0
What it is and why you should be
using it
D e b b i e N i e r i , M S
C e n t e r f o r H e a l t h S e r v i c e s a n d ...
Reference
Miller, WR and Rollnick, S (2012). Motivational
Interviewing: Helping People Change (3rd Ed.). New
York: Guilfor...
GOAL:
You will obtain a conceptual
understanding of the Processes and Core
Skills of Motivational Interviewing,
beginning ...
Evolution of MI and contributors
 William R. Miller and Stephen Rollnick
 Carl Rogers
 Non-directive client-centered ps...
Miller & Rollnick’s Summary of the Outcome Research
 Currently more than 1200 publications
 200 of which are Random Cont...
Hypotheses and conclusions proposed by M&R
Notable and replicated findings
 Small to medium effect sizes across a variety...
Hypotheses and conclusions proposed by M&R
 Within well controlled studies using treatment
manuals, substantial therapist...
Hypotheses and conclusions proposed by M&R
• MI is intended to influence client factors that are
associated with positive ...
Hypotheses and conclusions proposed by M&R
• Training in MI may help suppress counter-therapeutic
responses
• Findings sug...
Hypotheses and conclusions proposed by M&R
 Training in MI may help suppress counter-therapeutic
responses
• A counselor ...
Definition of Motivational Interviewing
What we know about change
Communication Traps and how they influence
conversations...
Miller and Rollnick’s Definition of MI
MIis a collaborative, goal-oriented
style of communication with particular
attentio...
Wait!
Before we talk about MI, it is helpful to first
talk about what is known about how people
change.
The Transtheoretical Model of Change
Prochaska and DiClemente’s
Transtheoretical Model of Change
 Stages of Change:
 Pre...
Pre-
Contemplation
Contemplation
Preparation
Action
How many client’s are ready for
treatment when they enter care?
Pre-Contemplation Stage of Change
The person is unaware there is a problem or
under-aware of consequences of the problem.
...
Contemplation Stage of Change
Beginning awareness and early understanding there
may be a problem yet is uncertain of what ...
Ambivalence is…
the hallmark of the Contemplation Stage of
Change
Ambivalence is…
Simultaneously wanting and not wanting
something
or
wanting both of two incompatible things
Ambivalence is…
a normal part of the change process
Ambivalence
Common to hear two kinds of talk mixed together:
Change talk: the person’s own statements that favor change, s...
“I want to quit smoking but
every time I’ve tried I gain weight then
start again.”
“I know it’s bad for my health
yet I ca...
The path out of ambivalence is
to choose a direction, follow it,
and keep moving in the chosen
direction.
Mind Committees: Our personal internal debate teams
We trust ourselves and our own
opinions more so than others
When the i...
“The Righting Reflex” Miller & Rollnick (2012, pg. 6)
“A natural and instinctive response of trained
care providers is to ...
Professional operating from
the Righting Reflex says to the:
Client feeling ambivalent,
who says/thinks in response:
 “Yo...
Who do we listen to most?
Which side of the ambivalence debate is the
professional likely to side with?
Which side of the ...
Preparation Stage of Change
The person has an appreciable understanding of the
nature of the problem; can express desires,...
Action
The client is actively taking steps to change but has not
yet reached a stable state
“I’ve been testing my glucose ...
Maintenance
The client has achieved initial goals (such as
abstinence) and is now working to maintain gains.
“I have so mu...
So, why discuss Stages of Change?
Understanding the process of change and being able to
identify where your client is in t...
The Practitioner and Practice
Characteristics that provide the
foundation for Motivational
Interviewing:
“Habits of the He...
MI Spirit
Partnership
Acceptance
Evocation
Compassion
Partnership
Dancing as opposed to wrestling
The willingness to suspend the reflex to dispense
expert advise is a key eleme...
Acceptance (Miller &Rollnick, 2012, p. 19)
A professional exhibiting Acceptance as intended in the
MI spirit:
“Honors each...
Compassion
To actively promote the other’s welfare by giving priority
to their individual needs
Evocation
A strengths-focused premise rather than a deficit-
focused model
People already have within themselves much of w...
MI Processes and Core Skills
The Method of Motivational
Interviewing
Four Overlapping Processes
 Engaging
 Focusing
 Evoking
 Planning
The confluence of these four processes describe MI
Engaging: The relational foundation
 Engaging is establishing a helpful connection and a
working relationship
Engagement ...
Engagement
Is paramount
The quality of the therapeutic alliance between client and
counselor directly predicts both retent...
Traps that Promote Disengagement
 The Assessment Trap
 The Expert Trap
 The Premature Focus Trap
 The Labeling Trap
 ...
Factors Influencing Engagement
 Desires or goals
 Importance
 Positivity
 Expectations
 Hope
Each of these factors sh...
Engaging: Reflective Listening
 Takes a fair amount of practice to become skillful, in
spite of seeming easy to do
The cr...
Focusing (Miller & Rollnick, 2012, p. 27)
“The process by which you develop and maintain a
specific direction in the conve...
Focusing
Answers the question:
What changes are hoped to arise from this consultation?
How often are the answers consisten...
Styles of Communication
 Directing: the focus is provider determined
As a default approach for promoting personal change ...
Evoking: preparing people to change
The heart of MI: It is in the process of evoking that
counseling becomes distinctly MI...
Component skills in Evoking
 Recognizing change talk when you hear it
 And, knowing how to evoke and respond to it when ...
If someone else voices an argument for
change, people are likely to respond by
expressing a counter-change argument from
t...
Preparatory Change Talk (The DARN’s)
Desire, Ability, Reasons, and Need
Each reflect the pro-change side of ambivalence.
T...
Mobilizing Change Talk (The CATS)
The CATS signal movement toward resolution of the
ambivalence in the favor of change.
 ...
Mobilizing Change Talk
 Taking Steps: the client has already done something in
the direction of change:
“I bought nicotin...
Sustain Talk
 “Any speech that can be uttered on behalf of change
can also be spoken as an equal and opposite reaction
on...
Evoking Motivation
Counselors can substantially influence the amount of
change talk spoken.
Strength and frequency of chan...
Ask evoking questions
 Ask open-ended questions surrounding the DARN’s:
(CAT’s are likely too premature)
 DESIRE: “How w...
Ask evoking questions (cont)
 Querying Extremes: “What concerns you the most
about…?”
 Looking back: “Do you remember a ...
Wrong Questions?
 Questions that would be ill-advised from an MI
perspective.
 “Why haven’t you changed?”
 “What keeps ...
Responding to Change Talk
When you hear it, respond to it!
 Open-ended questions: Ask for more detail or examples
 Affir...
Responding to Sustain Talk
It is not desirable in MI to evoke and explore all of the
client’s possible reasons for maintai...
Reflective responses to Sustain Talk
 Straight Reflection
 Amplified Reflection
 Double-sided Reflection
 Emphasizing ...
Planning
 Encompasses both developing commitment to change
and formulating a specific plan of action
 Is a conversation ...
Planning
There is a negotiation of change goals and plans, an
exchange of information, and usually a specification of
next...
Signs Clients are ready to transition to planning
 There is an increase in change talk with noticeable
strength in commit...
Transitioning Methods
 Recapitulation: A transitional collecting summary of
Change Talk, like adding flowers to a bouquet...
Key Points to planning
 Developing the plan is the beginning, not the final step.
 Implementation intentions involve bot...
Supporting Change
 Support persistence
 Provide flexible revisiting
 Re-planning
 Reminding
 Refocusing
 Reengaging
Core Skills
 Asking Open-ended questions
 Affirming
 Reflective Listening
 Summarizing
&
 Informing and Advising
Asking Open Questions
Gathering information is not the function of the question
in MI
 Responses help you understand the ...
Affirming
 Happens through the MI spirit in a general sense and
specifically through direct recognition of particular
str...
Reflective Listening
 Making a guess about the client’s meaning
 Functionally, it deepens the understanding of both the
...
Summarizing
 Reflection statements that collect what the person has
been saying and offers it back, as if in a basket.
 ...
Different functions of Summaries
 Functions are based on which MI process is at task
 Engaging: communicate what you’ve ...
Informing and Advising
 In MI, providing information and advising is
appropriate, with two considerations:
1. Information...
Exchanging Information
 Practitioners often overestimate the amount of
information clients need
It is unhelpful to give c...
Information Exchange: Principles of Good Practice
 Clients are the experts on themselves
(using affirmations and reflecti...
Simple Strategy for Information Exchange
Elicit Provide Elicit
Elicit Information Needs
 Ask permission and clarify information gaps and needs:
“May I…?”
“Would you like to know about…...
Provide the needed information
 Prioritize, be clear and concise, avoid jargon
 Support autonomy
 Offer small amounts w...
Elicit (again)
 Check back in with the client to see what they
understand the information to mean, their
interpretation, ...
Offering Advice
 A special form of information giving as it implies a “do”
component: a recommendation about making perso...
!! IMPORTANT TO REMEMBER !!
The vast majority of people
do not like receiving unsolicited advice.
Even more people don’t t...
Idea/ concept Motivational Interviewing
1. Identical to Rogers’
non-directive counseling
2. A technique or gimmick
to make...
Idea/ concept Motivational Interviewing
3. MI is a panacea, the
solution to all clinical
problems
3. MI blends well with
o...
Idea/ concept Motivational Interviewing
4. The Transtheoretical
Model (TTM), although
they are compatible and
complementar...
Idea/ concept Motivational Interviewing
6. Require the use of
assessment feedback
7. A way of manipulating
people into doi...
Goals:
1. You will understand what is known from the
research about learning and developing proficiency
in MI;
2. You will...
4 Broad Components of Skill in MI
2.
Engaging
3. Focusing
and
Evoking
4. Planning
and
Integration
1. MI
Knowledge
and Spir...
Training Guidelines
A single workshop is unlikely to improve competence
“In our first evaluation of our own 2-day training...
MI Learning Menu
12 Learning Tasks identified by Miller and Rollnick
(2012)
 Understanding the underlying MI Spirit (PACE...
MI Learning Menu (cont)
 Responding to Change Talk in a manner that
strengthens it
 Responding to Sustain Talk and Disco...
How can the 12 learning tasks be accomplished?
More than obtaining knowledge is involved
Feedback is fundamental and the m...
Developing Proficiency: What’s needed?
Knowledge development and the opportunity for
continued learning over time through ...
MI Coaching and Feedback
While still valuable, a coaches feedback may be
subjective
Coding systems are available and provi...
Types of Coding Systems
 Coding interviewer responses
 MITI: Motivational Interviewing Treatment Integrity
 Moyers, T.B...
Additional Learning Methods
 Learning Communities:
 Groups of interested MI professionals working together to
monitor an...
Listening to your own sessions
 Record (with permission) your session and:
 Count your reflections: were they simple or ...
Final Comments on Learning MI
 Workshop training is a good start but it is just the
beginning.
 Feedback and coaching ar...
Modes of Delivery and Service
Settings
Problem areas that have been
researched
Applying Motivational
Interviewing
Modes of Delivery
 Consultations with individuals
 Telephone and Televideo
 Dozens of studies have been done using thes...
Modes of Delivery
 Text formats:
 Early stage of research; shows promising results
 Examples include:
 Computer based ...
Modes of Delivery
 Family consultations:
 Doing so may increase social support for change.
 The significant other (SO) ...
Differing Roles and Contexts
 Coaching
 Education
 Opportunistic Interventions
 Corrections
 Organizations
 Cross-cu...
Organizational Considerations
Implementing MI
Considerations for scope of implementation
 Limited implementation with few staff vs. training for
all staff
 The role o...
Organizations: Common areas for improvement
 Communication style
 Avoid overuse of directing style
Have two feet planted...
Wrap-Up
Motivational Interviewing. What it is and why you should be using it.
Motivational Interviewing. What it is and why you should be using it.
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Motivational Interviewing. What it is and why you should be using it.

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Debbie Nieri, MS
Center for Health Services and Policy Research
University of South Carolina

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  • Miller: Using fidelity checks (direct observation and coding), 9 therapists delivered manual guided treatment and experienced different client outcomes: the therapist the client had been assigned to contributed significantly to client outcomes: those that had established greater accurate empathy, had more positive client outcomes.During fellowship, trained graduate students on Rogerian client-centered counseling techniques. “There is a lovely resonance in the fact that Motivational Interviewing was literally evoked from me” (pg. 373).Australia: Met Steve Rollnick who was interested in learning ways to teach MI. Decided to write about MI together resulting in the first edition of MI in 1991. The book focused on alcohol addiction.The principles of client-centered treatment heavily influence both the importance and process of engaging clients and establishing empathy and the use of reflective listening, promoting unconditional positive regard, affirming, etc.
  • Discuss “Yea-buts”
  • Transcript of "Motivational Interviewing. What it is and why you should be using it."

    1. 1. What it is and why you should be using it D e b b i e N i e r i , M S C e n t e r f o r H e a l t h S e r v i c e s a n d P o l i c y R e s e a r c h U n i v e r s i t y o f S o u t h C a r o l i n a Motivational Interviewing (MI)
    2. 2. Reference Miller, WR and Rollnick, S (2012). Motivational Interviewing: Helping People Change (3rd Ed.). New York: Guilford Press.
    3. 3. GOAL: You will obtain a conceptual understanding of the Processes and Core Skills of Motivational Interviewing, beginning with an appreciation of the research which has enabled it to be considered an evidence-based practice. Part I
    4. 4. Evolution of MI and contributors  William R. Miller and Stephen Rollnick  Carl Rogers  Non-directive client-centered psychotherapy principles  Rogers protégé’s: Truaxx and Carkhuff: measuring degree of proficiency in demonstrating Rogerian client-centered responses
    5. 5. Miller & Rollnick’s Summary of the Outcome Research  Currently more than 1200 publications  200 of which are Random Control Trials  Primary focus has been on addictive behaviors  Research base is broadening into the areas of healthcare, corrections, and working with youth
    6. 6. Hypotheses and conclusions proposed by M&R Notable and replicated findings  Small to medium effect sizes across a variety of behavioral outcomes.  There are substantial effects on client outcomes based on relationship with and characteristics of the therapist.  Empathy, a key construct of MI, has been found to promote positive client outcomes
    7. 7. Hypotheses and conclusions proposed by M&R  Within well controlled studies using treatment manuals, substantial therapist effects remain.  Also, variability by site occurs, more as the norm than exception: Client response is significantly effected by counselor traits and contextual aspects of delivery, factors that aren’t easily standardized by following a treatment manual.
    8. 8. Hypotheses and conclusions proposed by M&R • MI is intended to influence client factors that are associated with positive outcomes • The instillation of hope, supporting self-efficacy, and active engagement • MI may benefit from the contrast effect: • Clients may have experienced more directive and confrontational approaches and thus find MI relieving • Cultural differences may exist: • There were more substantial effect sizes with minority clients as compared to the majority white population
    9. 9. Hypotheses and conclusions proposed by M&R • Training in MI may help suppress counter-therapeutic responses • Findings suggest it takes few directive and confrontational responses by the counselor to lead to resistance and self- defensiveness in the client. • Effectiveness of MI is linked to aspects of language: • Specific forms of language presage greater behavior change and can be demonstrated as directly related to counselor responses: Change talk is the precursor to change. Sustain talk is the hallmark of ambivalence- maintaining the status quo.
    10. 10. Hypotheses and conclusions proposed by M&R  Training in MI may help suppress counter-therapeutic responses • A counselor who is focused on responding to clients using CORE skills is less likely to insert their own opinions and views • Client characteristics may moderate the measured degree of effectiveness of MI • Clients in action typically have already resolved ambivalence
    11. 11. Definition of Motivational Interviewing What we know about change Communication Traps and how they influence conversations about change What is Motivational Interviewing?
    12. 12. Miller and Rollnick’s Definition of MI MIis 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
    13. 13. Wait! Before we talk about MI, it is helpful to first talk about what is known about how people change.
    14. 14. The Transtheoretical Model of Change Prochaska and DiClemente’s Transtheoretical Model of Change  Stages of Change:  Pre-contemplation  Contemplation  Preparation  Action  Maintenance Relapse to prior stages is entirely possible, if not probable, even following extensive periods of abstinence
    15. 15. Pre- Contemplation Contemplation Preparation Action How many client’s are ready for treatment when they enter care?
    16. 16. Pre-Contemplation Stage of Change The person is unaware there is a problem or under-aware of consequences of the problem. “I am here because THEY made me come, it’s their problem, not mine”
    17. 17. Contemplation Stage of Change Beginning awareness and early understanding there may be a problem yet is uncertain of what to do or not fully understanding the nature of the dilemma. “I know I lost control again and did things I regret, but I only go overboard with the drinking because she makes me angry”
    18. 18. Ambivalence is… the hallmark of the Contemplation Stage of Change
    19. 19. Ambivalence is… Simultaneously wanting and not wanting something or wanting both of two incompatible things
    20. 20. Ambivalence is… a normal part of the change process
    21. 21. Ambivalence Common to hear two kinds of talk mixed together: Change talk: the person’s own statements that favor change, self- motivational statements. & Sustain talk: the opposite of change talk, the persons own arguments for not changing, for maintaining the status quo. Sometimes in the same sentence…
    22. 22. “I want to quit smoking but every time I’ve tried I gain weight then start again.” “I know it’s bad for my health yet I can’t imagine not smoking.”
    23. 23. The path out of ambivalence is to choose a direction, follow it, and keep moving in the chosen direction.
    24. 24. Mind Committees: Our personal internal debate teams We trust ourselves and our own opinions more so than others When the internal debate team is in conflict there is no change. When the internal debate team settles on a direction change occurs.
    25. 25. “The Righting Reflex” Miller & Rollnick (2012, pg. 6) “A natural and instinctive response of trained care providers is to fix the problem, make things right, to use knowledge acquired from training and experience to help the individual seeking care to overcome their problems.”
    26. 26. Professional operating from the Righting Reflex says to the: Client feeling ambivalent, who says/thinks in response:  “You need to stop ______”  “You haven’t been compliant with the treatment plan”  “You have to take this to get better”  “Tell me something I don’t already know”  “I’ve tried numerous times and can’t seem to stick with it”  “You sound like my wife/husband” What happens when these two meet?
    27. 27. Who do we listen to most? Which side of the ambivalence debate is the professional likely to side with? Which side of the ambivalence debate is left for the client to side with (internally or verbally)? Sustain Talk opportunity wins! = No Change Change Talk opportunity lost!
    28. 28. Preparation Stage of Change The person has an appreciable understanding of the nature of the problem; can express desires, reasons, abilities, and needs; discusses making or considering plans to change however; sustain talk remains. “I know I need to manage what I eat and exercise to help control my diabetes yet every other time I’ve tried I’ve gone right back to the same ole-same ole. I just don’t know if I have what it takes to go the long haul.”
    29. 29. Action The client is actively taking steps to change but has not yet reached a stable state “I’ve been testing my glucose levels and am keeping track of what I’ve been eating” “Yea, I quit smoking!” “I started exercise boot camp last week!”
    30. 30. Maintenance The client has achieved initial goals (such as abstinence) and is now working to maintain gains. “I have so much more energy now I’m thinking of joining the YMCA and taking exercise classes”
    31. 31. So, why discuss Stages of Change? Understanding the process of change and being able to identify where your client is in the change process facilitates choice in use of MI techniques and practices.
    32. 32. The Practitioner and Practice Characteristics that provide the foundation for Motivational Interviewing: “Habits of the Heart” The Spirit of Motivational Interviewing
    33. 33. MI Spirit Partnership Acceptance Evocation Compassion
    34. 34. Partnership Dancing as opposed to wrestling The willingness to suspend the reflex to dispense expert advise is a key element in establishing collaboration necessary to build partnership
    35. 35. Acceptance (Miller &Rollnick, 2012, p. 19) A professional exhibiting Acceptance as intended in the MI spirit: “Honors each person’s absolute worth and potential as a human being; Recognizes and supports the person’s irrevocable autonomy to choose his or her own way; Seeks through accurate empathy to understand the other’s perspective; and, Affirms the person’s strengths and efforts
    36. 36. Compassion To actively promote the other’s welfare by giving priority to their individual needs
    37. 37. Evocation A strengths-focused premise rather than a deficit- focused model People already have within themselves much of what is needed and your task is to evoke it A client’s own arguments for change are more persuasive than whatever arguments you might be able to provide
    38. 38. MI Processes and Core Skills The Method of Motivational Interviewing
    39. 39. Four Overlapping Processes  Engaging  Focusing  Evoking  Planning The confluence of these four processes describe MI
    40. 40. Engaging: The relational foundation  Engaging is establishing a helpful connection and a working relationship Engagement is a prerequisite for everything that follows  Engagement is an open-ended period that moves toward a clear focus
    41. 41. Engagement Is paramount The quality of the therapeutic alliance between client and counselor directly predicts both retention and outcome The client’s perspective more strongly predicts outcome than does the therapists’ perspective Therapist style directly impacts development of engagement
    42. 42. Traps that Promote Disengagement  The Assessment Trap  The Expert Trap  The Premature Focus Trap  The Labeling Trap  The Blaming Trap  The Chat Trap
    43. 43. Factors Influencing Engagement  Desires or goals  Importance  Positivity  Expectations  Hope Each of these factors should be attended to in the first visit when engagement is the goal
    44. 44. Engaging: Reflective Listening  Takes a fair amount of practice to become skillful, in spite of seeming easy to do The crucial element of good listening is what the counselor says in response to what the speaker offers. The choice in what content the counselor reflects and how is where MI becomes directional. Avoid Communication Roadblocks
    45. 45. Focusing (Miller & Rollnick, 2012, p. 27) “The process by which you develop and maintain a specific direction in the conversation about change” Both client and counselor have agendas which may or may not align
    46. 46. Focusing Answers the question: What changes are hoped to arise from this consultation? How often are the answers consistent between your staff and the people they serve?
    47. 47. Styles of Communication  Directing: the focus is provider determined As a default approach for promoting personal change this approach has serious limitations  Following: entirely from what the client brings to each consultation. This may be the communication style used in initial encounters, particularly when building engagement  Guiding: promotes a collaborative search for direction, the focus is negotiated between experts (the client and counselor) Focusing calls for this is the style of communication (wherein MI falls)
    48. 48. Evoking: preparing people to change The heart of MI: It is in the process of evoking that counseling becomes distinctly MI Evoking involves eliciting the client’s own motivations for change The expert/ directing approach does not facilitate personal change Personal change requires the individual’s active participation and is a long term process
    49. 49. Component skills in Evoking  Recognizing change talk when you hear it  And, knowing how to evoke and respond to it when it occurs  Recognizing sustain talk when you hear it  And, understanding what it signifies and how to respond to it Sustain Talk is the hallmark of ambivalence
    50. 50. If someone else voices an argument for change, people are likely to respond by expressing a counter-change argument from the other side of their ambivalence. People literally talk themselves out of changing. Similarly, people talk themselves into changing by continuing to voice pro-change arguments.
    51. 51. Preparatory Change Talk (The DARN’s) Desire, Ability, Reasons, and Need Each reflect the pro-change side of ambivalence. They are considered preparatory change talk because none of them, alone or together, indicate that change is going to happen.
    52. 52. Mobilizing Change Talk (The CATS) The CATS signal movement toward resolution of the ambivalence in the favor of change.  Commitment: signals the likelihood of action “I will”; “I promise”; “I guarantee”; “I intend to” (decision with a little doubt)  Activation: movement toward but not quite a commitment “I’m willing to try”; “I am ready to”; “I am prepared to”
    53. 53. Mobilizing Change Talk  Taking Steps: the client has already done something in the direction of change: “I bought nicotine patches”; “I didn’t snack any evening this past week”; “I quit smoking inside my house & car” The DARN CATS: Language that signals movement toward change
    54. 54. Sustain Talk  “Any speech that can be uttered on behalf of change can also be spoken as an equal and opposite reaction on behalf of the status quo” (p. 164) In MI, sustain talk is not ignored, in the spirit of acceptance, it is reflected, respected and included in the larger picture
    55. 55. Evoking Motivation Counselors can substantially influence the amount of change talk spoken. Strength and frequency of change talk increase over the course of a MI session. Amount of change talk predicts behavior change So, how do you increase the amount of change talk spoken by clients?
    56. 56. Ask evoking questions  Ask open-ended questions surrounding the DARN’s: (CAT’s are likely too premature)  DESIRE: “How would you like for things to change?”  ABILITY: “Of these various options you’ve considered, what seems most possible?”  REASONS: “Why would you want to get more exercise?”  NEED: “How serious is this to you?”
    57. 57. Ask evoking questions (cont)  Querying Extremes: “What concerns you the most about…?”  Looking back: “Do you remember a time when things were going well for you?”  Looking forward: “If you did decide to make this change, what do you hope would be different in the future?” OR: “Suppose you don’t make any change, what do you think the future would hold?”  Explore broader goals and values
    58. 58. Wrong Questions?  Questions that would be ill-advised from an MI perspective.  “Why haven’t you changed?”  “What keeps you doing this?”  “Why do you smoke?”  “Why aren’t you trying harder?”  “Why can’t you?”
    59. 59. Responding to Change Talk When you hear it, respond to it!  Open-ended questions: Ask for more detail or examples  Affirmation: Comment positively about what you heard  Reflections: simple or complex, continuing the paragraph  Summaries: include change talk content in summaries
    60. 60. Responding to Sustain Talk It is not desirable in MI to evoke and explore all of the client’s possible reasons for maintaining the status quo The intent of reflecting sustain talk is to acknowledge what the person is saying without pushing against it as this is likely to entrench sustain talk.
    61. 61. Reflective responses to Sustain Talk  Straight Reflection  Amplified Reflection  Double-sided Reflection  Emphasizing Autonomy  Reframing  Agreement with a twist  Running head start  Coming alongside
    62. 62. Planning  Encompasses both developing commitment to change and formulating a specific plan of action  Is a conversation about action that:  is conducted with a sharp ear for eliciting clients’ own solutions;  promotes their autonomy of decision making; and,  continues to elicit and strengthen change talk as a plan emerges
    63. 63. Planning There is a negotiation of change goals and plans, an exchange of information, and usually a specification of next steps that may or may not involve further treatment It is common for progress and motivation to fluctuate, inviting renewal of planning, evoking, refocusing, or even re-engagement
    64. 64. Signs Clients are ready to transition to planning  There is an increase in change talk with noticeable strength in commitment language (The CATS)  The client has begun taking steps toward change- testing the water  There is a noticeable reduction in the amount of Sustain Talk  The Client demonstrates resolve  The client asks questions about change
    65. 65. Transitioning Methods  Recapitulation: A transitional collecting summary of Change Talk, like adding flowers to a bouquet “I’ve heard you say you want to feel better, live a longer life, be able to do more things with your grandkids and set a better example for them by not smoking. What do you think you need to do to get there?”  Key question: from the bouquet, ask a short and simple question about doing “What do you think will make that happen?”  Pregnant Pause: waiting for the client to hear themselves or feel the affect associated with their statement, allows them to sit with the discomfort without rescuing them.
    66. 66. Key Points to planning  Developing the plan is the beginning, not the final step.  Implementation intentions involve both a specific plan and the intention or commitment to carry it out.  Public commitment, social support, and self- monitoring can reinforce the best of intentions.
    67. 67. Supporting Change  Support persistence  Provide flexible revisiting  Re-planning  Reminding  Refocusing  Reengaging
    68. 68. Core Skills  Asking Open-ended questions  Affirming  Reflective Listening  Summarizing &  Informing and Advising
    69. 69. Asking Open Questions Gathering information is not the function of the question in MI  Responses help you understand the person’s internal frame of reference which strengthens the collaborative nature of the relationship  Responses aid in finding a clear direction
    70. 70. Affirming  Happens through the MI spirit in a general sense and specifically through direct recognition of particular strengths, abilities, good intentions and efforts Opposite stance to supporting and providing affirmations is the idea that people will change if you can just make them feel bad enough. “You keep drinking when you know its ruining your relationship”
    71. 71. Reflective Listening  Making a guess about the client’s meaning  Functionally, it deepens the understanding of both the counselor and client by clarifying  Allows people to hear again the thoughts and feelings they are expressing and ponder them  Keeps the person talking, exploring, and considering The listener chooses which aspects of the client’s statements to reflect
    72. 72. Summarizing  Reflection statements that collect what the person has been saying and offers it back, as if in a basket.  Summaries:  Pull together information at the end of a session  Suggest links between present material and past  Function to transition from one task to another  Provide a ‘what else?’ opportunity  Have different functions
    73. 73. Different functions of Summaries  Functions are based on which MI process is at task  Engaging: communicate what you’ve heard, provide lead for further development of collaborative relationship  Focusing: the ‘what else?’ opportunity: ‘what have we missed’  Evoking: there are particular guidelines regarding eliciting change talk and moving along  Planning: draw together the person’s motivation, intentions, and specific plans for change
    74. 74. Informing and Advising  In MI, providing information and advising is appropriate, with two considerations: 1. Information and advice are offered with permission 2. The goal for the counselor is to understand the client’s perspective of the topic, their needs, and to facilitate the client drawing their own conclusion about the relevance of any information provided
    75. 75. Exchanging Information  Practitioners often overestimate the amount of information clients need It is unhelpful to give clients information they already have (e.g., “smoking is bad for your health”)  It is more useful to learn what they know, what they’ve already done or tried
    76. 76. Information Exchange: Principles of Good Practice  Clients are the experts on themselves (using affirmations and reflections elicits a wealth of information)  Find out what they know and need to know  Match information to clients needs  Clients can tell you what kind of information would be helpful  Advice that meets clients needs is helpful
    77. 77. Simple Strategy for Information Exchange Elicit Provide Elicit
    78. 78. Elicit Information Needs  Ask permission and clarify information gaps and needs: “May I…?” “Would you like to know about…?” “What would you like to know about…?” “Is there any information I can help you with?” “What might be the biggest benefit to you if you were to quit smoking?” “What might you be most interested in knowing about treatment options that help people quit smoking?”
    79. 79. Provide the needed information  Prioritize, be clear and concise, avoid jargon  Support autonomy  Offer small amounts with time to reflect  Acknowledge the freedom to disagree or ignore  Present what you know without interpreting the meaning for the client
    80. 80. Elicit (again)  Check back in with the client to see what they understand the information to mean, their interpretation, or response “So, what do you make of that?” “Have I been clear so far?” “You look puzzled?” “How does this apply to you?” “I wonder what all this means to you?” “Tell me in your own words what I’ve said.”
    81. 81. Offering Advice  A special form of information giving as it implies a “do” component: a recommendation about making personal change  Follow steps to providing information: EPE Advice carries a strong potential for reactance Emphasize personal choice and offer a menu of options
    82. 82. !! IMPORTANT TO REMEMBER !! The vast majority of people do not like receiving unsolicited advice. Even more people don’t think twice about giving it.
    83. 83. Idea/ concept Motivational Interviewing 1. Identical to Rogers’ non-directive counseling 2. A technique or gimmick to make people change 1. MI’s focusing, evoking, and planning have clear directionality to them. 2. MI was specifically developed to help clients resolve ambivalence and strengthen their own commitment to change MI: Is NOT/ Does NOT:
    84. 84. Idea/ concept Motivational Interviewing 3. MI is a panacea, the solution to all clinical problems 3. MI blends well with other approaches and does not negate the value of other techniques. MI is a style of being with people, an integration of clinical skills to foster movement for change. MI: Is NOT/ Does NOT:
    85. 85. Idea/ concept Motivational Interviewing 4. The Transtheoretical Model (TTM), although they are compatible and complementary. 5. The “Decisional Balance” technique exploring the pros and cons of change 4. TTM defines stages of change while MI provides a means of moving through the stages 5. Decisional balance is more associated with counseling with neutrality as the counselor explores con’s of change. MI is more directional, with the intent being to strengthen the arguments for change MI: Is NOT/ Does NOT:
    86. 86. Idea/ concept Motivational Interviewing 6. Require the use of assessment feedback 7. A way of manipulating people into doing what you want them to do 6. While personal feedback may be particularly useful for persons who aren’t considering change, it is not a necessary nor a sufficient component of MI. 7. MI cannot be used to manufacture motivation that isn’t already there. It is a collaborative partnership that honors and respects the other’s autonomy, seeking to understand the person’s internal frame of reference. MI: Is NOT/ Does NOT:
    87. 87. Goals: 1. You will understand what is known from the research about learning and developing proficiency in MI; 2. You will be exposed to some of the types of services in which MI has been used (and evaluated); and, 3. You will be able to identify characteristics of practitioners/ practice settings which may influence organizational adoption of MI. Part II
    88. 88. 4 Broad Components of Skill in MI 2. Engaging 3. Focusing and Evoking 4. Planning and Integration 1. MI Knowledge and Spirit
    89. 89. Training Guidelines A single workshop is unlikely to improve competence “In our first evaluation of our own 2-day training workshop1, participants showed very little improvement in skills, certainly not enough to make any difference in how their clients responded, but we did manage to significantly decrease their interest in learning more about MI” (p. 329) 1Miller, W.R., & Mount, K.A. (2001) A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioural and Cognitive Psychotherapy, 29, 457-471.) However, there are some who may attend one workshop and “get it” (p. 329)  Typically such ‘protégé’s re reasonably skillful in reflective listening prior to the training
    90. 90. MI Learning Menu 12 Learning Tasks identified by Miller and Rollnick (2012)  Understanding the underlying MI Spirit (PACE variables)  Developing skill and comfort with reflective listening  Identifying change goals (Focusing)  Exchanging information and providing advice within an MI style (EPE)  Being able to recognize Change Talk and Sustain Talk  Evoking Change Talk
    91. 91. MI Learning Menu (cont)  Responding to Change Talk in a manner that strengthens it  Responding to Sustain Talk and Discord in a way that does not amplify it  Developing hope and confidence  Timing and negotiating a change plan  Strengthening commitment  Flexibly integrating MI with other clinical skills and practices
    92. 92. How can the 12 learning tasks be accomplished? More than obtaining knowledge is involved Feedback is fundamental and the more immediate the better “it’s hard to learn archery in the dark” (p. 323) Clients provide immediate feedback through their responses to the counselor
    93. 93. Developing Proficiency: What’s needed? Knowledge development and the opportunity for continued learning over time through feedback and coaching based on direct observation Coaching need not be extensive “One study found that 6 individual expert coaching sessions of ½ hour each conducted by telephone were sufficient to bring trainees on average up to a level of proficiency that would be satisfactory for delivering MI in clinical trial” (p. 330) It is a matter of learning to criterion, not a fixed dose of training hours completed Martino, S., Canning-Ball, M., Carroll, K.M., & Rounsaville, B.J. (2011). A criterion-based stepwise approach for training counselors in motivational interviewing. Journal of Substance Abuse Treatment, 40, 357-365.
    94. 94. MI Coaching and Feedback While still valuable, a coaches feedback may be subjective Coding systems are available and provide objective feedback
    95. 95. Types of Coding Systems  Coding interviewer responses  MITI: Motivational Interviewing Treatment Integrity  Moyers, T.B., Martin, T., Manuel, J.K., Hendrickson, S.M., and Miller, W.R. (2005) Assessing competence in the use of motivational interviewing. Journal of Substance Abuse Treatment, 28(1), 19-26.  Coding client responses  Glynn, L.H., & Moyers, T.B. (2010). Chasing change talk; The clinician’s role in evoking client language about change. Journal of Substance Abuse Treatment, 39, 65-70.  Quantify interviewer and client responses:  MISC: Motivational Interviewing Skills Code  Moyers, T.B., Martin, T., Catley, D., Harris, K., & Ahluwalia, J.S. (2003). Assessing the integrity of motivational interventions: Reliability of the Motivational Interviewing Skills Code. Behavioral and Cognitive Psychotherapy, 31, 177-184. Visit: mi-campus.com
    96. 96. Additional Learning Methods  Learning Communities:  Groups of interested MI professionals working together to monitor and build personal skills.  Self-assessment:  Not an ideal practice.  This option requires the individual to take an unbiased look at their own performance. If doing so, record and listen to your sessions.
    97. 97. Listening to your own sessions  Record (with permission) your session and:  Count your reflections: were they simple or complex?  Offer more complex than simple reflections  Count your questions: were they open or closed?  Ask more open than closed questions  Count both reflections and questions: what is your ratio?  Aim for 2 reflections for every question  Listen for Change Talk and Sustain Talk: count each and determine the ratio.  Equal frequency = ambivalence (no change)  When Change Talk occurred, what was the next thing you said?  Count your OARS responses  Listen for MI inconsistent responses (giving advice without permission, confronting or arguing with the client, other “righting reflex” responses  How did the client respond to these?
    98. 98. Final Comments on Learning MI  Workshop training is a good start but it is just the beginning.  Feedback and coaching are important in learning MI and need to be based on observed practice and continue over time, even for the experts. Skills tend to drift over time  Skill development in MI is not a one-shot event but an ongoing process.
    99. 99. Modes of Delivery and Service Settings Problem areas that have been researched Applying Motivational Interviewing
    100. 100. Modes of Delivery  Consultations with individuals  Telephone and Televideo  Dozens of studies have been done using these methods for/to: promote physical exercise, colorectal cancer screening, medication persistence, dietary change; tobacco cessation; and, blood donation (See Miller and Rollnick, 2012, p. 337 for comprehensive list of citations)  Group Counseling  Strongly recommended practitioners hone their skills in individual first
    101. 101. Modes of Delivery  Text formats:  Early stage of research; shows promising results  Examples include:  Computer based delivery of the drinker’s check-up (Walters, Hester, Chiauzzi, & Miller (2005)  Smoking cessation: (Hollis, et al., 2005)  Depression and marijuana use: (Kay-Lambkin, Baker, Lewin, & Carr, 2009)  Drug use during pregnancy: (Ondersma, Chase, Svikis, & Schuster, 2005) Each of the formats involved providing personalized feedback regarding substance use, which in itself may enhance motivation to change (Juarez et al., 2005)
    102. 102. Modes of Delivery  Family consultations:  Doing so may increase social support for change.  The significant other (SO) may need coaching prior to involvement to reduce potential for their interactions to reinforce sustain talk (ie., they may blame, etc)  Using MI with personalized feedback (Motivational Enhancement Therapy) has been used within family treatment contexts  (Connell & Dishion, 2008; Slavet, et al., 2005; Van Ryzin, Stormshak, & Dishion, 2012)
    103. 103. Differing Roles and Contexts  Coaching  Education  Opportunistic Interventions  Corrections  Organizations  Cross-culture applications
    104. 104. Organizational Considerations Implementing MI
    105. 105. Considerations for scope of implementation  Limited implementation with few staff vs. training for all staff  The role of workshops “Workshop training is a good start, but only a beginning” (p. 354)  Ongoing Coaching and Peer Support  Improving service-wide conversations about change “Life inside a clinical consultation is often an expression of forces outside of it” ( p. 358)
    106. 106. Organizations: Common areas for improvement  Communication style  Avoid overuse of directing style Have two feet planted firmly in the Guiding Style  Engagement Client engagement is a thermometer of a well-functioning therapeutic relationship or service  Information Exchange Information exchange can be viewed as a process rather than an event, one that requires thoughtfulness on both sides
    107. 107. Wrap-Up
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