Motivational Interviewing Therese Killeen PhD Overlap in

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Motivational Interviewing

• Therese Killeen PhD

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Overlap in Treatment and Legal Systems

• About 50 to 60 of substance abuse clients are
  legally mandated to substance abuse treatment
• High rate of substance abuse in offenders
• High rate of recidivism in both populations
• Problems are complex
• Drug courts allow for collaboration with the
  treatment and legal system

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Commonalities in Client Characteristics

• Angry
• Frightened about what might happen
• Reluctant to examine abusive/illegal behavior
• Unwilling to relinquish their only sense of
  control
• Difficulty accepting responsibility for their
  behavior

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Goals for rehabilitation

• Increase effectiveness of interactions with
  clients/offenders
• Improve the climate of the criminal justice
  system/ addiction treatment
• Reduce Recidivism
• Help clients/offenders commit to or even consider
  change
• Help engage and remain in treatment
• Build supportive relationships

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Motivational Interviewing

• A client-centered goal directive method for
  enhancing intrinsic motivation to change by
  exploring and resolving ambivalence

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Motivational Interviewing in Special
Populations/Settings

• Substance Use Disorders/Dual Disorders
• Medical/Public Health Settings
• Criminal Justice
• Adolescents
• Couples
• Group Settings

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Outcome Effects Attributed to

• Therapist effects who delivers treatment and
  how
• Process effects what happens between clients
  and therapists
• Laws of learning principles of behavior and
  change

Mesa Grande Review, W. Miller
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AMBIVALENCE

• a state of mind in which a person has coexisting
  but conflicting feelings, thoughts, and actions
  about something
• The I do but I dont dilemma

Status ambivalence
change Quo movement
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Basic Assumptions about the Nature of Motivation

• Motivation is a key to change
• Motivation is Multidimensional
• Motivational is dynamic and fluctuating
• Motivational is influenced by social interactions
• Motivation can be modified
• Motivation can be influenced by clinician style

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Motivation

• Changes are more lasting when autonomously
  /intrinsically versus extrinsically motivated

no external intrinsic motivation
motivation /pressure motivation
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Recurrence
Action
Maintenance
Preparation
Contemplation
Precontemplation
Stages of Change
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How Many Patients Are Ready?
Action
Prep
Precon
Contemplation
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Matching Interventions to Client Stage of Change

• Precontemplation stage - must raise their
  awareness before they can consider change
• Contemplation stage - require help resolving
  their ambivalence and choosing positive change
  over their current situation
• Preparation stage - need help identifying
  potential change strategies and choosing the most
  appropriate one for their circumstances

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Continued -

• Action stage - need help implementing and
  complying with the change strategies and learning
  how to prevent or limit relapse
• Maintenance stage - may have to develop new
  skills for maintaining recovery /behavior change
• Recurrence stage - need help recovering quickly
  and resuming the change process.

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Flexible Pacing

• The concept of pacing requires that clinicians
  meet their clients at the clients levels and use
  as much or as little time as is necessary to
  accomplish the essential tasks of each stage of
  change.

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Critical to MIChange most likely to occur if
client experiences a discrepancy between
values/goals and current behavior.
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Readiness to Change

• Less ready the client is to change, the more
  important it is to do MI
• Clients may vacillate between and during sessions
• Moving into action strategy prematurely may
  adversely affect outcome
• Could be countertherapeutic to continue with MI
  when client is clearly ready for behavior change

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Spirit of MI

• Collaboration
• Evocation
• Autonomy

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Collaboration
Dancing
Wrestling
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High Spirit Evocation

• Elicits the clients ideas about change.
• Curious and patient
• Stay focused on whatever behavior change the
  client is willing to do.

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Being Supportive of High Autonomy

• Accept that the clients may not choose to change.
• Are invested in behavior change but dont push
  it, in order to maintain therapeutic alliance.
• Reinforce that ultimately any behavior change is
  within the realm of the client.

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How is Spirit different from other counseling
characteristics?

• Not sympathy or being soft
• No emphasis on expertise (on the part of the
  counselor)
• Education of client not considered effective (not
  to be confused with exchanging information)
• Does not focus on skill-building
• Does not analyze unconscious motivations

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Fundamental Principles

• Express Empathy
• Develop Discrepancy
• Roll with Resistance
• Support Self-efficacy

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MI MICRO-SKILLSOARS

• Open-ended Questions
• Affirmation
• Reflective Listening
• Summary

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OPEN-ENDED QUESTIONS

• An open-ended question is one where there is more
  than a yes or no response
• Do you realize the number of charges against
  you?
• versus
• What is your understanding of the charges you
  have against you?

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AFFIRMATIONS

• Client Focused
• Building Rapport
• Recognizing and reinforcing Client Strength and
  Effort
• Aimed at
• Supporting Clients Involvement
• Encouraging Continued Attendance
• Assisting Client to see the Positives

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Affirmation Examples

• That was quite an accomplishment.
• You have really done well this week.
• Congratulations, you stuck to your plan.
• You are really putting a lot of effort into this.
• It took a lot to come in today, but you made it.
• You really handled that situation well.

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Reflective Listening

• Statements that lets the client know you are
  listening
• Reasonable guess as to the meaning of what was
  said
• Checking out your assumption with the client

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REFLECTIVE LISTENINGFine tuning

• Level One Repeat
• Level Two Rephrase
• Level Three Paraphrase
• Reflect Feelings
• Summary
• Metaphors, Similes
• Continue the sentence/paragraph

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Client I work hard all day, and deserve some
time to myself. Marijuana helps me wind down.

• Clinician Marijuana helps you settle down after
  a stressful day at work.

Simple reflection
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Client I got charged for distribution of
marijuana. One of my friends turned me in so that
he would get a lesser charge.

• Clinician I imagine you are pretty angry that
  you friend did this to you.

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SUMMARIZING

• Special form of reflection
• Counselor chooses what to include and emphasize
• Include clients concerns about change, problem
  recognition, optimism about change, ambivalence
  about change
• Restatement of any change talk about intention to
  change, and confidence in his or her ability to
  change
• Let client know you are listening

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• You have been charged with a DUI and you really
  dont want to lose your drivers license. Your
  lawyer has recommended that you enter this
  treatment program. While you dont think it is
  necessary because you dont feel you have a
  problem with alcohol, you plan on completing this
  program because you do not want to have this
  charge on your record. In addition, you are
  thinking that maybe getting into this program may
  also improve the situation at home.

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MI Clinician Goals

• Talk less than your client
• Most common response - reflection
• Reflect twice for each question
• Complex reflections (paraphrase and summarize)
  over half the time
• Use open questions
• Avoid getting ahead of clients readiness level

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Change Talk

• Disadvantage of the status quo
• Advantage of change
• Optimism about change
• Intention to change

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EVOCATIVE OPEN QUESTIONS Desire "What do you
want to do about this behavior?" Ability "What
makes you believe you can do this?" Reason/Need
"Why would you want to make this
change?" Commitment "So what are you willing to
do now. Exploring reasons against change. For
example, "What keeps you from making this change"
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Change most likely to occur if client experiences
a discrepancy between values/goals and current
behavior.
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Evoking Change Talk Strategies

• Evocative questions
• Explore decisional balance
• Elaboration
• Examples
• Look back

• Look forward
• Query extremes
• Explore goals and values
• Come alongside

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Evocative Questions

• How might you go about making this change?
• What would be a good first step?
• What obstacles do you foresee and how might you
  deal with them?
• What gives you the confidence that you can do
  this?

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Elaboration

• Tell me more about that.
• What about the last time that happened?
• Give me an example?
• What else?

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Developing Discrepancies

• Use of summaries
• Differences between stated goals and actual
  behavior
• Tip the Balance by making a decision to change
• Use of pros and cons exercise
• So you say that you need to save money to move
  but on the other hand you find yourself spending
  100 a week buying MJ What do you make out of
  this?
• How does your drinking fit in with your having a
  happy family and good job?

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Exploring pros and cons Developing Discrepancies

• What are the good things about your drinking?
• What are the not so good things?

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Readiness Ruler Eliciting Change Talk

• 0 1 2 3 4 5 6 7 8 9
  10
• Not at all Extremely
• How important is it to you to change this?
• How confident are you that you can change this?

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Evoking Change talk

• Why are you at a 5 and not a 1 or 2 ?
• What would need to happen to take it from a 5 to
  say a 7 or 8?

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Imagine extremes

• What is the worst that can happen if you
  continued?
• What do you think would have to happen to make
  you decide to tell yourself, ok thats enough?

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Looking Forward

• What would you like your life to be like in 2
  years?
• How does what you are doing now make that
  difficult?
• What would it be like if you continue with the
  way things are now?
• Suppose things dont change, how do think your
  life will look?

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Looking Back

• When was the last time things were going well
  for you and what was it like for you?
• What do you think could have prevented this
  setback?
• Before you used , what was your life like?
• As you step back and look at all this, what do
  you make of it?

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CLIENT RESISTANCE

• Involves feelings-actions-behaviors of an
  interpersonal nature where there is a lack of
  collaboration

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Identifying resistance

• Arguing
• Discounting
• Disagreeing
• Hostility
• Blaming

• De - focus
• Defensive
• Pessimism
• Passivity
• Body language

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What is resistance?

• Interpersonal behavior
• Information
• Clinician influences resistance How you respond
  matters?
• Not a client problem, but a clinician skill issue
• Cue to change direction/back off

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Responses to Resistance

• Shifting focus
• Reframing
• Agreeing with a twist
• Emphasize personal choice and control
• Coming alongside

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Agreement with a twist

• Initial agreement but with a slight change of
  direction
• Example Youve got a good point there. All this
  nagging and blaming is not helpful. This is a
  problem that involves the whole family.

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Emphasizing Personal Choice and Control

• It is entirely up to you. This is really your
  decision. No one can make that decision for you.
• If you decide that you do not want to change,
  then that is your decision.

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Reframing

• Acknowledge what client has said but offer a
  different perspective
• Example I wonder if all that complaining your
  wife does is her way of showing her concern.
• Focus on how long the client stayed in treatment
  the last time rather than the fact that he/she
  did not complete.

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Coming alongside

• Taking the side of no change as a way to foster
  the clients ambivalence and elicit change talk.

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Shifting focus

• Going around the resistance taking a detour
• Example Maybe we are getting ahead of ourselves
  here. I am worried, as you are, about some of the
  things that are going on in your life right now.
  Tell me more about

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Information exchange versus information giving
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Information Giving

• A one-way process
• Combine facts with interpretation persuasion
• Decide what to assess what information to
  provide
• Reinforce passivity in patient
• Ask lots of closed questions

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Information Exchange

• Elicit needs knowledge
• What would you most like to know about.?
• How much do you know about...?
• Ask permission to provide information
• Keep to information, away from personal
  interpretation
• Some clients say that it helps to..
• This may or may not help but ..
• You may or may not agree ..
• Elicit clients interpretation
• What do you make of that...?
• What does this mean for your future...?

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Summary

• Stay in the spirit of MI
• Use OARS skills
• Identify and reinforce change talk
• Identify and roll with resistance
• Do not get ahead of clients stage of change

motivationalinterviewing.org
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Eight Stages of Learning MI

• Overall MI Spirit
• OARS Skills
• Recognizing change talk and resistance
• Eliciting/strengthening change talk
• Rolling with Resistance

• Developing change plan
• Consolidating commitment
• Transition and blending (with other approaches)

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