Motivational Interviewing

Halima S. Qureshi
Lecturer | Clinical Psychologist
NUMS

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-1
Reserved
 Introduction

•Collaborative, person-centered, form of

guiding to elicit and strengthen motivation to
change
•Born out of the substance abuse field and is
becoming more accepted amongst other
clinical issues

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-2
Reserved
 History of MI

•Created in early 1980’s by William R. Miller and Stephen

Rollnick
•Started in response to then current beliefs about substance
abuse counseling that stated:
• Substance abusers are defective and must be “fixed”
• Substance abusers offer nothing in counseling
• Use of confrontation is necessary to break down denial
• Clients must admit to being addicts before they can
change
•These beliefs increased client resistance

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-3
Reserved
 Goals of MI

•Increase intrinsic motivation to change a

behavior

•Help lower resistance during counseling

•Help clients resolve ambivalence

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-4
Reserved
 Influences on MI
•Client-centered counseling
• MI is considered a gentle, persuasive style, but
can differ from client-centered counseling in that it has
a directive quality as well
•Transtheoretical model of change
• The stages of change (precontemplation,
contemplation, preparation, action, maintenance)
provides a model for how to implement MI techniques
•It is important to note that MI is not the same as either
theory; but rather, it uses each theory to inform it’s
techniques and principles
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-5
Reserved
 MI Spirit
•The foundation of MI
•Adherence to MI spirit requires
• Collaboration
• Evocation
• Client autonomy
• Compassion
•Techniques and principles of MI must be
implemented in a way that highlights the MI spirit
•Consistent with a guiding communication style

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-6
Reserved
 Principles of MI

•Avoiding argumentation
• Arguments are counterproductive and
increase resistance
•Rolling with resistance
• Understanding and accepting clients’
resistance increasing feelings of respect in the
counseling relationship
•Expressing empathy
• Clients can identify their own reasons for
change when they feel unconditionally
accepted in the counseling relationship
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-7
Reserved
 Principles of MI Continued
•Developing discrepancy
• In order for change to take place, it is helpful for
clients to experience a discrepancy between their goals
and the problematic behavior
•Supporting self-efficacy
• Enhance clients’ perceptions of their ability to change
•Remember: RULE
• Resisting the righting reflex
• Understanding the client’s own motivations
• Listen with empathy
• Empower client
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-8
Reserved
 The Four Key Processes of MI
•Engaging
• Establishing a solid, collaborative relationship
with the client
•Focusing
• Help clients find direction in terms of what they
want
•Evoking
• Explore client ambivalence
•Planning
• Strengthening commitment and developing a
collaborative plan to move ahead
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-9
Reserved
 Increasing Importance
•The more important change is perceived to be by the client, the
more effort they will put in to working toward change
•Techniques to facilitate increasing importance
• Reflective listening
• OARS: open-ended questions, affirmations, reflections, and
summary
• Develop discrepancies
• Ruler exercise
• Roll with Resistance
• Worst-case/best-case outcomes
• Find out what is important and negotiate for change
• Explore importance of events that instigated counseling

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-10
Reserved
 Resolving Ambivalence
•MI considers ambivalence to be normal.
•One goal of MI is to decrease ambivalence
so clients do not feel stuck between feelings
(giving up substances vs. continuing to use
substances)
•Eliciting change talk
• MI highlights clients’ natural
statements about making changes and
reinforcing them in order to decrease
ambivalence
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-11
Reserved
 Resolving Ambivalence Continued
•Methods for eliciting change talk
• DARN: desire to change, ability to change, reasons to
change, need for change
• Commitment language
• Taking steps
• Problem recognition
• Expression of concern
• Intention to change
• Optimism
•Handling resistance
• Low resistance in the counseling environment is necessary
to resolving ambivalence
•

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-12
Reserved
 Resolving Ambivalence
•Strategies for handling resistance
• Reflective responses
• Strategic responses
•Strategies to resolve ambivalence
• OARS
• Clarify target behavior
• Importance ruler exercise
• Explore both sides of ambivalence
• Decisional Balance (pro/con exploration)

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-13
Reserved
 Enhancing Confidence
•Clients may place high importance on changing behaviors but
have difficulty making changes because they lack confidence
•Strategies for building confidence
• Open-ended questions focused on ability and strengths
• Ruler exercise focused on confidence
• Personal supports
• Past successes at changing a behavior
• Offering information and advice-MI consistent
• Hypothetical change, envisioning change, anticipating
barriers
• Explore barriers to change

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-14
Reserved
 Strengthening Commitment
•Clients are ready for change when they express a
lot of change talk and are high on importance,
confidence and readiness.
•Clinicians assist in developing a plan and
encouraging action
•It is importance for clinicians to be sure the client is
ready for change rather than pushing for change
(collaboration)
•Change plans should be specific, include awareness
of barriers and plans to overcome barriers, include
personal supports and time frames

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-15
Reserved
MI in the Treatment of Diverse Populations

•The basic tenets of MI seem to be well suited

for work with diverse populations; however,
little research has been done to support this
•MI has gained support worldwide and is used
with a variety of client populations
•Most research supports MI as effective with
diverse populations, but more research is
needed

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-16
Reserved
 Running Case Study: Michael

•Michael is high on importance related to his drinking,

but continues to feel strong ambivalence about stopping
•Clinician uses affirmations while setting the agenda. He
uses open questions, affirming, reflecting, summarizing,
the ruler exercise, pro/con exploration, best-case/worst-
case outcomes, and emphasizing change talk throughout
the session in order to resolve ambivalence and enhance
client confidence.
•Client and clinician collaboratively developed an action
plan
•Michael remained non-defensive and demonstrated little
resistance
•
•
Lewis. Substance Abuse and Addiction Treatment: Practical Application of
Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-17
Reserved
 Strengths, Limitations, and Ethical Issues of MI
•Strengths
• Applicable with diverse populations
• Respectful and strength-based
• Applicable across a wide range of behavior problems
• Places greater responsibility on clinician when
resistance is high
• Offers skills for “difficult” clients
• Empirically supported
• Can be integrated into other approaches to substance
abuse treatment

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-18
Reserved
 Strengths, Limitations, and Ethical Issues of MI
Continued
•Limitations
• Some situations may warrant education, advice, and
direction
• Little is known about when MI is most and least
effective
• More research is needed on use with diverse
populations
•Ethical issues
• Some concern about manipulation
• Can be unethical if the clinician has bias about the
needs of the client, has influence over the client, or is
personally invested in the outcome of the client

Lewis. Substance Abuse and Addiction Treatment: Practical Application of

Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights 5-19
Reserved