Mi queen's 2013 pub

Motivational Interviewing
Marilyn Herie PhD RSW
Health, Counselling and Disability Services
Queen’s University
September 4, 2013

marilyn.herie@utoronto.ca
@MarilynHerie
www.educateria.com
• Dr. Marilyn Herie is the Academic Chair, Community Services at
Centennial College in Toronto, Canada, and Assistant Professor (Status
Only), University of Toronto Factor-Inwentash Faculty of Social Work. She
is a member of the international Motivational Interviewing Network of
Trainers (MINT), and has published numerous books, chapters and journal
articles on addiction, professional education and evidence-based practice,
including Substance Abuse in Canada with Oxford University Press. Dr.
Herie’s areas of interest and focus include e-learning and classroom
teaching, motivational interviewing and health behaviour change,
education research and evaluation, social media and interprofessional
education. She blogs about education and teaching-related topics at
www.educateria.com.

A scientist went to visit a famous Zen master.
While the master quietly served tea, the
scientist talked about Zen. The master poured
the visitor's cup to the brim, and then kept
pouring. The scientist watched the overflowing
cup until he could no longer restrain himself.
"It's overfull! No more will go in!" the scientist
blurted. "You are like this cup," the master
replied, "How can I show you Zen unless you
first empty your cup?"
http://users.rider.edu/~suler/zenstory/emptycup.html

Confidence Ruler
0 1 2 3 4 5 6 7 8 9 10
No Way I am
Bill Miller
http://www.williamrmiller.net/

Learning Objectives
At the end of this session, you will be able to:
1. Frame MI as a way of being with your client
– evocation versus installation
2. Review and practice the five key MI
strategies
3. Troubleshoot challenging practice
issues/cases
4. Identify barriers and enablers to
implementing MI skills with clients
5. Set concrete implementation objectives for
clinical practice

Three Definitions

1. What is it for?
Motivational interviewing is a
collaborative conversation to
strengthen a person’s own
motivation for, and commitment
to, change

Who was your favourite teacher?
Why?

The “Spirit” of Motivational
Interviewing
• Partnership
• Acceptance
• Compassion
• Evocation
• Absolute worth
• Accurate empathy
• Autonomy support
• Affirmation
12
Miller & Rollnick 2013

Partnership
“You are the best judge of what is
going to work for you.”

Acceptance
“I am here to help whatever you decide to do.”

Compassion
Guide me to be a patient companion,
to listen with a heart as open as the
sky. Grant me vision to see through
his eyes, and eager ears to hear his
story…Let me honour and respect his
choosing of his own path.
Adapted from Miller, 2013, “A Meditative Preparation” (p.24)

Evocation
“What were you hoping for by coming here
today?”

Common Human Reactions to
Being Listened to
• Understood
• Want to talk more
• Liking the counselor
• Open
• Accepted
• Respected
• Engaged
• Able to change
• Safe
• Empowered
• Hopeful
• Comfortable
• Interested
• Want to come back
• Cooperative
17Slide from Bill Miller

2. Why would I use it?
Motivational interviewing is a person-
centered counseling method for
addressing the common problem of
ambivalence about change

The “Righting Reflex”
http://tinyurl.com/lyk4gqo

http://www.usmagazine.com/celebrity-body/news/hollywoods-most-extreme-diets-2010121

http://www.keepcalm-o-matic.co.uk/p/keep-calm-and-have-safe-sex-9/

“Unsolicited advice is the junk
mail of life.” (Bern Williams, in Miller &
Rollnick 2013)

Common Reactions to Righting Reflex
• Angry, agitated
• Oppositional
• Discounting
• Defensive
• Justifying
• Not understood
• Not heard
• Procrastinate
• Afraid
• Helpless, overwhelmed
• Ashamed
• Trapped
• Disengaged
• Not come back – avoid
• Uncomfortable

Common Human Reactions to
Being Listened to
• Understood
• Want to talk more
• Liking the counselor
• Open
• Accepted
• Respected
• Engaged
• Able to change
• Safe
• Empowered
• Hopeful
• Comfortable
• Interested
• Want to come back
• Cooperative

But what if the person refuses to
change?

A 'No' uttered from the deepest
conviction is better than a 'Yes'
merely uttered to please, or
worse, to avoid trouble.
Mahatma Gandhi

“He that complies against his will
is of the same opinion still.”
Samuel Butler
1612-1680
English Poet

Motivational Interviewing in Dental Practice
How NOT to do it: Emily’s Oral Piercing
http://tinyurl.com/c2kh3z9
The Righting Reflex

Motivational Interviewing in Dental Practice
Emily’s Oral Piercing
http://tinyurl.com/bojtj92
A Better Way

Quick Reflection:
How confident are you feeling?
0 1 2 3 4 5 6 7 8 9 10
“Spirit” of MI – Resist the Righting Reflex
0 1 2 3 4 5 6 7 8 9 10
“Spirit” of MI – Directional (versus directive)
0 1 2 3 4 5 6 7 8 9 10
“Spirit” of MI – Evoke (versus educate)

The Evidence Base for

Research publications evaluating MI
effectiveness have been doubling every
three years.
www.motivationalinterview.org

MI Applications
• Public health &
workplace
• Sexual health
• Dietary change
• Weight management
• Voice therapy
• Gambling
• Physical activity
• Stroke rehab
• Chronic pain
• Medication adherence
• Diabetes
• Mental health
• Addictions
• Fibromyalgia
• Chronic leg ulceration
• Self-care
• Criminal justice
• Vascular risk
• Domestic violence
Anstiss, 2009

A Causal Chain for MI
Therapist MI-
consistent speech
Increased client
change talk
Improved treatment
outcomes
Moyers et al., 2009

“What [practitioners]
reflect, they will hear
more of.”
Moyers et al., 2009

Engaging
Focusing
Evoking
Planning
Four Processes in MI
Adapted from Miller and Rollnick, 2013, p. 26

3. How does it work?
Motivational interviewing is 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.

Change Talk and Sustain Talk
Opposite Sides of a Coin

Sustain Talk and Resistance
• Sustain Talk is about the target behavior
• Discord is about your relationship
• Both are highly responsive to counsellor
style
• We respond to both in the same way

DARN CAT
• Desire
• Ability
• Reasons
• Need
• Commitment
• Activation
• Taking Steps

Yet another metaphor
MI Hill
Contemplation Preparation Action(Pre-)
Slide from Bill Miller, 2010

DARN CAT
• Desire
• Ability
• Reasons
• Need
• Commitment
• Action
• Taking Steps
Snap fingers = DARN
Clap = CAT
Silence = No change talk
Motivational Interviewing Network of Trainers (MINT)

Listening for Change Talk
“Things are getting totally messed
up with my courses.”
• Desire
• Ability
• Reasons
• Need
• Commitment
• Action
• Taking Steps

“My parents are the ones who are
worried about my grades.”
• Desire
• Ability
• Reasons
• Need
• Commitment
• Action
• Taking Steps

“I am not addicted to smoking pot.
I can quit anytime I want.”
• Desire
• Ability
• Reasons
• Need
• Commitment
• Action
• Taking Steps

“I want to get well again, but this
whole situation is totally unfair.”
• Desire
• Ability
• Reasons
• Need
• Commitment
• Action
• Taking Steps

“I have started working out, quit
smoking and drinking, have joined
Varsity basketball and am attending all
of my classes.”
• Desire
• Ability
• Reasons
• Need
• Commitment
• Action
• Taking Steps

When you are not sure where to
go next…

“Tell me more…Tell me more…”

0 1 2 3 4 5 6 7 8 9 10
Recognizing Change Talk
0 1 2 3 4 5 6 7 8 9 10
Evoking Change Talk
Quick Reflection:

FOUR KEY STRATEGIES – OARS
OPEN questions (to elicit client change talk)
AFFIRM the client appropriately (support, emphasize
personal control)
REFLECT (try for complex reflections)
SUMMARIZE ambivalence, offer double-sided
reflection

Open versus Closed Questions
• CLOSED questions invite a “yes/no”,
one- word or very limited answer
• OPEN questions encourage elaboration –
they evoke the client’s ideas, opinions,
hopes, concerns, etc.

Affirmations:
• Go beyond “giving a good grade”
• Are not about the practitioner’s approval
of the client
• Acknowledge the client’s experience,
struggle, expertise, efforts, etc.

Example of
Praising:
You are such a
wonderful group -
I have really
enjoyed our
session.

Example of Affirming
The group has worked hard today
in exploring some tough issues,
and we have come closer as a
result of that.

Choose one of your most
challenging patients – and
come up with an affirmation
that you could offer

0 1 2 3 4 5 6 7 8 9 10
Open-ended Questions
0 1 2 3 4 5 6 7 8 9 10
Affirmations (versus praise)
Quick Reflection:

EAR
EYES
UNDIVIDED
ATTENTION
HEART
“To Listen”
IMPERIAL

Simple Reflection
Complex Reflection

Simple Reflection
Complex Reflection
They are really on your case
about your cannabis use.
It wasn’t your idea to come,
and you’re not sure this is
going to be at all helpful to
you.
“I’m only coming to see you because my parents and my
boyfriend are all pressuring me about smoking pot.”

Simple Reflection
Complex Reflection
How you see it is, they are
the ones who have a
problem with it, and that is
frustrating.

Simple Reflection
Complex Reflection
It would feel a lot better if
they respected that what
you do or not do is your
choice and decision.

Simple Reflection
Complex Reflection
Even if you did have any
concerns, all this pressure
makes it hard to want to
change.

Video Demonstration:
A tough question…
http://tinyurl.com/kxomabp

Practicing Reflective
Listening
Individually, take a moment to write
down an example of a simple and a
complex reflection for the following
statement (coming up – next slide).
Then compare what you wrote with
others at your table. As a group,
choose the best examples to share with
the larger group.

Practicing Reflective Listening (1)
“How I live my life is no
one else’s business, and
certainly not yours!”

Simple Reflection:
___________________________________
___________________________________
Complex (Enhanced) Reflection:
___________________________________
___________________________________
“How I live my life is my own business and
certainly not yours.”

Simple Reflection:
You are the only one to decide how to
live your life.
You’re being told you have to make all
these changes, and that doesn’t feel very
respectful of your choice and autonomy.
“How I live my life is my own business and
certainly not yours.”

Practicing Reflective Listening (2)
“I know you mean well, but
I don’t need this
medication any more.”

Simple Reflection:
___________________________________
___________________________________
___________________________________
___________________________________
“I know you mean well, but I don’t need this

Simple Reflection:
You see that I am concerned, but you are
ready to stop taking the medication.
You feel like I am pushing for you to take
this medication, and not really
appreciating where you are at.
“I know you mean well, but I don’t need this

More Reflections
• I am not going to call a crisis line.
• I was too busy to do that homework
you gave me.
• I am a perfectionist – I don’t stop until I
get something perfect.
• How am I supposed to improve my self-
esteem?
• I don’t have time to eat.
• Anxiety motivates me.

Reflecting Panel

1. Four volunteers:
Counsellors

2. One volunteer: Client
Something you are considering
changing/struggling with

3. One volunteer: Coach
A sounding board for the “client”

Reflecting Panel Instructions
1. Client: Share a paragraph with the Reflecting
Panel about your struggle/experience
2. Panel: Take turns offering a single reflection
3. Client: After ALL Panel members are done,
talk to your coach about which reflection
resonates most for you and why
4. Client: Offer this feedback to the panel, and
continue the paragraph

0 1 2 3 4 5 6 7 8 9 10
Simple Reflections
0 1 2 3 4 5 6 7 8 9 10
Complex Reflections
Quick Reflection:

Why use summary
statements?
• To check your understanding of the
person’s situation as a whole
• To reflect back key components of what
the person has discussed
• To signal a transition to another topic or
the end of the session/consultation
• To highlight change talk

Example of OARS (including Summary Statement)
“Angry Bob”
http://www.youtube.com/user/teachproject#p/u/5/79YTuZUFRIc

Partner A: Something you are considering changing
Partner B:
• Start with an open question
• Follow up with two reflective statements
• Offer an affirmation
• End with a summary statement
Hands-on Practice: O A R S

The 5th Foundation Skill:
Providing Information in a
Motivational Way

“Advice is what we ask for when
we already know the answer but
wish we didn’t.”
(Erica Jong, in Miller & Rollnick 2013)

Agenda Mapping
• A brief discussion with the client, where
he/she has the most decision-making
freedom possible
• The client chooses what area toward
better health they want to discuss
• No topic is off limits – success in one
area can lead to success in another

• Start with understanding the patient’s
perspectives and preferences
• Try not to ‘trap’ the person by suggesting
a lifestyle change (or focusing too soon on
change) once the person raises a lifestyle
area
Tips for Agenda Mapping

• Consider providing the patient with a finite
list of topics to choose from, and asking
them if any of the areas they want to
discuss are included in that list
• After the patient responds, feel free to
mention topics that you want to talk about
Tips for Agenda Mapping

Strategies Include…
• Asking for elaboration
• Reflective listening
• Emphasizing personal choice and
control
• Asking permission before making
suggestions
• Summary statements

Agenda-Mapping Worksheet
Priorities

Priorities
Diagnosis Treatment
Plan
Symptoms
$$$

Priorities
Diagnosis Treatment
Plan
Symptoms
$$$
Grades
Stress
Relationship
Sex

“Given these possible areas to focus,
what would you like to talk about in our
time together today?”

Agenda Mapping conversation with "Sal“
http://www.youtube.com/watch?v=klnHJ4coG8o
Agenda Mapping

“Readiness Ruler”
• How important is it to change this
behaviour?
• How confident are you that you could
make this change?
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
People usually have several things they would like to change in their lives – this may be only one of those
things. Answer the following two questions with respect to your goal for this week.

0 1 2 3 4 5 6 7 8 9 10
Agenda-mapping
0 1 2 3 4 5 6 7 8 9 10
Readiness Ruler
Quick Reflection:

“A Psychological Law”
I learn what I believe
as I hear myself speak.
Bill Miller (Based on D. Bem, 1967, “Self-Perception: An
alternative interpretation of cognitive dissonance
phenomena”)

…or put another way…
The word you keep between
your lips is your slave. The
word you speak is your
master.
- Arabic proverb

Motivational Interviewing Coding Sheet
• Number of closed questions: __________
• Number of open questions: __________
• Number of simple reflections: _________
• Number of complex reflections: _______
• Change statements by client: _______
• Sustain statements by client: __________
• Therapist talk time (approx.): __________ %
Targets:
Twice as many reflections as questions
At least 50% complex reflections
No more than 50% therapist talk time
MI “Spirit” (low) (high)
Partnership 1 2 3 4 5
Acceptance 1 2 3 4 5
Compassion 1 2 3 4 5
Evocation 1 2 3 4 5
Herie & Skinner 2013, adapted from Moyers et al. MITI coding guide

How Not to Do It
A conversation with Sal about his asthma
http://www.youtube.com/watch?v=kN7T-cmb_l0

Motivational Interviewing Coding Sheet
• Number of closed questions: __________
• Number of open questions: __________
• Number of simple reflections: _________
• Number of complex reflections: _______
• Change statements by client: _______
• Sustain statements by client: __________
• Therapist talk time (approx.): __________ %
Targets:
Twice as many reflections as questions
At least 50% complex reflections
No more than 50% therapist talk time
MI “Spirit” (low) (high)
Partnership 1 2 3 4 5
Acceptance 1 2 3 4 5
Compassion 1 2 3 4 5
Evocation 12 3 4 5
Herie & Skinner 2013, adapted from Moyers et al. MITI coding guide

A Better Way
A conversation with Sal about his asthma
http://www.youtube.com/watch?v=-RXy8Li3ZaE

Ineffective
Practitioner
Effective
Practitioner
Closed Questions 2 0
Open Questions 0 3
Simple Reflections 0 1
Complex Reflections 1 6
Change Statements 1 7
Sustain Statements 8 8
Therapist Talk Time 70% 50%
Let’s Compare

Hands-on Practice
• In groups of three, take three roles:
– Person “A” describe a change you are thinking of
making in the next 6 months – 1 year
– Person “B” respond using motivational strategies
– Person “C” observe and give feedback
Each “Real Play” will take 5 minutes.
After each turn, rotate the roles so that everyone has
a chance to practice and receive feedback.
Please HOLD your feedback until everyone has
had a chance to practice – you will have an
opportunity to debrief as a small group at the end of
this exercise

In groups of three, take three roles:
– Person “A” describe a change you are thinking
of making in the next 6 months – 1 year
– Person “B” respond using motivational
strategies
– Person “C” observe and give feedback
A
B C

Re-write this challenging case:
• From the client’s perspective
• From the client's parents’ or
partner’s perspective
• From the faculty’s perspective

Here’s how we see the case from
our perspective:

Let’s re-imagine this case in a
different way

Bridging the learning-practice gap

What are the MI skills that you
will commit to using?
• MI Spirit
• Identify and evoke change talk
• OARS
• Using Elicit/Provide/Elicit to provide
information
• Agenda-mapping
• Other?

Engaging
Focusing
Evoking
Planning
Motivational Interviewing: Practice Tips
MI Spirit: The Essential Foundation
Partnership: You and the client are equal
experts
Acceptance: Absolute worth, accurate empathy,
autonomy support, affirmation
Compassion: Beneficence, caring, focus on the
other
Evocation: The client’s wisdom is most
important
OARS: Key Skills
Open Questions: What are your reasons for
change? How might you go about it in order to
succeed?
Affirmation: You have worked hard to make this
happen. I can see that you’ve given this a lot of
thought.
Reflections: You wish that… You would like to…
Summary Statements: Let me make sure I
understand how this all fits together…
Diagnosis
Treatment
Plan
Symptoms
Benefits
Finances
Stress
Relationship
Agenda-Mapping
Can we take a few minutes to talk about the different issues or
concerns that you or others have? Just to get a “big picture” view of
what you are coping with right now…
Given all of these possible areas for change, what are your priorities?
Where would be the most helpful place for us to start?
0 1 2 3 4 5 6 7 8 9 10
People usually have multiple or competing priorities. On a
scale of zero-to-ten, how important is it to change…? How
confident are you that you could make this change?
Readiness Ruler
Why did you say [lower number] and not [higher number]?
What would it take to go from [lower number] to [higher number]?
Elicit: What do you already know about…?
Provide information: Be brief!
Elicit: How does that fit for you? What do
you make of that?
Listen for Change Talk: DARN CAT
Desire, Ability, Reasons, Need
Commitment, Activation, Taking Steps
Reference: Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd Edition). New York: Guilford.
© 2013 Marilyn Herie, PhD RSW marilyn.herie@utoronto.ca
Four MI Processes

Recommended Resources
Martino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C.,
Hamilton, J., and Hausotter, W. (2006). Motivational Interviewing Assessment:
Supervisory Tools for Enhancing Proficiency (MIA STEP). Salem, OR: Northwest
Frontier Addiction Technology Transfer Center, Oregon Health and Science
University.
http://www.motivationalinterview.org/Documents//MIA-STEP.pdf
Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change
(Third Edition). New York: Guilford.
Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not.
Behavioural and Cognitive Psychotherapy, 37, 129-140.
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=531
8416
Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health
Care: Helping Patients Change Behavior. New York: The Guildford Press.
First chapter and table of contents available at www.motivationalinterview.org
Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner
Workbook. New York: Guilford.
Wagner, C.C. & Ingersoll, K.S. (2013). Motivational Interviewing in Groups. New
York: Guilford
Useful Websites
Motivational Interviewing Website
http://www.motivationalinterview.net/
Motivational Interviewing Network of Trainers (MINT) Website
www.motivationalinterviewing.org
Examples of Motivational Interviewing Videos on YouTube
http://www.youtube.com/user/teachproject#p/u

Motivational Interviewing Glossary of Acronyms
Compiled by Marilyn Herie, PhD, RSW November, 2012
ACE (Spirit of MI from Miller and Rollnick 2002 edition)
Autonomy / Collaboration / Evocation versus
Authority / Coercion / Education
OARS (Fundamental strategies of MI)
Open questions / Affirmations / Reflections / Summary statements
EARS (Strategies for eliciting change talk)
Evocation / Affirmation / Reflective listening / Summary statements
RULE (Fundamental strategies in MI v.2)
Resist the righting reflex / Understand reasons for change (motivation) / Listen empathically / Empower
the client to use own resources
DARN CAT (Types of preparatory change talk and commitment language)
Desire / Ability / Reasons / Need / Commitment / Action / Taking steps
FRAMES (Ingredients of brief, motivational interventions)
Feedback / Responsibility / Advice / Menu (of strategies)/ Empathy / Self-efficacy
RAISE (How to give advice)
Relationship / Advice to change / “I” statements (affirmation) / Support autonomy / Empathy
READS (Principles of MI)
Roll with resistance / Express empathy / Avoid argumentation / Develop discrepancy / Support self-
efficacy
PACE (Spirit of MI from Miller and Rollnick 2013 edition)
Partnership / Acceptance / Compassion / Evocation
MIST (Coding form)
Motivational Interviewing Supervision and Training Scale
MITI (Coding form)
Motivational Interviewing Treatment Integrity Coding Form
MET (Manual-based motivational intervention)
Motivational Enhancement Therapy
MIA (Coding abbreviation, used in the MITI)
Motivational Interviewing Adherent
MINA (Coding abbreviation, used in the MITI)
Motivational Interviewing Non-Adherent
MIA-STEP (MI supervision manual and coding resource)
Motivational Interviewing Assessment – Supervisory Tools for Enhancing Proficiency
AMI
Adaptations of Motivational Interviewing

Additional Reflections
and Next Steps

“When people are ready to, they change.
They never do it before then, and
sometimes they die before they get
around to it. You can't make them change
if they don't want to, just like when they do
want to, you can't stop them.”
― Andy Warhol, Andy Warhol in His Own Words
http://en.wikipedia.org/wiki/File:Warhol-Campbell Soup-1-screenprint-1968.jpg

Thank
you
marilyn.herie@utoronto.ca
www.educateria.com
@MarilynHerie

Life can only be understood backwards, but it
must be lived forwards.
-Kierkegaard

Mi queen's 2013 pub

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