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? .

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

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 .

– The kind of help an individual needs depends on their readiness to change.Recovery means Change • The decision to change a behavior occurs in a series of steps. • Match help to the stage. .

Di Clemente.Stages of Change Diagram Termination Action Maintenance Preparation Relapse & Recycle Contemplation Pre-contemplation Prochaska. Norcross 1992 .

Action 5. 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. Contemplation 3. Precontemplation Basic Definition A person that is not seeing a need for a lifestyle or behavior change 2.Stages of Change Stage 1. Maintenance .

Stages of Change & Therapist Tasks PRECONTEMPLATION Raise doubt .Evoke reasons for change.Increase the client’s perception of risks and problems with current behavior Tip the decisional balance . Develop a plan Help the client implement the plan. Strengthen client’s self-efficacy for behavior change Help the client to determine the best course of action to take in seeking change. Support self-efficacy Help the client identify and use strategies to prevent relapse. Use skills. and action. without becoming stuck or demoralized because of relapse CONTEMPLATION PREPARATION ACTION MAINTENANCE RELAPSE . Resolve associated problems Help the client recycle through the stages of contemplation. Problem solve. risks of not changing. preparation.

WAR • Willing: The importance of change • Able: Confidence for change • Ready: A matter of priorities Able .Readiness Ruler .

The first step towards getting somewhere is to decide that you are not going to stay where you are. Pierpont Morgan . J.

The goal of motivational interviewing is to create and amplify discrepancy between present behavior and broader goals. client-centered counseling style that enhances motivation for change by helping the consumer clarify and resolve ambivalence about behavior change.Motivational Interviewing Motivational interviewing is a directive. Create cognitive dissonance between Where one Is now Where one wants to be .

he will stay as he is. but if you treat him as if he were what he ought to be and could be. Johann Wolfgang Von Goethe . he will become what he ought to be and could be.If you treat an individual as he is.

• Motivation for change does not reside solely within the client.Motivational Interviewing Assumptions • Motivation is a state of readiness to change. This state can be influenced. • People struggling with behavioral problems often have fluctuating and conflicting motivations for change. which may fluctuate from one time or situation to another. also known as ambivalence. Ambivalence is a normal part of considering and making change and is NOT pathological .

. 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.Motivational Interviewing Assumptions • The counselor’s style is a powerful determinant of client resistance and change.

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

Express Empathy • • • • • Acceptance Warmth Openness Personal value Understanding .1.

.Reflective Listening • Reflective listening is key to accurate empathy.e. when there is resistance. . • Use reflective listening when you get ahead of your client. i. • Reflective listening is a fundamental skill of motivational interviewing.

What people really need is a good listening to. Mary Lou Casey .

but substitute words or slightly rephrase. • Rephrasing: Stay close to what the client said.Types of Reflective Statements • Repeating: Repeat a portion of what the client has said. May only consist of one or two words. .

Types of Reflective Statements • Paraphrasing: Therapist makes a guess at the unspoken meaning and reflects this back in new words. (Not an interpretation.) . • Reflection of feeling: Paraphrase which emphasizes the emotional content of the consumer’s statement.

“On the one hand… On the other hand…” • Provides a summary of the conversation up to that point.Summarizing • Allows individual to hear him/herself a second time. . • Allows the interviewer to reflect both sides of the ambivalence. • Can be used to transition to a new topic.

I’m a lousy father. Everything I try to do turns rotten. Sometimes I wonder whether it’s worth it.” . Nothing good ever happens to me.A fifty-nine-year-old unemployed teacher says: “ My life just doesn’t seem worth living any more. I can’t get a job.

you can imagine ever taking medication for something. . • Amplified reflection: – Client: No one I know know takes medication. – Counselor: You’re not feeling talkative today.More Types of Reflective Statements • Simple reflection: – Client: I don’t have anything to say. – Counselor: So. it just seems like it would be such a hassle.

but it’s so hard to stick to a workout plan. you think your self-esteem would improve if you lost weight.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 on the other hand. trying to work out consistently is challenging. – Counselor: On the one hand.

Directing. or Providing Solutions • Persuading with Logic.Roadblocks to Listening • Ordering. Lecturing. Making Suggestions. or Arguing . or Commanding • Warning or Threatening • Giving Advice.

Criticizing. or Blaming • Agreeing. or Praising • Shaming. or Telling Clients what they “should” do • Disagreeing. Approving.Roadblocks to Listening • Moralizing. or Labeling . Preaching. Ridiculing. Judging.

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

Develop Discrepancy • Awareness of consequences is important • Discrepancy between behaviors and goals motivates change • Have the client present reasons for change .2.

do not impose them • Clients are valuable resources in finding solutions to problems . Roll with Resistance • Use momentum to your advantage • Shift perceptions • Invite new perspectives.3.

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 .4.

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 .

• Listen Reflectively • Summarize • Elicit self-motivational statements/change talk – DARN C .Five Early Strategies: OARS • Ask Open-ended questions • Affirm: Try to reinforce anything that leads to change and builds the relationship.

Eliciting Change Talk • • • • D = Desire statements A = Ability statements R = Reasons statements N = Need statements • C = Commitment language .

” .” “I want to take better care of my kids.” “I wish I could make my life better.” “Getting in shape would make me feel so much better about myself.Desire Statements • • • • “I’d like to quite drinking if I could.

I could probably find a job.” • “That might be possible.Ability Statements • “I think I could do that.” .” • “I’m thinking I might be able to cut back on cigarettes.” • “If I just had someone to help me.

even if you decided to? • What do you see in yourself in terms of ability that might be encouraging. what do you think would work for you? • What makes you think you can change.Questions To Elicit Change Talk Desire/Ability: • If you decided to change. if you decided to change? .

” • “To keep my truck driving license. I should probably cut down on my drinking.” .Reasons Statements • “I have to quite smoking because of my asthma.” • “I want my kids to have someplace they can call home.” • “My husband may leave me if I don’t go to therapy.

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.” • “I’ll die if I keep using like this.” • “Something has to change or my marriage will break.

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.

.what makes you think you should change? ...and on the other side..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.

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

use complex reflections more than half the time .Remember • Talk less than your client does • On average. reflect (at least) twice for each question you ask • When you reflect.

taking the “good” side of an argument) . confronting. giving unwelcome advice or direction.Remember • When you do ask questions. ask mostly open-ended questions • Avoid getting ahead of your client’s readiness (warning.

Ask evocative questions 2. Explore goals and values 10. Come alongside . Ask for examples 5. Ask for elaboration 4. Explore decisional balance 3. Query extremes 8.10 Strategies for Evoking Change Talk 1. Look back 6. Use change rulers 9. Look forward 7.

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) _______________ _______________ _______________ .

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 .Thinking About Drinking Here is an example of a woman drinker.

Conducting a Decisional Balance Discussion • Accept all answers.) • Explore answers. • Explore costs/benefits with respect to client’s goals and values. (Don’t argue with answers given by client. • Review the costs and benefits. • Be sure to note both the benefits and costs of current behavior and change. .

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. or objecting • Decreased questions about the problem – the client seems to have enough information • Resolve – the client appears to have reached a resolution . interrupting. denying.

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 .

what can you do? .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 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 • Key Questions cont.. -how would you like things to turn out for yourself? -of the things that concern you.

what would be different? .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.

. in making a change are.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. ...

I will know that my plan is working if: 6. The ways people can help me are: Person Possible ways to help 5. The steps I plan to make in changing are: 4. The changes I want to make are: 2.Change Plan Worksheet 1. The most important reasons I want to make these changes are: 3. The things that could interfere with my plan are: .

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

8 Stages in Learning Motivational Interviewing 1. 5. 7. 6. 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 . 3. 2. 4.

0) • Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA:STEP) – Self-Assessment .Motivational Interviewing Tools • Motivational Interviewing Treatment Integrity (MITI 3.

motivationalinterview.midattc. one is in the substance abuse section and the other is in the MISA section. Guilford Press • Squires.bhrm. (2002).References www. D. T. William R.B.org (There are actually two different papers. Miller & Stephen Rollnick. & Moyers.D.org/MIASTEP/ • Motivational Interviewing:Preparing People for Change. Online at www. Motivational Interviewing.org http://www. 2nd Edition.) .