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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)
Reference
Miller, WR and Rollnick, S (2012). Motivational
Interviewing: Helping People Change (3rd Ed.). New
York: Guilford Press.
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
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
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
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
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.
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
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.
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
Definition of Motivational Interviewing
What we know about change
Communication Traps and how they influence
conversations about change
What is Motivational Interviewing?
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
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-contemplation
 Contemplation
 Preparation
 Action
 Maintenance
Relapse to prior stages is entirely possible, if not probable, even
following extensive periods of abstinence
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.
“I am here because THEY made me come, it’s their
problem, not mine”
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”
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, 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…
“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.”
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 internal debate team is in conflict there is no
change.
When the internal debate team settles on a direction
change occurs.
“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.”
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?
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!
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.”
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!”
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”
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.
The Practitioner and Practice
Characteristics that provide the
foundation for Motivational
Interviewing:
“Habits of the Heart”
The Spirit of Motivational
Interviewing
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 element in establishing
collaboration necessary to build partnership
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
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 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
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 is a prerequisite for everything
that follows
 Engagement is an open-ended period that moves
toward a clear focus
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
Traps that Promote Disengagement
 The Assessment Trap
 The Expert Trap
 The Premature Focus Trap
 The Labeling Trap
 The Blaming Trap
 The Chat Trap
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
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
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
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?
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)
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
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
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.
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.
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”
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
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
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?
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?”
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
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?”
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
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.
Reflective responses to Sustain Talk
 Straight Reflection
 Amplified Reflection
 Double-sided Reflection
 Emphasizing Autonomy
 Reframing
 Agreement with a twist
 Running head start
 Coming alongside
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
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
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
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.
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.
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 person’s internal
frame of reference which strengthens the collaborative
nature of the relationship
 Responses aid in finding a clear direction
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”
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
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
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
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
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
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
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…?”
“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?”
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
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.”
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
!! IMPORTANT TO REMEMBER !!
The vast majority of people
do not like receiving unsolicited advice.
Even more people don’t think twice about
giving it.
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:
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:
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:
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:
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
4 Broad Components of Skill in MI
2.
Engaging
3. Focusing
and
Evoking
4. Planning
and
Integration
1. MI
Knowledge
and Spirit
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
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
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
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
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.
MI Coaching and Feedback
While still valuable, a coaches feedback may be
subjective
Coding systems are available and provide objective
feedback
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
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.
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?
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.
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 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
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)
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)
Differing Roles and Contexts
 Coaching
 Education
 Opportunistic Interventions
 Corrections
 Organizations
 Cross-culture applications
Organizational Considerations
Implementing MI
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)
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
Wrap-Up

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Motivational Interviewing. What it is and why you should be using it.

  • 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. Reference Miller, WR and Rollnick, S (2012). Motivational Interviewing: Helping People Change (3rd Ed.). New York: Guilford Press.
  • 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. 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. 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. 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. 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. 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. 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. 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.
  • 12. Definition of Motivational Interviewing What we know about change Communication Traps and how they influence conversations about change What is Motivational Interviewing?
  • 13. 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
  • 14. Wait! Before we talk about MI, it is helpful to first talk about what is known about how people change.
  • 15. 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
  • 16.
  • 17. Pre- Contemplation Contemplation Preparation Action How many client’s are ready for treatment when they enter care?
  • 18. 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”
  • 19. 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”
  • 20. Ambivalence is… the hallmark of the Contemplation Stage of Change
  • 21. Ambivalence is… Simultaneously wanting and not wanting something or wanting both of two incompatible things
  • 22. Ambivalence is… a normal part of the change process
  • 23. 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…
  • 24. “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.”
  • 25. The path out of ambivalence is to choose a direction, follow it, and keep moving in the chosen direction.
  • 26. 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.
  • 27. “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.”
  • 28. 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?
  • 29. 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!
  • 30. 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.”
  • 31. 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!”
  • 32. 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”
  • 33. 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.
  • 34. The Practitioner and Practice Characteristics that provide the foundation for Motivational Interviewing: “Habits of the Heart” The Spirit of Motivational Interviewing
  • 36. 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
  • 37. 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
  • 38. Compassion To actively promote the other’s welfare by giving priority to their individual needs
  • 39. 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
  • 40. MI Processes and Core Skills The Method of Motivational Interviewing
  • 41. Four Overlapping Processes  Engaging  Focusing  Evoking  Planning The confluence of these four processes describe MI
  • 42. 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
  • 43. 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
  • 44. Traps that Promote Disengagement  The Assessment Trap  The Expert Trap  The Premature Focus Trap  The Labeling Trap  The Blaming Trap  The Chat Trap
  • 45. 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
  • 46. 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
  • 47. 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
  • 48. 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?
  • 49. 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)
  • 50. 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
  • 51. 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
  • 52. 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.
  • 53. 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.
  • 54. 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”
  • 55. 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
  • 56. 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
  • 57. 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?
  • 58. 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?”
  • 59. 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
  • 60. 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?”
  • 61. 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
  • 62. 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.
  • 63. Reflective responses to Sustain Talk  Straight Reflection  Amplified Reflection  Double-sided Reflection  Emphasizing Autonomy  Reframing  Agreement with a twist  Running head start  Coming alongside
  • 64. 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
  • 65. 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
  • 66. 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
  • 67. 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.
  • 68. 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.
  • 69. Supporting Change  Support persistence  Provide flexible revisiting  Re-planning  Reminding  Refocusing  Reengaging
  • 70. Core Skills  Asking Open-ended questions  Affirming  Reflective Listening  Summarizing &  Informing and Advising
  • 71. 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
  • 72. 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”
  • 73. 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
  • 74. 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
  • 75. 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
  • 76. 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
  • 77. 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
  • 78. 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
  • 79. Simple Strategy for Information Exchange Elicit Provide Elicit
  • 80. 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?”
  • 81. 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
  • 82. 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.”
  • 83. 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
  • 84. !! IMPORTANT TO REMEMBER !! The vast majority of people do not like receiving unsolicited advice. Even more people don’t think twice about giving it.
  • 85. 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:
  • 86. 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:
  • 87. 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:
  • 88. 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:
  • 89. 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
  • 90. 4 Broad Components of Skill in MI 2. Engaging 3. Focusing and Evoking 4. Planning and Integration 1. MI Knowledge and Spirit
  • 91. 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
  • 92. 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
  • 93. 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
  • 94. 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
  • 95. 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.
  • 96. MI Coaching and Feedback While still valuable, a coaches feedback may be subjective Coding systems are available and provide objective feedback
  • 97. 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
  • 98. 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.
  • 99. 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?
  • 100. 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.
  • 101. Modes of Delivery and Service Settings Problem areas that have been researched Applying Motivational Interviewing
  • 102. 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
  • 103. 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)
  • 104. 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)
  • 105. Differing Roles and Contexts  Coaching  Education  Opportunistic Interventions  Corrections  Organizations  Cross-culture applications
  • 107. 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)
  • 108. 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

Editor's Notes

  1. 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.
  2. Discuss “Yea-buts”