Motivational Interviewing Effective Programing with Voluntary Services Training May 14 & 15 2013 Motivational Interviewing is defined as: a collaborative, person-centered form of guiding to elicit and strengthen motivation for change" (Rollnick, 2008).
Basic Principles of Motivational Interviewing Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy Express empathy Acceptance facilitates change. Skillful reflective listening is fundamental. Ambivalence is normal. Develop discrepancy The client rather than the counselor should present the arguments for change. Change is motivated by perceived discrepancy between present behavior and important personal goals and values. Roll with resistance Avoid arguing for change. Resistance is not directly opposed. New perspectives are invited but not imposed. The client is a primary resource in finding answers and solutions. Resistance is a signal to respond differently. Support self-efficacy A person s belief in the possibility of change is an important motivator. The client, not the counselor, is responsible for choosing and carrying out change. The counselor s own belief in the person s ability to change becomes a self-fulfilling prophecy. Taken from Miller & Rollnick (2002). Motivational Interviewing: Preparing people for change. New York: The Guilford Press.
SPIRIT OF MI Understanding Client Centered Collaborative Individualized Emphasizing Freedom of choice Respectful/accepting KEY ELEMENTS 1. Understanding Empathic, careful listening, attentive, non-judgmental, warm and supportive. Seeking to see things from the client s perspective. 2. Client -centered Encouraging clients to be as active as possible in making decisions about health behavior change. Eliciting motivation to change from the client, not imposing it from without. Encouraging clients to do most of the talking. 3. Collaborative Pursing common goals. Sharing of agendas and responsibility. Working together in partnership to determine the best course of action (a meeting between experts ). 4. Individualized Tailoring intervention approaches to match the client s personal needs and readiness to change. Moving at the client s pace. 5. Emphasizing freedom of choice Acknowledging that the decision if, when, and how to change is the client s. Avoiding restrictive messages (e.g. you have to, you must, you can t ). 6. Respectful/accepting Conveying respect by accepting whatever decisions a client makes about health behavior change.
OPENING STRATEGIES: OARS Open-ended Questions Questions that cannot be answered yes/no, but which encourage clients to express their thoughts, feelings, or concerns. Affirmation Expression of appreciation for client s efforts or participation. Reflective Listening Accurate understanding of clients experience, communicated in a warm, nonjudgmental manner. Summarizing Bringing together of several of clients previously expressed thoughts, feelings, or concerns, often including the clinician s understanding of how these fit together.
Open-Ended Questions Goal To encourage the client to think and talk about change. Key Elements Ask the client specific open-ended questions to elicit change talk. Ask questions in a way that is open and inviting. Avoid Asking closed-ended questions (yes or no answers). Sample Questions Why do you wish to get and HIV test? Let s suppose you decided to cut back on your needle sharing, how would your life be different? What brings you here today? What do you want to change? What do you like about sharing needles? What would need to be different for you to be safer when you have penetrative sex? What might get in your way of reaching your goals?
QUESTION QUIZ Open Closed 1. Where were you born? 2. What do you want to do about your smoking: stop, cut down, or stay the same? 3. What brings you here today? 4. Did the judge require you to attend treatment? 5. What do you like about marijuana? 6. Isn t it important to you to have meaning in your life? 7. In what ways is your diabetes a problem for you? 8. How have you overcome other obstacles in the past? 9. Have you ever thought about just walking as a simple way of exercising? 10. Are you willing to try this for one week? 11. Do you care about your health? 12. What are the most important reasons why you want to make a change? 13. Do you want to stay in this relationship? 14. Where did you grow up? 15. Is this an open question? Make up two OPEN questions of your own: Give two examples of CLOSED questions you might ask:
Reflective Listening Accurate reflection Gordon s roadblocks to communication Nonverbal Thinking reflectively Goals To establish report. To create a supportive environment for the client to think and talk about change. To let the client know you are listening and understand. To tap into the natural change potential of the client. Key elements Demonstrate open and receptive non-verbal behaviors. Let the client talk without interruption. Employ minimal encouragers: Mm-hmmm I see Go on For instance Oh? And? Tell me more Really? What else? Use attentive silence to allow the client to think and process. Listen without judgment or rebuttal. Avoid Roadblocks to communication. [See handout on Gordon s roadblocks to communication]
Thomas Gordon s 12 Roadblocks to Communication Ordering, directing, or commanding Warning or threatening Giving advice, making suggestions, or providing solutions Persuading with logic, arguing, or lecturing Moralizing, preaching, or telling clients what they should do Disagreeing, judging, criticizing, or blaming Agreeing, approving, or praising Shaming, ridiculing, or labeling Interpreting or analyzing Reassuring, sympathizing, or consoling Questioning or probing Withdrawing, distracting, humoring, or changing the subject Four Types of Reflective Listening Repeat- These reflections add nothing at all to what the client has said, but simply repeat or restate it using some or all of the same words. Rephrase- These reflections stay close to what the participant has said, slightly rephrase it, usually by substituting a synonym. It is the same thing said by the client, but in a slightly different way. Paraphrase- These reflections change, or add to what the client has said in a significant way, to infer the client s meaning. Reflect Emotion- Regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimensions through feeling statements.
Summarizing Goals To reinforce what the client has said, especially self-motivational statements. To show that you have been listening. To provide a mirror for the client to see themselves. To allow the client to hear her change talk. To tie together what has been said, to provide a transition link, and/or to bring closure to a conversation. Key Elements Summarize in a brief, concise manner. Preface a summary statement with an introduction (ex. let me see if I understand what you ve told me so far ). If a client has expressed ambivalence, it is useful to capture both sides of the ambivalence in the summary statement ( On the one hand..on the other ). End a summary statement with an invitation for the client to respond, such as: How did I do? What have I missed? Avoid Rambling summaries. Analyzing the meaning of what a client has said.
Assessing Motivation, Confidence, and Readiness Goal To determine a client s readiness to change or initiate a behavior. Reflect on process of change. Key Elements Show the client the readiness to change ruler and ask her to indicate where she is in relation to the particular behavior. Acknowledge and accept the client s position on the ruler. Ask specific open-ended questions to elicit change talk. Avoid Showing bias or judging the client s position on the ruler. Rushing this process, as it is crucial to decision making. Key Questions/Statements On a scale of 0-12, how ready are you right now to participate in the group activities? (0 = not ready at all, 12 = very ready). Key Follow-up Questions: Straight question: Why did you pick a? Backwards question: Why did you pick a 4 and not a 1? Forwards question: What would need to be different for you to move from a 2 to an 8? Future question: Let s suppose you decided to participate, why would you want to?
PERSONAL RULERS WORKSHEET Motivation Ruler 0 1 2 3 4 5 6 7 8 9 10 Not at Somewhat Fairly Motivated Very Extremely all motivated motivated motivated motivated motivated Confidence Ruler 0 1 2 3 4 5 6 7 8 9 10 Not at Somewhat Fairly Confident Very Extremely all confident confident confident confident confident Readiness Ruler 0 1 2 3 4 5 6 7 8 9 10 Not at Somewhat Fairly Ready Very Extremely all ready ready ready ready ready
Goals Exploring Ambivalence The goal of exploring ambivalence is to help the client verbalize all the conflicting thoughts and feelings about the behavior change. It is also to convey to the client a complete verbal picture of her/his uncertainty and ambivalence. Key elements WHEN I HEAR MYSELF TALK, I LEARN MY BELIEFS Always ask permission to talk about a certain topic. Begin by asking the client for their reasons for not changing the behavior, then ask about the reasons for change. Summarize the reasons for not changing first, followed by the reasons for change. Ask if you got it all. Ask about the next step. Where does this leave you now? Avoid Using words like problem or concern unless the client uses them. Telling the client your perceptions of the reasons for change. Arguing with the client about the validity of their thoughts and feeling. Key questions What are some of the things you like about drinking alcohol? What are some of the things you dislike about drinking alcohol? What are some of the reasons why you would want things to stay just the way they are? What are some of the reasons for making a change? What are the advantages/disadvantages to running away? What are the advantages/disadvantages of stealing?
Change Talk DARN-C language Desire: Desire is much like "wish hope" as it is the wish for better/different. "I wish I could quit smoking." (I Want to, prefer, wish). Bill, from your recent postings, which would you plant here: preferred self, ideal self, possible self? Ability: Ability deals with confidence and self-efficacy. "I could quit smoking cigarettes" (I Can, able, could, possible) Reasons: Reasons involve issues of incentive, motive or rational -contextual issues (I Should, why do it?). "Smoking really flares up my asthma." A way of making sense that involve more logical pronouncements I should do it for this/that reason. Need: Need seems to overlap with "Reasons" but deals more with "must" rather than "should" (I Must, importance, got to). Deals more with necessity and what is emotionally charged, rather than detached or dispassionate logic and rational. Need moves beyond logical reasons and moves into urgency. Commitment: All of the previous elements (DARN) have the component of strength/weakness to the verbiage. Commitment implies an agreement, intention, or obligation to change (I might, I will, I m going to).
Recognizing Resistance Resistance Behaviors ARGUMENT. The client contests the accuracy, expertise, or integrity of the counselor. Challenging. The client directly challenges the accuracy of what the counselor has said. Discounting. The client questions the counselor s personal authority and expertise. Hostility. The client expresses direct hostility toward the counselor. INTERRUPTION. The client breaks in and interrupts the counselor in a defensive manner. Talking over. The client speaks while the counselor is still talking, without waiting for an appropriate pause or silence. Cutting off. The client breaks in with words obviously intended to cut the counselor off (e.g. Now wait a minute. I ve heard about enough. ) DENIAL. The client expresses an unwillingness to recognize problems, cooperate, accept responsibility, or take advice. Blaming. The client blames other people for problems. Disagreeing. The client disagrees with a suggestion that the client has made, offering no constructive alternative. This includes the familiar, Yes, but... which explains what is wrong with suggestions that are made. Excusing. The client makes excuses for his or her own behavior. Claiming Impunity. The client claims that he or she is not in any danger (e.g. from drinking). Minimizing. The client suggests that the counselor is exaggerating risks or dangers, and that it really isn t so bad. Pessimism. The client makes general statements about self or others that are pessimistic, defeatist, or negativistic in tone. Reluctance. The client expresses reservations and reluctance about information or advice given.
Unwillingness to change. The client expresses a lack of desire or an unwillingness to change, or an intention not to change. IGNORING. counselor. The client shows evidence of not following or, of ignoring the Inattention. The client s response indicates that he or she has not been following or attending to the counselor. Non-answer. In answering a counselor s query, the client gives a response that is not an answer to the question. Side-tracking. The client changes the direction of the conversation that the client has been pursuing. Source: Motivational Interviewing Workshop, October 22-23, 1999, Department of Psychology and enter on Alcoholism, Substance Abuse and Addictions (CASAA), The University of New Mexico.
RESISTANCE STEMS 1. I m not the one with the problem. If I drink, it s just because my husband is always nagging me. (blaming) 2. Who are you to tell me what do to? What do you know about crack? You probably never even smoked a joint! (discounting) 3. Your little test here says I m an alcoholic, but that can t be right. I can quit drinking any time I feel like it. (disagreeing) 4. I really like pot! I don t want to quit! (unwillingness) 5. I ve tried to stop smoking before, and I just don t think I can do it. (pessimism) 6. But everybody I know drinks! What am I going to tell my friends if I can t have a drink when I want to? (reluctance) 7. My wife is always exaggerating! I haven t ever been that bad! I m the first to admit that I drink too much sometimes, but I m no alcoholic! (minimizing) 8. I can really hold my liquor. I m still standing when everybody else is under the table. (claiming impunity) 9. I don t smoke any more than my friends do. What s wrong with smoking a joint? (excusing) 10. I know you re sitting there thinking that I m a junkie, but it s not like that. I just like getting high sometimes. (minimizing) 11. Why are you and my husband so stuck on my drinking? What about all of his problems? You d drink, too, if you had a family like mine. (blaming, excusing) 12. I don t know why my doctor sent me here? She said something about my blood test looking like I m an alcoholic. Now, I suppose you re gong to lecture me about my drinking. (challenging, hostility) 13. Everybody has to die sometime. Maybe smoking will do me in, but lots of people smoke all their lives and die of old age. Besides, they ve never really proved that smoking causes cancer. (minimizing) 14. Tranquilizers aren t really my problem. What I want to talk about is my son- now he s a problem! (sidetracking)
Strategies for Working With Resistance Goal Simple reflection- Reflect what is said (not always simple to do) Amplified reflection- Add some intensity Double sided reflection- Reflect the ambivalence Shifting focus- Change the focus/subject Reframing- Offer new meaning or interpretation Agreement with a twist- Reflection followed by a reframe Emphasize personal choice Siding with the negative To minimize and manage client resistance. Key Elements Recognize resistant behaviors as a signal to change strategies. The clinician can generate resistance by: Avoid Using a judgmental or confrontational approach. Jumping ahead of where the client actually is on the readiness-to-change continuum. Mis-assessing the client s readiness to change. Discounting the client s feelings and thoughts. When you encounter resistance, step back, listen, and try to understand things from the client s perspective. Arguing Confronting Persuading Telling the client what to do and how to do it Judging Tools Listen, listen, listen.
EXCHANGING INFORMATION WORKSHEET Write and educational statement for the scenario described below. 1. The client s family members, who function as her primary support system, sabotage her medication compliance protocols because of questionable or blatantly incorrect information they have gleaned from the popular press. Education statement: 2. This client tells you that she doesn t think she can quit using pot because the pot helps her deal with the world better, especially when she feels stressed and anxious. Education statement: 3. This client wants to quit drinking, and has cut back from drinking a six pack to three hard alcohol drinks a day. The client doesn t realize that the actual alcohol intake of the hard liquor is equivalent to the amount she was drinking in beer. Education statement:
Offering Support/ Change Options Goal To work with the client in deciding what to focus on. Key Elements The Options tool consists of a group of several circles that list the options for discussion from the provider s perspective. These circles are separated from two blank circles by a heavy line. The blank circles may be used to include options suggested by the client. It is important to have the blank circles. Options tools can be tailored to the area of focus and institutional resources available for support. Show the client the appropriate options tool and ask if any of these behaviors/topics/issues might be of interest to her to discuss, or if there is something else that she/he would rather like to focus on that might be impacting his/her participation. Invite the client to express his/her views on the subject. Honor the client s choice of behavior/topic/issue. Avoid Setting the agenda on your own and/or pushing the client into premature focus on any one behavior of your choosing before he/she is ready. Action planning unless specifically indicated by the client. Problem solving for the client. Giving advice. Being a cheerleader for change. Being judgmental about where he/she is. Sample Script This worksheet represents some of the issues that may concern (be a part of) your life at the moment. What, if any, of these would you be interested in spending some time on? It could be one that you ve been thinking about concerning safer sex practices. From my perspective it seems like issues around support sobriety has been important to you. However, it is up to you. Or maybe there is something else that you consider more important to discuss at this time. What do you think?
Options Worksheet Self-care Substance Use Health Violence Depression Medication
Clinical Demonstration and Training Videos Additional Resources Jennifer Hettema Motivational Interviewing Training Videos: http://www.mitrainingvideo.com/ Miller WR (1989). Motivational Interviewing. Available from the author of the Department of Psychology, University of New Mexico, Albuquerque, New Mexico 87131 Motivation for Change (1990). Two training videotapes available from Addiction Research Foundation, 33 Russell Street, Toronto M5S 2S1, Ontario, Canada. Miller WR, Rollnick S, directed by TB Moyers (1998). Motivational Interviewing. Series of six training tapes. Available from Delilah Yao, Department of Psychology, University of new Mexico, Albuquerque, New Mexico 87131-1161. Dyao@unm. Edu. European format available from European Addiction Training Institute, Stadhouderskade 125, 1074 AV Amsterdam, The Netherlands. Telephone: 31-20-675-2041; Fax: 31-20-675-4591. http://www.eati.org: info@eat.org. Books Miller, W., & Rollnick. S. (2002). Motivational Interviewing: Preparing people for change. New York: The Guilford Press. Rollnick, S., Mason, P., Butler, C. (1999). Health Behavior Change: A guide for practitioners. New York: Churchill Livingstone. Arkowitz, H., Westra, H. A., Miller, W. M., & Rollnick, S. (2008). Motivational interviewing in the treatment of psychological problems. New York: Guildford Press. Training in Motivational Interviewing Stephanie Wahab, Ph.D, Stephanie Wahab Training Inc. swtreeoflife@gmail.com For a complete list of all publications on MI, including all clinical trials and problem areas go to the Motivational Interviewing Home Page- http://www.motivationalinterview.org/