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 BeOr Not To Be Motivational?

Conflict Coercion Persuasion External Contingencies (threats) Bribe/incentive Begging Fear

What is the goal?

Were 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

Positive Behavior Focused
Purpose/Intent is to DO BETTER Purpose/Intent is to THRIVE

Risk Reduction
Purpose/Intent is to STOP Purpose/Intent is to OVERCOME

Promotion

Problem Behavior Focused

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
Action Maintenance Preparation Relapse & Recycle

Contemplation

Pre-contemplation
Prochaska, Di Clemente, Norcross 1992

Stages of Change
Stage 1. Precontemplation Basic Definition
A person that is not seeing a need for a lifestyle or behavior change

2. Contemplation
3. Preparation

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

A person has decided to make changes and is considering how to make them A person is actively doing something to change A person is working to maintain the change or new lifestyle, possibly with some temptations to return to the former behavior or small lapses

4. Action
5. Maintenance

Stages of Change & Therapist Tasks

PRECONTEMPLATION Raise doubt - Increase the clients perception of risks and problems with current behavior Tip the decisional balance - Evoke reasons for change, risks of not changing; Strengthen clients self-efficacy for behavior change Help the client to determine the best course of action to take in seeking change; Develop a plan Help the client implement the plan; Use skills; Problem solve; Support self-efficacy Help 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

CONTEMPLATION

PREPARATION

ACTION MAINTENANCE

RELAPSE

Readiness Ruler - WAR

Willing: The importance of change
Able: Confidence for change Ready: A matter of priorities

Able

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 Is now Where one 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 counselors 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 consumers 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 doesnt seem worth living any more. Im a lousy father. I cant get a job. Nothing good ever happens to me. Everything I try to do turns rotten. Sometimes I wonder whether its worth it.

More Types of Reflective Statements

Simple reflection:
Client: I dont have anything to say. Counselor: Youre 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 its 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

Roadblocks to Listening
Interpreting or Analyzing
Questioning or Probing Withdrawing, Distracting, Humoring, or Changing the Subject
From T. Gordon (1970). Parent Effectiveness Training. New York: Wyden.

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
Id 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. Im 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 dont 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
Its really important to my health to change my diet. Something has to change or my marriage will break. Ill 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 dont make a change?

Commitment Language
I might change.

I could consider changing.

Im 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:

Im really mixed up. A lot of my friends, they stay out real late and do things their parents dont know about. They always want me to come along and I dont want them to think Im weird or something, but I dont 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 clients 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 No Change

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

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

Thinking About Drinking

Here is an example of a woman drinker. Remember, every person has different reasons in their decisional consideration about drinking
Good things about my drinking:
More relaxed Will not have to think about my problems for a while More comfortable with drinking friends More control over my life Support from family and friends

Good things about changing my drinking:

Less legal trouble & Better health

Not so good things about my drinking:

Disapproval from family and friends Increased chance of legal and job trouble Costs too much money

Not so good things about changing my drinking:

More stress or anxiety
Feel more depressed Increased boredom

Conducting a Decisional Balance Discussion

Accept all answers. (Dont 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 clients 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

Signs of Readiness to Change

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

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 cant 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....

Change Plan Worksheet

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:

I have not the right to want to change another if I am not open to be changed. Martin Buber

8 Stages in Learning Motivational Interviewing

1. 2. 3. 4. 5. 6. 7. 8. Overall spirit of Motivation Interviewing OARS: Client-Centered counseling skills Recognizing change talk and resistance Eliciting and strengthening change talk Rolling with resistance Developing a change plan Consolidating commitment 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.)