Advanced Motivational Interviewing

Allyse D. Sturdivant, Ph.D.

Illinois Co-Occurring Center for Excellence

www.illinoiscoce.org

Training Objectives

• To facilitate a deeper understanding of Motivational Interviewing principles and strategies.

• To improve Motivational Interviewing skills.

• To increase self-awareness of competency in Motivation Interviewing.

To Be…Or Not To Be Motivational?

• Conflict

• Coercion

• Persuasion

• External Contingencies (threats)

• Bribe/incentive

• Begging

• Fear

What is the goal?

We’re here for a reason. I believe a bit of the reason is to throw little torches out to lead

people through the dark.

Whoopi Goldberg

Human Development Approach

Risk Reduction

Promotion

Problem Behavior Focused

Positive Behavior Focused

Purpose/Intent is to

STOP

Purpose/Intent is to

OVERCOME

Purpose/Intent is to

THRIVE

Purpose/Intent is to

DO BETTER

Recovery means Change

• The decision to change a behavior occurs in a series of steps.

• Match help to the stage.

– The kind of help an individual needs depends on their readiness to change.

Stages of Change Diagram

Termination

Pre-contemplation

Maintenance

Relapse & Recycle

Action

Preparation

Contemplation

Prochaska, Di Clemente, Norcross 1992

Stages of Change

Stage Basic Definition

1. Precontemplation A person that is not seeing a need for a lifestyle or behavior change

2. Contemplation A person is considering making a change but has not decided yet

3. Preparation A person has decided to make changes and is considering how to make them

4. Action A person is actively doing something to change

5. Maintenance A person is working to maintain the change or new lifestyle, possibly with some temptations to return to the former behavior or small lapses

RELAPSE

CONTEMPLATION

PRECONTEMPLATION

Raise doubt - Increase the client’s perception of risks and problems with current behavior

Tip the decisional balance - Evoke reasons for change, risks of not changing; Strengthen client’s self-efficacy for behavior change

PREPARATIONHelp the client to determine the best course of action to take in seeking change; Develop a plan

ACTIONHelp the client implement the plan; Use skills; Problem solve; Support self-efficacy

MAINTENANCEHelp the client identify and use strategies to prevent relapse; Resolve associated problems

Help the client recycle through the stages of contemplation, preparation, and action, without becoming stuck or demoralized because of relapse

Stages of Change & Therapist TasksStages of Change & Therapist Tasks

Readiness Ruler - WAR

Able

Ready

Wil

ling

• Willing:

The importance of change

• Able: Confidence for change

• Ready:

A matter of priorities

The first step towards getting somewhere is to decide that

you are not going to stay where you are.

J. Pierpont Morgan

Motivational Interviewing

Motivational interviewing is a directive, client-centered counseling style that enhances motivation for change by helping the consumer clarify and resolve ambivalence about behavior change.

The goal of motivational interviewing is to create and amplify discrepancy between present behavior and broader goals.

Create cognitive dissonance between

Where one Where oneIs now wants to be

If you treat an individual as he is, he will stay as he is, but if you treat him as if he were

what he ought to be and could be, he will become what he ought to be and could be.

Johann Wolfgang Von Goethe

Motivational Interviewing Assumptions

• Motivation is a state of readiness to change, which may fluctuate from one time or situation to another. This state can be influenced.

• Motivation for change does not reside solely within the client.

• People struggling with behavioral problems often have fluctuating and conflicting motivations for change, also known as ambivalence. Ambivalence is a normal part of considering and making change and is NOT pathological

Motivational Interviewing Assumptions

• The counselor’s style is a powerful determinant of client resistance and change. An empathic style is more likely to bring out self-motivational responses and less resistance from the client

• Each person has powerful potential for change. The task of the counselor is to release that potential and facilitate the natural change process that is already inherent in the individual.

Defining Motivation

• Motivation is the tipping point for making change happen• Most of the time it is defined after the fact: if you are

successful, you were motivated• Alternative terms for motivation:

– Willpower– Commitment– Resolution– Determination– Readiness

Qualities of a Good Motivational Counselor

• Respect for individual differences

• Tolerance for disagreement and ambivalence

• Patience with gradual approximations

• Genuine caring and interest in clients served

Motivational Interviewing Spirit

• Collaboration

• Evocation

• Autonomy

• Direction

Motivational Interviewing Principles

1. Express Empathy

2. Develop Discrepancy

3. Roll Resistance

4. Support Self-efficacy

1. Express Empathy

• Acceptance

• Warmth

• Openness

• Personal value

• Understanding

Reflective Listening

• Reflective listening is key to accurate empathy.

• Reflective listening is a fundamental skill of motivational interviewing.

• Use reflective listening when you get ahead of your client, i.e., when there is resistance.

What people really need is a good listening to.

Mary Lou Casey

Types of Reflective Statements

• Repeating: Repeat a portion of what the client has said. May only consist of one or two words.

• Rephrasing: Stay close to what the client said, but substitute words or slightly rephrase.

Types of Reflective Statements

• Paraphrasing: Therapist makes a guess at the unspoken meaning and reflects this back in new words.

• Reflection of feeling: Paraphrase which emphasizes the emotional content of the consumer’s statement. (Not an interpretation.)

Summarizing

• Allows individual to hear him/herself a second time.

• Allows the interviewer to reflect both sides of the ambivalence. “On the one hand… On the other hand…”

• Provides a summary of the conversation up to that point.

• Can be used to transition to a new topic.

A fifty-nine-year-old unemployed teacher says:

“ My life just doesn’t seem worth living any more. I’m a lousy father. I can’t get a job. Nothing good ever happens to me. Everything I try to do turns rotten. Sometimes I wonder whether it’s worth it.”

More Types of Reflective Statements

• Simple reflection:– Client: I don’t have anything to say.– Counselor: You’re not feeling talkative today.

• Amplified reflection:– Client: No one I know know takes medication, it just

seems like it would be such a hassle.– Counselor: So, you can imagine ever taking

medication for something.

More Types of Reflective Statements

• Double – sided reflection:– I think I would feel so much better about myself if

I were in better shape, but it’s so hard to stick to a workout plan.

– Counselor: On the one hand, trying to work out consistently is challenging, but on the other hand, you think your self-esteem would improve if you lost weight.

Roadblocks to Listening

• Ordering, Directing, or Commanding

• Warning or Threatening

• Giving Advice, Making Suggestions, or Providing Solutions

• Persuading with Logic, Lecturing, or Arguing

Roadblocks to Listening

• Moralizing, Preaching, or Telling Clients what they “should” do

• Disagreeing, Judging, Criticizing, or Blaming

• Agreeing, Approving, or Praising

• Shaming, Ridiculing, or Labeling

From T. Gordon (1970). Parent Effectiveness Training. New York:

Wyden.

Roadblocks to Listening

• Interpreting or Analyzing

• Questioning or Probing

• Withdrawing, Distracting, Humoring, or Changing the Subject

2. Develop Discrepancy

• Awareness of consequences is important

• Discrepancy between behaviors and goals motivates change

• Have the client present reasons for change

3. Roll with Resistance

• Use momentum to your advantage

• Shift perceptions

• Invite new perspectives, do not impose them

• Clients are valuable resources in finding solutions to problems

4. Support Self-efficacy

• Belief that change is possible is important motivator

• Client is responsible for choosing and carrying out actions to change

• There is hope in the range of alternative approaches available

Two Phases of Motivational Interviewing

Phase I: Building motivation

Phase II: Strengthening commitment to change

Phase I: Building Motivation To Change

Avoid at all costs:

• Question-Answer Trap• Confrontation-Denial Trap• Expert Trap• The Labeling Trap• Premature-Focus Trap• The Blaming Trap

Usual Indicators of Low Motivation

• Disagrees with worker

• Refuses advice

• Expresses no desire or need for help or change

• Appears unconcerned about problem

Five Early Strategies: OARS

• Ask Open-ended questions

• Affirm: Try to reinforce anything that leads to change and builds the relationship.

• Listen Reflectively

• Summarize

• Elicit self-motivational statements/change talk– DARN C

Eliciting Change Talk

• D = Desire statements

• A = Ability statements

• R = Reasons statements

• N = Need statements

• C = Commitment language

Desire Statements

• “I’d like to quite 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 better about myself.”

Ability Statements

• “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 probably find a job.”

Questions To Elicit Change Talk

Desire/Ability:

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

• What makes you think you can change, even if you decided to?

• What do you see in yourself in terms of ability that might be encouraging, if you decided to change?

Reasons Statements

• “I have to quite smoking because of my asthma.”

• “To keep my truck driving license, I should probably cut down on my drinking.”

• “My husband may leave me if I don’t go to therapy.”

• “I want my kids to have someplace they can call home.”

Questions To Elicit Change Talk

Reasons:

• What difficulties have you had in relation to your behavior?

• In what ways has this been a problem for you?

• How does your behavior interfere with who you want to be?

Need Statements

• “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.”

Questions To Elicit Change Talk

Need:

• What about your behavior causes you concern?

• What worries you about your behavior?

• What can you imagine happening to you as a result of your behavior?

• In what way does all this concern you?

• What do you think will happen if you don’t make a change?

Commitment Language

• “I might change.”

• “I could consider changing.”

• “I’m planning to change.”

• “I will change.”

Questions To Elicit Change Talk

Commitment Language:

• What makes you think you need to do something different?

• What would be the advantage to changing your behavior?

• What things make you think you should keep drinking the way you do...and on the other side...what makes you think you should change?

A fifteen-year-old girl says:

“I’m really mixed up. A lot of my friends, they stay out real late and do things their parents don’t know about. They always want me to come along and I don’t want them to think I’m weird or something, but I don’t know what would happen if I went along either.”

Remember

• Talk less than your client does

• On average, reflect (at least) twice for each question you ask

• When you reflect, use complex reflections more than half the time

Remember

• When you do ask questions, ask mostly open-ended questions

• Avoid getting ahead of your client’s readiness (warning, confronting, giving unwelcome advice or direction, taking the “good” side of an argument)

10 Strategies for Evoking Change Talk

1. Ask evocative questions

2. Explore decisional balance

3. Ask for elaboration

4. Ask for examples

5. Look back

6. Look forward

7. Query extremes

8. Use change rulers

9. Explore goals and values

10. Come alongside

Decisional Balance

• Ambivalence is a normal part of the process of change

• Use “conflict” to promote positive change• Weighing pros and cons of behavior• Increasing discrepancy• Most useful in Precontemplation and

Contemplation stages as a tool to increase motivation

Decisional Balance Worksheet

• PROS (Behavior)• _______________• _______________• _______________• CONS (Behavior)• _______________• _______________• _______________

• PROS (Change)• _______________• _______________• _______________• CONS (Change)• _______________• _______________ • _______________

No Change Change

Thinking About DrinkingThinking About DrinkingHere is an example of a woman drinker.

Remember, every person has different reasons in their decisional consideration about drinking

Not so good things about my drinking:

Good things about my drinking:

More relaxed

Will not have to think about my problems for a while

More comfortable with drinking friends

Disapproval from family and friends

Increased chance of legal and job trouble

Costs too much money

Not so good things about changing my drinking:

Good things about changing my drinking:

More control over my life

Support from family and friends

Less legal trouble & Better health

More stress or anxiety

Feel more depressed

Increased boredom

Conducting a Decisional Balance Discussion

• Accept all answers. (Don’t argue with answers given by client.)

• Explore answers.

• Be sure to note both the benefits and costs of current behavior and change.

• Explore costs/benefits with respect to client’s goals and values.

• Review the costs and benefits.

Phase II: Strengthening Commitment to Change

The goal of therapy shifts from building motivation to strengthening commitment

Hazards in Phase II:

-Underestimating ambivalence

-Overprescription

-Insufficient direction

• Decreased resistance– the client stops arguing, interrupting, denying, or

objecting

• Decreased questions about the problem– the client seems to have enough information

• Resolve– the client appears to have reached a resolution

Signs of Readiness to Change

Signs of Readiness to Change

• Self-motivational statements– statements reflect recognition, concern,

openness to change, or optimism

• Increased questions about change– the client wants to know what they can do

about the problem

Signs of Readiness to Change

• Envisioning– talks about how life could be after a change,

or discusses advantages of change

• Experimenting– begins to try different change approaches

Strategies for Strengthening Commitment

• Key Questions to get the client talking and thinking about change:-what do you think you will do?-what does all this mean about your behavior?-what do you think has to change?-what could you do, what are your options?-it sounds like things can’t stay the same, what can you do?

Strategies for Strengthening Commitment

• Key Questions cont...

-how would you like things to turn out for yourself?

-of the things that concern you, what are the most important reasons to change?-what concerns you about changing?-what would be some of the benefits of changing?

Strategies for Strengthening Commitment

• Negotiating a Plan

Setting goals: • How would you like things to be different?

• What is it you would like to see changed?

• If you were completely successful in accomplishing what you want, what would be different?

Strategies for Strengthening Commitment

• Considering Change Options-presenting a menu -patient-treatment matching

• Arriving at a Plan-the most important reasons why I want

to change-my main goals for myself, in making a change are....

1. The changes I want to make are:

2. The most important reasons I want to make these

changes are:

3. The steps I plan to make in changing are:

4. The ways people can help me are:

Person Possible ways to help

5. I will know that my plan is working if:

6. The things that could interfere with my plan are:

Change Plan Worksheet

I have not the right to want to change another if I am not

open to be changed.

Martin BuberMartin Buber

8 Stages in Learning Motivational Interviewing

1. Overall spirit of Motivation Interviewing

2. OARS: Client-Centered counseling skills

3. Recognizing change talk and resistance

4. Eliciting and strengthening change talk

5. Rolling with resistance

6. Developing a change plan

7. Consolidating commitment

8. Transition and blending

Motivational Interviewing Tools

• Motivational Interviewing Treatment Integrity (MITI 3.0)

• Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA:STEP)– Self-Assessment

References

www.motivationalinterview.org

http://www.midattc.org/MIASTEP/

• Motivational Interviewing:Preparing People for Change. William R. Miller & Stephen Rollnick. 2nd Edition. Guilford Press

• Squires, D.D. & Moyers, T.B. (2002). Motivational Interviewing. Online at www.bhrm.org (There are actually two different papers, one is in the substance abuse section and the other is in the MISA section.)