Motivational Interviewing Preparing People for Change

Motivational Interviewing Preparing People for Change
Opening - centering silence – Merton Pipe cleaners - Handouts – see outline – this is roadmap for the day – will refer to handouts occasionally, but primarily supplemental What works (homeless service providers) Seek interactive environment – comments, questions welcomed throughout Strive to accommodate various learning styles – presentation of material, demonstration, modeling, practice/doing Clenched fist exercise My interest and involvement with MI Scale of 1-10 knowledge of MI; practice consciously Note concept of “preparing people for change” vs. changing people/getting people to change/convincing people to change Ken Kraybill Center for Social Innovation

Sound familiar? I give people my BEST ADVICE, but they won’t listen.
I EDUCATE and GIVE OPTIONS; what else can I do? She RESISTS everything I suggest. Some folks just DON’T WANT TO BE HELPED. He’s in TOTAL DENIAL about his problems. Some people just need A GOOD TALKING TO! I give, educate, suggest, help, talk to …

Changing the conversation
How to make it a transformative conversation?

Dedicated to all who are weary…
of trying to educate, advise, entice, convince, coax, cajole, persuade, sweet-talk, smooth-talk, guilt-trip, bribe, manipulate … or otherwise get people to change Educate – from Latin “educare” – to draw out – draw out self-knowledge, true self – “help you discover yourself.” To educate, therefore, is to draw out something that fundamentally is already there. In the process of education, you actually become aware of yourself. You grow, you transform and become the real you. Rather than simply memorizing a bunch of information, you absorb ideas that draw out the inner you and bring you into the world of relationships. Indoctrination is the complete opposite. Indoctrination seeks to put something into you, while education tries to bring something out of you. While an educator is like a gardener, an indoctrinator is like a carpenter. A carpenter imposes one’s own vision on a raw material, while a gardener sets a vision according to the seed; whatever you are, the gardener wants you to become. To indoctrinate is to coerce. It involves imposing the teacher's values-aspirations, identity and character-on the student, so that the student will become like the teacher and reflect the teacher. In the process of indoctrination, a conflict is liable to arise between the teacher and the student because the teacher has a message he wants the student to accept, even at the expense of the student's unique identity and individuality. Rabbi David Aaron

Evoking from people what they already have
hurts hopes nightmares dreams addictions desires delusions wisdom, impairments strengths needs resources What do you see? Which glass best represents our clients/patients? What is in our clients’ glasses? Discuss MI consistent “helping” as drawing from vs. pouring in. Giving people what they lack Evoking from people what they already have

“People possess substantial personal expertise and wisdom regarding themselves – and tend to develop in a positive direction, given the proper conditions and support.” Miller & Moyers, 2006

Motivational Interviewing
What is it? Why it matters? What’s it made of? How do you do it? 1. What is it? – definitions, hx of MI, tranformative conversation, a way of being, etc 2. Why it matters? – we hope people will change, effective approach to foster motivation to change 3. What’s it made of (ingredients)? – centered helper, spirit with compassion, OARS, using OARS to explore ambivalence and elicit change talk to guide towards change 4. How you do it? - PRACTICE

Eight Stages of Learning MI
Overall spirit Person-centered interviewing skills (OARS) Recognizing change talk Eliciting change talk Rolling with resistance Consolidating commitment Developing a change plan Transition and blending with other methods We will address all 8 stages this week. In a 2.5 day workshop, there is usually not sufficient time to develop even threshold proficiency in the last 4 stages. Learning the first 4 stages is enough to begin allowing ones clients to train you. Then, most people need more training to gain real proficiency in all of the 8 steps.

Objectives Examine what motivates people to change
Learn about the spirit, principles, and core methods of motivational interviewing Practice incorporating MI skills into your work MI: 1) What is it? Why it matters? What’s it made of? How do you do it?

Spirit of Motivational Interviewing
COMPASSIONATE - come along side, be with, grieve/suffer with COLLABORATIVE – form a partnership, both parties have expertise EVOCATIVE – client’s own knowledge, wisdom, strengths, motivation called forth EMPOWERING - person’s right and capacity for self-direction affirmed (p.35) MI is as much a “way of being with people”as it is a series of techniques. One can mimic the techniques of MI but miss the spirit of it. Note contrast in the two approaches in slide. Collaboration - “co-laborers” - provider avoids authoritarian, one-up stance, instead communicating a partner-like relationship. Thus, a focus on exploration vs. exhortation, support vs. persuasion/argument. Provider seeks to create a positive interpersonal atmosphere that’s conducive to change, not coercive. The interpersonal process is a meeting of two people’s beliefs/wishes, which may differ. Provider must be attuned to own beliefs/aspirations. Evocation - provider’s tone not one of imparting wisdom/insight/reality but of eliciting/drawing out these things from the client. Requires a certain humility on part of provider. Latin docere (root of doctor, doctrine, indoctrinate) - implies an expert, imparting role Latin ducere (root of educare - education) means “to draw out” Autonomy - in MI, responsibility for change is left with the client (where it must lie, despite belief people can be “made”, “permitted” to do and choose. Overall goal is to build intrinsic motivation, so that change arises from within rather than being imposed from without.

“A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” An evolving definition. Adapted from Miller & Rollnick’s Motivational Interviewing: Preparing People for Change, Original: “A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” Point out and describe the key components of the definition: Person-centered (vs. program centered or provider centered) – “meeting person where they’re at vs. where you think they should be” – focus on person’s present interests, concerns, perspectives, wishes, values – “hearing person’s story” - Person-centered doesn’t mean passive, but active in guiding vs. directing. Guiding method – MI consciously and carefully guides the client towards exploring and resolving ambivalence, eliciting and reinforcing change statement, etc. MI is a method of communication rather than a set of techniques – not a “bag of tricks” – not something you do to people, but is fundamentally a way of being with and for people – a facilitative approach to communication that evokes natural change. Motivation – MI focuses on enhancing the person’s internal motivation. This is based on the belief that unless a person has an inherent interest in change, it probably won’t happen, or if it does, is less likely to be maintained. Change – Seen as step by step movement towards healthier/less risky behaviors. Very compatible with risk/harm reduction. Exploring and resolving ambivalence – MI views ambivalence as a normal part of the change process. Becomes a problem if one gets stuck there. Resolving ambivalence is a key factor in enhancing motivation to change.

A collaborative, person-centered form of guiding to elicit and strengthen motivation for change. Miller & Rollnick, 2/09 Person-centered AND counselor-led (strategic direction) = reflective listening is a way to reconcile person-centeredness and guiding style (reflect as a mirror; reflect as mind to go deeper in conversation) – a way of acceptance AND strategic direction

Helping people talk themselves into changing
Or… Helping people talk themselves into changing "I learn what I believe as I hear myself speak.“ D. Bem Vs. “talking people into changing” – What’s going on when we try to talk people into changing? How well does it work? Whose needs are we trying to meet – our own, theirs, both? What is the message we are sending to the person? Bem, D. J., Self Perception Theory. In L. Berkowitz (ed). Advances in Experimental Social Psychology, Vol 6, "Individuals come to know their own attitudes, emotions and internal states by inferring them from observations of their own behavior and circumstances in which they occur. When internal cues are weak, ambiguous, or not interpretable, the individual is in the same position as the outside observer”. Applies to “internal talk” as well (self-talk) “The more a person argues on behalf of a position, the more he or she is committed to it.” We believe what we hear ourselves say. When a person publicly takes a position, his/her commitment to that position increases.

Henri Nouwen – Reaching Out
"We cannot change the world by a new plan, project, or idea. We cannot even change other people by our convictions, stories, advice and proposals, but we can OFFER A SPACE where people are encouraged to disarm themselves, lay aside their occupations and preoccupations and listen with attention and care to the voices speaking in their own center.” Henri Nouwen – Reaching Out Hospitality – “create a free and friendly space for the stranger” (Nouwen)

"People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others.“ Blaise Pascal - French mathematician and philosopher (1623 –1662)

“Talking oneself into changing”
MI conversation  Preparatory change talk Commitment talk Taking steps MI conversation = spirit + OARS + particular focus + explore ambivalence + elicit and reinforce change talk + change plan

Why MI? Evidence-based practice Kindness with skill
Effective across populations and cultures Applicable to range of professional disciplines Effective in briefer encounters Actively involves people in own care Improves adherence and retention in care Promotes healthy “helping” role for providers Instills hope and fosters lasting change

Five things MI is not William R. Miller
A way of tricking people into doing what you want them to do A technique Easy to learn Practice as usual A panacea Bill Miller: 10 things that MI is not: (1) the transtheoretical model of change; (2) a way of tricking people into doing what you want them to do; (3) a technique; (4) decisional balance; (5) assessment feedback; (6) cognitive-behavior therapy; (7) client-centered therapy; (8) easy to learn; (9) practice as usual; and (10) a panacea.

Why do people change? Because they want to…client motivation is key to change AND client motivation is greatly influenced by the provider Also: Change-talk effects Autonomy, choice

The righting reflex … AKA “helping”
“The world is out of joint Oh cursed spite that ever I was born to set it right.” William Shakespeare (Hamlet) “Those who want to help in the worst way, usually do.” - Unknown author But… here’s what typically happens. Humans have built-in desire to set things right – to fix things. Especially people in helping professions – “helping gene”

When the righting reflex meets ambivalence…
There’s trouble. You get resistance! Consider what happens when person with righting reflex (R) meets ambivalent person (A) - As A talks to R about dilemma of ambivalence, R forms opinion of what course of action A should take. R then proceeds to counsel, advise, persuade to take a particular action. Person A predictably argues the opposite or suggests shortcomings of proposed solution – this is natural because the person is ambivalent What happens next? R may up the ante and make the case more strongly for change (sees A as being resistant); A may intensify reaction or withdraw Or R may suggest alternative solutions; A likely will respond with “yes, but…” This interchange is playing out both sides of the ambivalence. Unfortunately, an important principle of social psychology (self-perception theory) – as a person argues on behalf of one position, becomes more committed to it (“As I hear myself talk, I learn what I believe.” In effect, A is inadvertently talked out of making the change needed. What are some common human reactions to the righting complex (the Answer Man/Woman)? Angry, agitated; Oppositional; Discounting; Defensive; Justifying; Not understood; Not heard; Procrastinate; Afraid; Helpless, overwhelmed; Ashamed; Trapped; Disengaged; Don’t come back – avoid; Uncomfortable; Resistant EXAMPLE ROLE PLAY – e.g. smoking, exercise

Common human reactions to the righting reflex
Angry, agitated Oppositional Discounting Defensive Justifying Not understood Not heard Procrastinate Afraid Helpless, overwhelmed Ashamed Trapped Disengaged Don’t come back – avoid Uncomfortable Resistant Essentially, person feels invalidated, actively resists, or withdraws (or some combination). Is this the person/client you want to be talking to?

A thought… "People are not resistant to change; they resist being changed." Kevin Eikenberry

Activity #2 Your counselee is ambivalent about smoking. Simply seek to understand the ambivalence. AVOID any temptation to give “helpful” information or advice! Initially, ASK “Would it be all right if we talk together about your smoking?” Assuming yes, ASK “Tell me about your relationship with smoking. (What are the good things? What are the not so good things?)” (Respond with reflective statements.) i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)

Activity #2 (continued)
“If you were to cut down or stop smoking, why would you want to make that change?” (reflect) “What would be your best reason(s) to do so?” (reflect) “How might you go about it in order to succeed?” (reflect) i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)

On a scale from 0 to 10, how important would you say it is for you to make this change? What makes you say ___ and not zero? What would it take to move from ___ to (next highest number)? How might I help you with that?” (reflect) i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)

Now, provide a brief summary of both sides of the client’s ambivalence, without taking sides, but with emphasis on the patient’s statements indicating a DESIRE, NEED and IMPORTANCE to change. Then, ask if you missed anything. i tell people that they are the experts on them and my only role is to help them clarify what is important in their life and identify anything that might be getting in the way of those things. (MINT trainer)

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 Essentially, person feels affirmed, is open/accepting, and engaged.

4 processes of MI planning evoking focusing engaging
Engaging, Focusing, Evoking, Planning (ROEM – Approach: making a connection; Companionship: building the relationship; Partnership: enhancing motivation and linking; Mutuality: supporting wellness and stability) engaging

How do people change?

Stages of change Prochaska & DiClemente
Termination Maintenance Action Preparation Contemplation Go through each stage and relapse. E.g. brushing teeth, doing laundry, deciding on what movie to see, what college to go to, exercise, diet, etc. Stages of change are like developmental stages – can’t skip a stage. Precontemplation No intention to change behavior in foreseeable future (next 6 months). Many unaware or barely aware of their problems. Others might wish to change, but not serious considering it in near future. Contemplation Aware problem exists - seriously thinking about addressing it, but not yet committed to preparing for and taking action. Experiencing ambivalence, weighing pros and cons. Can remain stuck here. Preparation Person committed to taking action soon - making concrete steps. Individuals in this stage often report small behavioral changes in positive direction. Ambivalence may still be present but diminishing. Action Individual actively modifies his or her behavior, experiences, or environment to overcome the problem. Person’s commitment is clear. Considerable commitment of time and energy required in this stage. Action is critical part of changing, but not to be confused with change itself, which is a process encompassing all of the stages of change. Maintenance Person continues to work at stabilizing behavioral change and consolidating the gains made during the action phase. Effort is put forth to prevent relapse (can include medically assisted treatment eg. Naltrexone for ETOH;. Buprenorphine and Methadone (also Naltrexone) for opiate addiction and soon (hopefully) a new one for cocaine). This stage not static, but very active. Often requires great deal of hard work and perseverance. Also is a time to enjoy the rewards resulting from the change. (Relapse) Person reverts to the problem behavior. Might happen at any time during change process. The duration of relapse may be very brief or lengthy. Relapse not a stage of change per se, but is seen as a normal occurrence in the change process for many people. Viewed as a temporary loss of motivation and a learning opportunity. Can go back to any stage. Relapse = temporary loss of motivation Precontemplation

Stages of Change: Counselor Tasks
PRECONTEMPLATION: Raise doubt; increase person’s perceptions of risk of behavior, dissonance with values CONTEMPLATION: Explore ambivalence; evoke reasons for change, risks of not changing PREPARATION: Help individual determine best course of action; develop change plan

Stages of Change: Counselor Tasks
ACTION: Help person implement plan, use skills, problem-solve; support self-efficacy MAINTENANCE: Help individual identify and use strategies to prevent relapse RELAPSE: Guide through stages of contemplation, preparation, and action without becoming stuck or demoralized due to relapse

OARS: Basic Skills of Motivational Interviewing
Open Questions Affirmations Reflective Listening Summaries OARS – are the basic interaction techniques/skills of MI – used “early and often” in MI “Way of being” – what does this mean? What are aspects of your “way of being” with clients/patients? degree of welcoming attitude defensiveness level posture/body language friendliness openness accessibility how deal with pt. when symptomatic (using, psychotic, depressed, ambivalent, angry, etc.) empathy shown empowerment shown Pay attention to the notes, but never forget that what really matters is the music. Motivational Interviewing is not a series of techniques for doing therapy but instead is a way of being with patients. William Miller, Ph.D.

Open Questions Backbone of MI info-gathering process
Set tone for non-judgmental setting Invite story – what is important to person Demonstrate genuine interest and respect Clarify, help go deeper, provoke thought Affirm autonomy, self-direction Some short-reply, info gathering, closed questions may be necessary. Can feel like interrogation. Open questions set non-judgmental tone. Also, help people listen to themselves talk!

Sound like… How are things going?
What is most important to you right now? What are your concerns about taking these pills? What have you noticed about ____? Hmm… Interesting… Tell me more… How did you manage that in the past? When have you been most likely to share needles? How would you like things to be different? What will you lose/gain if you give up drinking? What do you want to do next? How can I help you with that? Open questions encourage people to talk about whatever is important to them. Help establish rapport, gather information, and increase understanding. Open questions are opposite of closed questions - elicit a limited response e.g. yes or no. Open questions invite others to “tell their story” in their own words without leading them in a specific direction. Closed questions are “leading questions.” Should be used often in conversation but not exclusively. Must be willing to listen to the person’s response. Note that questions are oriented towards the present (green), past (brown), or future (blue). We particularly want to encourage thinking that envisions a different future. To contrast open vs. closed questions, consider the following examples. Note how the topic is the same in both questions, but the likely responses will be very different. 1. Did you have a good relationship with your parents? 2. What can you tell me about your relationship with your parents? What are examples of open questions you use in you practice? Quiz “Open vs. Closed” – p. 67

Converting Closed Questions
Are you having a good day? How long have you been homeless? Are you married? How many drinks do you have on a given day? Are the medications working well for you? Will you be able to make it to your appointment?

Forming Good Questions
So, instead of yelling like I usually do, I went for a walk. I love my kids, but they drive me crazy. I’m really tired of all this crap. Something’s got to change. I don’t see why I have to take these medications. So, I drink a little. It’s no big deal.

Guidelines: Open Questions
Seek to UNDERSTAND and GUIDE the conversation Ask MORE open questions than closed ones Keep questions CLEAR and BRIEF AVOID NEGATING open questions with closed ones – e.g. How is it going? Have you been taking your medications?

Activity: Open Questions
Pair up. Decide who will speak and who will “ask and listen.” LISTENER – Ask partner to describe a deeply held value. When you hear signal, ask an open question to draw out more of person’s story. Ask only open questions. SPEAKER – Describe one of your deepest held values. If closed question comes out, convert it into open question. (speaker can help)

OARS: Affirmations Recognize individual’s strengths, personal qualities, core values Build confidence in ability to change Must be congruent and genuine Different from praise Affirmations are reflected in statements, gestures, and attitudes that recognize client strengths and acknowledge behaviors that lead in the direction of positive change, no matter how big or small. Working in a collaborative, empowering manner with clients in which they are valued for the expertise they bring is also an important part of an affirming relationship. Affirmations in all forms build confidence in one’s ability to change. To be effective, affirmations must be genuine and congruent. Examples of affirming responses: I appreciate that you are willing to meet with me today. You are clearly a very resourceful person. You handled yourself really well in that situation. That’s a good suggestion. If I were in your shoes, I don’t know I could have managed nearly so well. I’ve enjoyed talking with you today. I look forward to seeing you next week. Can also be in form of seeking input/information – a question can be an affirmation What’s your opinion about that? How do you see it? Can you tell me about the services they offer at that shelter? What advice would you give me when I refer the next person there? How respected did you feel when you went there? Do you have any thoughts how I might improve the way I work with you?

Sound like… You were very kind towards… I noticed that you…
You showed a lot of patience… You are a courageous person to… You really value being… I wonder how you found the strength to… That took a lot of persistence to… Thank you for…

OARS: Reflective Listening
Reflective listening is the KEY to this work…LISTEN CAREFULLY to your clients. They will tell you what has worked and what hasn't. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen. Miller & Rollnick, 2002 The first duty of love is to listen. – Paul Tillich Reflective listening is primary skill - pathway for engaging others in relationship, building trust, and fostering motivation to change. Reflective listening appears deceptively easy, but takes hard work and skill to do well. Sometimes the “skills” we use in working with clients do not exemplify reflective listening but instead serve as roadblocks to effective communication. Examples include misinterpreting what is said or assuming what a person needs. It is vital to learn to think reflectively. This is a way of thinking that accompanies good reflective listening that includes interest in what the person has to say and respect for the person's inner wisdom. Its key element is a hypothesis testing approach to listening. What you think the person means may not be what they really mean. Listening breakdowns occur in any of three places: Speaker does not say what is meant Listener does not hear correctly Listener gives a different interpretation to what the words mean e.g. What do you know about a person who “eats(,) shoots and leaves” Reflective listening is meant to close the loop in communication to ensure breakdowns don’t occur. The listener’s voice turns down at the end of a reflective listening statement. This may feel presumptuous, yet it leads to clarification and greater exploration, whereas questions tend to interrupt the client's flow. Some people find it helpful to use some standard phrases: “So you feel...” “It sounds like you...” “You're wondering if...”

“What people really need is a good listening to.”
vs. “what people really need is a good talking to” The first duty of love is to listen. – Paul Tillich “What people really need is a good listening to.” Mary Lou Casey

Activity: Nonverbal Listening
Pair up. Decide who will speak and who will listen. SPEAKER - Talk for 3 minutes – something you are passionate about. LISTENER – Give partner “a good listening to.” No words, not even “mm hmm.” Do use your best NON-VERBAL listening skills. SPEAKER – Affirm strengths and provide constructive feedback.

Reflective Listening A way of… showing acceptance, understanding
checking, rather than assuming, what someone means guiding, deepening the conversation Ref lective listening is more than just keeping quiet while the other person talks. Crucial element is how the counselor responds Too often we put up roadblocks – p. 68 (Thomas Gordon’s 12 Roadblocks) – Read sample interchange p of well-intentioned but unhelpful counselor. Essence of reflective listening to make a reasonable guess what is meant. A statement? Why not a question? A well-formed reflective statement less likely to evoke resistance. A question requires a response. The difference is subtle. It’s in the inflection. Voice tone goes up with a question, gently down at end of a statement. E.g. You’re feeling uncomfortable? You’re feeling uncomfortable. They are statements of understanding. Note importance of “thinking reflectively” – includes continual awareness that what you believe or assume people mean is not necessarily what they really mean. Most statements can have multiple meanings. E.g. I wish I were more sociable. Possible meanings: I feel lonely, I get nervous, I’d like to be popular, I can’t think of anything to say, people don’t invite me to their parties Reflective listening is way of checking rather than assuming you know what someone means. READ interview p good example. Then go back and have participants try their hand at giving a reflective response. OR Show Rounder tape.

Thinking reflectively
The TROUBLE with words Listener does not hear the words correctly Speaker does not say what is meant Listener gives a different interpretation to what the speaker means Requires REFLECTIVE THINKING Interest in what person has to say and respect for their inner wisdom A hypothesis-testing approach to listening Essentially asks: “Is this what you mean?”

Levels of Reflection SIMPLE
Repeating or rephrasing – listener repeats or substitutes words or phrases; stays close to what speaker said COMPLEX Paraphrasing – listener makes a major restatement that infers or guesses the speaker’s meaning Reflection of feeling – emphasizes the emotional aspects of communication; deepest form of listening There are three basic levels of reflective listening that may deepen or increase the intimacy and thereby change the affective tone of an interaction. In general, the depth should match the situation. Examples of the three levels include: Repeating or rephrasing – listener repeats or substitutes synonyms or phrases; stays close to what the speaker has said Paraphrasing – listener makes a major restatement in which the speaker’s meaning is inferred Reflection of feeling – listener emphasizes emotional aspects of communication through feeling statements – deepest form of listening Varying the levels of reflection is effective in listening. Also, at times there are benefits to over‑stating or under-stating a reflection. An overstatement (i.e. an amplified reflection) may cause a person to back away from a position while an understatement may lead to the feeling intensity continuing and deepening. Practice making reflective statements: “I had a terrible time at that shelter last night.” “I’ve got to do something about my drinking before it kills me.” “I don’t think there’s any hope for me.” “I’m going to die out here if I don’t get some help.” “Nobody cares about people like me.” “I haven’t had an HIV test in over a year.”

Forming Reflections Appears deceptively easy, but requires practice
Statement, not a question, voice turns down at end Common word is “you” You… So you… It sounds like you… You’re wondering… That would be… for you

OARS: Summarizing “Let me see if I understand thus far…”
Special form of reflective listening Ensures clear communication Use at transitions in conversation Be concise Reflect ambivalence Accentuate “change talk” Summaries are special applications of reflective listening. Can be used throughout conversation but particularly helpful at transition points, e.g., after person has spoken about particular topic, has recounted a personal experience, or when encounter is nearing an end. Summarizing helps to ensure that there is clear communication between the speaker and listener. Also, it can provide a stepping stone towards change. Structure of Summaries Begin with a statement indicating you are making a summary. E.g. “Let me see if I understand so far …Here is what I’ve heard. Tell me if I’ve missed anything.” 2) Give special attention to Change Statements - statements made by client that point towards willingness to change. Four types of change statements, all of which overlap significantly: Problem recognition - “My use has gotten a little out of hand at times.” Concern - “If I don’t stop, something bad is going to happen.” Intent to change - “I’m going to do something, I’m just not sure what it is yet.” Optimism - “I know I can get a handle on this problem.” If the person expresses ambivalence, it is useful to include both sides in the summary statement. For example: “On the one hand …, on the other hand …” It can be useful to include information in summary statements from other sources (e.g. your own clinical knowledge, research, courts, family). Be concise. 6) End with an invitation. For example: Did I miss anything? If that’s accurate, what other points are there to consider? Anything you want to add or correct? 7) Depending on the response of the client to your summary statement, it may lead naturally to planning for or taking concrete steps towards the change goal.

Activity: Summarizing
Triads – counselor, client, observer/ coach CLIENT: Talk about something you want/need/should change but haven't changed yet – something you're ambivalent about. COUNSELOR: Facilitate a guided conversation with mix of OPEN QUESTIONS, AFFIRMATIONS and varying levels of REFLECTIONS. OBSERVER: Upon signal from instructor, provide a SUMMARY of client’s statements – especially those indicating the client’s readiness, willingness, or ability to change.

Using Skills: Clarifying Ambivalence

Ambivalence “People often get stuck, not because they fail to appreciate the down side of their situation, but because they feel at least two ways about it.” Miller & Rollnick, 2002 Ambivalence closely related to concept of conflict which is central to many psychological theories. Conflict comes in several forms: Approach - approach – choosing between two similarly attractive options – the candy story problem – is the best kind of conflict (“Should I work on this HCH team or the other?”) Avoidance – avoidance – choosing between two (or more) evils, options with negative consequences – “caught between a rock and a hard place”. (“Should I work on this HCH team or the other!!”) Approach – avoidance – tend to keep people stuck – both attracted to repelled by the same object – “fatal attraction” – “I can’t live with you and I can’t live without you” (1930’s Fletcher Henderson tune – “My sweet tooth says I want to, but my wisdom tooth says no.”) Double approach – avoidance – torn between two alternatives (lovers, lifestyles) both of which you are drawn to and repelled by; grand champion of all conflicts

Ambivalence: The dilemma of change
“My sweet tooth says yes, but my wisdom tooth says no” 1930’s Fletcher Henderson tune “I’m so miserable without you, it’s almost like you’re here.” Unknown country & western song

Sounds like… I can’t figure out what to do about… Maybe…
I think I should get tested, but… I can’t make up my mind whether to… On the one hand...on the other hand... It scares me to take all these medicines, but I suppose… I know I’d be better off if… If only it weren’t such a hassle to… No way! I will never, ever do that! Nope, not me!

Activity: Clarifying Ambivalence
Sample Conversation – Simply seek to understand. Avoid any temptation to give “helpful” information or advice! Do guide the conversation to elicit change talk. “Tell me about _________. What are the good things… and not so good things about _____________?” (reflect)

Using Skills: Recognizing, Eliciting and Responding to Change Talk
"People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come into the mind of others.“ Blaise Pascal - French mathematician and philosopher (1623 –1662)

Change talk = client speech that favors movement in the direction of change
The body of research on MI indicates that Change Talk predicts Commitment Talk Commitment Talk predicts actual behavior change!

Change Talk: DARN-CT Preparatory change talk
DESIRE to change (want, like, wish) ABILITY to change (can, could) REASONS to change (if … then) NEED to change (need, have to, got to) Activating change talk COMMITMENT language (intention, decision, readiness) TAKING steps So, we want to learn to recognize change talk when we hear it. Change Talk manifests itself in 4 different ways represented by the acronym D-A-R-N. You can distinguish the type of change talk by the verbs that are used as shown on the slide. Why might it be important to recognize change-talk? Hopefully, you will evoke at least the following: because it predicts commitment-talk, so we can reinforce it!

Examples of Change Talk
D: I’d like to have better control of my drinking A: I think I could quit R: If I want to get my kids back, then I have to quit drinking N: I’ve got to do something about my drinking C: I’m going to quit T: I’m going to call tomorrow to make an appointment

Responding to Change Talk: O-A-R-S
Open/elaborative questions (e.g., what else; tell me more) Affirmations Reflective statements Summaries So, when we hear change talk, how do we reinforce it? By doing what we have been doing: reflecting, elaborating, summarizing and affirming.

Eliciting Change Talk Change talk often flows naturally by simply using OARS When it doesn’t occur naturally, we can elicit change talk using seven strategies

Strategies for Eliciting Change Talk
IQ-LEDGE Decisional Balance Goals & Values Elaboration Questions Importance Ruler Query Extremes Looking Ahead/Back Evocative Questions These are all more specific uses of Open-Ended Questions or Reflections--actually more examples of complex reflections. It is hard to make a clear distinction about where the “client-centered” emphasis ends and the “helper-directive” part begins, but this is a way to talk about this transition. But, it is directive in a different sense than we might usually think about that. It is helping direct the client toward a deep understanding of their ambivalence and helping them be open to the possibility of change. It is NOT telling what they need to do much less must do.

Decisional Balance Not Changing Changing Benefits of 1. 4. 2. 3.
Costs of Can use for lots of issues – e.g. Applying SSI Going to medical clinic to check out persistent cough See mh worker about depression Cutting back on smoking Staying at the shelter, instead of street Getting picture ID Getting tested for HIV Telling friend re: your HIV status Getting on methodone Going into inpatient tx Taking your meds regularly Changing diet Exercise Etc.

Decisional Balance Drinking Stopping drinking Benefits of
1. Helps me relax; enjoy drinking with friends; eases boredom 4. Feel better physically; have more $; less conflict with family, work 2. Hard on my health; spending too much $; might lose my job 3. Would miss getting high; would change my friendships; have to find other ways to deal with stress Costs of Can use for lots of issues – e.g. Applying SSI Going to medical clinic to check out persistent cough See mh worker about depression Cutting back on smoking Staying at the shelter, instead of street Getting picture ID Getting tested for HIV Telling friend re: your HIV status Getting on methodone Going into inpatient tx Taking your meds regularly Changing diet Exercise Etc.

Importance Ruler ASSESS EXPLORE
“On a scale of 1-10, how important is it at this time for you to (change)? EXPLORE “What made you give it a __ and not (several numbers lower)? “What would take to raise that score from a __ to a __ (next highest number)? “How might I help you with that?” Or…"Oh, that's interesting. A 6 rather than a 4. Tell me more about that.“ Or…"How convinced are you, on a scale of 1 to 10 that ________ is in your best interest? (“stronger statement” than importance)

Confidence Ruler ASSESS
“On a scale of 1-10, how confident are you that you could make this change? EXPLORE “Why a __ and not (several numbers lower)? “What would take to raise that score from a __ to a __ (next highest number)? “How might I help you with that?”

Evocative Questions What do you think you will do? What changes, if any, are you thinking of making? What are your options? Of the things we have discussed, which ones concern you most? What happens next? Where do we go from here? How would you like things to turn out for you now, ideally? What could be some good things about making a change?

Looking Ahead “If you were to _______, why would you want to make this change?” (reflect) “What would be the best reasons to make this change?” (reflect) “How might you go about it in order to succeed?” (reflect)

Using Skills: Responding to Resistance
"It's always easier to plow around the stump".

Resistance “Ambivalence under pressure”
A signal of dissonance in the relationship Influenced by clinician responses Resistance vs. cooperation – dancing vs. wrestling p.43 Consonance and dissonance – two poles on a continuum (“dancing” and “wrestling”) Read dialogue between probation officer and client – p. 44 (Handout) Resistance occurs only in the context of a relationship (in same way as cooperation happens in relational context - can’t say that one person is not cooperating!) What doe resistance look like? Takes 4 basic forms: 1. Arguing, 2. Interrupting, 3. Negating (unwilling to recognize problem, cooperate, accept responsibility), 4. Ignoring What causes dissonance in provider-client relationship that leads to resistance? 1. Different goals; 2. Mismatch of provider strategy with client’s readiness; 3. If either brings anger, frustration into the room; 4. Not listening, assuming, interrupting; 5. Lack of agreement about roles in relationship (“I’m in charge here” up against “You can’t tell me what to do.”) Provider behaviors that tend to elicit or increase resistance: Arguing for change - tries to persuade client to change Assuming the expert role - e.g. take on a lecturing role Criticizing , shaming, blaming - trying to invoke change by instilling negative emotions Labeling - “that’s because you’re an alcoholic/addict” - focus on what person “is” or “has” Being in a hurry - having little time leads to more forceful tactics (Monte Roberts - with horses - if you act like you only have a few minutes, it can take all day; if you act like you have all day, it may take only a few minutes.) Paternalism - “I know what’s best for you.”

Sounds like… You don’t really care about me.
Who are you to tell me what to do. Have you ever smoked crack? This place sucks. Stop repeating everything I say. Yeah, whatever.

Looks like… Unengaged posture Ignoring, avoiding Anger Does not return

Responding to Resistance
Reflective responses Simple Amplified Double-sided Other responses Shifting focus Reframing Agreeing with a twist Emphasizing personal choice and control Coming alongside

Activity: Responding to Resistance
Form triads. Choose who will be 1) client, 2) counselor, and 3) observer. Client chooses an issue about which you are quite resistant to change. Counselor responds to resistance using both reflective responses and other responses. Observer provides counselor with suggestions as needed.

Using Skills: Strengthening Commitment
Phase 1 of MI = Enhancing and importance and confidence; Phase 2 = Strengthening commitment to change There comes a time when person shows signs of readiness to commit to change – counselor needs to know how to identify and respond when the window is open – this requires a change in guiding strategies

Strengthening Commitment to Change
AWARENESS Recognize signs of readiness Beware of hazards ACTION Recap/summarize Ask key questions (and reflect) Give information and advice Negotiate a change plan

Signs of readiness Less resistance More openness Enough talking
Sense of resolution More change talk Questions about change Envisioning change Experimenting

Recapping SUMMARY OF… Person’s own perceptions of problem
Client’s ambivalence Relevant objective evidence Statements of desire or intent to change Your own assessment of person’s situation, especially points of convergence with client’s concerns

Change Plan Worksheet

General Practice Guidelines
Talk less than your client Offer 2 or 3 reflections for every question you ask Ask twice as many open questions as closed questions When listening empathically, more than half of your reflections should go beyond simple reflection

Traps to Avoid Question – Answer Taking Sides Expert Labeling
Premature Focus Blaming p. 55… Question-Answer – read DIALOGUE p. 55 – is less empathic - can be related to counselor anxiety – need to control session Taking sides – most important trap to avoid – when you take a side, client who is ambivalent takes the other – read DIALOGUE p. 57 Expert – p.60 – desire to help can unwittingly lead counselor into expert trap – trying to “fix” the situation. In MI, in a real sense the client is the expert – esp. re: his/her situation, values, goals, concerns, skills, motivation. MI is about collaboration (side x side) not installation. Labeling – p. 60 – Some counselors believe is important for client to accept the counselor’s diagnosis – “You’re an addict. You’re in denial.” Is little evidence for any benefit from pressuring people to accept a label. Underlying issue is likely a power struggle. Read DIALOGUE p. 61 Premature focus – p. 62 – counselors often want to identify and hone in on what they perceive to be the client’s problem; the client may have more pressing concerns – The trap is to persist in draw the client back to talking about your conception of “the problem” Blaming – p. 63 – client may be defensive, wanting to assign blame for the problem – Who’s fault? Who’s to blame? – best to render blame irrelevant – read STATEMENT p. 63

Resources Motivational Interviewing (2nd Ed.), Miller, WR & Rollnick, S., The Guilford Press, 2002. Motivational Interviewing in Health Care, Rollnick, S, Miller, WR and & Butler, C. The Guilford Press, 2008. Motivational Interviewing in the Treatment of Psychological Problems, Edited by Arkowitz, Westra, H, Miller, WR, & Rollnick, S, The Guilford Press, 2007. TIP # Enhancing Motivation for Change in Substance Abuse Treatment, CSAT, 1999. – NCADI Website:

Now what (personally)? Read more about MI
Observe and discuss professional training videotapes Practice reflective listening with “talk radio” Tape (audio or video) your own practice Work with a supervisor knowledgeable about MI Form a peer discussion/supervision group to support mutual skill-building

Now what (organizationally)?
Designate a Skills Developer to provide and promote ongoing training/observation/feedback Offer various lengths of booster trainings Supervisors add staff progress in MI skill-building in supervisory sessions and evaluations Rethink the notion of doing intake assessments Develop an MI materials and tools library Create MI posters with MI definition, OARS, etc. as reminders Develop own MI listserv

MI Self Check My clients would say that I…
Believe that they know what’s best for themselves Help them to recognize their own strengths Am interested in helping them solve their problems in their own way Am curious about their thoughts and feelings Help guide them to make good decisions for themselves Help them look at both sides of a problem Help them feel empowered by my interactions with them Adapted from Hohman, M. & Matulich, W. Motivational Interviewing Measure of Staff Interaction, 2008.

Remember… your clients/patients will teach you!

Motivational Interviewing Preparing People for Change

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