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Motivational Interviewing Mary Dugan, Ph.D., LCSW Amanda Anderson Shelly Evans & Jennifer Bartlett Marla Gamble.

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Presentation on theme: "Motivational Interviewing Mary Dugan, Ph.D., LCSW Amanda Anderson Shelly Evans & Jennifer Bartlett Marla Gamble."— Presentation transcript:

1 Motivational Interviewing Mary Dugan, Ph.D., LCSW Amanda Anderson Shelly Evans & Jennifer Bartlett Marla Gamble

2 Objectives  MI Definitions  Processes of MI  OARS  Change Talk  Resistance  Learning to use MI

3 MI: A way to talk about behavior change  Person-centered  Directional method  Enhances internal motivation for change  Explores and resolves ambivalence  Empirically supported

4 Motivational Interviewing.. ... is a clinical method that overlaps humanistic and cognitive therapies ... is not behavior therapy although there is some use of reinforcement to elicit and shape client speech ... Has a strong focus on acceptance and commitment as interpersonal transactions

5 MI is an Evidence Based Practice  On the federal NREPP list  Being vetted by American Psychological Association  Strongest evidence in alcohol and drug abuse  Good outcomes for alcohol, drugs, hypertension, bulimia, and compliance in diabetes  Support for smoking, physical activity, and adherence with hyperlipidemia treatment  AMIs (Adaptations of MI) were superior to placebo controls and equal to active treatments.  Noonan and Moyers (1997); Dunn (2003)

6 Broader than Behavior Change  Decision – to make a choice –Forgiveness, Leaving or staying  Attitude - to become a different person –To be more Compassionate, Assertive etc.  Resolution - Acceptance –Complicated grief –Finding peace regarding a decision –Tolerance for anxiety, uncertainty etc.

7 Three Essential Elements in any Definition of MI 1. MI is a particular kind of conversation about change (counseling, therapy, consultation, method of communication) 2. MI is collaborative (person-centered, partnership, honors autonomy, not expert-recipient) 3. MI is evocative, seeks to call forth the person’s own motivation and commitment

8 DEFINITIONS OF MI Three levels of definition (of increasing specificity) 1. A layperson’s definition (What’s it for?) 2. A pragmatic practitioner’s definition (Why would I use it?) 3. A technical therapeutic definition (How does it work?)

9 1. A layperson’s definition (What’s it for?) Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change

10 2. A pragmatic practitioner’s definition (Why would I use it?) Motivational interviewing is a person- centered counseling method for addressing the common problem of ambivalence about change

11 3. A technical therapeutic definition (How does it work?) Motivational interviewing is a collaborative, goal- oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change

12 Four Fundamental Processes in MI

13 Relational Motivational Foundation Interviewing 1. Engaging 2. Focusing 3. Evoking 4. Planning

14 4 Fundamental Processes in MI 1. Engaging – The Relational Foundation Person-centered style Listen – understand dilemma and values OARS core skills Learn this first

15 4 Fundamental Processes in MI 1. Engaging – The Relational Foundation 2. Focusing – Strategic Centering Agenda setting Finding a focus Information & advice

16 4 Fundamental Processes in MI 1. Engaging – The Relational Foundation 2. Focusing – Strategic Centering 3. Evoking – The Transition to MI Selective eliciting Selective responding Selective summaries

17 4 Fundamental Processes in MI 1. Engaging – The Relational Foundation 2. Focusing – Strategic Centering 3. Evoking – The Transition to MI 4. Planning – The Bridge to Change Replacing prior Phase I and Phase II Negotiating a change plan Consolidating commitment

18 Is it MI Yet?

19 Can it be MI without... Engaging ? Focusing ? Evoking ? Planning ? No Yes

20 So it’s MI when.. 1. The communication style and spirit involve person-centered, empathic listening (Engage) AND 2. There is a particular identified target for change that is the topic of conversation (Focus) AND 3. The interviewer is evoking the person’s own motivations for change (Evoke)

21 The 4 processes are somewhat linear....  Engaging necessarily comes first  Focusing (identifying a change goal) is a prerequisite for Evoking  Planning is logically a later step Engage Focus Evoke Plan

22 .... and yet also recursive  Engaging skills (and re-engaging) continue throughout MI  Focusing is not a one-time event; re-focusing is needed, and focus may change  Evoking can begin very early  “Testing the water” on planning may indicate a need for more of the above

23 Four Foundational Processes Planning Evoking Focusing Engaging

24 Engaging – The Relational Foundation  Best Developed Process  Person-centered style  Listen – understand dilemma and values MI SPIRIT OARS core skills

25  Exercise

26 The “Spirit” of Motivational Interviewing  Collaboration  Evocation  Autonomy  Compassion

27 The Underlying Spirit of MI

28 How do we help people solve problems? Steve Rollnick (Sophia, Bulgaria 2007)

29 manage, prescribe, lead, tell, show the way, take charge of, preside, govern, rule, have authority, exert authority, reign, take the reins, take command, point towards; conduct, determine, steer one’s course, pull the stroke oar. Direct

30 Go along with, allow, permit, be responsive, have faith in, go after, attend, take in, shadow, understand, observe. Follow

31 A widespread dichotomy DirectManagePrescribeLeadTellFollowPermit Let be Allow Go along

32 Enlighten, shepherd, encourage, motivate, support, lay before, look after, support, take along, accompany, awaken, promote autonomy, elicit solutions Guide

33 Guiding: a neglected style DirectManagePrescribeLeadGuideShepherdEncourageMotivate FollowPermit Let be Allow


35 Fundamental MI skills  Open Questions  Affirmation  Reflective Listening  Summarizing  Elicit

36  Questions can’t be answered yes or no  Questions that can’t be answered with one or two words  Questions that are not rhetorical What does open-ended mean?

37 Open-Ended Questions  Probe widely for information  Help uncover the individual’s priorities and values  Avoid socially desirable responses  Draw people out

38 Some Guidelines with Questions  Ask fewer questions!  No more than three questions in a row  Ask MORE OPEN than closed questions  TWO REFLECTIONS for each question

39 Open Ended Questions Video

40  Affirm a person’s struggles, achievements, values, and feelings  Emphasize a strength  Notice and appreciate a positive action  Should be genuine  Express positive regard and caring  Examples –“It takes courage to face such difficult problems” –“This is hard work you’re doing” –“You really care a lot about your family” –“Your anger is understandable” Affirmations

41 Affirmations Video

42 The Function of Reflection What the speaker means 1 What the listener hears 3 What the speaker says 2 What the listener thinks the speaker means 4 Bridge the gap by reflection R

43 Reflective Listening  A critical MI skill  Mirrors what the individual says  Is non-threatening  Deepens the conversation  Helps people understand themselves

44 MI Listening Method  Reflective listening encourages disclosure and exploration.  Listen carefully  Generate hypothesis about content, meaning, emotion  Put your hypothesis in form of a statement  Keep voice inflection neutral/down at end  Listen to individual’s clarification  Restate hypothesis of the clarified content

45 Reflective listening stems  So you feel like..  It sounds like you….  You’re wondering if…  In other words you’re saying….  Let me see if I heard you correctly….  What I hear you saying…  Ask for clarification- I want to understand, help me to understand what you’re saying  You’re feeling...  It seems that you ….  So you….

46 Reflections  First, train yourself to think reflectively  What does this person really mean?  How does this fit with cultural competence?  Reflective listening is a way to check in with the patient. Can be a guess about what they really meant.

47 Reflections Video

48  “What you’ve said is important.”  “I value what you say.”  “Here are the salient points.”  “Did I hear you correctly?”  “We covered that well. Now let's talk about...” Summarization

49  After a minimum of 3 reflections  Good for moving the conversation or transitioning to the next topic Using Summaries

50 Summaries Video

51 Practice Exercises  Workbook  OARS Practice sheet  Virginia Reel

52 Focusing – Strategic Centering  Developing a clear direction and goal(s)  Sometimes the change goal is clear, but often it’s not  Most often, from the client’s agenda; Sometimes prescribed by the context

53 Agenda Setting  Eliciting the client’s agenda –“Miracle question”  Offering a menu –What are the options?  Asking permission to discuss your agenda –I’d also like to talk a bit about ? and you can decide if that would be helpful

54 Finding a Focus  What is the focus, the “change goal” for MI?  Most often, it is from the client’s agenda  Sometimes prescribed by the context  What if you have your own goal(s) that the client does not currently share?

55 Evoking – The Transition to MI  A clear focus is a prerequisite  Eliciting change talk –Selective eliciting –Selective responding –Selective summaries

56 Change Talk Change talk is any client speech that favors movement in the direction of change Previously called “self-motivational statements” (Miller & Rollnick, 1991) Change talk is by definition linked to a particular behavior change goal DARN CATs

57 Preparatory Change Talk Four Examples DARN  D ESIRE to change (want, like, wish.. )  A BILITY to change (can, could.. )  R EASONS to change (if.. then)  N EED to change (need, have to..)

58 Mobilizing Change Talk Reflects resolution of ambivalence CATs  COMMITMENT (intention, decision, promise)  ACTIVATION (willing, ready, preparing)  TAKING STEPS

59 Yet another metaphor MI Hill Preparatory Change Talk Mobilizing Change Talk Contemplation PreparationAction (Pre-)

60 Responding to Change Talk

61 Responding to Change Talk All EARS  E: Elaborating: Asking for elaboration, more detail, in what ways, an example, etc.  A: Affirming – commenting positively on the person’s statement  R: Reflecting, continuing the paragraph, etc.  S: Summarizing – collecting bouquets of change talk

62 MI Flow Chart OARS Does change-talk occur naturally without explicit elicitation ? yes no Develop a plan, etc Apply Techniques For Eliciting Change-Talk Respond with Elaboration Qs Reflection Affirmation &or Summarization https://adept.missouri.edu

63 DESIRES Strengthen Client Commitment Talk ABILITIES REASONS NEEDS Client Behavior al Change Seeing Behavior Change Asking for Clients Assessing Hearing Strong Commitment Talk MI Change Talk Strategy Process

64 Change Talk and Sustain Talk Opposite Sides of a Coin

65 Examples of Sustain Talk  Desire for status quo  Inability to change  Reasons for sustaining status quo  Need for status quo  Commitment to status quo

66 Sustain Talk The other side of ambivalence  I really like marijuana(D)  I don’t see how I could give up pot (A)  I have to smoke to be creative (R)  I don’t think I need to quit (N)  I intend to keep smoking and (C) nobody can stop me  I’m not ready to quit (A)  I went back to smoking this week (T)

67 Change Talk Video

68 Evoking Change Talk! Giving goal-oriented or target behavior- oriented direction…

69  Previously, we learned that change talk can flow naturally by simply using OARS  In this lesson, we will learn strategies for eliciting change-talk when it does NOT naturally occur  We will list, define, and discuss 7 strategies for eliciting change talk Eliciting change talk

70 Ask Evocative Questions (Assumes a problem)- What happened the last time you used? How did your little sister react the last time you and your mom fought? Explore Decisional Balance – Weighing Costs & benefits. *Consider short & long term consequences (+/-) How to Evoke Change Talk! (How MI becomes directive)

71 Ask for Elaboration or Examples – What else do you think is going on with that? Tell me a little more about your situation at school… Tell me about the last time you got in a fight…. Looking Back – Think back to a time when things were OK [you weren’t using]? What things did you do to keep you on track? More Strategies…

72 Looking forward – How would you like your life to look a year form now? What will be different in a year if you stop using? Query Extremes - what is the worst that could happen if you [quit behavior]? What is your worst fear? What is the best thing that could happen if you [quit behavior]? More Strategies….

73 Use Change Rulers – On a scale of 1-10, how important is it for you to get through treatment? What would it take for you to go even higher on the scale? Explore Goals & Values – What’s most important to you? Where would YOU like to start? Which of these 3 areas would you like to work on first? More Strategies….

74 Come Alongside – Explicitly side with the negative (or status quo) side of ambivalence. This may be so important to you that changing is out of the questions, no matter what the cost. More Strategies….

75  Change talk: I wouldn’t have a hangover.  Open Question: What might be some advantages of quitting?  Change talk: I suppose I could go with a buddy.  Open Question: What might make it easier for you to get to the program? Change Talk Jeopardy: Examples

76 Recognizing and Attending to Commitment High Commitment Strength Medium Commitment Strength I will I definitely will I promise I swear I guarantee I know I will I intend to I am ready to I am going to I plan to I think I will I expect to

77 Planning – The Bridge to Change  Replacing prior Phase I and Phase II  Negotiating a change plan & Consolidating commitment

78 It’s time for the Planning Process when:  There is sufficient engagement AND  A clear shared goal AND  Sufficient client motivation for change Often a “testing the water” strategy such as recapitulation and key question

79 Planning: A Continuum Clear Plan Menu of Options Unclear What is the client/patient role in planning? How does the interviewer influence planning? What are the key elements of MI-guided planning?

80 Motivation is Interactional 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.. could be, he will become what he.. could be. (Johann Wolfgang von Goethe) Change the interaction and the person changes!

81 Ambivalence: A Central Concept  Simultaneous motivations leading in different directions –Desire to gain medication benefits and avoid side-effects –Desire to be strong and healthy and to relax and eat enjoyable foods –Desire to be in greater control/feel on top of things, desire to let go and escape –Hope for change / fear of failure

82 Role of Ambivalence  Ambivalence is a normal component of psychological problems  Acknowledge and protect the side that doesn’t want to change  Explore pros and cons of change (decisional balance)  Specifics are unique to each person--try not to assume

83 What is Resistance?  Behavior (a state not a “trait”)  Interpersonal (It takes two to resist)  A signal of dissonance  Predictive of (non) change  Highly responsive to practitioner style

84 Psychological reactance  Individuals will defend their freedom when it is threatened, especially when the threat is perceived as unfair. –Restricted behaviors may increase in attractiveness (forbidden fruit) –Person may become aggressive or assert other freedoms  Therapeutic relationship (advising, addressing problems) may induce reactance (Brehm, 1966)

85 Status Quo or Option A Change or Option B Advantages + Good things about Status Quo or Option A CON Good things about Change or Option B PRO Disadvantages - Less-good things about Status Quo or Option A PRO Less-good things about Change or Option B CON 2 x 2 Decisional Balance Grid PROs and CONs of Change

86 Rolling with Resistance  Don’t push back  Avoid arguments  Reflect  Remind the person (and yourself) about autonomy What do you feel when the individual resist?

87 Sustain Talk and Resistance  Sustain Talk is about the target behavior –I really don’t want to stop smoking –I have to have my pills to make it through the day  Resistance is about your relationship –You can’t make me quit –You don’t understand how hard it is for me  Both are highly responsive to practitioner’s style

88 Traps to Avoid  Question/Answer  Premature Focus  Taking Sides  Expert Role  Blaming

89 Another Trap: The Righting Reflex  Born of concern and caring  There’s a problem? Let’s fix it!  Fails to consider ambivalence in change process  May engender resistance

90 Possible contraindications for MI  Clients who are already ready for change or appear to be at the action stage  Clients who are low in anger or resistance  Clients making a decision we should not be involved with!

91 When, in MI, do you give information and advice?

92 Three kinds of permission:  The person asks for advice  You ask permission to give advice: “Can I make a suggestion?” “Would you be interested in some resources?” “Would you like to know what has worked for some other people?”)  You qualify your advice to emphasize autonomy: “A lot of people find that _____works well, but I don’t know if that’s something that interests you.” Giving information & Advice

93 Get Permission (sometimes best to ask permission to listen & learn more before giving advice!) Qualify, honoring autonomy For suggestions, offer several instead of just one The Process for giving advice…

94 Building MI Skills  Ongoing training in MI  Supervision/Coaching and feedback  Reading  MI Workbook  Watching training videos (YouTube)  Watching or listening to your own sessions  Coding sessions  Peer support

95 Getting Stuck while learning MI  Being open to change & letting go of some old habits  Proficiency in reflective listening  Recognizing change talk & evoking change talk  Summarizing  Transitions to other therapeutic methods

96 The FRAMES Model  F – providing feedback  R – emphasizing that the individual is responsible  A – giving clear advice  M – providing a menu of alternative options  E – using empathetic conversational style (reflective listening)  S – supporting self-efficacy

97 Using FRAMES in MOSBIRT  F – providing feedback on the patient’s screening results  R – emphasizing that the individual is responsible for their own behavior  A – giving clear advice that the best way to reduce the risk is to cut down or stop engaging in the risky behavior (drinking, using drugs, etc.)  M – providing a menu of alternative change options  E – using empathetic conversational style (reflective listening)  S – supporting self-efficacy of the individual

98 Brief Education  Provided when ASSIST Score for Alcohol = 11 to 19 and/or ASSIST Score for Drugs = 4 to 19  Consists of 1 Session  Follows (usually immediately) completion of the Screening forms  Average time about 30 minutes

99 Brief Education in 3 Steps  Step 1: Orientation & Print Personal Feedback Form  Step 2: Build Rapport, Review Personal Feedback Form, Provide Feedback on Screening Results, Give Clear Advise, and Provide a menu of alternatives  Step 3: Summarize Session, and emphasize personal responsibility.

100 Brief Education Handout  Personal Feedback Form

101 Brief Education Step 1: Orientation & Print Personal Feedback Form  Deliver orientation: welcome and rational –Brief Assessment (Pre-Screening) –HIPPA Consent Form –ASSIST & GPRA Interviews –Follow-up Survey Contact Form (when appropriate)  Print Personal Feedback Form (PFR) –Review the patient’s ASSIST Score to determine level of intervention

102 Brief Education Step 2: Build Rapport, Review Form, Provide Feedback, Advise, and Menu of Alternatives  Rapport building – focus on strengths (use Empathy & Support self-efficacy)  Review Personal Feedback Form  Provide Feedback on the screening results – focus on concerns (remind Responsibility of patient use Empathy & Support self-efficacy)  Give clear Advice (with permission) that the best way to reduce the risk is to cut down or stop drinking  Provide a Menu of alternatives for change

103 Brief Education Step 3: Summarize Session, Emphasize Responsibility, and Feedback from Patient  Summarize session  Emphasize that the individual is Responsible for their own behavior


105 References Arkowitz, H., Westra, H.A., Miller, W.R., & Rollnick, S. (eds) (2008). Motivational Interviewing in the Treatment of Psychological Problems. Guilford Press: New York. Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing, 2 nd Edition: Preparing People for Change. Guilford Press: New York. Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Healthcare: Helping Patients Change Behavior. Guildford Press: New York. Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. Guildford Press: New York.

106 Thank You! Mary Dugan, Ph.D. LCSW Member of MINT, Inc. Research Assistant Professor Missouri Institute of Mental Health 5400 Arsenal St St. Louis, MO 63139 (314) 877-6451

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