Motivational Interviewing

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Motivational Interviewing Ed Stellon, Heartland
Alliance
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Introductions

• Who are you?
• With which program and in what capacity are you
  working?
• What do you hope to learn from this workshop?

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Heartland AlliancePhilosophy of Care

• Human Rights
• Harm Reduction
• Strength-Based Assessment Intervention
• Trauma-Informed
• Invite, Recognize, Embrace Differences

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Primary Source

• Miller, W. R. Rollnick, S. (2002). Motivational
  interviewing Preparing people for change, Second
  Edition. New York The Guilford Press.

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• Anyone who willingly enters into the pain of a
  stranger is truly a remarkable person.
• Henri J. M. Nouwen

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• When given a choice between changing and proving
  that it is not necessary, most people get busy
  with the proof.
• John Galbraith

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Are you Ready?Importance and Confidence

• How important is it to you now to learn new ways
  to enhance the motivation of your participants?
• How confident are you that you could employ new
  methods if you wanted to?

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Stages of Change
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Research Evidence Suggests

• A cyclical pattern of movement through specific
  stages of change
• A common set of processes of change
• A systematic integration of the stages and
  processes of change (doing the right things at
  the right times)

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Stages of Change

• Precontemplation
• Contemplation
• Determination/Preparation
• Action
• Maintenance
• Termination

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Stages of Change
PRE-CONTEMPLATION Not yet considering possibility
of change.
RELAPSE Help renew contemplation, action without
giving up.
CONTEMPLATION Considers change rejects
it.Reasons for concern vs. justifications for
concern
MAINTENANCE Identify Strategies support
to prevent relapse
PREPERATION or DETERMINATION Ive got to
do something about this problem. This is
serious. Something has to change.
ACTION
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Stages of Change

• Precontemplation No intention to change
  behavior in the foreseeable future. Individuals
  in this stage are unaware or underaware of their
  problem(s).
• Not even thinking about it

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The Five Rs of How and Why People Stay in
Precontemplation

• Reveling
• Reluctance
• Rebellion
• Resignation
• Rationalization

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Stages of Change (cont.)

• Contemplation A person is aware that a problem
  exists, are seriously considering changing, and
  have not yet made a commitment to take action.
  Contemplators perform a risk-reward analysis.
• Thinking about it or maybe

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Stages of Change (cont.)

• Preparation Individuals are intending to take
  action and may practice some of the behaviors
  necessary.
• Getting ready to do it
• Action In this stage individuals modify their
  behavior, experiences, or environment in order to
  overcome their problems. Doing it
• Maintenance Individuals in this stage work to
  prevent lapse/relapse and consolidate gains.
  Living it
• Termination The problem ceases to be a problem.
  Moving on

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STAGES OF CHANGE THERAPIST TASKS
Raise doubt - Increase the participants
perception of risks and problems with current
behavior
PRECONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing Strengthen
self-efficacy for behavior change
CONTEMPLATION
Help to determine the best course of action to
take in seeking change Develop a plan
PREPARATION
Help implement the plan Use skills Problem
solve Support self-efficacy
ACTION
Help identify and use strategies to prevent
lapse/relapse Resolve associated problems
MAINTENANCE
Help recycle through the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
RELAPSE
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TerminationLeaving the Cycle of Change

• Low temptation
• High self-efficacy
• Firmly established pattern of new behavior
• New behavior is normative
• Multiple changes in other dimensions to sustain
  change

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Approaches to Change
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Why Do People Change?

• People change voluntarily only when
• They become interested in or concerned about the
  need for change
• They become convinced that the change is in their
  best interests or will benefit them more than
  cost them
• They organize a plan of action that they are
  committed to implementing
• They take the actions that are necessary to make
  and sustain the change

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Motivational Statements

• The beatings will continue until morale
  improves.
• If you dont stop crying, Ill give you
  something to cry about.
• You will take this medicine, because as your
  Doctor, I say so.
• If you dont stop, I guarantee something bad
  will happen!

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Motivational Approaches

• Coercion
• Persuasion
• Constructive Confrontation
• External Contingencies (threats)
• Bribe/Incentive
• Beg

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• People are generally better persuaded by the
  reasons they themselves discover than by those
  that enter the minds of others.
• Pascal

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• It is the truth we ourselves speak rather than
  the treatment we receive that heals us.
• O. Hobart Mowrer

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Predictable Effects of Confrontation

• Resistance Non-cooperation
• Reversal Eliciting the Opposite in
  Ambivalence
• Reactance Assertion of Autonomy

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Q
Where does the statement
You have a problem.
get you and the participant?
A
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In motivational interviewing, confrontation is the
GOAL, not a style.
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The purpose of confrontation is to see and accept
reality,
so one can change accordingly.
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Ambivalence

• Conflict between two courses of action
• Normal, acceptable, and understandable
• Must be resolved to move forward with change and
  reduce the probability of lapse/relapse

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What is Motivation?

• Motivation can be thought of not as a
  participant attribute, but as an interpersonal
  process between therapist and participant.
  Research clearly demonstrates that the
  interaction between therapist and participant
  powerfully influences participant resistance,
  adherence, and change.

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Motivation The Change Process

• Participants are not unmotivated. They are just
  motivated to engage in behaviors that others
  consider harmful and problematic or are not ready
  to begin behaviors that others think would be
  helpful.

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What is Motivation?

• The proper question is not,
• Why isnt this person motivated?
• But rather,
• For what is this person motivated?

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Principles of Motivational Interviewing
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The Spirit of Motivational Interviewing (Miller
Rollnick, 2002)

• Motivational Interviewing
• Collaboration
• Evocation
• Autonomy
• Dancing

• Opposite Approach
• Confrontation
• Education
• Authority
• Wrestling

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What is Motivational Interviewing?
Motivational Interviewing is a
directive, client-centered
counseling style that
enhances motivation
for change by
helping the client
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
and where one
is now
wants to be
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What is Motivational Interviewing?

• Style
• Non- Authoritarian
• Responsibility for change is ultimately left with
  the participant, but the therapist plays a
  crucial role.
• Evokes high levels of change talk, low levels of
  resistance
• Consciously collaborative and intentionally
  directive
• Emphasizes why to change, not how to change

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Some Things We Do To Get in the Way Roadblocks
to Listening (Gordon, 1970)

• Ordering, directing, or commanding
• Warning or threatening
• Giving advice, making suggestions, or providing
  solutions
• Persuading with logic, lecturing, or arguing

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Roadblocks to Listening, cont.

• Moralizing, preaching, or telling participants
  what they should do
• Disagreeing, judging, criticizing, or blaming

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Roadblocks to Listening, cont.

• Agreeing, approving, or praising
• Shaming, ridiculing, or labeling
• Interpreting or analyzing
• Questioning or probing
• Withdrawing, distracting, humoring, or changing
  the subject

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Exercise Roadblocks to Effective Listening

• Discuss something that you are of two minds
  about. Not trivial and not too revealing.
• Responder Use at least two of the roadblocks to
  listening.

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Experience the Problem

• Ordering, Directing, or Commanding
• Warning or Threatening
• Advice, Suggestions, Solutions
• Persuading, Lecturing, Arguing
• Moralizing, Preaching, you should
• Disagreeing, Judging, Criticizing, Blaming.
• Agreeing, Approving, Praising.
• Shaming Ridiculing, Labeling.
• Interpreting, Analyzing.
• Questioning, Probing.
• Withdrawing, Distracting, Humoring, Changing
  Subject

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Principles of Motivational Interviewing

• Principle 1 Express Empathy
• Acceptance facilitates change
• Reflective listening is crucial
• Ambivalence is normal
• Necessary, not sufficient
• Not agreement, approval, permission

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Express Empathy

• Convey sense that participants behaviors make
  sense given their context and participants
  current way of thinking about them.

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Exercise Express Empathy

• Sentence Stems

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Principles of Motivational Interviewing

• Principle 2 Develop Discrepancy
• Awareness of consequences
• Change motivated by highlighting discrepancy
  between current behavior and important personal
  goals/values
• The participant rather than the worker should
  present the arguments for change

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Principle 2 Develop Discrepancy

• Examining, exploring, and exercising ambivalence
  requires that participants take more diverse and
  often conflicted experiences and emotional states
  into account
• Invites participant to consider optionsto create
  space between impulse and action

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Strategies to Develop Discrepancy

• Ask open-ended questions that elicit
  self-motivational statements
• Reflect back, selectively, the self-motivational
  aspects of what the participant states
• Affirm and reinforce the participant for making
  self-motivational statements

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Strategies to Develop Discrepancy

• cont....
• Offer periodic summaries of self-motivational
  themes
• Use substance use assessment results

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Principles of Motivational Interviewing

• Principle 3 Roll with Resistance
• Momentum can be used to good advantage
• Perceptions can be shifted
• New perspectives are invited, not imposed
• The participant is a valuable resource in finding
  solutions

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Principles of Motivational Interviewing

• Principle 3 Roll with Resistance, cont.
• Avoid arguing for change defending causes
  defensiveness
• Resistance is not directly opposed
• Resistance is a signal to respond differently

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Principles of Motivational Interviewing

• Principle 4 Support Self-Efficacy
• Belief that one can change is an important
  motivator
• The participant is responsible for choosing and
  carrying out personal change
• There is hope in the range of alternative
  approaches available
• The worker's own belief in the persons ability
  to change becomes a self fulfilling prophecy

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• If you treat an individual as she is, she will
  stay as she is, but if you treat her as if she
  were what she ought to be and could be, she will
  become what she ought to be and could be.
• Johann Wolfgang von Goethe

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Phase 1 Building Motivation for Change
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Readiness Ruler
Ready

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

Willing
Able
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Importance and Confidence
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Phase I Building Motivation To Change

• Some Early Traps to Avoid
• Question-Answer Trap
• Trap of Taking Sides
• Expert Trap
• Labeling Trap
• Premature-Focus Trap
• The Blaming Trap

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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
• -problem recognition -expression of concern
• -intention to change -optimism about change

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1. Ask Open Questions

• Participant should be doing more than half the
  talking
• Questions that do not invite brief answers
• Avoid asking three questions in a row
• Exercise Is It an Open or a Closed Question?

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2. Listen Reflectively

• S Face the participant SQUARELY
• O Adopt an OPEN posture
• L LEAN toward the participant at times
• E Maintain appropriate eye contact
• R Be RELAXED

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ExerciseLearning to THINK Reflectively

• Reflective listening
• One thing I like about myself is
• You mean that
• The person initiating may only say, yes or no
  to the reflections
• Keep going until you have made five correct
  reflections.

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Reflective Listening

• There are many clinical skills that are helpful
  when one is doing this work. But the most
  important skill to develop, in practicing harm
  reduction work, is that of listening to our
  clients. They will tell us what they need
  (Little, 2001, p. 31).

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• It takes two to speak the truth One to speak,
  and another to hear.
• Henry David Thoreau

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3. Affirm

• Compliments or statements of appreciation and
  understanding

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4. Summarize

• Reinforce what has been said
• Show that you have been listening carefully
• Prepare the participant to elaborate further
• Allow participant to hear his or her own change
  talk for a second or third time
• Type of summaries
• Collecting
• Linking
• Transitional

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5. Eliciting Change Talk

• Invite the participant to give the arguments for
  change
• Types of Change Talk
• Disadvantages of the status quo
• Advantages of change
• Optimism about change
• Intention to change

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Methods for Evoking Change Talk

• Asking Evocative Questions
• Using the Importance Ruler
• Exploring the Decisional Balance
• Elaborating
• Querying Extremes
• Looking Back
• Looking Forward
• Exploring Goals and Values

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Questions that Evoke Self-Motivational Statements

• Disadvantages of the status quo
• What difficulties have you had in relation to
  your drug/alcohol use?
• In what ways has this been a problem for you?
• How does your drug/alcohol use interfere with who
  you want to be?
• What do you think will happen if you dont change?

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Questions that Evoke Self-Motivational Statements

• Advantages of change
• How would you like for things to be different?
• What would be the good things about changing?
• What would you like your life to be like a year
  from now?
• What are the main reasons you see for making a
  change?

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Questions that Evoke Self-Motivational Statements

• Optimism about change
• 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?
• Who could offer you support in making this change?

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Questions that Evoke Self-Motivational Statements

• Intention to change
• 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?

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Decisional Balance

• Ambivalence is a normal part of the process of
  change
• Use conflict to promote positive change
• Weighing pros and cons of behavior
• Highlighting discrepancy
• Most useful in Precontemplation and Contemplation
  stages as a tool to increase motivation

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Decisional Balance Worksheet
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Decisional Balance Worksheet
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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
Good things about changing 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 Less legal trouble Better health
Not so good things about my drinking
Not so good things about changing my drinking
Disapproval from family and friends Increased
chance of legal and job trouble Costs too
much money
More stress or anxiety Feel more
depressed Increased boredom
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Conducting a Decisional Balance Discussion

• Accept all answers. (Avoiding arguing
  with/disputing answers given by participant).
• Explore answers.
• Be sure to note both the benefits and costs of
  current behavior and change.
• Explore costs/benefits with respect to
  participants goals and values.
• Review the costs and benefits.

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Exercise

• Conduct a decisional balance discussion about the
  pros and cons of changing some aspect of his/her
  life, e.g., exercise, smoking, drinking, or diet.

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Resistance

• Arises from the interpersonal interaction between
  counselor and participant
• The participants way of communicating that the
  therapist and participant are at different places
• Change talk reflects movement of the person
  toward change, resistance represents and predicts
  movement away from change
• An opportunity

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Change Talk and Resistance

• Change Talk
• Disadvantages of status quo
• Advantages of change
• Intention of change
• Optimism about change

• Resistance talk
• Advantages of status quo
• Disadvantages of change
• Intention not to change
• Pessimism about change

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What causes resistance?

• Two parties have different goals
• Mismatch of counselor strategy and participant
  readiness level
• Participant or counselor start with a high level
  of anger or frustration
• Roadblocks to communication
• Misunderstanding of the participants intent
• Lack of agreement about roles

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What causes resistance?

• Counselor Responses
• Arguing for change
• Assuming the expert role
• Criticizing, shaming, or blaming
• Labeling
• Being in a hurry
• Claiming preeminence

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Strategies for Handling Resistance

• Simple Reflection (respond with nonresistance)
• Amplified Reflection (my wife nags she
  doesnt have any reason to worry?)
• Double-Sided Reflection (on one hand you like
  the effects of pot, but on the other you worry
  about getting caught)

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Strategies for Handling Resistance

• Shifting Focus (lets not worry about being
  called an alcoholic, maybe we should focus on the
  consequences)
• Agreement with a Twist (youre right, alcohol is
  probably not the only thing affecting your
  marriage)
• Reframing (I know that you could hold your
  liquor from the beginning, but what I suspect, is
  that it indicates a genetic vulnerability)

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Strategies for Handling Resistance

• Emphasizing Personal Choice and Control (it is
  you who ultimately determines how this turns
  out)
• Coming Alongside (maybe you cant live without
  smoking pot)

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Enhancing Confidence

• In general people cannot be ready to change until
  they perceive BOTH that they want to (importance)
  and are able to do so (confidence)
• Confidence is treated as an ambivalence issue it
  is unlikely that the person feels totally unable
  to change
• Low self-efficacy vs. depression, low self
  esteem, learned helplessness

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Enhancing Confidence

• Finding hope and confidence for change is a
  collaborative process in which the counselor is
  privileged to participate (Miller Rollnick,
  2002, p. 125).

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Confidence Traps

• Ill take over now, thank you.
• There, there, youll be fine.
• Gloom à Deux

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Eliciting and Strengthening Confidence Talk

• Evocative Questions
• Confidence Ruler
• Reviewing Past Successes
• Personal Strengths and Supports
• Brainstorming

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Eliciting and Strengthening Confidence Talk

• Giving Information and Advice
• Reframing
• Hypothetical Change
• Responding to Confidence Talk
• Radical Change

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How do I know when a participant is ready to
change?
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Signs of Readiness to Change

• Decreased resistance
• the participant stops arguing, interrupting,
  denying, or objecting
• Decreased discussion or questions about the
  problem
• the participant seems to have enough information
• Resolve
• the participant appears to have reached a
  resolution

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Signs of Readiness to Change

• Change Talk
• statements reflect recognition, concern, openness
  to change, or optimism
• Increased questions about change
• the participant wants to know what they can do
  about the problem

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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

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• We found thatdrinkers would not take pressure in
  any form, excepting from John Barleycorn himself.
  They always had to be led, not pushedWe found we
  had to make haste slowly.
• Bill Wilson

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Strengthening Commitment to Change

• The goals are to channel intrinsic motivation
  into a negotiated, workable plan for change and
  to strengthen the participant's commitment for
  carrying out that plan.
• Does not involve telling people what they must
  do, but rather, eliciting what they want and plan
  to do.

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Strategies for Strengthening Commitment

• A few potential hazards
• Underestimating Ambivalence
• Over-prescription
• Insufficient Direction

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Strategies for Strengthening Commitment

• Recapitulation
• -a summary of participants own perception of
  the problem
• -a summing up of the ambivalence
• -a review of the objective evidence
• -a restatement of participant offerings of
  wanting, intending, or planning to change
• -your own assessment of participants situation,
  particularly when it matches the participants

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Strategies for Strengthening Commitment

• Key Questions to get the participant talking and
  thinking about change
• -what do you think you will do?
• -what does all this mean about your use?
• -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?

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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?

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Strategies for Strengthening Commitment

• Giving Information and Advice
• Quite possible and appropriate to share ones
  expertise
• When a person requests it
• With the persons permission

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Giving Information and Advice

• Have I elicited the participants own ideas and
  knowledge on this subject?
• Is what I am going to convey important to the
  participants safety, or likely to enhance the
  participants motivation for change?
• Have I asked the participants permission to
  share some advice?

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Giving Information and Advice

• Respect, choice, collaboration
• Use qualifiers
• Dont be too eager to offer advice
• Offer a cluster of options
• Solicit request from the person for information
  and advice

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Remember

• Talk less than the participant does
• On average, reflect twice for each question you
  ask
• When you reflect, use complex reflections more
  than half the time

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Remember

• When you do ask questions, ask mostly open
  questions
• Avoid getting ahead of your participants
  readiness (warning, confronting, giving unwelcome
  advice or direction, taking the good side of an
  argument)

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Additional Resources

• www.motivationalinterview.org
• TIP 35 available from www.ncadi.gov
• The books First Second Editions
• Articles
• Additional training and supervision

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