Motivational Interviewing

Copyright © 2014, Glenn Duncan Do not reproduce any workshop materials without express written consent.
Motivational Interviewing
Glenn Duncan LPC, LCADC, CCS,
ACS

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Traits of an Effective Therapist
Core Tasks of an Expert Therapist - Working with Addicted Clients
1. Develop a Therapeutic Alliance
2. Nurture Hope
3. Understand & Implement Best Practices in Theory and Application –
knowledge of the main therapeutic paradigms when working with addicted
clients individually, in group settings and with their families. Be able to properly
assess individual client problems and needs and tailor theory and techniques
that best suite individual client needs.
4. Teach Skills – emotional regulation, relaxation, problem-solving, cognitive
restructuring skills, interpersonal skills, tolerance and acceptance skills.
5. Provide Ongoing Education to the Client – the ability to conduct accurate
assessments, working with the client towards individualized, behavioral
treatment planning, having the client engaged in self-monitoring of thoughts,
feelings and behaviors, enhance client awareness of the addition process.

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Traits of an Effective Therapist
Core Tasks of an Expert Therapist - Working with Addicted Clients (continued)
6. Build in Generalization and Maintenance Procedures – understand the
concept of skill generalization to the target problem, involve significant others as
allies in obtaining generalization of targeted positive behaviors, feelings and
thoughts, and helping with the maintenance of them.
7. Assess/Possibly Treat/Possibly Refer Co-occurring Problems – be able to
look past substance specific issues to accurately identify possible Co-occurring
problems and treat (if education ethically provides the ability to do so), or refer
client to have Co-occurring problems addressed.
8. Assess For & Conduct Relapse Prevention – assess and work with relapse
triggers and high risk situations that will occur for the client.
9. Ensure Clients “Take Credit” and “Ownership” for Their Changes – foster
independence and client ownership of the changes made.
10. Other important clinician factors include: experience, personal characteristics of
the counselor and therapist, cultural competence, and comfort with ambiguity.

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Definition of Motivational Interviewing
 Motivational interviewing is a collaborative conversation style for
strengthening a person’s own motivation and commitment to change.
 The overall style of MI is one of guiding style that is in the middle of
the continuum of styles:
 Directing Guiding Following
 A skillful guide is a good listener and also offers expertise where
needed. MI lives in this middle ground of styles between directing
and following, often incorporating elements of both but doing too
much of either.

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 Ambivalence
 Ambivalence is a normal part of preparing for change and a place
where a person can remain stuck for some time.
 When a helper uses a directing style and argues for change with a
person who is ambivalent, it naturally brings out the person’s
opposite reaction.
 People are more likely to be persuaded by what they hear
themselves say.

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Spirit of Motivational Interviewing
 Partnership
 MI is not something done to a passive recipient by an expert. MI is not done
“to” or “on” someone, but is rather done “for and “with” a person.
 MI is an active collaboration between experts. When it comes to change, the
counselor cannot do it alone. The client has a vital expertise that is
complementary to the clinician’s; the expertise of themselves. Activation of
that expertise is vital for change.
 The interviewer seeks to create a positive interpersonal atmosphere that is
conducive to change but not coercive.
 The interpersonal process of MI is a meeting of aspirations which may differ
from client to counselor. Honesty about aspirations is essential.

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 Acceptance
 MI is about an attitude of profound acceptance of what the client brings.
 To accept does not necessarily mean you approve of their actions or
acquiesce to the status quo. Acceptance has 4 aspects.
– Absolute Worth – acceptance of the person as an individual, respect for them as
having worth, and a belief that the person is fundamentally trustworthy.
– Accurate Empathy – an active interest in and effort to understand the other’s
internal perspective, to see the world through their eyes.
– Autonomy Support – the person’s irrevocable right and capacity of self-direction.
– Affirmation – to seek and acknowledge the person’s strengths and efforts (more
than just a private experience of appreciation, but it is the search for what is right
with people).

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 Compassion
 New to MI when describing the essence of MI
 To be compassionate is to actively promote the other’s welfare, to give priority to
the other’s needs.
 This was added to MI because it was felt that many clinicians could practice the
principles of MI in the pursuit of self-interest.
 Knowledge and techniques can be used to exploit, to pursue one’s own
advantage and gain undeserved trust and compliance.
 To work with a spirit of compassion is to have your heart in the right place so that
the trust you engender will be deserved.

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 Evocation
 Premise: People already have within them much of what is needed, and your
task is to evoke it, to call it forth. The message is: “You have what you need,
and together we will find it.”
 Approach: To draw out: MI perspective is the belief that there is a deep well of
wisdom and experience within the person from which the counselor can draw.
 MI is about evoking that which is already present, not installing what is missing.
 People who are ambivalent already have the pro-change argument and the pro
status-quo argument within them. The client likely already has the pro-change
arguments within them, and those arguments are likely more persuasive than
any you could make. Your task, then, is to evoke and strengthen these change
motivations already present.

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 Evocation - Guard Against The righting reflex. The righting reflex involves the belief that you
must convince or persuade the person to do the right thing.
 Counselors not realizing they are in the midst of this often think/feel:
– They just need to ask the right questions
– They just need to find the proper arguments
– They need to provide the client with critical information.
– The need to provoke the decisive emotions to make change occur.
– They need to pursue the correct logic to make the person see and change.
 This brand of counseling was, and still sometimes is, rampant in substance use counseling.
It is the belief that clients had to have their pathological defenses torn down before they could
change. The formula goes as follows:
A. Confront the client. Louder = Better.
B. Provide the solution. The saltier the solutions was provided … the cooler the counselor.
C. If you meet denial/resistance pump up the volume on A and B.
D. Rinse/repeat

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 Evocation – Questions that are the opposite of the righting reflex
 Some questions beginning counselors using MI can ask, that do not incorporate
the “righting reflex”:
1. Why would you want to make this change?
2. How might you go about it in order to succeed?
3. What are the three best reasons for you to do it?
4. How important is it for you to make this change, and why?
5. How confident do you feel about being able to make this change, and why?
6. So what do you think you’ll do?

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Lay Person’s Definition
Motivational interviewing is a collaborative conversation style for
strengthening a person’s own motivation and commitment to change.
Practitioner’s Definition
Motivational interviewing is a person-centered counseling style for
addressing the common problem of ambivalence about change.

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The Method of Motivational Interviewing
 Four Processes in Motivation Interviewing
 Engaging – engaging is the process by which both parties establish a helpful
connection and a working relationship.
 Focusing – process of engaging leads to a focus on a particular agenda: what
the person came to talk about. The provider may also have an agenda, some of
which may overlap with the client and some of which may not. One or more
change goals may emerge. The focusing process helps clarify direction.
 Evoking – evoking involves eliciting the client’s own motivation for change. Most
simply put, evolving is having the person voice the arguments for change.
 Planning – planning encompasses both the commitment to change and
formulating a specific plan of action.

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Method of MI – Questions to Ask Yourself
 Engaging
1. How comfortable is this person in talking to me?
2. How supportive and helpful am I being?
3. Do I understand this person’s perspective and concerns?
4. How comfortable do I feel in this conversation?
5. Does this feel like a collaborative partnership?

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 Focusing
1. What goals for change does this person really have?
2. Do I have different aspirations for change for this person?
3. Are we working together with a common purpose?
4. Does it feel like we are moving together, not in different directions?
5. Do I have a clear sense of where we are going?
6. Does this feel more like dance or wrestling?

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 Evoking
1. What are this person’s own reasons for change?
2. Is the reluctance more about confidence or importance of change?
3. What change talk am I hearing?
4. Am I steering too far or too fast in a particular direction?
5. Is the righting reflex pulling me to be the one arguing the change?

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 Planning
1. What would be a reasonable next step towards change?
2. What would help this person to move forward?
3. Am I remembering to evoke rather than prescribe a plan?
4. Am I offering needed information or advice with permission?
5. Am I retaining a sense of quiet curiosity about what will work best for this
person?

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The Skills of Motivational Interviewing
 Core Skills and the Four Processes of MI
 Asking Open Questions – open questions are those that invite the person to reflect and
elaborate. Open questions help you understand the person’s internal frame of reference.
This helps in engaging by strengthening a collaborative relationship and finding a clear
direction.
 Affirming – The counselor in general respects and honors the client as a person of worth.
The counselor also comments on the client’s particular strengths, abilities, good intentions,
and efforts.
 Reflective Listening – statements that make a guess about the client’s meaning which can
deepen understanding by clarifying the accuracy of the guess.
 Summarizing – reflections that collect what a person has been saying and offering it back.
They can be used to: 1) Pull together information; 2) suggest links between present and
past material; 3) used as a transition; 4) promote understanding; 5) direct the flow of
change talk or discussion.

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Lay Person’s Definition
Motivational interviewing is a collaborative conversation style for strengthening a
person’s own motivation and commitment to change.
Practitioner’s Definition
Motivational interviewing is a person-centered counseling style for addressing the
common problem of ambivalence about change.
Technical Definition
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 and commitment to a specific goal by eliciting and exploring the
person’s own reasons for change within an atmosphere of acceptance and
compassion.

Working Alliance
 The working alliance, or “collaboration to change” is common in to
all models of therapy, and common to the supervisory
relationship.
 It is composed of 3 elements:
1. The bond between therapist and client.
2. The extent to which they agree on goals.
3. The extent to which they agree on tasks to obtain the goals.
The real change in therapy occurs during the process of
weakening of the relationship and then repair of the relationship.

Working Alliance Main Features
There are 4 main features in viewing the working alliance:
1. The therapist must possess certain facilitating human qualities, the
qualities of a good parent.
2. These qualities permit the potential establishment of a power base for
the therapist, in which the therapist uses the client’s desire to please as
leverage.
3. Within the context of the therapeutic relationship, experiential learning
occurs through the normal developmental processes of imitation and
identification.
4. The success of this relationship-based learning experience depends on
preexisting client qualities that permit at least a beginning level of trust
and openness.

Working Alliance Goals
 Goals in the working alliance model are defined (in part) as the
expectations to the nature and quality of the therapeutic relationship.
– For example one such goal would be to ensure a constructive therapeutic
environment, that foster’s an awareness of others, of oneself in terms of
motivation, self-efficacy. Foster two-way feedback with client.
 Expectations can be defined as “a person’s anticipatory beliefs about the
nature (i.e., roles, behaviors, interactions, and tasks) or outcome of a
particular event.”
 The congruence of expectations (i.e., shared goals) between or among
people in a relationship is at least as important, and likely more important,
than the expectations of any one individual.

MI - Engagement
 Factors that can influence engagement and disengagement:
 Desires or goals. What did you want or hope for in going? What is it that
you’re looking for?
 Importance. How important is what you’re looking for? How much of a priority
is it?
 Positivity. Did you feel good about the experience? Did you feel welcomed,
valued, and respected? Were you treated in a warm and friendly manner?
 Expectations. What did you think would happen? How did the experience fit
with what you expected? Did it live up to (or even exceed) your expectations?
 Hope. Do you think that this situation helps people like you to get what you’re
seeking? Do you believe that it would help you?

MI - Listening
 Factors that can influence engagement and disengagement:
 Desires or goals. What did you want or hope for in going? What is it that
you’re looking for?
 Importance. How important is what you’re looking for? How much of a priority
is it?
 Positivity. Did you feel good about the experience? Did you feel welcomed,
valued, and respected? Were you treated in a warm and friendly manner?
 Expectations. What did you think would happen? How did the experience fit
with what you expected? Did it live up to (or even exceed) your expectations?
 Hope. Do you think that this situation helps people like you to get what you’re
seeking? Do you believe that it would help you?

MI – Reflective Listening
 Using reflection to encourage continued personal exploration – broad goal of
reflective listening.
 Overshooting. Overstating the intensity of an emotion. The person will tend to
deny and minimize it.
 Undershooting. Slightly understating the expressed intensity of an emotion,
the person is more likely to continue to explore and tell you about it.
 Length. The reflection should not be longer than the statement. If longer,
then make it purposeful by placing emphasis on particular content.
 Direction. Clients provide a variety of material even within a short 5 minute
time span. Reflection can therefore be used to shine a light on certain aspects
of what a person has said or to reframe its meaning slightly.

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Building Motivation for Change (cont)
Listening Reflectively
a. The crucial element to reflective listening is how the counselor
responds to what the client says. What responses are not
considered to be listening:
 Ordering, directing, or commanding
 Warning or threatening
 Persuading with logic, arguing, or lecturing
 Moralizing preaching or telling clients what they “should” do
 Disagreeing, judging, criticizing, or blaming
 Shaming, ridiculing, or labeling
 Withdrawing or distracting
b. Reflective listening isn’t making a statement that is a roadblock, but rather a
guess about what the person means.

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Other Engagement Skills
1. Assess Motivation, which consists of the following:
- Importance – the extent to which one wants, desires, or wills
change.
- Readiness – what is the priority level of the presenting problem(s).
- Confidence – self-efficacy, or the perceived ability to make a change.
2. Ask open ended questions to the client in response to their answers during
the assessment period.
- (e.g., “What are some other ways marijuana has interfered with other
areas that are important to you?” versus “Is marijuana a problem for
you?”)
1. Affirmation
- To recognize and acknowledge that which is good including their
inherent worth. AFFIRMATION IS NOT PRAISE
- To accentuate the positive
- To support and encourage. Focus on the client, do not make
affirmations self-focused.

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Other Engagement Skills
4. Summarizing
- Reflections that pull together several thoughts or topics that that the
client is talking about.
- They can be affirming (imply that you’re listening, remembering and
putting together how things connect).
- To support and encourage. Focus on the client, do not make
affirmations self involved.
 Collecting Summary – recalls a series of interrelated items as they
accumulate.
 Linking Summary – reflecting what the person has said and link it to
something else you remember from prior conversation
 Transitional Summary – to wrap up a task or topic in order to shift to either
a new topic or to steer the direction where you want the conversation to
turn.

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Empathic Communication Scale
Level 1: Low-Level Empathic Responding
 The practitioner communicates little or no awareness or understanding of even
the most obvious of the client’s feelings.
 The practitioner’s responses can be irrelevant, often abrasive, hindering, rather
than facilitating communication.
 Styles of Communication: changing the subject, arguing, giving advice
prematurely, lecturing, or other ineffective styles that block communication.
 Nonverbal responses are often not appropriate to the mood and content of the
client’s statements.
 Client reaction: can become confused, defensive, argumentative, withdrawing
into silence, begin discussing superficialities, change the subject.
 RESULT: Client’s energies are diverted from exploration and/or working on the
problems.

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Level 2: Moderately Low-Level Empathic Responding
 The practitioner responds to the surface message of the client but erroneously
omits feelings or factual aspects of the message.
 The practitioner may also inappropriately qualify client feelings (e.g., “you’re
somewhat agitated about this issue with your mother”, “isn’t that a little bit
exaggerated”.
 The practitioner may inaccurately interpret client’s feelings (e.g., identifying
“hurt” as “anger”, “being tense” for “fear”).
 Responses may come from the practitioner’s own conceptual formulations about
the client, which may be diagnostically accurate, but which are not empathically
attuned to the client’s expressions or attuned to the client’s phenomenological
realities.
 RESULT: Level 2 reactions are partially accurate, they do convey an effort to
understand, thus do not completely block client’s communication.

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Level 3: Interchangeable or Reciprocal Level of Empathic Responding
 The practitioner’s verbal and nonverbal responses at this level convey
understanding and are essentially interchangeable with the obvious expressions
of the client.
 The practitioner accurately reflects factual aspects of the client’s messages and
surface feelings or state of being.
 These responses do not add affect or reach beyond the surface feelings, nor do
they subtract from the feeling or the tone expressed.
 Responses of this level facilitate further exploration and problem-focused
responses by the client.
 RESULT: Level 3 responses are effective, working responses that should be
sought by practitioners as a base level of empathic responding.

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Level 1 – 3 type of responses
 Client statement: “I don’t trust you people. You do everything you can to keep
me from getting back my son. I have done everything I am supposed to do and
you people always come up with something else.”
 Level 3 response: “You’re really angry about the slow progress in your case and
are wondering if your efforts are going to succeed.”
 Level 2 response: “You feel angry because your case plan has not been more
successful to date. Maybe you’re expecting too much too soon; there’s a lot of
time yet.”
 Level 1 response: “Just think what would have happened if you had devoted
more energy in the last year to carry out your case plan; you would have been
further along and less frustrated than you are now.”

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Level 4: Moderately High-Level Empathic Responding
 Responses at this level are somewhat additive, accurately identifying
implicit underlying feelings and/or aspects of the problem.
 The practitioner’s response highlights subtle or veiled aspects of the
client’s message, enabling the client to get in touch with somewhat
deeper-level feelings and unexplored meanings.
 Level 4 responses are aimed at enhancing client’s self-awareness.

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Level 5: High-Level Empathic Responding
 Responses at this level reflect each emotional nuance.
 The practitioner accurately responds to the full range and intensity of both
surface and underlying feelings and meanings.
 The practitioner may connect current feelings and experiencing, to previous
expressed experiences and feelings.
 Responses may also identify goals embodied in the client’s message, which
enhance self-awareness while paving the way for potential action.
 This type of response facilitates the client’s exploration of feelings and problems
in a much greater breadth and depth than at lower levels.

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Level 4 – 5 type of responses
 Client statement: “I don’t trust you people. You do everything you can to keep
me from getting back my son. I have done everything I am supposed to do and
you people always come up with something else.”
 Level 4 Response: “You feel very frustrated with the lack of progress in getting
your son back. You wonder if there is any hope in working with a new worker
and this system which you feel hasn’t been helping you.” (additive reflecting the
client’s deeper feelings of suspicion of institutional racism).
 Level 5 Response: “Not succeeding in getting custody of your son by now has
angered and frustrated you very much. I’m sensing that you’re unsure of
whether any efforts will succeed and maybe thinking the ‘system is stacked
against me’. You want to be able to trust that efforts are likely to succeed and
that I and this child welfare system will do all we can do to assist you.”
(substantially additive to both institutional suspicion and primal fear of never
regaining son).

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Empathic Communication Scale Exercise
Client Statement
 Group member: “It’s really hard for me to say what I want to say in this group.
When I do start to talk, I get tongue tied and my heart starts beating faster. I feel
like some of you are critical of me.
Group Leader/Member Responses
 What Level Response?: “Yeah, I feel that same way sometimes, too”.
 What Level Response?: “It is frightening to you to try to share you feelings with
the group. Sounds like you find yourself at a loss for words and wonder what
others are thinking of you.”
 What Level Response?: “I know you’re timid, but I think it’s important that you
make more of an effort to talk in the group, just like you’re doing now. It’s
actually one of the responsibilities of being a group member.”
 What Level Response?: “You get scared when you try to talk in the group.”

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Client Statement
 What Level Response?: “I sense that you’re probably feeling pretty tense and
tied up inside right now as you talk about the fear you’ve had in expressing
yourself. Although you’ve been frightened of exposing yourself, I gather there’s
a part of you that wants to overcome that fear and become more actively
involved with the rest of the group.”
 What Level Response?: “What makes you think we’re critical of you? You come
across a bit self-conscious, but that’s no big deal.”
 What Level Response?: “You remind me of the way I felt the first time I was in a
group. I was so scared, I just looked at the floor most of the time.”
 What Level Response?: “I wonder if we’ve done anything that came across as
being critical of you.”

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Client Statement
 Level 1 Response: “Yeah, I feel that same way sometimes, too”.
 Level 4 Response: “It is frightening to you to try to share you feelings with the
group. Sounds like you find yourself at a loss for words and wonder what others
are thinking of you.”
 Level 2 Response: “I know you’re timid, but I think it’s important that you make
more of an effort to talk in the group, just like you’re doing now. It’s actually one
of the responsibilities of being a group member.”
 Level 2 Response: “You get scared when you try to talk in the group.”

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Client Statement
 Level 5 Response: “I sense that you’re probably feeling pretty tense and tied up
inside right now as you talk about the fear you’ve had in expressing yourself.
Although you’ve been frightened of exposing yourself, I gather there’s a part of
you that wants to overcome that fear and become more actively involved with
the rest of the group.”
 Level 1 Response: “What makes you think we’re critical of you? You come
across a bit self-conscious, but that’s no big deal.”
 Level 2 Response: “You remind me of the way I felt the first time I was in a
group. I was so scared, I just looked at the floor most of the time.”
 Level 2 Response: “I wonder if we’ve done anything that came across as being
critical of you.”

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Client Statement
 Male, age 17, in a weekly visit to social work probation officer. “I don’t see the
sense in having to come here every lousy week. I haven’t been in trouble now
since I went to court 3 months ago. You should know by now that you can trust
me.”
Probation Officer Responses
 What Level Response?: “3 months isn’t very long you know, you’re on probation
for at least 1 year. And how can I be sure you’re staying out of trouble?”
 What Level Response?: “I gather you’d rather not have to see me. I can
understand that, but the judge ordered it and you’d be in trouble with him if you
didn’t meet the conditions of you probation.”
 What Level Response?: “Has it been 3 months since we went to court? I didn’t
think it had been that long.”
 What Level Response?: “You’d prefer not coming here and feel you’ve earned
my trust.”

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Client Statement
me.”
 What Level Response?: “Having to come here each week gripes you, and I
gather you’re irritated with me for encouraging you to follow the judges order.”
 What Level Response?: “Lets take a look at who exactly got themselves into this
mess … don’t complain to me if you don’t like it. Maybe you’d like to talk the
Judge into changing her mind.”
 What Level Response?: “It irritates you to have to come here each week. You’d
like to get me off your back.
 What Level Response?: “You’re confused about why you have to come here and
wish you didn’t have to.”

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Client Statement
me.”
 Level 1 Response: “3 months isn’t very long you know, you’re on probation for at
least 1 year. And how can I be sure you’re staying out of trouble?”
 Level 2/3 Response: “I gather you’d rather not have to see me. I can
understand that, but the judge ordered it and you’d be in trouble with him if you
didn’t meet the conditions of you probation.”
 Level 1 Response?: “Has it been 3 months since we went to court? I didn’t think
it had been that long.”
 Level 2 Response?: “You’d prefer not coming here and feel you’ve earned my
trust.”

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Client Statement
me.”
 Level 3 Response: “Having to come here each week gripes you, and I gather
you’re irritated with me for encouraging you to follow the judges order.”
 Level 1 Response: “Lets take a look at who exactly got themselves into this
mess … don’t complain to me if you don’t like it. Maybe you’d like to talk the
Judge into changing her mind.”
 Level 2/3 Response: “It irritates you to have to come here each week. You’d like
to get me off your back.
 Level 2 Response: “You’re confused about why you have to come here and wish
you didn’t have to.”

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Constructing Reciprocal Responses
 To reach level 3 on the empathic scale (the baseline of what you want
to accomplish with clients), you must be able to forumlate responses
that accurately capture the content and the surface feelings in the client
message.
 It is also important to frame the message so that you simply don’t
restate the client’s message.
 You can use the following to help master the skill of empathic
responding:
You feel ______________ about (or because) ______________
(Accurately (Accurately
identifies describes situation
feelings of client) or event referred
to by the client)

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Multiple Uses of Empathic
Communication
1. Establishing relationships with clients in initial sessions (research shows that
empathic communication, along with respect and genuineness, facilitate the
development of the working relationship).
2. Staying in touch with clients (meeting the client where they’re at).
3. Accurately assessing client problems (evidence shows that the levels of
empathy offered by practitioners correlate with the levels of exploration by
clients).
4. Responding to the nonverbal messages of clients.
5. Making confrontations more palatable (be prudent when deciding when to use
confrontation, however, empathic responses attuned to client reactions
immediately following confrontation can be an effective tool.

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Multiple Uses of Empathic
Communication
6. Handling obstacles presented by the client (What is often interpreted as
unconscious resistance may be a negative reaction to poor interviewing and
intervention techniques, or to client confusion and misunderstanding.
Empathic communication can be used to carefully monitor client reactions and
to deal directly and sensitively to their feelings).
7. Managing anger and patterns of violence (empathic communication can be an
essential tool in helping clients work through these feelings).
8. Utilizing empathic responses to facilitate group discussions (facilitating
discussion by using empathic responses to reflect the observations of various
group members).

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Focusing
 Focusing in MI is an ongoing process of seeking and maintaining direction.
 The 3 sources of focus:
1. Client – people come through the door with presenting problems
2. Setting – agencies are funded to address specific issues and provide certain
services
3. Clinical Expertise – client coming with 1 goal in mind and the clinical perceiving
another goal need to be of focus. The challenge is to explore the client’s
willingness to entertain this additional focus.
 The 3 styles of focusing:
1. Directing – this is where the provider determines the focus, rooted in their own
agenda or the agenda of the agency.
2. Following – the opposite where the focus solely depends on client priorities.
3. Guiding – the focus, momentum and content are mutually forged utilizing client
priorities, constraints of the agency and setting, and expertise of the clinician.

48
Focusing – Issues that may arise
 3 Common Focusing Scenarios
1. The focus is clear.
2. There are options to choose from.
3. The focus is unclear.
 Issues regarding focus:
1. Tolerating Uncertainty and Ambiguity – resisting the righting reflex.
2. Sharing Control – sharing control of the flow of the interview/session.
3. Searching for strengths and openings for change – be careful not to over focus on
risks, problem management, and completion tasks and keep a focus on a client’s
strengths or a small nugget of change talk that could easily be overlooked by over-
focusing on problems.

49
Focusing – Issues that may arise
 When there are options to choose from – Agenda Mapping
 Agenda mapping is a tool to help you focus faster, and with a more active
client, to avoid unnecessary confusion about direction.
 First make it clear what you are doing, with a structuring statement such as
“would you mind if we consider some topics that could discuss?”
 Considering options
1. Allow clients the space to reflect and express their preferences.
2. Include information and support as appropriate.
3. Allow the client to raise completely new ideas that haven’t been discussed yet.
4. Use hypothetical language such as “we might” or “you could” gliding over the
landscape of options.
5. Include your own opinion, in a modest way that acknowledges their autonomy.

50
Focusing – Differing Goals & Ethics
 An ethical issue within helping relationships is whether the clinician should encourage
resolution of ambivalence in a particular direction.
 Ethical concerns arise particularly in situations where the clinician or agency has an
aspiration for change that the client does not yet share.
 Four key ethical considerations in such situations include nonmaleficence (do no harm),
beneficence (provide benefit), autonomy (self-determination) and justice (fairness).
 It is inappropriate to use MI to influence choice when the practitioner has a personal or
institutional investment in a certain outcome, especially when this is combined with
coercive power.
 MI should be adapted to clients needs, e.g., evoking may be unnecessary with clients
who have already decided to make a change.

51
Focusing – Information Exchange
 Elicit before providing information.
1. Ask permission.
2. Explore client’s prior knowledge.
3. Querrying interest in the information available.
 Provide the information.
1. Prioritize. Focus on what the client most wants or needs to know.
2. Clear and Manageable. Present clearly and in manageable doses.
3. Support Autonomy. When the information has implications for client change,
you language needs to support their autonomy.
 Self Disclosure
1. Is it true? Focus on being genuine without selfish/inappropriate disclosure.
2. Could it be harmful?
3. Is there a clear reason why it would be helpful?

52
Principles of Motivational Interviewing
 The strategies of Motivational Interviewing are more persuasive
than coercive, more supportive than argumentative.
 The counselor seeks to create a positive atmosphere that is
conducive to change.
 The overall goal is to increase the client’s intrinsic motivation, so
that change arises from within, rather than being imposed from
without.
There are 5 general principles underlying motivational interviewing:

53
Principle – Express Empathy
 Empathy is NOT an ability to identify with a person’s
experiences.
 Empathy is a learnable skill for understanding another’s
meaning through reflective listening, whether or not you’ve had
similar experiences yourself. This is done without judging,
criticizing or blaming … but with acceptance.
 Empathic listening requires sharp attention to each new client
statement, and a continual generation of hypotheses as to the
underlying meaning.
 Your interpretation as to the meaning is reflected back to the
client, often adding to the content that was overtly stated.

54
Principle – Develop Discrepancy
 Create and amplify, in the client’s mind, a discrepancy between
present behavior and broader goals.
 Motivation for change is created when people perceive a
discrepancy between their present behavior and important
personal goals.
 MI Therapist wants to develop discrepancy, make use of it,
increase it, and amplify it until the discrepancy overrides
attachment to the present behavior.
 This change needs to occur within the client (not external
forces), the client should present the arguments for change.

55
Principle – Avoid Argumentation
 A key principle to MI is to avoid arguments and head-to-head
confrontations.
 One place that arguments are very likely to emerge is in regard
to the applicability of a diagnostic label. Some counselors place
great importance on a client’s willingness to “admit” to a label
such as “alcoholic”.
 AA the emphasis is more on self-recognition. “We do not like to
pronounce any individual as alcoholic, but you can quickly
diagnose yourself.” (Bill W.)
 Ambivalence and sustain talk is a signal for the therapist to
change strategies.

56
Principle - Roll with Ambivalence or
Sustain Talk
 Reluctance and ambivalence are not opposed, but are
acknowledged by the therapist to be natural and
understandable.
 The therapist does not impose new views or goals. Rather, the
client is invited to consider new information and is offered new
perspectives.
 Rolling with ambivalence includes involving the client actively in
the process of problem solving. The client is a valuable
resource in finding the solution to their problems.

57
Principle – Support Self-Efficacy
 Self-efficacy is a person’s belief in his/her ability to carry out and
succeed with a specific task.
 General goal of MI is to increase the client’s perceptions of
his/her capability to cope with obstacles and to succeed in
change.
 The client not only can, but must make this change for
themselves.
 There is hope in the range of alternative approaches available.
Thus a person who has failed in the past, may not have found
the right approach.

58
Common Therapist “Traps”
 The Confrontation – Denial Trap
 The Expert Trap
 The Labeling Trap
 The Premature Focus Trap
 The Blaming Trap

59
Building Motivation for Change (cont)
Elicit Self-Motivational Statements
 This is the guiding strategy that helps clients to resolve their
ambivalence. Self-motivational statements fall into four general
categories:
1. Problem recognition
2. Expression of concern
3. Intention to change
4. Optimism about change
 These four kinds of statements reflect cognitive (recognition,
optimism), affective or emotional (concern), and behavior (intention
to act) dimensions of commitment to change.

60
Eliciting Self-Motivational Statements
 Asking Evocative Questions (e.g., problem recognition, asking
areas of concern).
 Exploring Pros and Cons
 Asking for Elaboration (tell you more about it, give you an
example of it, to talk you through one).
 Imagining Extremes (best and worst things that could come out
of making a change like this).

61
Eliciting Self-Motivational Statements
 Looking Forward (think ahead five years, where would you like
to be and what would you like your life to be like) Getting at a
person’s hopes and desires.
- What would it take for you to give up a certain behavior?
- If behavior changes, if behavior doesn’t change, where
would your life be 5 years from now?
 Looking Backwards (contrast present situation by looking back
before the problem behavior(s) were present.
 Case Example

62
Eight General Motivational Strategies
What strategies can a counselor use to enhance motivation for
change?
 Giving Advice
 Removing Barriers
 Providing Choice
 Decreasing Desirability
 Practicing Empathy
 Providing Feedback
 Clarifying Goals
 Active Helping

63
MI view of Confrontation
 Confrontational clinicians, groups, and programs have been
linked to poorer outcomes.
 Successful outcomes have been linked to therapists showing
high levels of accurate empathy.
 The linguistic root of the verb “to confront” means to come face
to face. Thus we are trying to allow our clients to come face to
face with with a difficult and often times threatening reality.
 In this light, confrontation is a goal of therapy. What is the best
way to achieve that goal?

64
MI View of Confrontation (cont.)
 Evidence is strong that direct, forceful, aggressive approaches are
perhaps the least effective way to help people consider new information
and change their perceptions.
 Such confrontation increases the very phenomenon it is supposed to
overcome … defensiveness … and decreases the client’s likelihood of
change.
 The goal of the MI therapist is to evoke from the client statements of
problem perception and the need for change.
 This is the opposite of those strategies in which the therapist is
responsible for voicing these perspectives (e.g., “You’re an alcoholic,
and need to stop drinking.”) and persuading the client to the truth.

65
Client Ambivalence
 People struggling with addictive problems usually enter
counseling with fluctuating and conflicting motivations. This
conflict is known as ambivalence.
 Ambivalent clients are often seen as abnormal or unacceptable,
and having poor motivation. In this thinking the client needs to
be persuaded and educated regarding the negative effects.
 This can lead to the confrontation - denial trap.
 Ambivalence is normal, acceptable, and understandable.
Working with ambivalence is the heart of the problem in MI.

66
Some Complications of Ambivalence
1. Values - Never assume that the client will view a given cost or
benefit the same way you do.
2. Expectancies - People have certain expectancies regarding the
likely results of certain courses of actions.
3. Self-esteem - Sometimes bolstering self-esteem is a necessary
prerequisite to motivation for change.
4. Social Context - A client’s motivational system cannot be
understood outside the social context of family, friends, and
community.
5. Impaired Control - A person may persist in a harmful behavior
through a breakdown of normal self-regulation (self-control)
processes.

67
Dealing with Ambivalence and
Sustain Talk
 MI has stopped using the term resistance, but now focuses on
ambivalence.
 Sustain talk is a normal part of ambivalence. Sustain talk is that
which occurs in treatment, and shows that the client may be
moving away from the direction of change.
 Sustain Talk and Discord can be determined by therapist style.
Therefore, your style as a therapist will determine how much
ambivalence, sustain talk and discord is elicited by the client.
 Discord signals dissonance in the working alliance.
 An important goal of Motivational Interviewing is to avoid
eliciting or strengthening sustain talk.

68
Dealing with Ambivalence – 4 Types
1. Arguing – The client contests the accuracy, expertise or
integrity of the clinician.
2. Interrupting – The client breaks in and interrupts the clinician
in a defensive manner.
3. Denying – The client expresses an unwillingness to recognize
problems, cooperate, accept responsibility, or take advice.
4. Ignoring – The client shows evidence of ignoring or not
following the clinical advice.

69
Strategies for Handling Ambivalence
Simple Reflection
 This is responding to ambivalence/sustain talk with non-
resistance.
 A simple acknowledgement of the client’s disagreement,
emotion, or perception can permit further exploration rather than
defensiveness.
Client: I don’t think that anger is really my problem.
Counselor: You anger hasn’t’ cause any real difficulties for you.
Client: Well, sure it has. Anyone who gets into scraps as much
as I do is about to have some consequences.

70
Strategies for Handling Ambivalence (cont.)
Amplified Reflection
 Reflecting back what the client has said in an exaggerated form, to
state it in an even more extreme form than the client did. These
responses must be straightforward and supportive, not in a tone of
sarcasm or impatience.
Client: I think things are just fine in our marriage the way they
are.
Counselor: Things couldn’t possibly be better in your marriage
than they are right now.
Client: I’m pretty satisfied, but I guess both of us aren’t.

71
Double-Sided Reflection
 This is acknowledging what the client has said, and add to it the other
side of the client’s ambivalence. This may require material that the
client has offered previously.
CLIENT: “OK, maybe I’ve got some problems with drinking, but
I’m not an alcoholic.” (minimizing)
THERAPIST: You don’t have any problem seeing that your
drinking is hurting you, but you surely don’t want to be labeled.

72
Shifting Focus
 This is shifting the client’s attention away from what seems to be a
stumbling block standing in the way of progress. Such detouring can
be a good way to ambivalence/discord when encountering a particularly
difficult issue.
Client: “I know that you want me to give up drugs completely,
but I’m not going to do that!” (unwillingness)
Therapist: What is it that you would like out of this.
Client: I want that witch of a probation officer out of my life.
Therapist: So lets discuss that issue, what problems are you
experiencing with her?

73
Emphasizing Autonomy - Personal Choice and Control
 This works in working with discord that comes from REACTANCE. When
people think their freedom of choice is being threatened, they tend to
react by asserting their liberty. Antidote for reactance is to assure the
client it is he/she who determines what happens.
CLIENT: “I know that you want me to give up drugs completely,
but I’m not going to do that!” (unwillingness)
THERAPIST: Nobody can change your drug usage for you, it’s
totally your choice to either stop using or continue using.

74
Reframing
 This approach acknowledges the validity of the client’s raw observations, but
offers a new meaning or interpretation for them. The client’s information is
viewed in a new light that is more likely to be helpful and to support change.
Case Example:
CLIENT: “I can hold my liquor just fine. I’m still standing when everybody else is
under the table.”
THERAPIST: I hear you saying that you can drink a lot more without looking or
feeling drunk. When people start feeling the effects of being drunk, they tend to
curb their drinking. Sometimes that built in warning system changes due and
can result in a higher tolerance for alcohol than existed previously.

75
Siding with the Negative
 This is where the Clinician presents, or takes up, the negative voice in the
discussion … the voice of precontemplation and status quo.
 This works well with clients still in contemplation, and needing to elicit self-
motivational, change oriented statements but needs help doing so.
 Taking the negative side can evoke a response of the positives for change from
the client, thus the client would be making your argument for you. This is often
times called a “paradoxical intervention” or “prescribing the problem”.
 Therapist: “From what I’m seeing, you don’t have a problem, everything is
functioning perfectly well in your life, and there doesn’t appear a need to
continue addressing this issue.”
 Client: Well there have been some problems, I do have 1 DWI, my wife has
been complaining recently because of my drinking away from home, and my
kids have made comments to me, so I wouldn’t go so far to say there is “no
problem”.

76
Tracks of Services
Precontemplation =
Contemplation =
Preparation =
Action =
Maintenance =
Relapse/Recycling =
Discovery Track
Discovery Track
Discovery/Recovery Tracks
Recovery Track
Recovery Track
Relapse Track

77
MI is not based on:
Stages of Readiness for Change Model
 Precontemplation – The client is not ready to change and
identification with the “problem” is marked with positive
associations. Goal is to get client to form some ambivalence
regarding problem.
 Contemplation – Ambivalence exists with the client regarding
problem (the association with the identified problem are now
good and bad). Goal is to move the client into preparation
stage.
 Preparation – Client has substantially resolved ambivalence and
prepares to commit to a change in the problem behavior. Goal
is to move the client into the action stage.

78
MI is not based on:
Stages of Readiness for Change
Model
 Action – The client has committed to specific actions intended to bring
about change, but needs help in maintaining this level of change. Goal
is to provide client with help in this area and work client towards next
stage.
 Maintenance – The client enters the point of being able to sustain the
changes accomplished previously. Replacing problem behaviors with
new, healthy life-style.
 Termination – Person exits the cycle of change without fear of relapsing
to previous behavior. Much debate over whether certain problems can
be terminated.
 Relapse/Recycling – Relapse to one of the first three stages of change.
Expectable setbacks and hopefully learn from relapse before
committing to a new cycle of action. Multidimensional assessment to
explore relapse reasons.

79
Defining Termination of a Problem
 How far and how long must a client go before the problem can
be considered to be terminated?
 How can you distinguish the real signs of termination from the
rationalizations that will cause a client to return to the problem
behavior?

80
A New Self-Image
 If a significant revision in your attitude and self-image takes
place, there is a good chance a client will approach termination.
 A feeling (understanding) that the change in the problem is
“theirs”.
 More than just the “mastering” of the problem behavior(s), this is
where a clients holds a new self-image , one that is consistent
with healthier behavior(s).

81
No temptation in Any Situation
 No temptation to return to the problem behavior(s), regardless
of the situation.
 No temptation to return to the problem behavior(s), no matter
how you are feeling.
 These clients experience themselves in the same way as
individuals who have never experienced the problem.

82
Solid Self-efficacy
 Client’s who transfer their “center of gravity” from
their problems to themselves.
 They look, act, and feel with genuine confidence, not
false bravado.
 In regards to addictive behaviors, confidence peaks
after one year after action begins, but temptation
does not bottom out until 2 or 3 years after action
begins.

83
A Healthier Lifestyle
 Life changes are essential for the maintenance of a problematic
behavior; however, a new lifestyle is essential for termination.
The difference is permanence of change.
 In the maintenance stage, a client modifies parts of their life
(e.g., social contacts, daily schedules, behavior patterns), to
overcome their problem.
 In termination, clients institute a healthier lifestyle as a means of
preserving their gains and promoting new growth.

84
MI - Planning
 There comes a time in therapy when the emphasis shifts from
building motivation to strengthening commitment to change.
Signs of Readiness for Change
1. Decreased ambivalence
2. Decreased questions about the problem
3. Resolve
4. Self-Motivational statements
5. Increase questions about change
6. Envisioning or imagining aspects of change (good or bad)
7. Experimenting

85
MI - Planning
 Recapitulation – Summarizing clients current situation.
 The time to move from evoking to planning is clinical judgment
call guided by signals of readiness from the client.
 Developing a change plan usually involves moving from general
intention to a specific implementation plan
 3 planning scenarios:
1. The Change plan is already clear
2. There are options among which to choose in path mapping
3. The way forward is unclear and a change plan needs to be developed from
scratch.

86
MI - Planning
 Negotiating a Plan
- Setting Goals (client centered goals)
- Considering Change Options (possible methods for
obtaining goals, what would happen with different courses of
change, client may not choose the correct option the first time
… prepare clients for this).
- Arriving at a Plan
 Endgame
- Eliciting Commitment to Action
- Transition to the Action Phase

87
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Concept of the Working Alliance. Psychotherapy: Theory, Research
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on participation and outcome in residential alcoholism treatment.
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