MOTIVATIONAL INTERVIEWING

Jim Messina, Ph.D., CCMHC, NCC, DCMHS

Troy University Tampa Bay Site

Website: www.coping.us

Motivational Interviewing Training Site:

http://www.coping.us/motivationalinterviewing.html

Objectives of this MI PresentationAfter this presentation, the participants will be able to:

1. Define what is Motivational Interviewing and what are the major components of this

interventional technique

2. Define the specific Strategies and Skills of MI including:

A. RULE - Resist, Understand, Listen and Empower

B. MI’s 4 Processes: Engaging, Focusing, Evoking and Planning

C. MI’s Spirit: Collaboration, Evocation, Autonomy and Compassion

D. MI’s Principles: Express Empathy, Develop Discrepancy, Roll with Resistance and

Support Self Efficacy

E. OARS: Open-ended Questions; Affirmations, Reflections and Summaries

F. Change Talk’s DARN CAT: Desire, Ability, Reason, Need and Commitment, Activation,

Taking Steps

3. Explain how MI relates to the Transtheoretical Model of Change

4. Understand what it takes to Learn the skills of Motivational Interviewing

A Helping Truism

How many helpers does it take

to change a light bulb?

Just one, but the light bulb has

to want to be changed.

So How Do We Define Motivational Interviewing? Miller and Rollnick (2013) give us

three definitions:

Layperson’s definition: Motivational interviewing is a collaborative conversation

style for strengthening a person’s own motivation and commitment to change.

Practitioner’s definition: Motivational interviewing is a person-centered counseling

style for addressing the common problem of ambivalence about change.

Technical definition: Motivational interviewing is a collaborative, goal-oriented style

of communication with particular attention to the language of change. It is designed

to strengthen personal motivation for and commitment to a specific goal by eliciting

and exploring the person’s own reasons for change within an atmosphere of

acceptance and compassion.

Guiding Principles of Motivational InterviewingR: Resist the Righting Reflex with Clients

People who enter helping professions often have a powerful desire to set things right, to heal, to prevent harm and promote well-being which is called the Righting Reflex. When seeing someone headed down the wrong path, helpers will usually want to get out in front of the person and say, “Stop! Turn back! There is a better way!”

U: Understand the Clients’ Motivations

It is the clients’ own reasons for change, and not the helpers that are most likely to trigger behavior change. And so helpers need to be interested in the clients’ own concerns, values, and motivations.

L: Listen to the Clients

MI involves at least as much listening as informing. Normal expectations of a professional consultation are that the helpers have the answers and will give them to their clients. Often helpers do have answers, and clients come to them for this expertise. When it comes to behavior change, though, the answers most likely lie within the clients and finding them requires some listening.

E: Empower the Clients

Outcomes are better when clients take an active interest and role in their own health care. Empowerment is helping clients explore how they can make a difference in their own health. Clients’ own ideas and resources are key here.

(Rollnick, Miller, & Butler, 2008).

What is the Righting Reflex?■ It is the natural inclination we have to make it better for another person

■ What’s the danger? We tell the other person what to do, how to do it, and why

they should do it without talking to them and learning what they think.

■ It creates resistance in that we move away from the partnering stance of MI

and into the expert top down role.

■ What to do when you find yourself doing this? Stop and Reset: “Mrs. Smith, I

realize I have been just lecturing you on how you can deal with your diabetes

without learning what you are thinking. Let me back up and hear from you,

wherever you would like to start.”

Righting Reflex Assumptions to Let Go of in Motivational Interviewing1. They ought to change

2. They want to change

3. Their health is the prime motivating factor for them

4. If they do not decide to change, the consultation has failed

5. Individuals are either motivated to change, or they’re not

6. Now is the right time to consider change

7. A tough approach is always best

8. I’m the expert they must follow my advice

9. A negotiation approach is always best

Four Processes in Motivational Interviewing

Engaging: helpers and clients establish a helpful connection and a working relationship.

Therapeutic engagement is a prerequisite for everything that follows and it involves developing a

working alliance.

Focusing: helpers and clients develop and maintain a specific direction in the conversation

about change. In the course of helping relationships, a direction towards one or more change

goals usually emerges.

Evoking: eliciting the clients’ own motivations for change which is the heart of MI. It occurs

when there is a focus on a particular change and the helpers harness the clients’ own ideas and

feelings about why and how they might do it. Evoking is having the clients voice the arguments

for change.

Planning: encompasses both developing commitment to change and formulating a specific

plan of action. It’s a conversation about action that can cover a range of topics, conducted with

a sharp ear for eliciting clients’ own solutions, promoting their autonomy of decision making and

continuing to elicit and strengthen change talk as a plan emerges

The Spirit of Motivational Interviewing

1. Collaboration (vs. Confrontation) focused on mutual understanding, not the helper

being right

Collaboration is a partnership between the helper and the clients, grounded in the point of

view and experiences of the client. This contrasts with some other approaches which are

based on the helper assuming an “expert” role, at times confronting the clients and imposing

their perspective on the clients’ problem behaviors and the appropriate course of treatment

and outcome. Collaboration builds rapport and facilitates trust in the helping relationship,

which can be challenging in a more hierarchical relationship.

2. Evocation (Drawing Out, Rather Than Imposing Ideas) to "draw out" the persons' own

motivations and skills for change

The MI approach is one of the helpers’ drawing out the individuals' own thoughts and ideas,

rather than imposing their opinions as motivation and commitment to change is most

powerful and durable when it comes from the clients. No matter what reasons the helpers

might offer to convince the clients of the need to change their behavior or how much they

might want them to do so, lasting change is more likely to occur when the clients discover

their own reasons and determination to change.

The Spirit of Motivational Interviewing3. Autonomy (vs. Authority) clients encouraged to take lead in developing a “menu of options’

as to how to achieve desired change

Unlike some other treatment models that emphasize the clinicians/helpers as authority figures,

Motivational Interviewing recognizes that the true power for change rests within the clients.

Ultimately, it is up to the individuals to follow through with making changes happen. This is

empowering to the individuals, but also gives them responsibility for their actions. Helpers

reinforce that there is no single “right way” to change and that there are multiple ways that

change can occur. In addition to deciding whether they will make a change, clients are

encouraged to take the lead in developing a “menu of options’ as to how to achieve the desired

change.

4. Compassion helpers’ having their hearts in the right place so that the trust they engender

will be deserved

The helpers act benevolently to promote the clients’ welfare, giving priority to the clients’

needs. Helpers are for their clients benefit and not primarily for their own. Compassion is a

deliberate commitment to pursue the welfare and best interests of others. It is this promotion of

others’ welfare which motivates people to be drawn to the helping professions.

Principle 1 of Motivational Interviewing:

Express Empathy

■ Expressing empathy towards the clients shows acceptance and

increases the

■ chance of developing a rapport.

■ Acceptance enhances self-esteem and facilitates change.

■ Skillful reflective listening is fundamental.

■ Clients’ ambivalence is normal

Principle 2 of Motivational Interviewing: Develop Discrepancy

■ Developing discrepancy enables the clients to see that their

present situation does not necessarily fit into their values

and what they would like in the future.

■ The clients rather than the helpers should present the

arguments for change.

■ Change is motivated by a perceived discrepancy between

present behavior and important personal goals and values.

Ten Strategies for Evoking Change Talk1. Ask Evocative Questions: Ask open question, the answer to which is change talk.

2. Explore Decisional Balance: Ask first for the good things about status quo, then ask for the

not-so-good things.

3. Ask for Elaboration: When a change talk theme emerges, ask for more details. In what ways?

Tell me more…? What does that look like?

4. Ask for Examples: When a change talk theme emerges, ask for specific examples. When was

the last time that happened? Give me an example. What else?

5. Look Back: Ask about a time before the current concern emerged. How were things better,

different?

6. Look Forward: Ask what may happen if things continue as they are (status quo). Try the

miracle question: If you were 100% successful in making the changes you want, what would be

different? How would you like your life to be five years from now?

7. Query Extremes: What are the worst things that might happen if you don’t make this change?

What are the best things that might happen if you do make this change?

8. Use Change Rulers: Ask, “On a scale from zero to ten, how important is it to you to [target

change] - where zero is not at all important, and ten is extremely important? Follow up: And why

are you at ___and not _____ [lower number than they stated]? What might happen that could

move you from ___ to [higher number]? Instead of “how important” (need), you could also ask

how much you want (desire), or how confident you are that you could (ability), or how committed

are you to (commitment). Asking “how ready are you?” tends to be confusing because it

combines competing components of desire, ability, reasons and need.

9. Explore Goals and Values: Ask what the cleints’ guiding values are. What do they want in life?

Using a values card sort can be helpful here. If there is a “problem” behavior, ask how that

behavior fits in with the person’s goals or values. Does it help realize a goal or value, interfere

with it, or is it irrelevant?

10. Come Alongside: Explicitly side with the negative (status quo) side of ambivalence. Perhaps

_______is so important to you that you won’t give it up, no matter what the cost

Principle 3 of Motivational Interviewing: Roll with Resistance

■ Rolling with resistance prevents a breakdown in communication between

clients and helpers and allows the clients to explore their views.

■ Avoid arguing for change.

■ Do not directly oppose resistance.

■ New perspectives are offered but not imposed.

■ The clients are a primary resource in finding answers and solutions.

■ Resistance is a signal for the helpers to respond differently.

Principle 4 of Motivational Interviewing: Support Self-Efficacy

■ Self-efficacy is a crucial component to facilitating change. If the clients

believe that they have the ability to change, the likelihood of change

occurring is greatly increased.

■ Persons’ beliefs in the possibility of change is an important motivator.

■ The clients, not the helpers, are responsible for choosing and carrying out

change.

■ The helpers’ own believes in the clients’ ability to change becomes a self-

fulfilling prophecy

Motivational Interviewing Skills and Strategies

Practice of Motivational Interviewing involves the skillful use of certain

techniques for:

1. Bringing to life the “MI spirit”

2. Demonstrating the MI principles

3. Guiding the process toward eliciting clients’ change talk and commitment for

change

Change talk involves statements or non-verbal communications indicating the

clients may be considering the possibility of change.

OARS

OARS is a mnemonic to remember the basic approach used in Motivational Interviewing that are

core counselor behaviors employed to move the process forward by establishing a therapeutic

alliance and eliciting discussion about change.

■ Open Ended Questions

■ Affirmations

■ Reflections

■ Summaries

OARS - Open-ended questions

■ Open Questions are not easily answered with a "yes/no" or short answer containing only a

specific, limited piece of information.

■ Open-ended questions invite elaboration and thinking more deeply about an issue.

■ Although closed questions have their place and are at times valuable (e.g., when collecting

specific information in an assessment), open-ended questions create forward momentum

used to help the clients explore the reasons for and possibility of change.

Examples:

“Tell me what you like about your [insert risky/problem behavior].”

“What’s happened since we last met?”

“What makes you think it might be time for a change?”

“What brought you here today?”

“What happens when you behave that way?”

“How were you able to not use [insert substance] for [insert time frame]?”

OARS: Affirmations Affirmations:

■ Are statements that recognize clients’ strengths

■ Assist in building rapport and in helping the clients see themselves in a different, more positive light. To be effective they must be congruent and genuine.

■ Can help clients feel that change is possible even when previous efforts have been unsuccessful.

■ Often involve reframing behaviors or concerns as evidence of positive clients’ qualities.

■ Are a key element in facilitating the MI principle of Supporting Self-efficacy.

Examples:

Your commitment really shows by [insert a reflection about what the client is doing].”

“You showed a lot of [insert what best describes the client’s behavior—strength, courage, determination] by doing that.”

“It’s clear that you’re really trying to change your [insert risky/problem behavior].”

“By the way you handled that situation, you showed a lot of [insert what best

describes the client’s’ behavior—strength, courage, determination].”

“Thanks for coming on time today”

OARS - ReflectionsReflections or reflective listening is most crucial skill in Motivational Interviewing. It has two primary purposes.

1. To bring to life the principle of Expressing Empathy. By careful listening and reflective responses, the clients come to feel that the helpers understand the issues from their perspective.

2. It is a core intervention toward guiding the clients toward change, supporting the goal‐directed aspect of MI. In this use of reflections, the helpers guide the clients towards resolving ambivalence by a focus on the negative aspects of the status quo and the positives of making change.

Types of Reflections:

1. Simple Reflections

2. Amplified Reflections

3. Double Sided Reflections

4. Shifting Focus

5. Rolling with Resistance

6. Reframing

OARS - Levels of Reflective Listening

Simple Reflection. Helper simply rephrases what the client says.

Client: "But I can’t stop smoking. All of my friends smoke!"

Helper: "Quitting smoking seems nearly impossible because you spend so much time with

others who smoke."

Client: "Yes, right, although maybe I should.“

Amplified Reflection. Helper exaggerates the client’s statement to the point client may

disagree with it. Helper must not be mocking or patronizing.

Client: "But I can’t stop smoking. All of my friends smoke!"

Helper: "Oh, so you couldn’t really quit smoking because then you’d be too different to fit in

with your friends."

Client: "Well, that would make me different, although maybe they might not really care if I

didn’t try to get them to quit, too."

OARS - Levels of Reflective Listening

Double-Sided Reflection. Helper reflects both the current, resistant statement, and a previous,

contradictory statement the client has made.

Client: "But I can’t stop smoking. All of my friends smoke!"

Helper: "You can’t imagine how you would be able to not smoke with your friends, and at the

same time you’re worrying how it’s affecting you."

Client: "Well, yes, I guess I have mixed feelings.“

Shifting Focus. Sometimes MI goals are better achieved by simply not addressing the resistant

statement.

Client: "But I can’t stop smoking. All of my friends smoke!"

Helper: "Well, we’re not really there yet; I’m not talking about your quitting smoking here. Let’s

just keep to what we’re doing here - talking through the issues - and later on we can worry

about what, if anything, you want to do about smoking."

Client: "Well, I just wanted you to know."

OARS - Levels of Reflective ListeningRolling with Resistance. With clients who are extremely unreceptive to any idea or suggestion,

this technique can be effective. It involves a paradoxical element, which can often bring the

client back into a more balanced, non-combative perspective.

Client: "But I can’t stop smoking. All of my friends smoke!"

Helper: "And it may be that when we’re finished here, you’ll decide that it’s worth it to you to

keep on smoking. Right now it may be too difficult to make a change. That decision is yours to

make."

Client: "Okay."

Reframing. With this strategy, the helper invites clients to examine their perspective in a new

light, thereby giving new meaning to what the client has said.

Client: "My husband told me I really need to stop smoking. He’s always telling me what to do!”

Helper: “Your husband must really care a lot about you to say that, knowing you’d probably get

angry with him.”

OARS - SummariesSummaries:

1. Are a special type of reflection where the helpers recaps what has occurred in all or part of a counseling session(s).

2. Communicate interest, understanding and call attention to important elements of the discussion.

3. May be used to shift attention or direction and prepare the clients to “move on.”

4. Can highlight both sides of clients’ ambivalence about change and promote the development of discrepancy by strategically selecting what information should be included and what can be minimized or excluded.

Examples:

“It sounds like you are concerned about your cocaine use because it is costing you a lot of money and there is a chance you could end up in jail. You also said quitting will probably mean not associating with your friends any more. That doesn’t sound like an easy choice.”

“Over the past three months you have been talking about losing weight, and it seems that just recently you have started to recognize that your weight is impacting your daily life more and more. That, coupled with your recent diagnosis of pre-diabetes makes it easy to understand why you are now committed to losing some weight”

Change Talk

Change talk is defined as statements by the clients revealing consideration of:

1. Motivation for or

2. Commitment to change.

In Motivational Interviewing, the helpers seek to guide the clients to expressions of

change talk as the pathway to change.

Research indicates a clear correlation between clients’ statements about change and

outcomes-client-reported levels of success in changing a behavior.

The more clients talk about change, the more likely they are to change.

Different types of change talk can be described using the mnemonic DARN-CAT.

Preparatory Change Talk – DARN

DARN - Desire (I want to change)

Statements and Questions for Reinforcing Positive Change-talk and New Behaviors:

■ "That sounds like a good idea."

■ "That's a good point."

■ "You are very considerate of how your decisions effect other people."

■ "I can see that it's important to you to be a good parent."

■ "You've really changed the way you ____________. How do you feel about that?"

DARN - Ability (I can change)Ability involves Developing Discrepancy

"You have said that you know _______ is the best choice, but that it won't fit with your lifestyle. What are some of your concerns about fitting ________ into your current lifestyle?"

"What is it about your ___________ that others may see as reasons for concern?"

"What would be the good things about your child (your baby/you) being/having __________?"

"How has __________ stopped you from doing what you want to do?"

"How do you feel about ___________?"

"The fact that you are sharing with me indicates that you are interested in learning about ___________. Why do you want to learn about __________?"

"What makes you think that you need to make a change?"

"If things worked out exactly as you like, what would be different?"

"If you decided to change, what do you think would work for you?"

"What concerns do you have about making changes?"

"What things make you think that this is a problem?"

"What difficulties have you encountered trying to change your __________?"

DARN – Reason (It’s important to change)

With this strategy, the helper invites clients to examine their perspective in a new light,

thereby giving new meaning to what the clients have said.

Client: "My husband told me I really need to stop smoking. He’s always telling me what to do!”

Helper: “Your husband must really care a lot about you to say that, knowing you’d probably

get angry with him.”

DARN - Need (I should change)Rolling with Resistance. With clients who are extremely unreceptive to any idea or suggestion, this technique can be effective. It involves a paradoxical element, which can often bring the client back into a more balanced, non-combative perspective.

Client: "But I can’t stop smoking. All of my friends smoke!"

Helper: "And it may be that when we’re finished here, you’ll decide that it’s worth it to you to keep on smoking. Right now it may be too difficult to make a change. That decision is yours to make."

Client: "Okay."

"It's okay if you don't think any of these ideas will work for you, perhaps you've been

thinking about something that might work instead?"

"Ultimately, it is your decision. So, what would you like to try?"

"You are right. I am concerned about your _______, but you are the one in control."

"You're feeling uncomfortable with your _______."

"I don't understand everything you are going through, but if you want to share what

you've tried, maybe together we can find something that could work for you."

"Would you like to talk about some ideas that have worked for other moms and use what works for you?"

Implementing Change Talk CAT –Commitment, Activation & Taking Steps■ C - Commitment (I will make changes)

■ A - Activation (I am ready, prepared, willing to change)

■ T - Taking Steps (I am taking specific actions to change)

CAT – CommitmentTo determine Commitment (I will make changes) Use the Readiness to Change Ruler

Rationale: Assessing readiness to change is a critical aspect of MI. Motivation, which is

considered a state not a trait, is not static and thus can change rapidly from day to day.

Helper (H): “On the following scale from 1 to 10, where 1 is definitely not ready to change and 10

is definitely ready to change, what number best reflects how ready

you are at the present time to change your [insert risky/problem behavior]?”

Client (C): “Seven.”

H: “And where were you 6 months ago?”

C: “Two.”

H: “So it sounds like you went from not being ready to change your [insert risky/problem

behavior] to thinking about changing. How did you go from a ‘2’ 6 months ago to a ‘7’ now?”

H. “How do you feel about making those changes?”

H. “What would it take to move a bit higher on the scale?”

CAT - ActivationActivation (I am ready, prepared, willing to change) Use Advice/Feedback

Rationale: When relevant, new information should be presented in a neutral, nonjudgmental,

and sensitive manner that empowers clients to make more informed decisions about quitting or

changing a risky/problem behavior.

Examples of How to Provide Advice/Feedback (often this can start by asking permission to talk

about the client’s behavior)

“Do you mind if we spending a few minutes talking about….? [Followed by] “What do you know

about….?” [Followed still by] “Are you interested in learning more about…..?”

“What do you know about how your drinking affects your [insert health problem]?”

“What do you know about the laws and what will happen if you get a second drunk driving

arrest?”

“So you said you are concerned about gaining weight if you stop smoking. How much do you

think the average person gains in the first year after quitting?”

CAT – Taking StepsTaking Steps (I am taking specific actions to change) Uses Supporting Self-efficacy

"How important is this to you?"

"How much do you want to _______________?"

"How confident are you that you can make this change?"

"What encourages you that you can _______________, if you want to?"

"I know that it seems like such an uphill battle to __________, but now that we've discussed

some options that have worked for others, which ones sound like the best fit for you?"

"It sounds like you want to continue to ____________. What personal strengths do you have that

will help you succeed? Who could offer helpful support so you can continue to _____________?"

Sustain Talk Challenges that DARN Change Talk

Sustain Talk: The Reverse DARN CATDesire: I like my alcohol

Ability: I don’t see how I can give drinking

Reason: When I drink I feel free and able to handle life’s issues

Need: I need to drink to keep me sane

Commitment: Nobody can stop me. I will drink, as much and when I want

Action: I’m not ready to stop drinking

Taking Step: I started drinking again this week

Signs of Resistance - Forms of DiscordArguing

■ Challenging

■ Discounting

■ Hostility

Interrupting

■ Talking over

■ Cutting off

Ignoring

■ Inattention

■ Non-answer

■ No response

■ Sidetracking

Denying

■ Blaming

■ Disagreeing

■ Excusing

■ Claiming impunity

■ Minimizing

■ Pessimism

■ Reluctance

■ Unwilling to change

Strategies for Evoking Change Talk1. Ask Evocative Questions: Ask an open question, the answer to which is likely

to be change talk.

2. Explore Decisional Balance: Ask first for the good things about status quo,

then ask for the not-so-good things

Strategies for Evoking Change Talk

3. Ask for Elaboration: When a change talk theme emerges, ask for more details.

In what ways? Tell me more…? What does that look like?

4. Ask for Examples: When a change talk theme emerges, ask for specific

examples. When was the last time that happened? Give me an example. What

else?

5. Look Back: Ask about a time before the target behavior emerged. How were

things better, different?

6. Look Forward: Ask what may happen if things continue as they are (status

quo). Try the miracle question: If you were 100% successful in making the

changes you want, what would be different? How would you like your life to be

five years from now?

7. Query Extremes: What are the worst things that might happen if you don’t

make this change? What are the best things that might happen if you do make

this change?

Strategies for Evoking Change Talk8. Use Change Rulers: Ask: “On a scale from 1 to 10, how important is it to you to change (the specific target behavior) where 1 is not at all important, and a 10 is extremely important? Follow up: “And why are you at ___ and not ____ (a lower number than stated)?” “What might happen that could move you from _____to ____ (a higher number)?” Alternatively, you could also ask “How confident are that you could make the change if you decided to do it?”

NOTE: Instead of “how important” (need), you could also ask how much you want (desire), or how confident you are that you could (ability), or how committed are you to (commitment). Asking “how ready are you?” tends to be confusing because it combines competing components of desire, ability, reasons and need.

9. Explore Goals and Values: Ask what the clients’ guiding values are. What do they want in life? Ask how the continuation of target behavior fits in with the clients’ goals or values. Does it help realize an important goal or value, interfere with it, or is it irrelevant?

10. Come Alongside: Explicitly side with the negative (status quo) side of ambivalence. “Perhaps ____is so important to you that you won’t give it up, no matter what the cost.”

Clearing the Air about Misconceptions about Motivational Interviewing

MI is Not:

1. Identical to Rogers’ non-directive

counseling

2. A technique or gimmick to make people

change

3. MI is a panacea, the solution to all

clinical problems

4. The Transtheoretical Model (TTM) of

Change, although they are compatible and

complementary.

5. The “Decisional Balance” technique

exploring the pros and cons of change

6. Require the use of assessment

feedback

7. A way of manipulating people into doing

what you want them to do

MI is:

1. MI’s focusing, evoking, and planning have clear directionality

to them.

2. MI was specifically developed to help clients resolve

ambivalence and strengthen their own commitment to change

3. MI blends well with other approaches and does not negate

the value of other techniques. MI is a style of being with people,

an integration of clinical skills to foster movement for change.

4. TTM defines stages of change while MI provides a means of

moving through the stages

5. Decisional balance is more associated with counseling with

neutrality as the counselor explores con’s of change. MI is more

directional, with the intent being to strengthen the arguments for

change

6. While personal feedback may be particularly useful for

persons who aren’t considering change, it is not a necessary nor

a sufficient component of MI.

7. MI cannot be used to manufacture motivation that isn’t

already there. It is a collaborative partnership that honors and

respects the other’s autonomy, seeking to understand the

person’s internal frame of reference.

The Stages of Change in theTranstheoretical Model (TTM) of Change by Prochaska and DiClemente (1983)

Stages of Change ModelTranstheoretical Model of Change

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

1. Pre-contemplation

Task - to increase discrepancy

■ Educational confrontation - How

many joints do you smoke?

■ Use progression models

■ Accurate information about disease

■ Educational model

Good and less good aspects

■ Invites defensiveness

■ Narcissistic defense

Broad based assessment

■ Alcohol and drug history

■ Psychosocial history

■ Psychiatric evaluation

■ Medical evaluation

2. Contemplation

Task - tip the decisional balance scale

■ Normalize ambivalence

■ I know many other clients who felt the same way as you and they succeeded.

■ You are the best judge of which way to go.

■ Use reframing

What are the options?

■ Move from external to internal motivation

■ Real from perceived

■ There are many problems

■ Deal with first other issue

■ “Natural link”

■ Quit drinking for a week

■ Take meds for a month

List of concerns

■ “Pro’s and con’s”

■ Questions

■ It’s up to you…….

■ What do you plan to do next?

■ What is most important reason to change?

■ Where do we go from here?

■ How would you like for things to turn out?

3. Preparation

■ Identify and assist in problem solving re:

obstacles

■ Help client identify social support

■ Verify that client has underlying skills for

behavior change

■ Encourage small initial steps

4. Action

■ Practicing new behaviors

■ Focus on restructuring cues and social

support

■ Bolster self-efficacy for dealing with

obstacles

■ Combat feelings of loss and reiterate

long-term benefits

5. Maintenance

■ Continued commitment to sustaining new

behavior

■ Plan for follow-up support

■ Reinforce internal rewards

■ Discuss coping with relapse

■ (Prochaska, J.Q. & DiClemente, C.C.

(1983). Stages and processes of self-

change of smoking: Toward an integrative

model of change. Journal of Consulting

and Clinical Psychology, 51(3), 390-395.)

TTM defines stages of change and Motivational Interviewing provides a means of moving through the stages

12 Steps to Learning Motivational Interviewing 1. Understanding the underlying MI Spirit

2. Developing skill and comfort with reflective listening

3. Identifying change goals (Focusing)

4. Exchanging information and providing advice within an MI style (Engaging, Planning, Evoking)

5. Being able to recognize Change Talk and Sustain Talk

6. Evoking Change Talk

7. Responding to Change Talk in a manner that strengthens it

8. Responding to Sustain Talk and Discord in a way that does not amplify it

9. Developing hope and confidence

10. Timing and negotiating a change plan

11. Strengthening commitment

12. Flexibly integrating MI with other clinical skills and practices

Learning Motivational Interviewing How can the 12 learning tasks be accomplished? (Miller & Rollnick, 2013)

More than obtaining knowledge is involved. Feedback is fundamental and the more immediate the better “it’s hard to learn archery in the dark.” Clients provide immediate feedback through their responses to the helper.

Developing Proficiency in MI

What’s needed? Knowledge development and the opportunity for continued learning over time through feedback and coaching based on direct observation. However, coaching need not be extensive. It is a matter of learning and applying the MI criterion which is important and not completing a fixed number of training hours which makes for competent MI helpers.

Stephen Rollnick’s 5 Steps to Help Trainees in Learning Motivational Interviewing

1. Unlearn

2. Slow Down

3. Be humble

4. Believe in them

5. Go with their language about change

Personal Tip for Improving your MI SkillsListen to your own sessions by recording them (with permission) your session and then:

1. Count your reflections: were they simple or complex? Offer more complex than simple reflections

2. Count your questions: were they open or closed? Ask more open than closed questions

3. Count both reflections and questions: what is your ratio? Aim for 2 reflections for every question

4. Listen for Change Talk and Sustain Talk: count each and determine the ratio. Equal frequency = ambivalence (no change) - When Change Talk occurred, what was the next thing you said? Count your OARS responses

5. Listen for MI inconsistent responses (giving advice without permission, confronting or arguing with the client, other “righting reflex” responses - How did the client respond to these?

Workshop training is a good start but it is just the beginning. Feedback and coaching are important in learning MI and need to be based on observed practice and continued over time, even for the experts. Skills tend to drift over time. Skill development in MI is not a one-shot event but an ongoing process. Best of Luck!

References:Messina, J.J. (2016). Motivational Interviewing Retrieved at:

http://www.coping.us/motivationalinterviewing.html

Miller, W.R. & Rollnick, S. (2013). Motivational interviewing: Helping people change (Applications

of motivational interviewing), 3rd edition. New York: Guilford Press.

Prochaska, J.Q. & DiClemente, C.C. (1983). Stages and processes of self-change of smoking:

Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3),

390-395

Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational interviewing in Health Care: Helping

Patients Change Behavior. New York: Guilford Press.

Rosengren, D.B. (2009). Building Motivational Interviewing Skills – A Practitioner Workbook.

New York. Guilford Press