MOTIVATIONAL INTERVIEWING Linkage to care specialist training By: Abbe Shapiro, MSW Linkage to Care Program Manager The Damien Center ashapiro@damien.org

What is motivational interviewing? A semi-directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence A method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior Recognizes and accepts the fact that clients who need to make changes in their lives approach counseling at different levels of readiness to change their behavior Some clients may have thought about it but not taken steps to change, while some may be actively trying to change their behavior and may have been doing so unsuccessfully for years

Principles of Motivational Interviewing R – Resist the righting reflex U – Understand your client’s motivation L -- Listen to your client E -- Empower your client Complete exercise: Rating Samples for MI Spirit

Foundational skills Ask open ended questions Provide affirmations Use reflective listening Periodically provide summary statements to the client

reflective listening 1. Start from the obvious position that each client knows more about him- or herself than you ever will. 2. We can see blind spots that clients cannot – but they know far more about factors that have influenced their lives than we do. If we want to know these things, clients must tell us – and we must listen (though that still doesn’t mean that we will ever truly understand their experience). Key Element: Hypothesis Testing – what you think the person means may not be what he or she really means….so check! “So you feel…” “It sounds like you…” “You’re wondering if…” “What I heard you saying was …” “On the one hand you feel…on the other hand…” (double-sided reflection) Complete exercises: Hypothesis Testing and the Formation of Reflections; Directive Reflecting

Deepening Reflections So, I’m not too worried, but it’s been over a year since I’ve had a syphilis test. Paraphrase: Moves well beyond the client’s words and presents information in a new light. You’ve had some risk behavior. Amplified: Overstates what the client has said, often increasing the intensity by pressing on the absolute or resistant element. It’s no concern to you. Double-sided: Reflects both parts of the client’s ambivalence. You feel you’ve been pretty safe, while also recognizing that there has been some risk. Affective: Addresses the emotion either expressed or implied. It’s like there is always a little uncertainty – a little fear – since you’ve chosen to be sexually active.

Open-ended Questions Short-reply, Information-gathering questions are necessary during client contacts But open-ended questions are the ‘meat’ of the information-gathering process – but watch not to be too vague or too broad. How you ask a question will elicit different responses: Did you drink alcohol this week? How often and much do you drink? What are you drinking habits like? When you decide to drink, tell me about the circumstances. I wonder what it would be like if you decided to stop.

Key Questions There comes a point when the focus will shift from building motivation to asking for commitment to change. What’s the next step? What do you think you will do now? So, how will you proceed? What do you plan on doing to prepare for our next meeting? Again, resist the righting reflex – try to avoid the tendency to fix a ‘wrong’ choice.

Affirmations and Summaries Your role is to instill hope and the belief that the client can indeed change. Be genuine. Affirmations are: A way of reorienting the client to the resources he or she has available Statements of appreciation for the client and his/her strengths. Summaries are used to: Practitioners assist clients in organizing their experiences and goals. Assist you in ensuring you are retaining and understanding information.

Recognizing Change Talk Represents statements about change. Client statements that indicate they have the desire or ability to change, see benefits of change, observe the difficulties of their current situation, are committed to change, or are taking steps to change. Linked to a specific behavior or set of behaviors. Focused on a particular and attainable goal. Typically phrased in present tense. Talking about past behaviors does not indicate a readiness to change. Watch for statements to build on - Desire to change statements - “I wish things were different” Ability to change statements - “Well, I did stay clean and sober for 3 years once” Reasons for change statements - “I guess I wouldn’t even have to think about it, if I decided to use condoms every time.” Need to change statements – “I can’t go on with the behaviors I’ve been doing.”

Eliciting and Reinforcing Change Talk (And working with Ambivalence) Evocative Questions – Ask client directly if they are ready to change Elaboration – Ask clients for examples of situations that illustrate change Using Extremes – Identify client’s worst imagined outcomes if behavior continues and best hoped-for benefits if change occurs Looking Back – Ask client to remember how things were before problems emerged Looking Forward – Ask client how things might unfold in the future (with or without change) Exploring Goals Readiness Rulers – Scaling question used, followed by why a lower/higher number wasn’t used, and what it would take to move one step higher People resolve ambivalence by talking themselves into change.

Signs of Readiness for change Decreased Resistance Decreased discussion about the problem Resolve Change Talk Questions about change Envisioning Experimenting with change actions

Resources Building Motivational Interviewing Skills: A Practitioner Workbook by David B. Rosengren. Copyright 2009 by the Guildford Press.