Motivational InterviewingMotivational Interviewing

Jonathan Krejci, Ph.D.Director of Clinical Programs, Training & Research

Princeton House Behavioral Healthjkrejci@princetonhcs.org

Jonathan Krejci, Ph.D.Director of Clinical Programs, Training & Research

Princeton House Behavioral Healthjkrejci@princetonhcs.org

MI involves creating a certain kind of conversation about

change.

MI involves creating a certain kind of conversation about

change.

Take Home Point #1Take Home Point #1

“A person-centered counseling style for addressing the common problem of ambivalence about change”

“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 person’s own reasons for change within an atmosphere of acceptance and compassion”

Miller & Rollnick, 2013

“A person-centered counseling style for addressing the common problem of ambivalence about change”

“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 person’s own reasons for change within an atmosphere of acceptance and compassion”

Miller & Rollnick, 2013

Two Definitions of Motivational Interviewing

Two Definitions of Motivational Interviewing

Convincing ExerciseGoal: Experience mismatch between action-oriented

clinician and ambivalent clientSpeaker role: BE YOURSELF. Identify a change that

you are considering, something you are thinking about changing in your life, but have not definitely decided. It will be something you feel two ways about. It might be a change that would be “good for you”, that you “should” make for some reason, but have been putting off. Tell the counselor about this change you are considering.

Convincing ExerciseClinician role: Try as hard as you can to convince and

persuade the Speaker to make the change. Specifically, once you find out what the change is that the person is considering:– Explain why the person should make this change.– Explain the benefits of making the change.– Tell the person how they could make the change.

If you encounter resistance, repeat the above, perhaps more emphatically.

For this conversation to be effective, the clinician has to

embrace the spirit of MI.

For this conversation to be effective, the clinician has to

embrace the spirit of MI.

Take Home Point #2Take Home Point #2

Spirit of MI (PACE)

“Doing MI with someone is like entering their home. One should enter with respect, interest, and kindness, affirm what is good, and refrain from providing unsolicited advice about how to arrange the furniture.”

Kamila Venner

Partnership• Collaboration: MI is done for and with a

person, not to a person• MI is not a set of techniques for tricking

people into change• MI is a conversation between two people with

different but equally important areas of expertise

• Counseling should feel like moving with, not moving against (dancing vs. wrestling)

Four Aspects of Acceptance• Absolute worth: non-contingent acceptance of

the person as they are.– Rogers: unconditional positive regard

• Autonomy support: honoring client’s capacity for self-direction; not = passivity or abandonment

• Affirmation: active effort to seek and acknowledge strengths and efforts

• Accurate empathy

• Rogers: The therapist’s ability and willingness to understand the client’s thoughts, feelings and struggles from the client’s point of view

• “Understanding from the inside out”• Is not identification or sympathy• Empathy (as perceived by the client) is strongly

linked with positive outcome• Reflective listening is fundamental in MI to

conveying empathy

Accurate Empathy

• What are some roadblocks to experiencing empathy?

• What can clinicians do to develop and cultivate empathy for clients?

• What can clinicians do to communicate empathy for clients?

– Verbal/vocal– Non-verbal

Empathy discussion

Compassion and Evocation• Compassion:

– Ability to actively promote another’s welfare; to prioritize their needs

– Added to MI 3, because compassion ensures that we are applying principles and techniques in the interest of the client

• Evocation: – Evocation vs. installation (mid-wife vs. surgeon)– Strengths vs. deficit world view: “You have what

you need, and together we will find it”.

The main aim of this conversation is to elicit the client’s own motivation for

change.

The main aim of this conversation is to elicit the client’s own motivation for

change.

Take Home Point #3Take Home Point #3

TWO WAYS TO THINK ABOUT MOTIVATION

Dimensions of Motivation

• Importance: Change has to be personally relevant, meaningful

• Confidence: Change has to seen as possible (self-efficacy)

Stages of Motivation(Stages of Change)

• Precontemplation: No perceived need or ability to change

• Contemplation: Some desire, combined with ambivalence

• Preparation: Intention to change soon; some preliminary efforts

• Action: Meaningful, sustained attempts to change

• Maintenance: Change maintained over time

Motivation is not all or nothing, and is influenced by the behavior of the clinician.

Motivation is not all or nothing, and is influenced by the behavior of the clinician.

Take Home Point #4Take Home Point #4

Ambivalence

• Ambivalence is normal; almost all major change involves mixed feelings about whether a person:– Wants or needs to change (importance)– Feels they can change (confidence)

• Assume ambivalence, not denial• Where there is ambivalence there is

motivation

Strategies for Managing Resistance

• Cultivate and express acceptance• Offer simple reflections• Express empathy: “If I were in your situation I would feel…”• Find the strength within the resistance and speak it out loud:

– “independent, strong-minded”; “not someone who can be pushed around”• Support personal choice and emphasize your role in helping

them decide whether to change• If you evoke resistance, don’t be afraid to apologize:

– “I’m sorry, perhaps I misunderstood you…”

Resistance: Small Group Batting Practice

• Form circle• All but one member take turns rapidly generating

resistance statements• Listener – use skills:

– Acceptance– Simple reflections– Express empathy: “If I were in your situation I would feel…”– Find the strength within the resistance and speak it out loud:– Emphasizing autonomy– Don’t be afraid to apologize:

• Rotate!

A client who is not engaged in the conversation about change is a visitor, not a

client.

A client who is not engaged in the conversation about change is a visitor, not a

client.

Take Home Point #5Take Home Point #5

Engaging(Establishing a working relationship)

Key questions for the clinician:• How comfortable is this person talking with

me?• How supportive and helpful am I being?• Do I understand this person’s perspective

and concerns?• How comfortable do I feel in this

conversation?• Does this feel like a collaborative

relationship?

What Interferes with Engagement?

• The expert trap– Question and answer trap

• The premature focus trap– The righting reflex

• The labeling trap• The blaming trap• The chat trap

Take Home Point #6

Active listening (OARS) is the foundation of engagement and

conversations about change.

Open Questions• Cannot be answered with a simple yes or no,

or with concrete information• Do not lead, control or try to manipulate the

other person• Often begin with the words "when," "what,"

"how," "why" or "where" • General MI guidelines:

– Use more reflections than questions– Use more open than closed questions– Never ask 3 questions in a row

Affirmation• Requires clinician to seek out the person’s strengths,

efforts and struggles• Can be used as a reframe:

– Demoralized = cautious– Intellectualizing = curious, information-seeking

• A good affirmation is:– Genuine– Personalized– Relevant to treatment– Focused on qualities, not just behaviors– Not too incongruent with person’s self-perception

• Helps avoid 3 provider traps

TRAP ONE: ANGERTRAP ONE: ANGER

TRAP TWO: HOPELESSNESSTRAP TWO: HOPELESSNESS

TRAP THREE: CHEERLEADINGTRAP THREE: CHEERLEADING

Affirmation Practice• “I’ve tried to quit too many times to try again”• “They can make me come to see you, but they

can’t make me stop drinking”• “I guess maybe I haven’t been a very good mom”• “When I make my mind up to do something, I do

it”• “Nobody screws me over – I get them first”• “I don’t need AA – I just need to make my mind

up to quit drinking”

Reflective Listening• Your perspective is not present, except as a listener• Reflective listening:

– Is a restatement of what the person said, meant or experienced

– Requires “thinking reflectively”: listening for essential meaning, spoken and unspoken

• Reflective listening is not:– Agreeing or disagreeing– A question– A passive activity– Easy!

Reflective Listening – Why Bother?

• RL helps the client to feel understood. • RL imposes no demand. • RL avoids evoking resistance. • RL deepens the patient’s experience. • RL strengthens the alliance. • RL evokes change talk. • RL keeps the focus on the patient. • RL avoids prematurely focusing on solutions.

Reflective Listening Tips• Listen, listen, listen • Reflect strategically: what would you like the person to

hear themselves say?• Reflect unspoken meaning as well as surface content• Reflect feelings as well as thoughts and facts• Overstate to reduce intensity• Understate to increase intensity

– When in doubt, understate• Make it a statement, not a question• Avoid repetitive stems (“Sounds like…”)• KISS (Keep it Short and Sweet)

Thinking reflectively

• Pairs take turns• “One thing that I like about myself is…”• Listeners take turns responding: “you

mean that…”• Speaker can answer in five words or

less

Reflections - group practice

• “I know I could do some thing differently, but if she would just back off, the situation would be a lot less tense; then these things wouldn’t happen.”

• “I’ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work, except having a few drinks.”

Reflections - group practice

• “So I’m not too worried, but it’s been over a year since I’ve had an HIV test”.

• “I know I’m not perfect, but why do they have to always tell me what to do. I’m not three!”

Reflective Listening Exercise I

• Pairs take turns• “One thing that you should know about

me is…”• Listeners take turns responding with

simple reflections• Speaker can answer with a brief, 1 -2

sentence elaboration

Summaries• Summaries are “glorified reflections”.

Three types:– Motivational summary: summarizes both

sides of the ambivalence. – Gathering summary: organizes multiple

change talk themes– Transitional summary: provides transition

to new topic or to change planning

Summarization Exercise• Pairs take turns• Speaker: Speak uninterrupted for 1-2 minutes about

– Most rewarding and frustrating aspects of your job– Happy and sad things about your childhood– Hopes and fears for the future

• Listener: Offer a summary of both sides. End by checking in: “Is there anything I missed?” If you get more information, reflect it back.

• Speaker: Give feedback to listener; be honest!

Take Home Point #7

MI has clear guidelines for providing feedback, advice

and suggestions (“information exchange”)

“Unsolicited advice is the junk mail of life”Bern Williams

“Advice is what we ask for when we already know the answer but wish we didn’t”Erica Jong

“Unsolicited advice is the junk mail of life”Bern Williams

“Advice is what we ask for when we already know the answer but wish we didn’t”Erica Jong

Information ExchangeInformation Exchange

Principles of Information Exchange

• Know your motivation: Whose needs are being met? Is this what the client needs right now?

• When in doubt – don’t • Remember spirit of collaboration• Make it personal (“I statements”)• Clearly convey empathy and personal

concern• Use elicit-provide-elicit format

Elicit-Provide-Elicit• Elicit

– Ask permission (unless client asks first)– Clarify what information is needed

• Provide– Present information clearly and in manageable doses– Advice: provide a menu of options– Support autonomy; avoid coercion

• Elicit– Check person’s understanding and/or reaction

Take Home Point #8

Evoking personalized and genuine “change talk” is a

primary goal of this conversation about

change.

“It is the truth we ourselves speak rather than the treatment we receive that heals us”

O. H. Mowrer

“It is the truth we ourselves speak rather than the treatment we receive that heals us”

O. H. Mowrer

Evoking

Change Talk

• Key concept that distinguishes MI from other client-centered approaches

• Opposite = “sustain talk”– Make sure to distinguish from resistance

• Key principle: let the client make the argument for change

• Why? Self-perception Theory

Self-perception theory

• We learn about our beliefs and attitudes by hearing ourselves talk

• Eliciting “resistance talk” increases resistance• Eliciting “importance talk” increases

perceived importance• Eliciting “confidence talk” increases perceived

confidence

Evoking Change Talk – Ask Evocative Questions

• “How would you like for things to be different?”• “What is the downside of how things are now?”• “What concerns you most about your drinking?”• “How urgent does this feel to you right now?”• “How possible does this feel to you right now?”• “If you did decide to change, how do you think

you could do it?”

Evoking Change Talk – OARS

Open-ended question (elaboration)– “Sometimes I feel awful when I wake up the next

morning”• “In what ways does drinking make you feel bad?”

Affirmation– “I think my family would be happier if quit”

• “You really care about them”

Evoking Change Talk – OARS

Reflection: As a general principle, when in doubt, reflect change talk– “I know I could lose weight if I really tried”

• “And you have some ideas about what might work”• “You’ve given this a lot of thought”

Summaries (gathering)– “I’ve heard a number of concerns about your weight. First,

you get tired easily, and that really frightens you. Second, your children are worried, and it hurts to hear them say so. Third, you feel ashamed of your body. Anything else”?

Evoking Change Talk – Ask “Low Threshold Questions”

Involves framing questions in a way that avoids requiring the client to endorse “problem language”, or to commit to major changes. In general, low threshold questions:– Ask about “concerns” or “worries”, rather than

problems or commitment to change– Specifically ask about even very low levels of

concern

Evoking Change Talk – Ask “Low Threshold Questions”

• High threshold: “Do you think you are an alcoholic?”

• Low threshold: “Do you have any concerns about your drinking, even small ones?”

• High threshold: “Do you think anger is a problem for you?”

• Low threshold: “Has anything about the way you handle anger ever worried you, even a little bit?”

Evoking Change Talk –Importance Ruler

How important is it for you right now to change?

On a scale of 0 to 10, what number would you give yourself?

0 ………………………………………………………………….. 10not at all extremely important important

A. Why are you at 2 and not at 0?B. What would need to happen for you to get from 2 to 3?

Evoking Change Talk –Confidence Ruler

If you did decide to change, how confident are you that you could do it?

0 ………………………………………………………….. 10not at all extremely confident confident

A. Why are you at 2 and not at 0?B. What would need to happen for you to get from 2 to 3?C. How can I help you get from 2 to 3?

• A tool for weighing the “good things” and “not so good things” about change when you hear or suspect ambivalence

•Including the “good things” enhances credibility and rapport

•Always start with the “good things”

•Offer a summary statement of both sides

•Use the summary as a motivational tool

•Caution: don’t elicit too much sustain talk

• A tool for weighing the “good things” and “not so good things” about change when you hear or suspect ambivalence

•Including the “good things” enhances credibility and rapport

•Always start with the “good things”

•Offer a summary statement of both sides

•Use the summary as a motivational tool

•Caution: don’t elicit too much sustain talk

Evoking Change Talk –Decisional Balance

Evoking Change Talk – Special Considerations for Low Confidence

• Ask about previous successes • Ask about personal qualities that might

contribute to change• Highlight strengths

– Client: “I don’t know why I can’t leave this relationship. I left my last boyfriend when he started hitting me”

– Clinician: “So, when things get bad enough you make sure to take care of yourself”

Evoking Change Talk – Explore Values

Particularly helpful when no change talk is forthcoming. Basic principles:

• Everyone has something that is important (listen for roles, relationships, self-image)

• Most efforts at change reflect an underlying value

• Most targets of treatment affect an underlying value

Evoking Change Talk – Explore Values

Some initial questions:• “What is the one thing that is most important in your life?”• “What makes you feel that life is worth living?”• “What is one thing that you feel you could never give up?”• “What qualities do you have that you really value?”

Some follow-up questions:• “How do you reflect this value in your daily life?”• “How might you be even more true to this value in your life?”

Take Home Point #9

Planning for change happens only when there is commitment to change, and starts with the clients ideas and experiences.

“Action speaks louder than words, but not nearly as often”

Mark Twain

“Action speaks louder than words, but not nearly as often”

Mark Twain

Planning(Developing change strategies)

PlanningKey questions for the clinician:• What would be a reasonable next step

towards change?• What would help this person to move

forward?• Am I remembering to evoke rather than

prescribe a plan?• Am I offering advice or information with

permission?

PlanningFormulating a plan:• Start with the client’s ideas• Make sure to discuss anything that has

worked in the past• If you suggest a plan, follow guidelines for

information exchange• Consider a menu of options:

– “There are a few things I have noticed can be helpful…”

Planning

Finalizing a plan:• Assess readiness: “How ready are you

to do that?”• Ask for commitment (“will”, not “ought”)• Be specific about first steps, time frame• Trouble-shoot obstacles: “Can you think

of anything that would get in the way?”

Take Home Point #10

Nothing changes if nothing changes: What can you

take home and use in your work right away?

For More Information

• Motivational Interviewing: Helping People Change (3rd ed.), by Miller & Rollnick, 2013, Guilford Press

• www.motivationalinterview.org • Rosengren, D. B. (2009). Building

Motivational Interviewing Skills: A Practitioner Workbook. New York: Guilford Press

For More Information• Wagner, C, & Ingersoll, K.S. (2013).

Motivational Interviewing in Groups. New York: Guilford Press

• Project Match MET Manual - NIAAA, P.O. Box 10686, Rockville, MD 10849-0686 (Specify Project Match Manual #2)

• Rollnick, S., Mason, P., & Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press.