Reflections on Motivational Interviewing

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• Reflections on Motivational Interviewing

Cardiff September 27, 2011
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1983

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1991
MI-1

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2002
MI-2

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2008

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2012
MI-3

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2022
MI-4

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Generalized Principles of MI
X

1. Express Empathy
2. Develop Discrepancy
3. Avoid Argumentation
4. Roll with Resistance
5. Support Self-Efficacy

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Two Phases of MI
X

• Phase 1 Strengthen motivation for change
• Phase 2 Consolidate commitment to change

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RESISTANCE

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The Underlying Spirit of MI
Partnership Evocation Acceptance Compassion
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Change is Broader than Behavior

• Decision to make a choice
• Forgiveness, Leaving or staying
• Attitude - to become a different person
• To be more Compassionate, Assertive etc.
• Resolution - Acceptance
• Complicated grief
• Finding peace regarding a decision
• Tolerance for anxiety, uncertainty etc.

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Four Fundamental Processes in MI

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Relational Motivational
Foundation Interviewing

1. Engaging
2. Focusing
3. Evoking
4. Planning
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The processes are somewhat linear ... .

• Engaging necessarily comes first
• Focusing (identifying a change goal) is a
  prerequisite for Evoking
• Planning is logically a later step
• Engage Focus Evoke Plan

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. . . . and yet also recursive

• Engaging skills (and re-engaging) continue
  throughout MI
• Focusing is not a one-time event re-focusing is
  needed, and focus may change
• Evoking can begin very early
• Testing the water on planning may indicate a
  need for more of the above

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Planning
Evoking Evoking
Focusing Focusing Focusing
Engaging Engaging Engaging Engaging
Four Foundational Processes
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Is it MI Yet?
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Can it be MI without . . .

• Engaging ?
• Focusing ?
• Evoking ?
• Planning ?

No No No Yes
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So it becomes MI when . .

• 1. The communication style and spirit involve
  person-centered, empathic listening (Engage)
• AND
• 2. There is a particular identified target for
  change that is the topic of conversation (Focus)
• AND
• 3. The interviewer is evoking the persons own
  motivations (or plans) for change (Evoke)

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A continuum of styles that can be used in all
four processes
Directing ltgt Guiding ltgt Following
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Core counseling skills that can be used in all
four processes

• Open questions
• Affirmation
• Reflection
• Summary
• Offering information and advice

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Direction Language

• Directing as a counselor behavior
• Direction as focus
• Directional (not directive) as a
  description of MI as goal-oriented

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Three Essential Elements in any Definition of MI

1. MI is a particular kind of conversation about
   change (counseling, therapy, consultation, method
   of communication)
2. MI is collaborative (person-centered,
   partnership, honors autonomy, not
   expert-recipient)
3. MI is evocative, seeks to call forth the persons
   own motivation and commitment

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Definitions of MI

• Three levels of definition (of increasing
  specificity)
• 1. A laypersons definition
• (Whats it for?)
• 2. A pragmatic practitioners definition
  (Why would I use it?)
• 3. A technical therapeutic definition
• (How does it work?)

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1. A laypersons definition(Whats it for?)

• Motivational interviewing is a collaborative
  conversation style for strengthening a persons
  own motivation and commitment to change

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2. A pragmatic practitioners definition (Why
would I use it?)

• Motivational interviewing is a person-centered
  counseling method for addressing the common
  problem of ambivalence about change

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3. A technical therapeutic definition (How
does it work?)

• Motivational interviewing is a collaborative,
  goal-oriented style of communication with
  particular attention to the language of change.
  It is designed to strengthen personal motivation
  for and commitment to a specific goal by
  eliciting and exploring the persons own reasons
  for change within an atmosphere of acceptance and
  compassion.

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Counseling with Neutrality

• Neutality is not a therapist attribute (like
  equanimity composure, balance, emotional
  stability)
• Neutrality is the conscious clinical decision to
  try not to influence a clients direction of
  choice or change
• Neutrality can be about
• Focusing (whether to pursue a change goal)
• Planning (how to pursue a change goal)

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Counselor Aspiration

• Should I proceed strategically to favor the
  resolution of the clients ambivalence in a
  particular direction?
• or
• Do I want to maintain neutrality and not
  intentionally or inadvertently steer the person
  in one particular direction?
• MI was originally developed for the former
  situation

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Engaging and Focusing
Identification of Change Goal
A conscious choice
Aspiration
Equipoise
Evoking Planning
Decisional Balance
Both choices involve partnership, acceptance and
compassion
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Equipoise is where a classic decisional balance
makes sense
Giving intentionally balanced, equal attention
to pros and cons in Inquiry Elaboration
Affirmation Reflection Summaries
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2 x 2 Decisional Balance Grid PROs and CONs of
Change
Status Quo or Option A Change or Option B
Advantages Good things about Status Quo or Option A CON Good things about Change or Option B PRO
Disadvantages - Less-good things about Status Quo or Option A PRO Less-good things about Change or Option B CON
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Change Talk

• Change talk is any client speech that favors
  movement in the direction of change
• Previously called self-motivational statements
  (Miller Rollnick, 1991)
• Change talk is by definition linked to a
  particular behavior change goal
• DARN CATs

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Preparatory Change TalkFour Examples

• DARN
• DESIRE to change (want, like, wish . . )
• ABILITY to change (can, could . . )
• REASONS to change (if . . then)
• NEED to change (need, have to, got to . .)

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Mobilizing Change TalkReflects resolution of
ambivalence

• CATs
• COMMITMENT (intention, decision, promise)
• ACTIVATION (willing, ready, preparing)
• TAKING STEPS

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Yet another metaphor
MI Hill
Preparatory Change Talk
Mobilizing Change Talk
Preparation
Action
Contemplation
(Pre-)
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Responding to Change TalkAll EARS

• E Elaborating Asking for elaboration, more
  detail, in what ways, an example, etc.
• A Affirming commenting positively on the
  persons statement
• R Reflecting, continuing the paragraph, etc.
• S Summarizing collecting bouquets of change
  talk

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Change Talk and Sustain Talk

• Opposite Sides of a Coin

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Examples of Sustain TalkThe other side of
ambivalence

• I really like marijuana (D)
• I dont see how I could give up pot (A)
• I have to smoke to be creative (R)
• I dont think I need to quit (N)
• I intend to keep smoking and (C) nobody can
  stop me
• Im not ready to quit (A)
• I went back to smoking this week (T)

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What is Resistance?
X

• Sustain Talk Discord

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Sustain Talk and Discord

• Sustain Talk is about the target behavior
• I really dont want to stop smoking
• I have to have my pills to make it through the
  day
• Discord is about your relationship
• You cant make me quit
• You dont understand how hard it is for me
• Both are highly responsive to counselor style

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What is Discord?

• Behavior
• Interpersonal (It takes two to have discord)
• A signal of dissonance in your relationship
• Predictive of (non)change

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Some Discord Signals

• Defensiveness
• Arguing
• Challenging Discounting Hostility
• Interrupting
• Talking over the counselor
• Ignoring
• Inattention Changing the subject

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MI in Child Protection Services

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Dual Roles in CPS

• To facilitate change in the caregivers
• To protect and serve the childrens best
  interests
• Similar to dual roles in probation/parole
• Fulfilling role 1 serves role 2

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The Righting Reflex

• Righting is serious business in CPS
• Passion or anxiety to protect can easily create
  an adversarial role in which
• The worker advocates for change
• The client is defensive and resistive
• This is the quintessential clinical dilemma for
  which MI was developed

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Engaging

• An early and important task in MI
• Promoted primarily by OARS
• Can occur relatively quickly
• An opposite style from fact-questioning
• Research question Does MI-based engaging yield
  critical information more honestly and quickly
  than asking questions?

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Focusing

• Sometimes the worker must set the focus
• Violence
• Attending school
• Substance abuse
• Challenge How to avoid rapid focus problems
  and unconstructive adversarial interactions when
  you must address it?
• One key Engage first

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Evoking

• MI is all about confrontation
• Self- confrontation - Donald
  Forrester
• Open questions and reflection help people look in
  the mirror
• Evoking clients own change talk
• Challenge Practice may jump quickly to planning
  in CPS due to urgency

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Planning

• With engagement and focus in place,
• and evoking as much motivation and commitment to
  the goal as feasible
• Develop a specific plan and elicit an
  implementation intention
• Challenge Clearly and compassionately explain
  the consequences

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