An Introduction to Motivational Interviewing

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An Introduction to Motivational Interviewing

• Richard L. Ogle, Ph.D.
• Professor Chair
• Department of Psychology
• University of North Carolina Wilmington
• ogler_at_uncw.edu

2
Guiding Sentiments

• If you treat an individual as he is, he will stay
  as he is, but if you treat him as if he were what
  he ought to be and could be, he will become what
  he ought to be and could be.
• Johann Wolfgang Von Goethe
• People are generally better persuaded by the
  reasons which they have themselves discovered
  than by those which have come into the mind of
  others.
• Blaise Pascal
• You are a midwife, assisting at someone elses
  birth. Do good without show or fuss. Facilitate
  what is happening rather than what you think
  ought to be happening. If you must take the
  lead, lead so that the mother is helped, yet
  still free and in charge. When the baby is born,
  the mother will rightly say, We did it
  ourselves.
• TAO TE CHING

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Opening Conversation

• Why are you here?
• What do you want to learn?
• In what specific situations would you like to use
  MI?
• At what level do you want to engage?

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Motivation

• The probability of engaging in and maintaining a
  behavior over time.
• What are the three key words?
• Probability (0 1) not (0 or 1).
• Engage
• Maintain
• Motivation is continuous not dichotomous
• Fluctuating motivation can increase or decrease
  based on your behavior

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Change

• Change is more similar than different across
  behaviors
• Change is a process that is continuous like a
  dimmer switch, not discrete like an on/off switch
• Change depends on MOTIVATION.
• Because of this, there are multiple ways and
  times that change can derail
• Fortunately, there are multiple ways and times to
  facilitate the process

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Stages of ChangeProchaska DiClemente
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Change Talk - DARN CAT

• Client speech reflecting building motivation and
  correlated with behavioral change
• Desire
• Why a person would make a change.
• Ability
• How a person could you do it.
• Reasons
• What are good reasons to make the change?
• Needs
• How important is it and why? What are the
  negative that occur without change?
• Commitment
• What intentions are present?
• Activation
• What is the person ready or willing to do
  immediately?
• Taking Steps
• What have they already done?

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Commitment Language Pattern A
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Outcomes for Pattern A Group
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Commitment Language Pattern B
Amrhein et al., Journal of Consulting Clinical
Psychology 2003 71862-878
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Outcomes for Pattern B Group
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Righting Reflex

• Born of concern and caring
• Theres a problem? Lets fix it!
• Fails to consider ambivalence in change process
• May engender resistance

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Ambivalence

• Simultaneous feelings of approach and avoidance
• Yes, but
• I want to, but I cant
• The core of most motivational issues
• Completely normal
• Often uncomfortable
• Can be chronic

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Exercise

• Listen carefully - goal to understand the dilemma
• Ask these four questions
• Why would you want to make this change?
• How might you go about it, in order to succeed?
• What are the three best reasons to do it?
• On a scale of 1-10, how important would you say
  it is to make this change? And why are you a ___
  and not zero?
• Summarize

• Talk about something real that you
• Want to change
• Need to change
• Should change
• Have been thinking about changing
• But, havent yet changed.
• Not your deepest, darkest secret!

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Resistance

• A result of a focus on only one side of an
  individuals ambivalence
• If you argue for change, your collaborator argues
  against it
• It is relational. It is a signal that you are
  not meeting them where they are at therefore, it
  is you responsibility to resolve
• Sustain Talk
• Speech about the target behavior that reflects
  only one side of ambivalence (status quo)
• There is nothing inherently pathological about
  sustain talk
• Discord
• Speech reflecting a discord within the
  relationship/session
• Denying
• Arguing
• Ignoring
• Interrupting

• Reluctance
• May be concerned about the unknowns of change
• Need to verbalize their reluctance be heard
• Rebellion
• May have knowledge
• May have highly invested energy in no change
• Resignation
• No energy for change
• May feel overwhelmed hopeless
• Need to build hope
• Rationalization
• Has all of the answers
• Utilizes Harm Minimization

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Therapeutic Traps

• Question-Answer Trap
• Trap of Taking Sides
• Expert Trap
• Labeling Trap
• Premature Focus Trap
• Blaming Trap

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Definitions of MI

• Laypersons Definition (Why would be do it)
• MI is a collaborative conversational style for
  strengthening a persons own motivation and
  commitment to change
• Practitioners Definition (Why you would use it)
• MI is a person-centered counseling style for the
  common problem of ambivalence about change
• Technical Definition (How it works)
• MI 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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A Brief History to This Point

• MI is 31 years old this year
• Description first published in a journal article
  in 1983.
• First edition of book in 1991, second in 2002,
  third in 2013
• Over 1200 articles on MI
• MI cited over 25,000 times
• Over 200 RCTs
• Started as a vilified intervention in addictions
  and now is a best practice in all of behavioral
  health

• Here are some things we know
• MI is effective for a variety of behavioral
  targets
• MI can be used in a variety of settings
• MI is hard to standardize
• Significant variability across counselors

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Most Importantly, What We Know is

• MI training increases characteristic MI practice
  behaviors
• OARS
• Empathy
• These behaviors affect particular types of client
  speech
• Desire, Ability, Reasons, Need, Commitment,
  Activation, Taking Steps
• The level and strength of these types of speech
  predict behavioral outcome
• Findings are stronger in addictions than anywhere
  else

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Spirit of MIhttp//www.youtube.com/watch?vVr-aZ4
tdoac

• Acceptance
• Absolute worth
• Autonomy
• Accurate Empathy
• Affirmation
• Collaboration
• Partners
• Shared goals
• Evocation
• Pulling out instead of putting in
• Compassion
• For the others needs/self-interest

• Services exist to benefit the people we serve
• Change is fundamentally self change. Services
  facilitate
• People are experts on themselves
• We dont have to make change happen
• We dont have to come up with all the good ideas
• People have their own strengths, motivations,
  resources
• Therefore change requires partnership
• Understand, persons own perspective, what is
  needed and how to accomplish it
• Conversations about change should not be a
  struggle. Dancing, not wrestling
• Motivation for change is not installed, but
  evoked
• We cannot revoke peoples choice about their own
  behavior. People make their own decisions about
  what they will and will not do.

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MI Principles

• Express Empathy
• Empathy alone is predictive of change
• Roll w/Resistance
• Verbal judo
• Develop Discrepancy
• Goals and values contrasted with current behavior
• Support Self-Efficacy

• R Resist the righting reflex
• U Understand you clients motivation
• L Listen to you client
• E Empower your client

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Empathy

• Multiple Components
• Experience sharing (affective empathy)
  vicariously sharing targets internal states
  (feeling with), but knowing the target is the
  source of the emotional state in the self.
• Mentalizing (cognitive empathy) explicitly
  considering targets' states and their sources,
  without necessarily sharing another's state.
  Perspective-taking.
• Prosocial concern (compassion) feeling of concern
  for a target's suffering ("feeling for") that
  induces a motivation to alleviate that suffering.
• http//www.youtube.com/watch?vl7AWnfFRc7g
• http//www.youtube.com/watch?v1Evwgu369Jw

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The Importance of Empathy and Rolling w/Resistance
Miller, Benefield Tonigan (1993) JCCP 61
455-461
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Developing Discrepancy

• Finding, increasing or encouraging a discrepancy
  between present and desired states
• Can be positive or negative in valence
• Discontent with the status quo
• Opportunity for betterment
• Goldilocks Principle
• Discrepancy within limit

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Support Self-Efficacy

• Perception of the degree to which someone feels
  confident he/she can accomplish a particular
  goal/task
• Building confidence
• Building on past successes
• Translating things they do well in other life
  contexts to the behavior change context.
• Affirming smaller steps and approximations

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How Does MI Work

• Empathy allows clients to reduce resistance and
  resolve ambivalence
• Looking at the situation from their perspective
• People feel understood less resistant
• Selective reinforcement of change talk
• Focus on change talk
• We learn what we believe when we hear ourselves
  speak
• Therapist reinforces change talk that is
  consistent with therapeutic goals
• Reinforcement further increases change talk and
  allows of client to experience build in
  motivation to change

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Basic MI Tools

• O - Open Questions
• A - Affirmative Approach
• R - Reflective Listening
• S -Summaries

• Your OARS propel you and steer you through the
  encounter
• You have to do these well to do MI well
• Everything in MI is rooted in OARS

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Open Questions

• Questions that cannot be answered yes or no
  or with a discrete answer.
• Open questions generate more data more data,
  more empathy
• Open questions block momentum less than closed
  questions
• Open questions lessen the expert or
  investigator feel of interactions

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Opening Up Your Questions

• Do you drink? How much?
• Have you ever smoked a cigarette?
• Are you taking your medications as prescribed?
• Have you lost or gained weight in the last month?
• Are you sexually active?
• Do you always use birth control?
• How many alcoholic drinks do you have in a
  typical week?
• Did you take your insulin today?
• Do you get regular physical exercise?
• Is there a family history of heart disease?
• Have you ever been hospitalized or had surgery?
• On what day did your symptoms start?

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Affirmation

• Clients are often unsuccessful self-changers
• Demoralized
• Our role is to instill hope and a belief that the
  client can change
• Empower the client can do
• Attributions
• Focus on specific behaviors instead of attitudes
  or decisions
• Focus on descriptions not evaluations
• Attend to non-problem areas
• Nurture a world-view of competence not deficit

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Affirmation Exercise

• Listen to the statement
• Write down a few strengths
• Write down an affirmation

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Reflective Listening - Roadblocks to Listening

• 1. Ordering, directing, or commanding
• 2. Warning or threatening
• 3. Giving advice, making suggestions, or
  providing solutions
• 4. Persuading with logic, arguing, or lecturing
• 5. Moralizing, preaching, or telling clients what
  they "should" do
• 6. Disagreeing, judging, criticizing, or blaming
• 7. Agreeing, approving, or praising
• 8. Shaming, ridiculing, or labeling
• 9. Interpreting or analyzing
• 10. Reassuring, sympathizing, or consoling
• 11. Questioning or probing
• 12. Withdrawing, distracting, humoring, or
  changing the subject

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Reflective Listening What is it?

• A statement a hypothesis
• Vocal inflection is downward
• Keeps people in the meaning/feeling
• A verbal mirror to reflect back
• Exact words
• Paraphrase
• Meaning
• Emotion

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Reflection Exercises
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Summaries

• Groups of reflections that serve to
• Remind you and client of what has been said
• Highlight overarching themes Linking
• Transition when stuck or wanting to shift
  direction

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Video

• Listen for OARS

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Rolling w/Resistance

• Strategies
• Reflection (Under/Over)
• Reframe
• Double-sided reflection
• Emphasizing Personal Responsibility
• Shifting Focus
• Coming Alongside
• Exercise

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Exercise - Fishbowl

• Practice OARS
• Roll w/ resistance
• Listen for Change talk

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MI Processes

• MI occurs throughout four ongoing processes of
  change conversations
• Engaging
• Focusing
• Evoking
• Planning
• Often MI is about knowing how to skillfully and
  artfully move back and forth between each process

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Engaging

• The process by which counselor and client
  establish a helpful connection and a working
  relationship
• How comfortable is this person talking to me?
• How supportive and helpful am I being?
• Do I understand this persons perspective and
  concerns?
• How comfortable do I feel with this conversation?
• Does this feel like a collaborative partnership?

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Understanding Values

• Freely chosen core beliefs that drive and
  organize behavior that is intrinsically
  reinforcing.
• Values represent what one wants their life to
  look like, stand for and be about
• Global values
• Domain-specific values family, relationships,
  career, etc.
• Values provide direction
• Values are different from valuing
• Values cannot be accomplished in-and-of-themselves
  
• Instantiated moment by moment and over time
• No matter what direction life takes, you still
  have your values

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Values Assessment

• Informal
• How do you hope your life will be different a
  few years from now?
• Who do you respect in life and why?
• Tell me what you care most about in life.
• Tombstone
• Eulogy
• Values Card-Sort
• http//casaa.unm.edu/inst/Personal20Values20Card
  20Sort202.pdf
• Batteries Exercise
• Next Slide

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Focusing

• Process of clarifying direction find the
  horizon point toward which to move. Agenda
• What goals for change does this person really
  have?
• Do I have different aspirations for change than
  this person?
• Are we working together with a common purpose?
• Does it feel like we are moving together, not in
  different directions?
• Do I have a clear sense of where we are going?
• Does this feel more like dancing than wrestling?
• Sources client, setting, your experience

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Agenda Mapping

• A short meta-conversation in which you step back
  with the client to consider the way ahead
• Structuring
• Consider options
• Zoom in
• Zoom out

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Information Exchange Elicit - Provide - Elicit

• Elicit
• What would you like to know/do about?
• What do you already know/do about?
• Provide
• Provide information (not opinion) in manageable
  chunks
• Confirming
• New
• Disconfirming
• Elicit
• What do you make of that?
• What does this mean for you?
• What more would you like to know?

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Evoking

• Eliciting clients own motivations to change.
  Harness the clients own thoughts and feelings
  about why and how they might do it
• What are this persons reasons for change?
• Is the reluctance more about confidence or
  importance?
• What change talk am I hearing?
• Am I steering to far or too fast in a particular
  direction?
• Is the righting reflex pulling me to be the one
  arguing for change?

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Explore Importance of Situation/Change

• General
• How important is situation/issue, you need to
  make a decision or do something about it?
• Importance Ruler
• On a scale of 0 to 10, how important is this
  issue to you at this point in your life(0not at
  all, 10most important thing)
• What makes it an X and not a Y?
• What might make your rating a few points higher,
  a bit more important?
• What can you specifically do to increase?
• What might I, or others do to help it increase?

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Explore Confidence about Changing

• On a scale of 0 to 10, how confident are you that
  you could change if you decided to?
• What makes it an X and not a Y?
• What would make it a few points higher?
• What can you specifically do to increase?
• What might I, or others do to help it increase?

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DARN CAT Client Exercise

• Lets write down some statements about this change
  we are discussing.
• D Why do you want to make this change?
• A How could you do it?
• R What are good reasons to make the change?
• N How important is it and why?
• C What do you intend to do about it?
• A What are you ready or willing to do?
• T What have you already done?
• Use your OARS to expand, explore and solidify.

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Decisional Balance

• Not changing
• What concerns you the most about the possibility
  of not making a change?
• What might some benefits be of not addressing
  this, not making any changes?
• Changing
• What might you lose, have to give up, or risk, if
  you make a change? What might not be so good?
• What good things might happen if you did
  something about it, made a change?

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Exercise Decisional Balance
ff
Pros of Status Quo
Cons of Change
Cons of Status Quo
Pros of Change
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Looking Forward

• In general, what things are most important to
  you?
• Family? Cutting back on work? Getting some fun or
  excitement back in your life? Feeling better
  about yourself? Getting more involved in your
  community? Your spirituality? Having a partner?
  Being financially prepared? Autonomy?
• Thinking about whats important for you for the
  future, how does this current issue fit in?
• What is likely to be the outcome if you dont
  make any decisions, do anything about it? What do
  you think things will be like a year from now, or
  five?
• What might be the outcome if you were successful
  at making some changes? How might things be in a
  year from now, or five?

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Looking Back

• How long has it been going on?
• How did it come about?
• Did it start all at once or gradually?
• What were things like before?
• How were things better now?
• How are things worse?

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Building on Strengths

• What strengths might you draw on to make a
  change?
• Are you determined? Flexible? Careful? Organized?
  Creative? Resourceful? Stubborn?
• How have these strengths helped you before?
• What things might be changed in your environment
  to help you succeed? What might help you get
  ready?
• How might others help?

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Remembering Successes

• What have you been successful at changing in the
  past? No matter how small...
• What initiated you making this change?
• What did you do to get started, what did you do
  to stick with your decision to change?
• What barriers or obstacles did you run into? How
  did you get past them?
• How easy was it? How did you feel after making
  that change? How do you feel about it now?
• What other changes have you made?

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Other Strategies

• Typical Day
• Others Concerns
• Normative Feedback

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How to Reinforce Change Talk (EARS)

• Elaborate
• In what ways?
• Give me an example?
• What else?
• Why else?
• How else?
• Affirm
• Sounds like a good idea
• I think you could do that
• It is really important to you to
• Reflect
• Summarize
• Collect the flowers of change talk and give back
  a bouquet of change talk back to the client.
  Give them what you want them to hear not
  everything.

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Exercise

• Listening for change-talk

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Planning

• The process of developing commitment to change
  and a specific plan of action
• What would be a reasonable next step toward
  change?
• What would help this person to move forward?
• Am I remembering to evoke rather that prescribe a
  plan?
• Am I offering needed info and advice with
  permission?
• Am I retaining a sense of quiet curiosity about
  what will work best for this person?

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MI and Planning

• Moving from evoking to planning
• Comes from a sense of the interaction less
  resistance, more curiosity, more change talk,
  more optimism
• Summarize
• Change-talk focused
• Key question
• A questions that elicits what a client wants to
  do in relation to the problem of concern
• What do you think you will do?
• What are you thinking at this point about ______?
• What changes, if any, or you thinking about
  making?
• What are your options?
• It sounds like things cant stay the way they
  are, what do you think you might do?
• What are some of the good things about making a
  change?

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MI Change Planning

• Lots of freedom in how to do this, but do follow
  these 6 steps
• Confirm the goal
• State goals in behavioral terms
• Avoid dead person goals
• Itemize options
• Elicit the clients hunches and preferences
• Plan strategy
• What are the steps and how will they know its
  working
• Summarize and strengthen commitment
• Troubleshoot raise concerns you have

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Behavior Change Plan

• What, specifically, would you like to be
  different?
• What, specifically, could you do to get started?
• If the first step is successful, then what?
• Who else could you ask for support, assistance,
  if anyone? What could you ask for?
• What would be signs that things are going well?
• How would you know if you were off-track?
• What would you do if you got off-track?

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Supporting Change

• Subsequent treatment should integrate the
  processes of
• Replanning
• Reminding
• Refocusing
• Reengaging
• http//www.youtube.com/watch?vK1jJYON92m8listPL
  B234E53AF4293F2F

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Opening the Session

• Set the Agenda
• Spirit
• What will be talked about
• Your role
• Open Question
• Pick up your OARS and start paddling
• Perceptions of being there
• Perceptions of the issues
• Important current activities, requirements,
  and/or needs
• Paddle in order to build rapport (Joining) and
  elicit change talk

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Managing the Middle

• Assess/Understand Values
• Card Sort or Batteries Exercise
• Use EVOKING strategies
• Develop Discrepancy
• Support Self-Efficacy
• Provide information/feedback if necessary
• Elicit-Provide-Elicit

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Wrapping Up an MI Session

• If using MI brings you to a point where a client
  is making statements related to change or
  increased importance/confidence
• Summarize Key Question
• Behavior Change Plan
• Summarize Elicit Commitment
• If client is stuck/ambivalent
• Reflect the continued ambivalence in terms of
  Importance/Confidence
• Summarize

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Exercise Fishbowl

• Goal
• Practice OARS
• Listen for change talk
• Reinforce change talk
• Practice process-based exercises

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Questions
70
Specific MI Applications
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Treatment Engagement

• Turn your assessment into and MI-informed
  assessment
• There are number of questions I will need to ask
  you today, but first I would just like to know
  what brings you here today, what are your biggest
  concerns and how you hope we might be able to
  help you.
• Listen with empathy and to detect the process
  where you need to start
• Ask for permission to move into the assessment
  phase
• Use open-ended questions to replace closed
  prompts on your assessment.
• Listen for change talk
• Summarize and transition through each domain
• Use EPE for information exchange
• Use importance/confidence
• Summarize at the end

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Treatment Enhancement

• Boosts the effects of larger treatments
• Motivational Enhancement Therapy
• Now being integrated with other treatment formats
• CBT
• Now being developed to treat specific disorders
• Depression, OCD, eating disorders, GAD

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Medication Compliance
Purpose
Components

• Exploring of both sides of motivation/eliciting
  commitment.
• Exploration of previous concerns and result of
  nonadherence.
• Discuss and prepare for motivational issues that
  may arise.
• Feedback on dose-taking, reinforcement of
  adherence, and exploration of missed doses.
• Targeted information exchange
• Articulate patients reasons for adhering to
  treatment, anticipated barriers, and plan
• Mailed to participants 1 week after the
  intervention to provide additional information.
• Discussing adherence in alignment with sources of
  motivation.

• Assessing motivation for adherence.
• Discussing previous adherence
• Anticipating adherence difficulties
• Personalized feedback
• Informally assessing antidepressant knowledge
• Adherence plan
• Discussing goals/values

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MI and Suicidal Ideation

• Phase 1 Exploring the present problem and the
  motivation to die.
• Focus in on eliciting the ambivalence around
  suicide.
• Phase 2 Building motivation to live.
• Focus is on gently shifting toward the living
  side of the ambivalence
• Phase 3 Strengthening commitment to live.
• Focus is on moving reasons to commitment and
  planning for the next stage of treatment.

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Take Home

• Learning MI involves 10 steps of understanding
• Understand and invoke the underlying spirit
• Develop skill and comfort with reflective
  listening
• Learn to identify from clients agenda, goals
  that can become foci of the conversation
• Understand EPE as information exchange
• Learn to recognize change talk and sustain talk
• Learn to evoke change talk
• Learn to strengthen change talk
• Learn to respond to sustain talk in ways that do
  not amplify it
• Understand the timing when moving into planning
• Cant just get good at MI-consistent behaviors
  must eliminate MI-inconsistent behaviors
• Advice or info without permission
• Confronting by disagreeing, arguing, correcting,
  shaming, blaming, criticizing, etc.
• Directing by giving orders, commands or
  imperatives, or otherwise challenging autonomy
• One never stops learning MI