Motivational InterviewingMotivational Interviewing

Therese Killeen PhD Therese Killeen PhD

Overlap in Treatment and Legal Overlap in Treatment and Legal SystemsSystems

About 50 to 60% of substance abuse clients About 50 to 60% of substance abuse clients are legally mandated to substance abuse are legally mandated to substance abuse treatmenttreatment

High rate of substance abuse in offendersHigh rate of substance abuse in offenders High rate of recidivism in both populationsHigh rate of recidivism in both populations Problems are complexProblems are complex Drug courts allow for collaboration with the Drug courts allow for collaboration with the

treatment and legal systemtreatment and legal system

Commonalities in Client Commonalities in Client CharacteristicsCharacteristics

AngryAngry Frightened about what might happenFrightened about what might happen Reluctant to examine abusive/illegal Reluctant to examine abusive/illegal

behaviorbehavior Unwilling to relinquish their only sense of Unwilling to relinquish their only sense of

controlcontrol Difficulty accepting responsibility for their Difficulty accepting responsibility for their

behaviorbehavior

Goals for rehabilitationGoals for rehabilitation

Increase effectiveness of interactions with Increase effectiveness of interactions with clients/offendersclients/offenders

Improve the climate of the criminal justice Improve the climate of the criminal justice system/ addiction treatmentsystem/ addiction treatment

Reduce RecidivismReduce Recidivism Help clients/offenders commit to or even Help clients/offenders commit to or even

consider changeconsider change Help engage and remain in treatmentHelp engage and remain in treatment Build supportive relationships Build supportive relationships

Motivational InterviewingMotivational Interviewing

A client-centered goal directive method for A client-centered goal directive method for enhancing intrinsic motivation to change by enhancing intrinsic motivation to change by

exploring and resolving ambivalenceexploring and resolving ambivalence

Motivational Interviewing in Special Motivational Interviewing in Special Populations/SettingsPopulations/Settings

Substance Use Disorders/Dual DisordersSubstance Use Disorders/Dual Disorders Medical/Public Health SettingsMedical/Public Health Settings Criminal JusticeCriminal Justice AdolescentsAdolescents CouplesCouples Group SettingsGroup Settings

Outcome Effects Attributed to:Outcome Effects Attributed to:

Therapist effectsTherapist effects – who delivers treatment – who delivers treatment and howand how

Process effectsProcess effects – what happens between – what happens between clients and therapistsclients and therapists

Laws of learningLaws of learning – principles of behavior – principles of behavior and changeand change

Mesa Grande Review, W. Miller

AMBIVALENCEAMBIVALENCE

……a state of mind in which a person a state of mind in which a person has coexisting but conflicting feelings, has coexisting but conflicting feelings, thoughts, and actions about somethingthoughts, and actions about something

The “I do but I don’t” dilemmaThe “I do but I don’t” dilemma

Status ambivalence changeQuo movement

Basic Assumptions about the Nature Basic Assumptions about the Nature of Motivationof Motivation

Motivation is a key to changeMotivation is a key to change Motivation is MultidimensionalMotivation is Multidimensional Motivational is dynamic and fluctuatingMotivational is dynamic and fluctuating Motivational is influenced by social Motivational is influenced by social

interactionsinteractions Motivation can be modifiedMotivation can be modified Motivation can be influenced by clinician Motivation can be influenced by clinician

stylestyle

MotivationMotivation

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

no external intrinsicmotivation motivation /pressure motivation

RecurrenceRecurrence

MaintenanceMaintenanceActionAction

PreparationPreparationContemplatiContemplationon

PrecontemplatiPrecontemplationon Stages of ChangeStages of Change

How Many Patients Are Ready?How Many Patients Are Ready?

Prep

Contemplation

Precon

Action

Matching Interventions to Client Matching Interventions to Client Stage of ChangeStage of Change

Precontemplation Precontemplation stage - must raise their stage - must raise their awareness before they can consider change; awareness before they can consider change;

Contemplation Contemplation stage - require help resolving stage - require help resolving their ambivalence and choosing positive change their ambivalence and choosing positive change over their current situation;over their current situation;

Preparation Preparation stage - need help identifying stage - need help identifying potential change strategies and choosing the most potential change strategies and choosing the most appropriate one for their circumstances;appropriate one for their circumstances;

Continued - Continued - Action Action stage - need help implementing and stage - need help implementing and

complying with the change strategies and learning complying with the change strategies and learning how to prevent or limit relapse;how to prevent or limit relapse;

Maintenance Maintenance stage - may have to develop new stage - may have to develop new skills for maintaining recovery /behavior changeskills for maintaining recovery /behavior change

Recurrence Recurrence stage - need help recovering quickly stage - need help recovering quickly and resuming the change process.and resuming the change process.

Flexible PacingFlexible Pacing

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

Critical to MICritical to MI

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

Readiness to ChangeReadiness to Change

Less ready the client is to change, the more Less ready the client is to change, the more important it is to do MIimportant it is to do MI

Clients may vacillate between and during Clients may vacillate between and during sessionssessions

Moving into action strategy prematurely Moving into action strategy prematurely may adversely affect outcomemay adversely affect outcome

Could be countertherapeutic to continue Could be countertherapeutic to continue with MI when client is clearly ready for with MI when client is clearly ready for behavior changebehavior change

Spirit of MISpirit of MI

CollaborationCollaboration EvocationEvocation AutonomyAutonomy

Dancing

Wrestling

Collaboration

High Spirit EvocationHigh Spirit Evocation

Elicits the client’s ideas about change.Elicits the client’s ideas about change. ““Curious and patient”Curious and patient” Stay focused on whatever behavior change Stay focused on whatever behavior change

the client is willing to do.the client is willing to do.

Being Supportive of High Being Supportive of High AutonomyAutonomy

Accept that the clients may not choose to Accept that the clients may not choose to change.change.

Are invested in behavior change but don’t Are invested in behavior change but don’t push it, in order to maintain therapeutic push it, in order to maintain therapeutic alliance.alliance.

Reinforce that ultimately any behavior Reinforce that ultimately any behavior change is within the realm of the client.change is within the realm of the client.

How is “Spirit” different from other How is “Spirit” different from other counseling characteristics?counseling characteristics?

Not sympathy or being softNot sympathy or being soft No emphasis on expertise (on the part of the No emphasis on expertise (on the part of the

counselor)counselor) Education of client not considered effective Education of client not considered effective

(not to be confused with exchanging (not to be confused with exchanging information)information)

Does not focus on skill-buildingDoes not focus on skill-building Does not analyze unconscious motivationsDoes not analyze unconscious motivations

Express Empathy

Develop Discrepancy

Roll with Resistance

Support Self-efficacy

MI MICRO-SKILLSMI MICRO-SKILLSOARSOARS

Open-ended Questions

Affirmation

Reflective Listening

Summary

OPEN-ENDED QUESTIONSOPEN-ENDED QUESTIONS

An open-ended question is one where An open-ended question is one where there is more than a yes or no responsethere is more than a yes or no response

““Do you realize the number of charges Do you realize the number of charges against you?”against you?”

versusversus

“ “ What is your understanding of the What is your understanding of the charges you have against you?”charges you have against you?”

AFFIRMATIONSAFFIRMATIONS

Client Focused Client Focused Building RapportBuilding Rapport Recognizing and reinforcing Client Recognizing and reinforcing Client

Strength and EffortStrength and Effort Aimed atAimed at

– Supporting Client’s InvolvementSupporting Client’s Involvement– Encouraging Continued AttendanceEncouraging Continued Attendance– Assisting Client to see the PositivesAssisting Client to see the Positives

Affirmation ExamplesAffirmation Examples

That was quite an accomplishment.That was quite an accomplishment. You have really done well this week.You have really done well this week. Congratulations, you stuck to your plan.Congratulations, you stuck to your plan. You are really putting a lot of effort into You are really putting a lot of effort into

this.this. It took a lot to come in today, but you made It took a lot to come in today, but you made

it.it. You really handled that situation well.You really handled that situation well.

Reflective ListeningReflective Listening

““Statements” that lets the client know you Statements” that lets the client know you are listeningare listening

Reasonable guess as to the meaning of what Reasonable guess as to the meaning of what was saidwas said

Checking out your assumption with the Checking out your assumption with the clientclient

REFLECTIVE LISTENINGREFLECTIVE LISTENINGFine tuningFine tuning

REFLECTIVE LISTENINGREFLECTIVE LISTENINGFine tuningFine tuning

Level One: RepeatLevel Two: RephraseLevel Three: Paraphrase

Reflect FeelingsSummary Metaphors, SimilesContinue the sentence/paragraph

Level One: RepeatLevel Two: RephraseLevel Three: Paraphrase

Reflect FeelingsSummary Metaphors, SimilesContinue the sentence/paragraph

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

ClinicianClinician: Marijuana helps you settle : Marijuana helps you settle down after a stressful day at workdown after a stressful day at work. .

Simple reflection

ClientClient: “I got charged for distribution : “I got charged for distribution of marijuana. One of my friends of marijuana. One of my friends turned me in so that he would get a turned me in so that he would get a lesser charge.”lesser charge.”

ClinicianClinician: “I imagine you are pretty : “I imagine you are pretty angry that you friend did this to you.”angry that you friend did this to you.”

SUMMARIZINGSUMMARIZING

Special form of reflectionSpecial form of reflection Counselor chooses what to include and emphasizeCounselor chooses what to include and emphasize Include client’s concerns about change, problem Include client’s concerns about change, problem

recognition, optimism about change, ambivalence recognition, optimism about change, ambivalence about changeabout change

Restatement of any change talk about intention to Restatement of any change talk about intention to change, and confidence in his or her ability to change, and confidence in his or her ability to changechange

Let client know you are listening Let client know you are listening

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

MI Clinician GoalsMI Clinician Goals

Talk less than your clientTalk less than your client Most common response - reflectionMost common response - reflection Reflect twice for each questionReflect twice for each question Complex reflections (paraphrase and Complex reflections (paraphrase and

summarize) over half the time summarize) over half the time Use open questionsUse open questions Avoid getting ahead of client’s readiness Avoid getting ahead of client’s readiness

levellevel

Change TalkChange Talk

Disadvantage of the status quoDisadvantage of the status quo Advantage of changeAdvantage of change Optimism about changeOptimism about change Intention to changeIntention to change

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"

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

Evoking Change Talk StrategiesEvoking Change Talk Strategies Evocative Evocative

questionsquestions Explore Explore

decisional decisional balancebalance

ElaborationElaboration ExamplesExamples Look backLook back

Look forwardLook forward Query extremesQuery extremes Explore goals Explore goals

and valuesand values Come Come

alongsidealongside

Evocative QuestionsEvocative Questions

““How might you go about making this How might you go about making this change?”change?”

““What would be a good first step?”What would be a good first step?” ““What obstacles do you foresee and how What obstacles do you foresee and how

might you deal with them?”might you deal with them?” What gives you the confidence that you can What gives you the confidence that you can

do this?”do this?”

ElaborationElaboration

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

Developing DiscrepanciesDeveloping Discrepancies Use of summariesUse of summaries Differences between stated goals and actual Differences between stated goals and actual

behaviorbehavior Tip the Balance by making a decision to Tip the Balance by making a decision to

change change Use of pros and cons exerciseUse of pros and cons exercise

““So you say that you need to save money to So you say that you need to save money to move but on the other hand you find move but on the other hand you find yourself spending $100 a week buying MJ… yourself spending $100 a week buying MJ… What do you make out of this?”What do you make out of this?”

““How does your drinking fit in with your How does your drinking fit in with your having a happy family and good job?”having a happy family and good job?”

Exploring pros and cons – Exploring pros and cons – Developing DiscrepanciesDeveloping Discrepancies

““What are the good things about your What are the good things about your drinking?”drinking?”

““What are the not so good things?”What are the not so good things?”

Readiness Ruler: Eliciting Change Readiness Ruler: Eliciting Change TalkTalk

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10 Not at allNot at all ExtremelyExtremely

How How importantimportant is it to you to change this? is it to you to change this? How How confidentconfident are you that you can change are you that you can change

this?this?

Evoking Change talkEvoking Change talk

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

a 5 to say a 7 or 8?a 5 to say a 7 or 8?

Imagine extremesImagine extremes

““What is the worst that can happen if you What is the worst that can happen if you continued?”continued?”

What do you think would have to happen to What do you think would have to happen to make you decide to tell yourself, “ok that’s make you decide to tell yourself, “ok that’s enough?”enough?”

Looking ForwardLooking Forward

““What would you like your life to be like in What would you like your life to be like in 2 years?”2 years?”– ““How does what you are doing now make that How does what you are doing now make that

difficult?”difficult?” ““What would it be like if you continue with What would it be like if you continue with

the way things are now?”the way things are now?” Suppose things don’t change, how do think Suppose things don’t change, how do think

your life will look?”your life will look?”

Looking BackLooking Back

““When was the last time things were going When was the last time things were going well for you and what was it like for you?” well for you and what was it like for you?”

““What do you think could have prevented What do you think could have prevented this setback?this setback?

““Before you used , what was your life Before you used , what was your life like?”like?”

““As you step back and look at all this, what As you step back and look at all this, what do you make of it?”do you make of it?”

Involves feelings-actions-Involves feelings-actions-

behaviors of an interpersonal behaviors of an interpersonal

nature where there is a lack of nature where there is a lack of

collaborationcollaboration

Identifying resistanceIdentifying resistance

ArguingArguing DiscountingDiscounting DisagreeingDisagreeing HostilityHostility BlamingBlaming

De - focusDe - focus DefensiveDefensive PessimismPessimism PassivityPassivity Body languageBody language

What is resistance?What is resistance?

Interpersonal behaviorInterpersonal behavior Information Information Clinician influences resistance: How you respond Clinician influences resistance: How you respond

matters?matters? Not a client problem, but a clinician skill issueNot a client problem, but a clinician skill issue Cue to change direction/back offCue to change direction/back off

Responses to ResistanceResponses to Resistance

Shifting focusShifting focus ReframingReframing Agreeing with a Agreeing with a

twisttwist Emphasize personal Emphasize personal

choice and controlchoice and control Coming alongsideComing alongside

Agreement with a twistAgreement with a twist

Initial agreement but with a slight change of Initial agreement but with a slight change of directiondirection

Example: You’ve got a good point there. All Example: You’ve got a good point there. All this nagging and blaming is not helpful. this nagging and blaming is not helpful. This is a problem that involves the whole This is a problem that involves the whole family.family.

Emphasizing Personal Choice and ControlEmphasizing Personal Choice and Control

““It is entirely up to you. This is really your It is entirely up to you. This is really your decision. No one can make that decision for decision. No one can make that decision for you.”you.”

““If you decide that you do not want to If you decide that you do not want to change, then that is your decision.”change, then that is your decision.”

ReframingReframing

Acknowledge what client has said but offer Acknowledge what client has said but offer a different perspectivea different perspective

Example: “I wonder if all that complaining Example: “I wonder if all that complaining your wife does is her way of showing her your wife does is her way of showing her concern.”concern.”

Focus on how long the client stayed in Focus on how long the client stayed in treatment the last time rather than the fact treatment the last time rather than the fact that he/she did not complete.that he/she did not complete.

Coming alongsideComing alongside

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

Shifting focusShifting focus

Going around the resistance – taking a Going around the resistance – taking a detourdetour

Example – Maybe we are getting ahead of Example – Maybe we are getting ahead of ourselves here. I am worried, as you are, ourselves here. I am worried, as you are, about some of the things that are going on about some of the things that are going on in your life right now. Tell me more in your life right now. Tell me more about……about……

Information exchange versus Information exchange versus information givinginformation giving

Information GivingInformation Giving

– A one-way processA one-way process– Combine facts with interpretation & persuasionCombine facts with interpretation & persuasion– Decide what to assess & what information to Decide what to assess & what information to

provideprovide– Reinforce passivity in patientReinforce passivity in patient– Ask lots of closed questionsAsk lots of closed questions

Information ExchangeInformation Exchange Elicit needs & knowledgeElicit needs & knowledge

– ““What would you most like to know about.?”What would you most like to know about.?”– ““How much do you know about...?”How much do you know about...?”

Ask permission to provide information Ask permission to provide information – Keep to information, away from personal interpretationKeep to information, away from personal interpretation– Some clients say that it helps to…..Some clients say that it helps to…..– This may or may not help but …..This may or may not help but …..– You may or may not agree …..You may or may not agree …..

Elicit client’s interpretationElicit client’s interpretation– ““What do you make of that...?”What do you make of that...?”– ““What does this mean for your future...?”What does this mean for your future...?”

SummarySummary

Stay in the “spirit of MI”Stay in the “spirit of MI” Use OARS skillsUse OARS skills Identify and reinforce change talkIdentify and reinforce change talk Identify and roll with resistanceIdentify and roll with resistance Do not get ahead of client’s stage of changeDo not get ahead of client’s stage of change

motivationalinterviewing.org

Eight Stages of Learning MIEight Stages of Learning MI

Overall MI SpiritOverall MI Spirit OARS SkillsOARS Skills Recognizing change Recognizing change

talk and resistancetalk and resistance Eliciting/strengthening Eliciting/strengthening

change talkchange talk Rolling with Rolling with

ResistanceResistance

Developing change Developing change planplan

Consolidating Consolidating commitmentcommitment

Transition and Transition and blending (with other blending (with other approaches)approaches)