This document summarizes a training presentation on motivational interviewing and strengths-based counseling techniques. The presentation covers the core skills of motivational interviewing including empathy, developing discrepancy, avoiding argument, and reflective listening. It also discusses the principles of a strengths-based approach, which emphasizes clients' strengths and self-determination. The document provides examples of open-ended questions, affirmations, and reflections that counselors can use to help clients change behaviors and achieve goals. It concludes with a role play exercise and Q&A session.

1. National Center for Training, Support, and Technical Assistance
Linkage and Retention in HIV
Medical Care
Sarahjane Rath MPH,CHES

2. National Center for Training, Support, and Technical Assistance
Welcome and Introductions
1. What is your name?
2. Where do you work and what is your work
title?

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Agenda
• Fundamentals of motivational interviewing
• Strengths-based counseling
• Role play exercise

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Learning Objectives
• Summarize the core skills used in motivational
interviewing and strengths-based counseling
• Describe how to apply motivational interviewing
and strengths-based counseling to link and retain
clients in essential support services
• Recognize the fundamental skills that can be
used to facilitate a client’s behavior change

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The Spirit of Motivational
Interviewing (MI)
•Collaboration
•Evocation
•Autonomy

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Key Principles of Motivational
Interviewing
1. Empathy
2. Self-efficacy
3. Develop discrepancy
4. Avoid argument

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Key Principles of MI
1. Express Empathy
• Understand that acceptance increases
motivation
• Recognize that skillful reflective listening is
critical
• Regard ambivalence as a normal part of the
change process

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Key Principles of MI (Continued)
2. Support Self-Efficacy
• Reinforce even small changes
• Affirm strengths and competencies
• Remind client that relapse is normal
• Support optimism that change is possible
• Communicate that the decision & responsibility
to change belongs with the person
• Believe in client’s ability to make positive
changes in their life

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Support Self-Efficacy
• Engage client in conversations that give opportunity to
describe instances in which they have made successful
changes
• If client backtracks into old patterns, focus on the strides
accomplished, no matter how small
• Structure conversations to give client the chance to make
motivational statements
• Provide affirmations! “It’s up to you!”
Giving voice to success promotes confidence to change!

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Enhancing Self-Efficacy
Non-MI Clinician Statement MI Clinician Statement
Why didn't you use condoms this week? So you used condoms last week. Share
with me how it was?
Why did you stop using clean needles? Tell me what prompted you to use clean
needles in the past?
Because you have had unprotected sex
since your last test, I’d like to recommend
an HIV test.
Sounds like you’ve decided to have an HIV
test before, share with me how you feel
about getting one today?
You were supposed to be here Monday,
why didn’t you come in?
I just want to acknowledge that you came
in today.
How many children do you have? You seem like a very attentive father, how
many children do you have?
What is the person’s likely response to each prompt?

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What Does this Imply for Counselors?
Because motivation is modifiable and
affected by environment:
• You can help grow motivation (i.e.,
cultivate the right atmosphere or
interpersonal conditions)
• The climate you need is: Non-
judgmental, empathetic, genuine,
positive, and warm
• Acceptance facilitates change

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Key Principles of MI
3. Develop discrepancy/contradictions
• Avoid making arguments in favor of change
• Invite client to consider conflicts between behavior and
personal goals and values
• Ask client to clarify any discrepancies
• Build awareness of consequences

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ABCs of Developing Discrepancy
A. How does X (behavior to change) fit with your goal?
“How does your drug use fit with your goal of going back to
school?”
B. The Colombo Approach
“Help me understand on the one hand you say that you’ve
regretted having unprotected sex, and on the other, you feel
you don’t need to make changes?”
C. Ask for the specifics about the “less good things”
“You say contracting STI in the past has been awful. Tell me
about a time that happened.”

14. National Center for Training, Support, and Technical Assistance
Key Principles of MI
4. Avoid Argument:
• Invite client to consider a different perspective
• Look to client to find their own answers & solutions
• Avoid debate, proving a point, or imposing your point
of view
• Respond with greater adherence to a motivational
style if resistance or defensiveness increase
• Establish trust, ask permission, and elicit his/her
perceptions before offering information

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Reflective Listening
• A restatement of speaker’s meaning or emotion
• Gives the client an opportunity to clarify any
misunderstanding
• Involves rephrasing what was said using slightly
different words to clarify

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The ABCs of Reflective
ListeningA. Tests the hypothesis of what’s heard against what is
meant
B. Involves statements as opposed to questions
Use of an opener can help:
• “It sounds like you…”
• “You’re feeling…,”
• “It seems that you…,”
C. The ratio of reflections to questions should be about
3 to 1 (3 reflections for every 1 question)

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Four Levels of Reflection
1. Repeating what was said using exact words to
communicate understanding & prompt elaboration
2. Rephrasing what was said using slightly different
words to clarify meaning
3. Paraphrasing what was said using different words
to emphasize contradictions, convey underlying
meaning, or complete a thought
4. Communicate understanding of underlying
emotions or feeling, particularly when not explicitly
stated

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Levels of Reflection
(Continued)Vignette: “I want to ask my boyfriend to start using condoms but I don’t
think he would do it anyway. Plus, I think it would kill the mood in the
moment.”
1. Repeating: “You want to ask your boyfriend to wear a condom but you
don’t think he would do it.”
2. Rephrasing: “While you want to start using condoms, you’re afraid of
being turned down and of making things less romantic.”
3. Paraphrasing: “You want to start using condoms, but your worries keep
holding you back.”
4. Communicate understanding: “You’re worried about putting a strain on
your relationship .”

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Approach To MI Interactions
Open-ended questions
Affirmations
Reflective listening
Summaries

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Examples of Close-Ended
Questions
1. Are you concerned about whether you’re putting yourself at
risk for HIV or other diseases through drug use?
2. How frequently do you use condoms and with whom?
3. Do you have any questions about what you can do to
prevent HIV and other STI?
4. Do you agree that it would be a good idea to start using
condoms?
5. How long ago did you have your last HIV test?
6. Are there any barriers to you protecting yourself from HIV
and other STI?

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Open-Ended Questions that Grow
Motivation
1. Explore goals and values: Ask what values/goals are held
most dear, “What are the most important things in your
life?” What makes them so important to you?” “What gives
your life meaning?”
2. Looking forward to change: “If you make a change, how
will your future be different?” If you decided to start going
to church again, how would things be better in your life? In
what ways?
3. Optimism for change: What makes you think you can do IT?
“If you decide to start dating again, what makes you think
you could meet somebody special?”

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Open-Ended Questions that Grow
Motivation (Continued)
4. Extreme consequences: “What’s the worst that could happen if
you don’t make a change?” (What’s the worst thing that could
happen if you don’t start using condoms?)
5. Disadvantages of Status Quo: “What worries you about this
situation?” “How has THIS interfered with things that are
important to you?”
6. Looking back: “What were you like back then?” (before the
problem emerged), “What were you like before you contracted
Hepatitis?”
7. Best consequences of change: “If you succeed, how will things
be different?” (e.g., If you decide to stop using heroin, how will
your life improve?)

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Affirmations
• You took a big step in coming here today
• It seems that you have given this a lot of careful
consideration
• That’s an excellent idea
• You’ve shown a lot of courage in deciding to
come here today

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Reflections
• Reflective listening requires continuous attention
to client’s verbal and nonverbal responses and
his/her meanings, thoughts and feelings
• Reflections can be used to emphasize
motivational statements or to counter-motivate
statements such as barriers to change

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Summaries
• Demonstrates that you have been listening
carefully
• Reinforces material that has been discussed
• Acts as transition to shift focus

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In Summary
•Motivational Interviewing is very easy to use
•Small changes in counseling can result is big
changes with clients
•Practice, practice, practice!!!

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Strengths-Based Counseling
• Commonly used in social work
• Effective strategy to increase a person’s chance
of success
• Emphasizes persons self-determination and
strengths

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Competence
Capacities
Courage
Resilience
Reserves
Resources
Resourcefulness
The Lexicon of Strengths
Promise
Possibility
Positive Expectation
Potential
Strengths
Adapted from: Saleebey, D. (2009). The strengths perspective in social work practice (pp1-23). Boston, MA: Pearson

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Principles of the Strengths
Perspective
1. Every individual, group, family, and community has
strengths
2. Trauma and abuse, illness, and struggle may be injurious but
may also be sources of challenge and opportunity
3. Assume that you do not know the upper limits of the
capacity to grow; take individual, groups, and community
aspirations seriously
4. We best serve clients by collaborating with them
5. Every environment is full of resources
6. Caring, caretaking, and context

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Principles of
Strengths-Based Case Management
• Establish an effective working relationship
• Encourage clients to identify and use their strengths,
abilities, and assets to accomplish goals
• Recognize and support client control over goal-setting
and the search for needed resources
• View the community as a resource, and identify
information and sources of support within the
community
• Conduct case management as an active, community-
based activity

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What the Strengths-Based
Approach Is and Is Not
It means:
•Figuring out ways to
recognize and use
individual strengths to:
• Build onto existing
competencies and
• Address concerns
It does not mean:
• Simply focusing on
positive aspects and
ignoring concerns
• Fabricating strengths
that do not exist

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Examples of Strengths-Based
Questions
• What strengths do you think you have?
• What are your abilities?
• When have you successfully faced barriers, and
what did you do to overcome them?
• What are you good at?
• Tell me about a time when you felt most things
were going well. What were you doing to make
them go well?

34. National Center for Training, Support, and Technical AssistanceExercise
Role Play

35. National Center for Training, Support, and Technical Assistance
Debrief Exercise

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In Summary
•Strengths-based counseling is easy to use
•It is a positive approach to the client
•It really works, try it!

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What questions do you have?

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Additional Resources
• Center for Substance Abuse Treatment (1999). Enhancing Motivation for
Change in Substance Abuse Treatment. Treatment Improvement Protocol
(TIP) Series, Number 35. DHHS Pub. No (SMA) 99-3354. Washington, DC:
US Government Printing Office.
• Center for Substance Abuse Treatment (2004). Substance Abuse
Treatment and Family Therapy. Treatment Improvement Protocol (TIP)
Series, Number 39. DHHS Pub. No (SMA) 04-3957. Washington, DC: US
Government Printing Office.
• DiClemente, C.C. (1991) Motivational interviewing and the stages of
change. In: W.R. Miller & S. Rollnick (eds). Motivational interviewing:
Preparing people to change addictive behavior. New York: Guilford Press,
pp. 191-202.
• Kanfer, F.H. & Schefft, B.K. (1988). Guiding the process of therapeutic
change. Champaign, IL: Research Press.

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• Madson, M. B., & Campbell, T. C. (2006). Motivational Interviewing
Treatment Fidelity and Competence Measures: A Systematic Review.
Journal of Substance Abuse Treatment, 31, 67-73.
• Miller, W.R. (1983). Motivational interviewing with problem drinkers.
Behavioural Psychotherapy, 11, 147-172.
• Miller, W.R. (2004). Toward a Theory of Motivational Interviewing.
PowerPoint presentation, from
http://motivationalinterview.org/library/index.html
• Miller, W.R. & Jackson, K.A. (1985). Practical psychology for pastors.
Englewood Cliffs, NJ: Prentice Hall.
• Miller, W.R. & Rollnick, S. (1991) Motivational interviewing: Preparing
people to change addictive behavior. New York: Guilford Press.
• Miller, W.R., Sovereign, R.G., & Krege, B. (1988). Motivational
interviewing with problem drinkers: II. The Drinker's Check-up as a
preventive intervention. Behavioural Psychotherapy, 16, 251-268.

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• Miller, W.R., Zweben, A., DiClemente, C.C., & Rychtarik, R.G. (1995).
Motivational Enhancement Therapy Manual: A Clinical Research Guide
for Therapists Treating Individuals With Alcohol Abuse and Dependence.
Project MATCH Monograph Series, Vol. 2. NIH Pub. No. 94-3723.
Rockville, MD: National Institute on Alcohol Abuse and Alcoholism
• Prochaska, J.O. & DiClemente, C.C. (1982) Transtheoretical therapy:
toward a more integrative model of change. Psychotherapy: Theory,
Research and Practice, 19, 276-88.
• Rogers, C. (1961). On becoming a person: A therapist's view of
psychotherapy. London: Constable.

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This presentation is supported through funding from the Centers for Disease Control and Prevention under FOA-PS-14-
1403. The content of this presentation is solely the responsibility of PROCEED Inc. and does not necessarily represent the
official view of the Centers for Disease Control and Prevention.

42. National Center for Training, Support, and Technical Assistance
Thanks again!
My contact information:
Sarahjane Rath
srath@proceedinc.com
(908) 351-7727 Ext 274