Motivational Interviewing

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Motivational Interviewing
November 16, 2009 Nurse Practitioners
Roundtable The Homestead, Hot Springs,VA Cecilia
van Zyl-Knab, LCSW, MINT Motivation4Change
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You would think . . .

• that having had a heart attack would be enough to
  persuade a man to quit smoking, change his diet,
  exercise more, and take his medication
• that hangovers, damaged relationships, an auto
  crash, and memory blackouts would be enough to
  convince a woman to stop drinking

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And yet so often it is not enough What is the
Key?

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Client Motivation is a Key to Change

• Substance abuse treatment outcomes are predicted
  by
• Pretreatment motivation measures
• Treatment attendance
• Treatment adherence/compliance
• Counselor ratings of motivation and prognosis
• That is, more motivated clients do better

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And Client Motivation is Greatly Influenced by
the Counselor

• Clients motivation, retention and outcome vary
  with the particular counselor to whom they are
  assigned
• Counselor style strongly drives client resistance
  (confrontation drives it up, empathic listening
  brings it down)
• That is, the counselor is one of the biggest
  determinants of client motivation and change

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Readiness for What?

• Rather than asking Why isnt this person
  motivated?
• Ask What is this person motivated for?
• Potential Pitfall Assuming you know.

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Denial

• Research specifically has not found overuse of
  denial, or any other typical patterns of
  defensive styles among people with SUDs

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If its not personality, then what behaviors
cause counselors to perceive clients as being in
denial?

• Disagreeing with the counselor
• Resisting a diagnosis/label
• Declining help
• Showing little distress
• Disavowing a need for counseling or change
• Being non-compliant with treatment prescriptions
• Not changing

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In contrast, counselors tend to perceive clients
as being motivated when they

• Agree with the counselor
• Accept the counselors diagnosis/label
• Express a desire for help
• Show distress
• Voice a need for the counselor/counseling
• Comply with the counselors treatment plan
• Change

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In other words, client motivation is evident in

• Low resistance
• Openness and collaboration
• Expressing emotion
• Adhering to a change plan
• Changing
• All of which are strongly influenced, for better
  or worse, by what the counselor does

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Ambivalence

• The Dilemma of Change

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Stages of ChangeProchaska DiClemente
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Contemplation Stage

• It is easy to think that someone in this stage is
  ready to make a change.
• Work place smokers survey 70-80 contemplation,
  but only 3-5 attracted to programs for change
• Some studies Relationship between contemplation
  higher levels of depression

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Cognitive Behavioral Change

• Seems that cognitive and experiential processes
  of change more important in earlier stages
  (consciousness raising, self evaluation,
  environmental re-evaluation)
• Behavioral processes more important in later
  stages of change (efficacy)

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The Righting Reflex

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You take one side I another

• When you strong argue one side, the ambivalent
  naturally argue the other
• The stronger the argument the less likely
  change occurs

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Common Human Reactions to the Righting Reflex

• Angry, agitated
• Oppositional
• Discounting
• Defensive
• Justifying
• Not understood
• Not heard
• Procrastinate

• ? Afraid
• ? Helpless, overwhelmed
• ? Ashamed
• ? Trapped
• ? Disengaged
• ? Dont come back avoid
• ? Uncomfortable
• ? Resistant

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Common Human Reactions to Being Listened to

• Safe
• Empowered
• Hopeful
• Comfortable
• Interested
• Want to come back
• Cooperative

• Understood
• Want to talk more
• Liking the counselor
• Open
• Accepted
• Respected
• Engaged
• Able to change

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A Change of Role

• You dont have to make change happen
• You cant
• You dont have to come up with all the answers
• You probably dont have the best ones
• Youre not wrestling
• Youre dancing

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Motivational Interviewing Definition

• Motivational interviewing is
• a person-centered,
• directive
• method of communication
• for enhancing intrinsic motivation to change by
  exploring and resolving ambivalence.

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The Spirit of Motivational Interviewing

• Collaboration
• Evocation
• Docere and Ducere
• Autonomy

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Docere and Ducere

• Two Latin verbs regarding education
• Evoking vs. Imparting information
• Docere - lead / impart knowledge or info
• Ducere - to draw forth or evoke from within
• Spirit of MI Ability to draw forth rather than
• pulling the client toward the goal

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Thank You!

• Upcoming 2 Day Training Richmond, VA
• January 14 15, 2010 for more info visit
• Motivation4change.com

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Reference List

• Miller, W. R., Rollnick, S. (2002). Motivational
  Interviewing, Preparing People for Change. 2nd
  Ed. Guilford Press.