1. INTRODUCTION TO LEARNING MOTIVATIONAL INTERVIEWING
Lynn S Massey, LMSW
Health Services Research
University of Michigan
August 2013

2. Do you…….
Explain what the person could do differently to improve their health?
Advise / persuade / warn what will happen if they do not change?
Counsel the person about how to change?
Refer to a specialist?
Set goals for change?

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

4. Definitions

5. MI Definition-Layman’s
Motivational Interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change.

6. Why do I want to learn MI?
Motivational Interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change.

7. Technical Definition
Motivational Interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for and commitment to a change goal by eliciting and exploring an individual's own arguments for change.

8. Eight Stages in Learning MI
The spirit of MI
OARS- client-centered counseling skills
Recognizing change talk
Eliciting and reinforcing change talk
Rolling with resistance
Developing a change plan
Consolidating client commitment
Integrating MI with other methods
Miller, W.R., & Moyers, T. B. (2006). Eights stages in learning motivational interviewing. Journal of Teaching in the Addictions

9. Assumptions

10. Motivation
The probability that a person will enter into, continue, and adhere to a specific change strategy or plan
Motivation is a dynamic state (of readiness to change)
Part of clinician’s job
Occurs in an interpersonal context
“Noncompliance”, “resistance” and ”lack of motivation” are all partially due to therapists strategies

11. Ambivalence Is normal, acceptable and understandable
Helps clinician to appreciate the complexity of the individual and their situation
To explore ambivalence is to work at the heart of motivation
Usually mistaken for resistance (yes, but…)

12. Spirit of MI

13. Definition
MI is not a set of methods to learn, but a therapeutic way to being and interacting with a person – not everyone will be able to do it
Context or interpersonal relationship within which the techniques are employed
Spirit of MI is necessary for expert use, but not to begin to learn MI – spirit of MI can emerge from therapist-client interactions using the method
The extent of initial curiosity and willingness to learn MI seems to be a good predictor for speed and ease of acquiring MI skills

14. The Spirit of MI Is essential for the full and expert use of MI
Underlying assumption that “health is waiting inside” each person, and your role is to help it emerge (Humanistic Psychology)
Contrasted with the model that the patient is flawed
Therapists expression of spirit as measured by independent raters predicts client engagement, collaboration, and affect in sessions (Moyers et al, 2005)

15. Relational Components of MI
Empathy – genuine curiosity about client’s perspective (understanding)
MI Spirit:
Collaboration – fostering power sharing in the interaction
Evocation – elicitation / acceptance / understanding of client’s own ideas about change
Respect Autonomy – active fostering of client perception of choice

16. Collaboration
Fosters collaboration and power sharing so that client’s ideas impact the session
Encourages power sharing in the interaction in such a way that client’s ideas substantially influence the nature of the session
Builds rapport
Facilitates trust
Mutual understanding, not about the therapist being right.

17. Evocation
Accepting of the client’s own reasons for change and ideas about how change should happen
Doesn’t attempt to educate or direct if client resists
Proactively evokes client’s own reasons for change and ideas about how change should happen
The therapist’s job is to “draw out” the client’s own motivations and skills for change, not to tell them what to do or why they should do it

18. Autonomy Accepting and supportive of client autonomy
The true power of change rests within the client
Ultimately it is up to the client to change
Clients are encouraged to take the lead on developing a “menu of options” as to how to achieve the desired change

19. Thumbs up Thumbs down
C: I know my dad told you I’m depressed, but I’m not. Just because I don’t want to play football doesn’t mean I’m depressed.
T: Your father is worrying needlessly. What do you think he’s seeing that makes him worry this way?
Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren (2009)
Collaboration and evocation

20. Thumbs up Thumbs down
C: They told me I have to have this surgery right away. But I don’t trust them, so I haven’t scheduled it yet.
T: Why take the chance? They’re the experts, after all. Let’s call from this phone right now-maybe you can get in this week?
Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren (2009)
Misses opportunity for autonomy

21. MI Skills and Strategies

22. The Basics of MI
Client centered approach is necessary but not sufficient for behavior change
Client centeredness – the relational component- based on the Spirit of MI (collaboration, evocation, autonomy, respect) and Empathy
“It is not a goal unless it is a goal for the patient”
Change talk - the technical component – gives a voice to the person’s inner motivation based on what they value most

23. 4 Principles of MI
1) Express empathy – acceptance of people as they are frees them to change whereas non-acceptance immobilizes the change process 2) Develop discrepancy – between present behavior and broader goals and values; helping people get un-stuck 3) Roll with resistance – avoid arguing for change; new ideas/goals/options are not imposed; used as a signal 4) Support self-efficacy – belief in ability to change is a powerful predictor of change; counselor self-fulfilling prophesy

24. Basic Role of MI therapist
Is to help the client become his / her own advocate for change
Is to elicit rather than instill expertise on how to change
“Join with” a persons own intrinsic motivation to move towards more adaptive behavior (i.e. those that are in line with their values and goals)

25. Early strategies: OARS
Open Ended Questions “are you concerned about your health?” vs “to you, what are important reasons to cut down on your drinking?”
Affirmations “It really sounds like you have been committed to being the best father you can”
Reflective listening
Summary “Let me try to pull together what we have been talking about, let me know if I missed something; it sounds like on one hand you feel and were scared by the ER visit, but on the other hand, you don’t want to give up drinking completely”

26. Affirmations may include
Commenting positively on an attribute
You’re a strong person, a real survivor.
A statement of appreciation
I appreciate your openness and honesty today.
Catch the person doing something right
Thanks for coming in today!
A compliment
I like the way you said that.
An expression of hope, caring, or support
I hope this weekend goes well for you!

27. “If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be.”
- Johann Wolfgang von Goethe

28. OARS Exercises Open Ended Questions Quiz Thinking Reflectively
Group Batting Practice
Forming Reflections
Miller tape with OARS coding
Structured Practice

29. What the listener hears
What the speaker says
What the listener thinks the speaker means
What the speaker means

30. Communication errors 1) The speaker does not say exactly what is meant
2) The listener does not hear correctly
3) The listener gives a different interpretation to what the words mean

31. One thing that I like about myself is that…..
One thing you should know about me is…..
One thing about myself I’d like to change is…….

32. Listener Why would you want to make this change?
Listen carefully with a goal of understanding the dilemma
Give no advice.
Ask these four open questions and listen with interest:
Why would you want to make this change?
How might you go about it, in order to succeed?
What are the three best reasons to do it?
On a scale from 0 to 10, how important would you
say it is for you to make this change?
Follow-up: And why are you at __ and not zero?
Give a short summary/reflection of the speaker’s motivations for change
Then ask: “So what do you think you’ll do?” and just listen

33. Reflective Listening: Overview
The essence is that it makes a guess as to what the speaker means
Statements rather than questions
“Continue the paragraph” – not just re-iteration
It is an active process (counselor decides what to reflect or ignore, what to emphasize, preferentially reflects change talk)

34. Complex Reflections Adding content (interpretation or feeling)
Metaphor/Simile (picture language)
Amplification (stronger or weaker)
Double-sided (reflects two sides of person’s view)
Reframing (put situation in a different light)
Verbalization of unspoken emotion

35. Categories of Resistance
Arguing – challenging, discounting, hostility
Interruption – talking over, cutting off
Negating – blaming others, “yes, but”, excuse making, claiming impunity, minimizing, pessimism, reluctance, unwillingness to change
Ignoring – inattention, non-answers, no response to questions, side-tracking

36. Responding to Resistance
Simple Reflection – you feel stuck, etc.
Amplified Reflection – C: My wife thinks its worse than it is. T: It seems to you she has no reason for concern.
Double-sided Reflection - You don’t like the way this makes you feel sometimes, and you’re not sure how you might change things.
Reframing – C: I’ve tried to quit 3 times and failed. T: You’ve given it 3 good tries, and every try gets you closer. Its probably helped you learn some things that will and won’t work for you.
Emphasize personal choice and control – What you decide to do is completely up to you

37. Change Talk - DARN C Disadvantages of Status Quo Advantages of Change
Optimism about Change
Intention to Change
Desire
Ability
Reasons (to, not to)
Need
Commitment

38. The Flow of Change Talk MI Desire Ability Reasons Need Commitment

39. Eliciting Change Talk Evocative Questions Elaboration Using Extremes
Looking Back
Looking Forward
Exploring Goals

40. Giving Information and Advice
Get permission
• Qualify, honoring autonomy
• Ask – Provide – Ask
• For suggestions, offer several, not one

41. Thanks Questions Concerns Motivationalinterviewing.com
Building Motivational Interviewing Skills a practitioner workbook by David Rosengren
Motivational Interviewing: Preparing people for change by William Miller and Stephen Rollnick (3rd edition)