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

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

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

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

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)

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.

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

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?)

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

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

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

Four Fundamental Processes in MI

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

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

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

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

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

Is it MI Yet?

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

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) 3. The interviewer is evoking the person’s own motivations for change (Evoke)

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

. . . . 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

Four Foundational Processes Planning Evoking Focusing Engaging

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

Exercise 3-Famouse People

The “Spirit” of Motivational Interviewing Collaboration Evocation Autonomy Compassion Video on MI Spirit

The Underlying Spirit of MI 27

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

Direct 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.

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

A widespread dichotomy Direct Manage Prescribe Lead Tell Follow Permit Let be Allow Go along

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

Guiding: a neglected style Follow Permit Let be Allow Direct Manage Prescribe Lead Guide Shepherd Encourage Motivate

Fundamental MI skills Open Questions Affirmation Reflective Listening Summarizing Elicit

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

Open-Ended Questions Probe widely for information Help uncover the individual’s priorities and values Avoid socially desirable responses Draw people out 54

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

Open Ended Questions Video

Affirmations 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 Video

Bridge the gap by reflection thinks the speaker means The Function of Reflection Bridge the gap by reflection What the listener thinks the speaker means 4 What the speaker means 1 What the listener hears 3 ANIMATION: CLICK FOR EACH POINT. The following exercises form the most important building blocks to understanding and using reflections. Therefore, as a trainer, it is important to be absolutely clear about th flow and reasons for these exercises. Reflections are one of the hardest skills to learn, so depending on the group slow down here. The exercise is in two parts because there are basically two pieces to a reflection. One is that a reflection is a HYPOTHESIS of what may be going on. The second piece is that a reflection is a statement.   What the speaker says 2 R

Reflective Listening A critical MI skill Mirrors what the individual says Is non-threatening Deepens the conversation Helps people understand themselves 59

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

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….

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.

Reflections Video

Summarization “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 ...” 71

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

Summaries Video

Practice Exercises Workbook OARS Practice sheet Virginia Reel

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

Agenda Setting Eliciting the client’s agenda Offering a menu “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

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?

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

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

Preparatory Change Talk Four Examples DARN DESIRE to change (want, like, wish . . ) ABILITY to change (can, could . . ) REASONS to change (if . . then) NEED to change (need, have to . .)

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

Yet another metaphor MI Hill Preparatory Change Talk Mobilizing Change Talk Preparation Action (Pre-) Contemplation

Responding to Change Talk 60

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

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

MI Change Talk Strategy Process Asking for Clients    Seeing Behavior Change DESIRES Assessing readiness? Client Behavioral Change Strengthen Client Commitment Talk ABILITIES readiness? REASONS readiness?   Hearing Strong Commitment Talk CLIENT VALUES CLIENT STRENGTHS How MI is Directive Selective eliciting questions Selective reflections Selective elaborations Selective summarizing Selective affirming NEEDS  

Change Talk and Sustain Talk Opposite Sides of a Coin

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

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)

Change Talk Video

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

Eliciting change talk 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 Previously, we learned that change talk can flow naturally by simply using OARS

How to Evoke Change Talk! (How MI becomes directive) 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 (+/-) Let’s look at each of these strategies briefly. You have seen some of them and others are new. This will put it in a nice format for you to remember. I am also handing out another ‘cheat sheet’ to put on the wall with the one about reflections! This will help when you aren’t sure where to do with someone. Go through the three ECT slides swiftly. See modeling instructions next page.

More Strategies… 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? Let’s look at each of these strategies briefly. You have seen some of them and others are new. This will put it in a nice format for you to remember. I am also handing out another ‘cheat sheet’ to put on the wall with the one about reflections! This will help when you aren’t sure where to do with someone. Go through the three ECT slides swiftly. See modeling instructions next page.

More Strategies…. 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]? What I usually do here is demonstrate each strategy with someone from the group. I try to go back to something they’ve said before or a roleplay they’ve done and briefly demo the skill. OR use it in a more comprehensive roleplay, for example, “Tony, let’s say you are a drug addict and you just got out of jail on a violation for dirty UA’s” Prior to that you had been on paper for a year without any problems – you were working, staying clean, etc. When you got into trouble again, and had to go back in, your sister, to whom you are very close, stopped talking to you. This is upsetting, but you are afraid to call her and discuss it. You don’t know how she’ll respond. Then, I demonstrate each of these strategies in a mock roleplay with “Tony”. Each is very brief. EX: Elaboration, “Tony, I know this strain between you and your sister has been hard. Tell me more about her concerns.” Evocative question, “How has your sister responded in the past when you’ve gone to her with an apology and requesting support?”, etc. VIDEO OPTIONAL: Oftentimes I don’t need the Eliciting Change Talk video due to time constraints, but if you do show it, be sure to explain that we are trying to demonstrate each of the skills. In most cases, they would probably not use all of them in one session.

More Strategies…. 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? What I usually do here is demonstrate each strategy with someone from the group. I try to go back to something they’ve said before or a roleplay they’ve done and briefly demo the skill. OR use it in a more comprehensive roleplay, for example, “Tony, let’s say you are a drug addict and you just got out of jail on a violation for dirty UA’s” Prior to that you had been on paper for a year without any problems – you were working, staying clean, etc. When you got into trouble again, and had to go back in, your sister, to whom you are very close, stopped talking to you. This is upsetting, but you are afraid to call her and discuss it. You don’t know how she’ll respond. Then, I demonstrate each of these strategies in a mock roleplay with “Tony”. Each is very brief. EX: Elaboration, “Tony, I know this strain between you and your sister has been hard. Tell me more about her concerns.” Evocative question, “How has your sister responded in the past when you’ve gone to her with an apology and requesting support?”, etc. VIDEO OPTIONAL: Oftentimes I don’t need the Eliciting Change Talk video due to time constraints, but if you do show it, be sure to explain that we are trying to demonstrate each of the skills. In most cases, they would probably not use all of them in one session.

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….

Change Talk Jeopardy: Examples 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? Mary

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

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

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

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?

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!

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 MI is based on the idea that people generally are not UNmotivated. Even when they don’t change. Instead people tend to have multiple motivations that goes in different directions, or go direct against one another, and someone because of this, people get stuck. When people are stuck, particularly if they have been stuck a long time, or have tried unsuccessfully to change, or have made a change then fallen back, they tend to be a bit demoralized, discouraged, confused, conflicted. They might want things to be different, but feel there’s no hope. Something blocks them. They are too stressed out. Or don’t have certain skills. Or opportunities. Or they have other responsibilities that come before themselves or at least before the thing they are stuck with. Or people might know that they should make a change, or that things could be better, but they also are attached to something that holds them back. Drugs. Friends. A relationship. Convenience. Familiarity. Security. People who are stuck can sometimes be edgy. Especially if their being stuck somehow involves other people. They may feel guilty, responsible, anxious, depressed. Others might have tried to encourage them, then given up with they didn’t change, which can leave people feeling even worse about themselves. Or others might pressure them, sometimes subtly, sometimes directly, even harshly. This can make people defensive, feeling like they need to protect themselves, perhaps by focusing on difficulties involved in changing, or not really “seeing” the problem because it’s too painful, or some other way.

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 Do NOT want to join with side that wants to change prematurely or will invoke REACTANCE. Natural tendency to support or protect the opposite viewpoint that exists within the person. MI assumes that people have the capacity to solve their own problems and come up with resourceful solutions…if we help remove the barriers. Research supports this. For example, empirical evidence that large groups of problem drinkers are successful eventually in changing drinking behaviors. ONLY 5% require formal treatment to do so. WE are not the change process---only a small piece.

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 Dissonance – cognitive dissonance, uncomfortable feeling caused by 3 contradictory ideas such as when beliefs and values contradict one’s behavior. People are motivated to reduce the dissonance by changing attitudes, beliefs, and behaviors or justifying or rationalizing attitudes, beliefs, and behaviors.

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)

- 2 x 2 Decisional Balance Grid + PROs and CONs of Change 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 Less-good things about Change or Option B

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

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

Traps to Avoid Question/Answer Premature Focus Taking Sides Expert Role Blaming Premature focus: Underestimate ambivalence Rigid Prescription Insufficient Direction

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

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! Possible Contraindications for MI • Clients who are already ready for change • Clients who are low in anger/resistance • If a client appears to be at the action stage, ready for change, there is no need for MI

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

Giving information & Advice 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.” Even when the person asks for the advice, it’s important not to jump in if you feel that they are not ready or insincere. It’s okay to ask permission to get more information BEFORE giving advice, “You know, that’s cetainly something I can do, but I’m wondering if I really have enough information about the problem to really give you good advice right now. Would you mind telling me a little bit more about the situation? How do you feel about giving up marijuana?... “ “Can I make a suggestion?” “Would you be interested in some resources?” “Would you like to know what has worked for some other people?”) A lot of people find that _____works well, but I don’t know if that’s something that interests you.”

The Process for giving advice… 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

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

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

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

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

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

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.

Brief Education Handout Personal Feedback Form

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

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

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

Demonstration & Practice

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, 2nd 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.

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 Mary.dugan@mimh.edu