introduction to motivational interviewing state of hawaii, department of health, adult mental health...

Introduction to Motivational Interviewing

State of Hawaii, Department of Health, Adult Mental Health Division, Clinical Operations Team and

Mental Health Services Research and EvaluationIn Partnership with

Substance Abuse and Mental Health Services Administration (SAMHSA)

Evidence Based Practices Training and Implementation Grant

Acknowledgement

Material contained within this training was largely based on the work of William R. Miller and Stephen Rollnick in their groundbreaking book titled, Motivational Interviewing: Preparing People for Change

Published by Guilford Press, 2002

Beliefs About Motivation (True or False?)

• Handout Quiz: Beliefs About Motivation– Complete the true/false quiz and hang onto it– We will review the answers later

“Motivation can be understood not as something that one has, but as something that one does.

It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy.”

What is Motivation?

Ambivalence

“I want to change, but I don’t want to change.”

• Very few decisions in life are made with 100% certainty

• Ambivalence is normal and part of the change process for everyone

Ambivalence Exercise1. Find a partner.2. Each of you write down something you are interested in

doing but have mixed feelings about (e.g., buying a new car, quitting smoking, exercising, etc.).

3. Select who will speak first.4. The speaker presents what it is that you would like to do (but

haven’t done yet).5. The listener then argues strongly in favor of one of the

options or sides.6. Speaker, your job is to listen and note what you are thinking

and feeling.7. Switch roles.

Ambivalence Exercise

What were your thoughts/feelings as the speaker?

What happens when ambivalence collides with persuasion, prescription, convincing?

Motivational Interviewing is…

“a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”

(Miller & Rollnick, 2002)

Spirit of Motivational Interviewing

MI Mirror Image

Collaboration vs. Confrontation

Evocation vs. Education

Autonomy vs. Authority

Spirit of Motivational Interviewing

• Motivations to change are elicited from within the client, not imposed from outside.

• It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence.

• Direct persuasion is not an effective method for resolving ambivalence.

• Readiness to change is not a client trait, but fluctuating product of interpersonal interaction.

Spirit of Motivational Interviewing

• The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

• Positive atmosphere that is conducive but not coercive for change.

• The counselor is directive in helping the client to examine and resolve ambivalence.

NOT Motivational Interviewing

The Righting Reflex• Human beings have a built in desire to set things

right/to solve the problem.

• When the righting reflex collides with ambivalence, the client defends the status quo.

• If a person argues on behalf of one position, he or she becomes more committed to it.

NOT Motivational Interviewing

If following the righting instinct, you will ask:

• Why don’t you want to change?• Why don’t you try… ?

– Okay then, how about…

• What makes you think you are not at risk?• How can you tell me you don’t have a problem?

NOT Motivational Interviewing

• Argues that person has a problem and needs to change – emphasis on acceptance of problem/diagnosis.

• Offers direct advice or prescribes solutions (e.g., coping strategies) without actively encouraging person to make his/her choices.

NOT Motivational Interviewing

• Uses authoritative/expert stance and leaves client in passive role.

• Does most of talking or if acts as unidirectional information system – focus on imparting information.

NOT Motivational Interviewing

• Identifies and modifies maladaptive cognitions.

• Allows the client to determine the content and direction of the counseling.

• Behaves in a punitive or coercive manner.

Assumptions to Avoid• Person OUGHT to change.

• Health is the person’s prime motivating factor.

• People are either motivated or not.

• Now is the right time to consider change.

• I am the expert; therefore, the person must follow my advice.

Beliefs About Motivation (True or False?)

1. Until a person is motivated to change, there is not much we can do.

2. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change.

3. Motivation is influenced by human connections.

4. Resistance to change arises from deep-seated defense mechanisms.

Beliefs About Motivation (True or False?)

5. People choose whether or not they will change.

6. Readiness for change involves a balancing of “pros” and “cons.”

7. Creating motivation for change usually requires confrontation.

8. Denial is not a client problem, it is a therapist skill problem.

MI Principles

Express Empathy

Develop Discrepancy Roll with Resistance

Support Self-Efficacy

MI Methods

Open-Ended Questions Affirmations

Reflective Listening Summaries

Elicit Change Talk

Open-Ended Questions

What are open-ended questions?

• Gather broad descriptive information• Require more of a response than a simple yes/no or

fill in the blank • Often start with words like:

– “How…” – “What…” – “Tell me about…”

• Usually go from general to specific

OARS

Open-Ended Questions

Exercise:Turning closed-ended questions into open-ended ones

Open-Ended Questions

• Why open-ended questions?– Avoid the question-answer trap

• Puts client in a passive role• No opportunity for client to explore ambivalence

OARS

Affirmations

What is an affirmation?

• Compliments, statements of appreciation and understanding– Praise positive behaviors– Support the person as they describe difficult

situations

OARS

Affirmations

• Examples:– “I appreciate how hard it must have been for you

to decide to come here. You took a big step.”– “I’ve enjoyed talking with you today, and getting

to know you a bit.”– “You seem to be a very giving person. You are

always helping your friends.”

Affirmations

Why affirm?• Supports and promotes self-efficacy, prevents

discouragement• Builds rapport• Reinforces open exploration (client talk)

Caveat:• Must be done sincerely

OARS

Express Empathy

What is empathy?• Reflects an accurate understanding

– Assume the person’s perspectives are understandable, comprehensible, and valid

– Seek to understand the person’s feelings and perspectives without judging

Express Empathy

Empathy is distinct from… • Agreement • Warmth• Approval or praise• Reassurance, sympathy, or consolation• Advocacy

Express Empathy

Why is empathy important in MI and IDDT?

• Communicates acceptance which facilitates change• Encourages a collaborative alliance which also

promotes change

• Leads to an understanding of each person’s unique perspective, feelings, and values which make up the material we need to facilitate change

Express Empathy

Tips…Good eye contactResponsive facial expressionBody orientationVerbal and non-verbal “encouragers”Reflective listening/asking clarifying questionsAvoid expressing doubt/passing judgment

Empathy is NOT…

• The sharing of common past experiences• Giving advice, making suggestions, or

providing solutions • Demonstrated through a flurry of questions• Demonstrated through self-disclosure

The Bottom Line on Empathy

• Ambivalence is normal • Our acceptance facilitates change• Skillful reflective listening is fundamental to

expressing empathy- Miller and Rollnick, 2002

Reflective Listening

OARS

SPEAKER LISTENER

Words the speaker

says

Words the listener hears

What thespeaker means

What the listenerthinks the speaker

means1

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4

Thomas Gordon’s Model of Listening

Reflective Listening

“Reflective listening is a way of checking rather than assuming that you know what is meant.”

(Miller and Rollnick, 2002)

OARS

Reflective Listening

• Why listen reflectively?– Demonstrates that you have accurately heard and

understood the client– Strengthens the empathic relationship– Encourages further exploration of problems and

feelings• Avoid the premature-focus trap

– Can be used strategically to facilitate change

Reflective Listening

In motivational interviewing,• About half of all practitioner responses are

reflections • 2-3 reflections are offered per question asked

In ordinary counseling, • Reflections constitute a small proportion of all

responses • Questions outnumber reflections 10 to 1

Learning Reflective Listening

• Reflective listening begins with thinking reflectively

• Thinking reflectively requires a continual awareness that what you think people mean may not be what they really mean

Thinking Reflectively

Exercise:1. Split up into triads (1-speaker) (2-listeners).2. Each person will take a turn being a speaker.3. Each person will share a personal statement

“One thing I like about myself is …”(e.g., I am organized. I am creative.)

4. The listeners respond with “Do you mean that…..” (generate at least 5 for each).

5. The speaker responds with only yes/no.

Reflective Listening

• A reflection is two things:– A hypothesis as to what the speaker

means– A statement

• Statements are less likely than questions to evoke resistance

OARS

Reflections Are Statements

“DO YOU MEAN……?”

• Use a statement to reflect your understanding

• Inflection turns down at the end“You...” “So you...”“Its...” “Its like...”“You feel...”

Reflections Are Statements

• Question:– You’re thinking about stopping? (inflection goes

up)

• Versus a statement:– You’re thinking about stopping. (inflection goes

down)

Reflective Listening

Exercise:1. Split up into triads (1-speaker) (2-listeners).2. Each person will take a turn being a speaker.3. Each person will share a personal statement

“One thing I like about myself is …”OR“One thing about myself I’d like to change is…”

4. The listeners respond with reflections only.5. The speaker can respond with yes/no and elaboration.

Levels of Reflection

• Simple Reflection – stays close– Repeating– Rephrasing (substitutes synonyms)

• Complex Reflection – makes a guess– Paraphrasing – major restatement, infers

meaning, “continuing the paragraph’– Reflection of feeling - deepest

OARS

Not Reflective Listening

Thomas Gordon’s Roadblocks:1. Ordering, directing, commanding2. Warning, cautioning, threatening3. Giving advice, making suggestions, providing

solutions4. Persuading with logic, arguing, lecturing5. Telling what to do preaching6. Disagreeing, judging, criticizing, blaming

Not Reflective Listening

7. Agreeing, approving, praising8. Shaming, ridiculing, blaming9. Interpreting or analyzing, [also labeling]10. Reassuring, sympathizing, consoling11. Questioning, probing12. Withdrawing, distracting, humoring, changing

the subject

Summaries

• Pull together what has transpired thus far in a session

• Strategic use: practitioner selects what information should be included & what can be minimized or left out

• Additional information can also be incorporated into summary – e.g., past conversations, assessment results, collateral reports etc.

OARS

Summarizing

Exercise (part 1): 1. Choose a partner.2. Speaker: for 90 seconds talk about a habit,

behavior, situation you are thinking about changing.

3. Listener: listen only and then give a summary of what you’ve been told.

4. Change roles and repeat.

Summarizing

Exercise (part 2): 1. Change partners.2. Speaker: once again tell your story for 90

seconds w/out interruption.3. Listener: listen only and then give a

summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story.

4. Change roles and repeat.

MI is Directive

Nondirective/ Rogerian Motivational Interviewing

Allows client to determine content and direction of counseling

Systematically directs client toward motivation for change

Explores client’s conflicts and emotions without specific goals for change

Seeks to evoke and amplify discrepancy to enhance motivation for change

Uses empathic reflection noncontingently

Uses reflection selectively to reinforce motivation for change

Avoids interjecting counselor’s advice/feedback

Offers feedback where appropriate

Develop Discrepancy

The logic…• Motivation arises from a discrepancy between

actual and desired states• We can help with motivation by creating and

amplifying discrepancy

In short…• We want to help clients see the contrast

between what they want and what they do

Develop Discrepancy

Ambivalence Over Time in Treatment

Develop Discrepancy

• Explore goals and values with which substance use may conflictLong term recovery goalsValuesDreams Past preferred activitiesAdmired people

Develop Discrepancy

• Client verbalization of negative consequences amplifies discrepancy– Payoff matrix/decisional balance exercise

Advantages

Disadvantages

Using Substances

Not Using Substances

Change and Resistance

Opposite sides of a coin–Resistance–Change talk

Resistance

What is resistance?How is resistance expressed?

• Negating– Blaming, disagreeing, excusing,

minimizing, unwillingness to change• Ignoring

– Inattention, sidetracking, nonanswer• Arguing

– Challenging, discounting, hostility• Interrupting

Resistance

• Counselor behaviors that elicit resistance– Arguing for change (the trap of taking sides)– Assuming the expert role/claiming preeminence– Labeling– Being in a hurry– Criticizing, shaming, or blaming

Resistance

• Resistance is a product of the interpersonal relationship

• Hence, there are things we can do to diminish resistance

• Resistance is a signal to respond differently, it is valuable feedback

Change Talk

• Generally falls into one of these four categories:– Disadvantages of the status quo– Advantages of change– Optimism for change– Intention to change

Change Talk

• Disadvantages of the status quo“I can see that in the long run, this is going to do me in if I

don’t make a change.”“I am ruining my family life.”

• Advantages of change“My boys would like it. They’re always after me to quit.”“Probably I’d feel a lot better.”“At least it would get the courts off my back.”

Change Talk

• Optimism About Change“I think I could probably do it if I decided to.”“I did quit smoking a few years ago. That was tough, and it

took a few tries, but I did it.”“My family would be there to support me.”

• Intention to Change“I definitely don’t want to keep going the way I have been.”“I’ve got to do something.”

Recognizing Resistance and Change Talk

Exercise (part 1):1. Form groups of three.2. One person is the speaker: talk about

something you are trying to change.3. One is the listener: persuade your partner to

make the change (NOT MI).4. One is the recorder: listen for resistance and

change talk and record.

Recognizing Resistance and Change Talk

Exercise (part 2):1. Switch roles.2. Speaker: talk about something you are trying

to change.3. Listener: use OARS.4. Recorder: listen for resistance and

change talk and record.

In its simplest form, the implicit theory of MI posits:

1a. MI will increase client change talk. 1b. MI will diminish client resistance.2a. The extent to which clients verbally defend the

status quo (resistance) will be inversely related to behavior change.

2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change.

Miller, W.R. (2004) Toward a Theory of Motivational Interviewing. motivationalinterviewing.org

Responding to Resistance

• Roll with it!

Roll with Resistance

• Counselor behaviors that defuse resistance – strategies to use– Reflections– Shifting focus– Emphasizing personal control– (Agreement with a twist)– (Reframing)– (Coming alongside)

Reflections

• Simple & Complex Reflections– Repeating, rephrasing, paraphrasing, reflection of

feeling

Double-Sided Reflection

• Captures both sides of the ambivalence

– Client: Okay, maybe I’ve got some problems with gambling, but it’s not like I’m addicted to it.

– Interviewer: You see that your gambling is causing problems for you and your family, and it’s also important that people not think of you as some kind of addict.

Amplified Reflection

• Exaggerated to encourage some retreat

– Client: I couldn’t just give up drinking. What would my friends think?

– Interviewer: You couldn’t handle your friends’ reaction if you quit.

Shifting Focus

• Shift the person’s attention away from what seems to be a stumbling block in the way of progress.

– Client: You’re probably going to give me a diet that I need to stick to, and tell me that I have to get some of these exercise machines or go to a gym every day.

– Interviewer: I don’t know enough about you yet for us to even start talking about what makes sense for you to do. What we need to do right now is…

Emphasizing Personal Control

• Assuring the client that it is he/she who in the end will determine what will happen

– Client: Why are you giving me this booklet? Are you telling me I have to use condoms?

– Interviewer: It’s just information. What you do with it is completely up to you. Naturally, no one can make you use condoms.

Roll with Resistance

Exercise:• Get into groups of three.• Decide who will be the client, the counselor, and the

recorder. • Client: choose and read a resistant scenario or make up

your own.• Counselor: test out alternative strategies for responding.• Recorder: note strategies used and client response, what

seemed to work best?• Switch roles and use a new scenario.

Roll with Resistance

Exercise Scenarios:• “Who are you to tell me what to do? What do you know

about crack? You probably never even smoked a joint!

• “Cocaine is not really my problem. What I want to talk about is my roommate—now he’s a problem!”

• “Look, I’ve been in detox dozens of times before. I’m hopeless. I just want to dry out and go home.”

• “I really like pot! It’s the only good thing about my day and I don’t want to quit!”

Responding to Change Talk

• Elaborating • Reflecting• Summarizing• Affirming

Elaborating

• Ask for clarification– “In what ways? When?”

• Ask for a specific example– “Give me an example. Tell me about the last time that

happened.”

• Straightforward encouragement to continue– “What else?”– “What else have you noticed or wondered about your

_____?”

Reflecting

• Selectively reflecting• If the reflection evokes the other side

(resistance) then recover with a double sided reflection

Summarizing

• Consciously selective• Gather together “bouquets” of change

statements and offer them back

Affirming

• Simply comment positively– “That’s a good point”– “That sounds like a good idea”– “I think that could work”– “I can see how that would concern you”

Eliciting Change Talk

• Asking evocative questions• Using the importance ruler• Exploring the decisional balance• Describe a typical day• (Querying extremes)• (Looking back)• (Looking forward)

Asking Evocative Questions

• Use open questions to explore client’s own concerns

• Assume the person is feeling ambivalent and has at least some concerns

Asking Evocative Questions

• What hassles have you had in relation to your drug use?

• In what ways has your drinking been a problem for you?

• What is there about your drinking that you or other people might see as a reason for concern?

Using the Importance Ruler1.

2. “Why are you at a ___ and not a zero?”

“On a scale from 0 to 10, how important to you is it to change your ______ ?” Not at all Extremely Important Unsure Important

0 1 2 3 4 5 6 7 8 9 10

Importance Ruler

Exploring the Decisional Balance

• Asking about both the positives and negatives of the behavior

• Asking about the pros and cons of change• Doing the payoff matrix

Describe a Typical Day

• Ask the person to walk you through a typical day

• Areas of concern often emerge naturally

Change Talk

Exercise:• Get into groups of three.• Each person selects a role: speaker, listener, recorder.• This is the first session.• Speakers, your job is to come in considering that you want to make a

change either in yourself or in your life but still feel very ambivalent about.

• Listeners, your job is to open up the session and practice using OARS and strategies for eliciting change talk as best you can.

• Observers, your job is to note the open ended questions, reflective listening statements, affirmations, summaries and strategies to elicit change talk.

• Switch roles.

Support Self-Efficacy

What is self-efficacy?

• Extent to which the person feels ABLE to change

Support Self-Efficacy

• People cannot be ready to change until they perceive both that they want to and are able to do so

• The client, not the counselor, is responsible for choosing and carrying out the change

• Our own belief in the person’s ability to change becomes a self-fulfilling prophecy

• We can support self-efficacy in the spirit of MI

Responding to Confidence Talk

• Elaborating• Reflecting• Summarizing• Affirming• Raising possible problems and challenges

Responding to Confidence Talk

• Elaborating– Straightforward encouragement to continue

• “Why else do you think you could succeed?”• “How else could you do it?

• Reflecting– Selectively reflect themes, experiences, ideas &

preferences that suggest the client’s perceived ability to make the change

• “I quit once before.” “You can do it again.”

Responding to Confidence Talk

• Summarizing– Consciously selective– Gather together “bouquets” of confidence

statements and offer them back

• Affirming– Simply comment positively

• “I think that could work”• “I bet your family believes you can do this”

Responding to Confidence Talk

• Raising possible challenges – Stimulate further thought and specificity

• “What might you do if _____?”• “How could you respond if _____?”• “What do you think would happen if _____?”

Eliciting Confidence Talk

Strategies:• Evocative questions• Confidence ruler• Reviewing past successes• Exploring personal strengths & supports• Brainstorming• Reframing• Giving information & advice• Hypothetical change

Support Self-Efficacy

Traps:• “I’ll take over now, thank you”

• Abandons MI and responds to low confidence with a prescription

• “There, there you will be fine” • Not taking the confidence issue seriously

• Gloom a deux• Sharing the client’s hopelessness and helplessness

Take Home Messages

• Do a payoff matrix• Elaborate change talk• When in doubt, reflect

Learning MI – Next Steps

• What is one MI skill you are committed to developing in the next month?

• What are some of the barriers you see to using MI?

• How ready are you to start using some MI strategies and techniques?

• What specific plans do you have to continue learning MI?

Resources for Learning Motivational Interviewing

• Motivational Interviewing (2002) Miller & Rollnick

• www.motivationalinterview.com (Training tapes, articles, bibliographies, training opportunities)

• Enhancing Motivation for Change in Substance Abuse Treatment, Tip 35