1. A taste of Motivational Interviewing
Michael McLain
Director Outpatient Services
Phoenix Center, Greenville SC

2. A taste of MI
A Taste of MI 2017

3. A taste of MI - Round 1
The Client:  Role play a client presenting for services, where there is a clear behavior change goal (finding work, better nutrition, parenting skills, etc.)You are ambivalent and somewhat resistant to change.
A Taste of MI 2017

4. A taste of MI - Round 1 Support Group Leader
Explain why the client should make this change. 
Give at least three specific benefits that would result from making the change.
Tell the client how to change. 
Emphasize how important it is for the client to change, and
Tell the client to do it. 
A Taste of MI 2017

5. Process Role Play
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6. Compassionate Conversation
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7. MI Relational Style Empathic Warm & friendly Collaborative Accepting
Respectful
Optimistic
Eliciting & Listening
Honoring of autonomy & choice
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8. Empathy Empathy is not: Empathy is:
Having had the same experience or problem
Identification with the client
Let me tell you my story
Empathy is:
The ability to accurately understand the client’s meaning
The ability to reflect that accurate understanding back to the client
A Taste of MI 2017

9. A Taste of MI 2017

10. What most people really need is a good listening to. ~Mary Lou Casey
Motivational Interviewing Basics with Native American Populations
What most people really need is a good listening to. ~Mary Lou Casey
June 13, 2011
A Taste of MI 2017

11. Motivational Interviewing
Motivational interviewing is a person-centered, evidence- based, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence with the individual.
Motivational Interviewing 3rd Ed.
Miller and Rollnick, (2012)
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12. Collaboration Compassion Acceptance MI Spirit Evocation
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13. Four Fundamental Processes of MI
Planning
Evoking
Focusing
These are four fundamental processes utilized within MI, though they have broader applicability to the change process. These are generally thought to emerge in the order listed <click> and build upon each other. However, they are recursive and will likely need to be reworked. We will use these four domains to assist us in thinking about how we can broaden and deepen our skills in MI. I may describe each of these in more depth a bit later, but first I want to find out what ideas you have about these four processes. To help with that I’m going to give to you a speed task and have a bit of fun with it. I’m going to give you 2 minutes as a group to write down as many ideas as you can that match what your concept might mean in a helping context.
[Assign groups and topics. Provide sheets and markers.]
Now, I’m going to give you two more minutes to decide – as a group - what you think the three ideas that best capture this idea of what engaging means.
[time 2 minutes]
Okay, now you each need to appoint a spokesperson and your job is to be succinct. You’ll have one minute to explain these three concepts to the group.
[time each group for one minute]
If needed, add these ideas below, but its unlikely to be necessary.
Engaging refers to meeting the patientwhere she or he is. Focusing is finding out what is important to the patientand then matching patientgoals to the treatment agenda. Evoking is the process of pulling forward internal patientmotivation for change, based on what’s important to him or her. Planning is helping the patientdetermine how he or she will succeed in acting on this change. <click>
Engaging
A Taste of MI 2017

14. The 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 - Shall we walk together?
Focus - Where?
Evoke - Why?
Plan How?
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15. FOCUSING: Negotiate the Agenda
Clinical Roadmap
ENGAGING: Open the Conversation
Explain role
State appointment length
Ask permission
Provide Clinical Feedback
Use visual support materials
Be clear, succinct, and non-judgmental
Compare to norms and standards
Elicit Participant's interpretation
Elicit -
Provide -
Elicit
Education
Advice
Feedback
Skills
Referral
FOCUSING: Negotiate the Agenda
EVOKING: Build Motivation
Ask evocative questions
Encourage elaboration
Looking back/Looking forward
Explore/Amplify ambivalence
Explore goals and values
Assess importance/confidence
Support the Transition:
Recognizing readiness
Summarizing the big picture
Ask about next steps
PLANNING: Strengthening Commitment
Brainstorm ideas and opinions
Negotiate a plan
Explore barriers
Identify support
Elicit final commitment
Close the Encounter:
Summarize the session
Show appreciation
Support self-efficacy
Arrange follow-up as appropriate
Link with available resources
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16. Motivational Interviewing
Assumes motivation is fluid and can be influenced
Motivation influenced in the context of a relationship – developed in the context of a patient encounter
Principle tasks – to work with ambivalence and resistance
Goal – to influence change in the direction of health
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17. AMBIVALENCE
IS....
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18. Motivational Interviewing UNDERLYING ASSUMPTIONS
Acceptance/Potential for Growth
Autonomy/Choice
Elicit versus Impart
Ambivalence is normal
Care-frontation
Unconditional positive regard
Change talk
Righting reflex
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19. Common Reactions to Righting Reflex
Angry, agitated
Oppositional
Discounting
Defensive
Justifying
Not understood
Not heard
Procrastinate
Afraid
Helpless, overwhelmed
Ashamed
Trapped
Disengaged
Not come back – avoid
Uncomfortable
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20. To avoid this…
LET GO!!!
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21. Common Human Reactions to Being Listened to
Understood
Want to talk more
Liking the worker
Open
Accepted
Respected
Engaged
Able to change
Safe
Empowered
Hopeful
Comfortable
Interested
Want to come back
Cooperative
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22. OARS- MI Skills O – Open questions A – Affirmations R – Reflections
S – Summaries
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23. Closed Questions sound like…
Motivational Interviewing Basics with Native American Populations
June 13, 2011
Closed Questions sound like…
“Do you…Are you… Did you… Could you…Have you…?”
“Did you get a job yet?”
“Do you care about finishing your studies?”
“Did you think before you did that?”
“Do you have a drinking problem?” 64
When we get into these patterns it feels like ping-pong and eventually the patientjust sits back and lets you do the work.
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24. Open-Ended Questions sound like…
Motivational Interviewing Basics with Native American Populations
June 13, 2011
Open-Ended Questions sound like…
“What…. Which…. Where… How… Tell me…”
“How does it feel to be back at work?”
“Where do you think your biggest challenge lies?”
“What do you think you’ll take care of first?”
“Tell me about your relationship with your boss/partner/daughter”
Which “W” is missing? (why)
Why is Why missing? (Comes across judgmental or accusatory. Can demonstrate this with some humor by using a very non-judgmental tone with some who came in a little late: “Mary, why did you get here late today?” (Still feels very judgmental, even when not meant that way) 24
A Taste of MI 2017

25. Motivational Interviewing Basics with Native American Populations
June 13, 2011
Affirmations…
Affirmations are sincere, specific and immediate.
Affirmations are not cheerleading.
Emphasize the importance of making the affirmation very specific and genuine. Explain the “cheerleader” effect and how that can backfire.
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26. Affirmations Emphasize a strength
Notice and appreciate a positive action
Should be genuine
Build feelings of empowerment
Instill hope and “can-do” attitude
Express positive regard and caring
Strengthen the clinical relationship
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27. Affirmations Commenting positively on an attribute
You’re a strong person, a real survivor.
A statement of appreciation
I appreciate your openness and honesty today.
Catch the person doing something right
Thanks for coming in today!
A compliment
I like the way you said that.
An expression of hope, caring, or support
I hope this weekend goes well for you!
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28. Motivational Interviewing Basics with Native American Populations
June 13, 2011
Reflections
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29. How to Form a Reflection
Motivational Interviewing Basics with Native American Populations
June 13, 2011
How to Form a Reflection
1. You can reflect the patient’s…
speech,
facial expressions,
behavior
2. Make a guess about the deeper meaning (therapeutic hunch) 75

30. Reflective Listening A hypothesis (guess) about speaker’s meaning
A statement to convey understanding
Intonation down
Short stems
“So…”
“Sounds like…”
“So you…”
“Seems like …”
“Its like…”
“You feel…”
Purpose: This slide introduces reflective listening to patients, and build on the hypothesis building of the previous exercise.
Key Points:
Reflective listening makes hypotheses about what the speaker means.
Reflective listening conveys understanding/shows empathy
Tone is important for reflective listening. Toning up makes a reflection a closed questions. Reflections should tone down or flat as a statement.
Give some examples of reflections using the stems on the slide.
Notes:
The following slides will help patients differentiate reflections from questions.
Increased questions can raise levels of defensiveness in the person we are talking to.
The tone of a reflection only refers to the way that the tone goes at the end. Reflections do not need to be given in a toneless manner. It is helpful to demonstrate the tone of a reflection.
Encourage patients to be confident in their hypotheses. A tone up at the end can mean a lack of confidence or comfort in the hypothesis. People sometimes do not feel comfortable making guesses because it feels invasive or they are afraid of being wrong. It is ok to make these hypotheses because it can guide the conversation and show empathy.
If a reflection is wrong, the person you are talking to will correct you and put you both back on the same page. One of the main goals of reflective listening is to understand and show understanding.
Example – A plane travelling from city to city is off course 90% of the time. How does it get there? Continual course corrections and being in constant communication with the ground (air traffic control). Reflections are similar in that we use them to make constant corrections to stay on the same page as the person we are talking to.
Why is a reflection a listening behavior while questions are not? (Add that questions solicit information while reflections check understanding).
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31. Repeating (repeats an element of what the client said)
Simple (stabilizing)
Repeating (repeats an element of what the client said)
Rephrasing (uses new words)
Complex (forward moving)
Paraphrasing (makes a guess to unspoken meaning)
Reflection of feeling (deepest form; a paraphrase that emphasizes the emotional dimension through feeling statements)
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32. What I’m hearing is… So you’re saying that…
You’re feeling like… So you….
Almost as if… Sounds as if you…
For you, it’s a matter of….
From your point of view,…
I’m hearing that you…
I’m really getting that you…
I get the impression that you…
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33. Simple Reflection Example
Client: “This whole thing has been so confusing.”
Counselor: “It’s confusing…”
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34. Complex Reflection: Example
Client: “You’re not from around here. What do you know?”
Counselor: “You’re worried that I might not understand you.”
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35. Double-Sided Reflection
“So one one hand, you are afraid if you quit drinking you will be bored and lose your friends.. But on other side, if you don’t, you are faced with losing your wife and family…..” Role Play Exercise
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36. The summary is like a bouquet of flowers that we give to the client.
Each flower is something they have told us, usually change talk.
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37. Summary Set up Bookend: “Let me see if I have this right…”
“Let me summarize what you’ve said…”
Reflection, Reflection, Reflection
Follow up Bookend:
“So where does that leave you?
“What else would you like to add?”
“Now, tell me about ….”
“Tell me more about…”
The 4th basic skill of motivational interviewing is the summary. This slide tells us the structure of a summary. There are in fact three different types of summaries that have slightly different purposes. The purpose of summaries is covered on the next slide.
Explain the structure of the summary as having bookends with at least 3 reflections in between. A summary starts off with a set up statement, and closes with a question (sometimes open and sometimes closed depending on your purpose.) For now emphasize the open question, as we have been encouraging people to use open questions in the previous activities.
Also, point out that a summary is a type of complex reflection.
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38. Summaries Can… Give the message that the patient is being heard
Allow the patient to add important information
Shift the direction of the interview
Facilitate and guide
Reflect ambivalence
Accentuate “change talk”
The patients do not need to know much about the three types of summaries, but they include:
Transitional summaries – for changing the direction of an interview (Is that right? Now I need to ask you about ….?)
Collecting summaries – for reinforcing change talk and continuing exploration (What else?)
Linking summaries – for linking pieces of information e.g. something they’ve said with assessment results. (How does that fit together.)
“Use summaries to collect important points and move forward” (Bill Miller, July 2006).
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39. Fundamental Belief
The capacity and potential for change and adherence is within every person!
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40. Change and Sustain Talk
Ask group to:
Define change and sustain talk
Describe how practitioner behavior may influence the appearance of each
Add information below only if needed
Change and Sustain Talk are two sides of the same coin. These sides reflect the two sides of ambivalence. However, the frequency, intensity, and trajectory of each might predict outcome. Moreover, pratitioner behavior influences what type of language emerges from clients, which in turn predicts outcomes.
Describe different types of patienttalk:
There are parallels between these two types of patientlanguage. For example, we can identify two distinct types of language. There is preparatory language, which includes:
Desire
Ability
Reason (benefits)
Need (costs of the alternative)
(Might give examples of patientstatements in each)
And mobilizing language:
Commitment
Activation (ready, willing)
Taking Steps (engaging in behavior)
Our aim, as you will see, is to encourage Participantsto engage in change talk and avoid focus on sustain talk.
<click>
A Taste of MI 2017

41. Change talk is like gold!
As Participants speak about change, they begin to see the possibilities
No pressure or persuasion is needed
Example:
Doctor: What would be the benefits to you for cutting back to safer drinking limits?
client: Well, my wife would quit nagging me, she’d be a lot happier. I’d probably also lose some of this weight I’ve put on lately.
Doctor: So your home life would get better and you’d be healthier all around.
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42. Types of Change Talk: Desire I want to…. I’d really like to… I wish…
Ability I would… I can…. I am able to... I could…
Reason There are good reasons to…
This is important….
Need I really need to…
Commitment I intend to… I will… I plan to…
Activation I’m ready… I’m able
Taking Steps I completed my class assignment on time
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43. Eliciting Change Talk
What concerns you about your drinking/smoking/health habit?
What are others worried about regarding your drinking/smoking/health pattern?
What relevance/importance does smoking/drinking have in your personal goals?
If you decided to change your drinking/smoking/health habit, how would that change your life? Your family’s life?
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44. DARN CATs
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45. What is Resistance? CHANGE TALK SUSTAIN TALK DISCORD
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46. Sustain Talk and Discord
Sustain Talk is about the target behavior
I really don’t want to quit smoking
I need my pills to make it through the day
Discord 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 style
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47. Ambivalence / Resistance
It sounds like the pros of using still far outweigh the cons for you. So it may be that you decide drinking is something that you don’t want to give up despite the consequences
Sometimes, by siding with the client, it causes them to step back and move more towards our desired behavior.
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48. Change-talk Eliciting Strategies
Decisional Balance
Ambivalence is a normal part of the change process
Use ambivalence to promote positive change
Weigh pros and cons of behavior
Increase discrepancy
A Taste of MI 2016
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49. DECISIONAL BALANCE SHEET
1. Good things:
2. Not so good things:
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50. Importance/Confidence/Readiness Rulers
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51. Negotiate a plan of action
Invite active participation by the patient
Patient determines goals & priorities
Patient weighs options
Together, work out details of the plan
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52. Giving Information and Advice: 3 Kinds of Permission
The participant asks for advice
You ask permission to give advice
You qualify your advice to emphasize autonomy
MI Core Skills 2015 52

53. Finalizing the motivational interview
Review the commitment
Review the plan
Set up a new time to meet/follow up
Express encouragement
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54. A taste of MI - Round 2
The Client:  Talk about something about yourself that you want to change / need to change / should change / have been thinking about changing etc., but haven't changed yet (i.e., something you're ambivalent about.)
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55. A taste of MI - Round 2 cont’d
Worker: 
Listen carefully with a goal of understanding the dilemma.  Give no advice.  Ask these four questions:
Why would you want to make this change?
How might you go about it, in order to succeed?
What are the three best reasons to do it?
On a scale from 0 to 10, how important would you say it is for you to make this change?  Give a short summary/reflection of the speaker's motivations for change. 
Summarize what they said about Desire for change, Ability to change, Reasons for change, Need for change. 
Then ask, "So what do you think you'll do?"  and just listen with interest.
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56. Giving Advice / Information
Always ask for permission
“Other clients have found ___ to be of help. Are you interested in knowing about that or is there something we should discuss first?”
Offer alternatives (menu of options)
“We could give you a list of local resources or set up a session with a treatment provider.”
Provide more information according to the interest of the patient
“Would you like to know more about AA?”
Express concern when indicated
“Would it be all right if I tell you one concern I have about this plan?”
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57. Strength: Commitment Language
HIGH
I will / promise / swear / guarantee
I intend to / agree to / am ready to
I plan / expect / resolve / aim to
I hope to / will try to / will see about /I guess / think / suppose I will
LOW
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58. Extend gratitude Support autonomy Offer advice Voice confidence
Closing our Encounter
Extend gratitude
Support autonomy
Offer advice
Voice confidence
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59. The MI Shift
From feeling responsible for changing clients’ behavior to supporting them in thinking & talking about their own reasons and means for behavior change.
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60. Michael McLain mmclain@phoenixcenter.org 864-467-3769
Thank you!
Michael McLain
A Taste of MI 2017