)

• Qualify, honoring autonomy

• For suggestions, offer several instead of just one

The Process for giving advice…

Building MI Skills

Ongoing training in MI Supervision/Coaching and feedback Reading MI Workbook Watching training videos (YouTube) Watching or listening to your own sessions Coding sessions Peer support

Getting Stuck while learning MI

Being open to change & letting go of some old habits

Proficiency in reflective listening Recognizing change talk & evoking change talk Summarizing Transitions to other therapeutic methods

The FRAMES Model

F – providing feedback R – emphasizing that the individual is

responsible A – giving clear advice M – providing a menu of alternative options E – using empathetic conversational style

(reflective listening) S – supporting self-efficacy

Using FRAMES in MOSBIRT F – providing feedback on the patient’s screening

results R – emphasizing that the individual is responsible for

their own behavior A – giving clear advice that the best way to reduce the

risk is to cut down or stop engaging in the risky behavior (drinking, using drugs, etc.)

M – providing a menu of alternative change options E – using empathetic conversational style (reflective

listening) S – supporting self-efficacy of the individual

Brief Education

Provided when ASSIST Score for Alcohol = 11 to 19 and/or ASSIST Score for Drugs = 4 to 19

Consists of 1 Session Follows (usually immediately) completion

of the Screening forms Average time about 30 minutes

Brief Education in 3 Steps

Step 1: Orientation & Print Personal Feedback Form

Step 2: Build Rapport, Review Personal Feedback Form, Provide Feedback on Screening Results, Give Clear Advise, and Provide a menu of alternatives

Step 3: Summarize Session, and emphasize personal responsibility.

Brief Education Handout

Personal Feedback Form

Brief Education Step 1: Orientation & Print Personal Feedback Form

Deliver orientation: welcome and rational– Brief Assessment (Pre-Screening)– HIPPA Consent Form– ASSIST & GPRA Interviews– Follow-up Survey Contact Form (when

appropriate) Print Personal Feedback Form (PFR)

– Review the patient’s ASSIST Score to determine level of intervention

Brief Education Step 2: Build Rapport, Review Form, Provide Feedback, Advise,

and Menu of Alternatives Rapport building – focus on strengths (use Empathy

& Support self-efficacy) Review Personal Feedback Form Provide Feedback on the screening results – focus on

concerns (remind Responsibility of patient use Empathy & Support self-efficacy)

Give clear Advice (with permission) that the best way to reduce the risk is to cut down or stop drinking

Provide a Menu of alternatives for change

Brief Education Step 3: Summarize Session, Emphasize Responsibility, and

Feedback from Patient

Summarize session Emphasize that the individual is

Responsible for their own behavior

DEMONSTRATION & PRACTICE

References • Arkowitz, H., Westra, H.A., Miller, W.R., & Rollnick, S. (eds)

(2008). Motivational Interviewing in the Treatment of Psychological Problems. Guilford Press: New York.

• Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing, 2nd Edition: Preparing People for Change. Guilford Press: New York.

• Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Healthcare: Helping Patients Change Behavior. Guildford Press: New York.

• Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. Guildford Press: New York.

Thank You!• Mary Dugan, Ph.D. LCSW• Member of MINT, Inc.

Research Assistant Professor

Missouri Institute of Mental Health

5400 Arsenal St

St. Louis, MO 63139

(314) 877-6451

Mary.dugan@mimh.edu