1. Presented by Brett Engle, PhD, LCSW www.motivationalinterviewing.org
in SBIRT
Presented by
Brett Engle, PhD, LCSW

2. Overview Rationale and evidence-base Target behaviors/change goals
Spirit of MI
Collaboration, acceptance, evocation
Processes of MI and application
Engaging, focusing, evoking, and planning
Techniques of MI
OARS
Exchanging information using elicit-provide-elicit
DARN-CAT change and sustain talk

4. Rationale for MI Brief and cost effective (Dennis et al., 2004)
Versatile-intensity/duration, professions, combined treatments, settings (Lundahl et al., in press; Miller & Rose, 2009)
Humanistic-facilitates relationships, rapport and disclosure (Miller & Rose, 2009)
Consistent with SW ethics and values (Hohman, 2012)
May be more effective with minorities (Hettema, Steele, & Miller, 2005)
Established training tools and practices (Moyers et al., 2005; Madson & Lane, 2008)

5. Evidence-Base for MI
About 200 clinical trials and 1000 peer reviewed articles involving MI (Miller & Rose, 2009)
Average dose: 2 sessions/2 hours
Effect size is often maintained or even increases through 1 year follow up when MI is added to beginning of treatment (Miller, 2005)

6. Evidence-Base for MI: Target Behaviors/Outcomes
More likely to enter, stay in and complete treatment
Participate in follow-up visits
Adhere to glucose monitoring and improve glycemic control
Increase exercise and fruit and vegetable intake
Reduce stress and sodium intake
Keep food diaries
Weight loss
Reduce unprotected sex and needle sharing
Improve medication adherence
Decrease alcohol and illicit drug use
Quit smoking
Fewer subsequent injuries and hospitalizations
Rollnick, Miller, & Butler (2008)

7. MI Spirit
Collaboration/Partnership
Acceptance
Compassion
Evocation

8. Collaboration
Interviewer functions as a partner or companion, collaborating with the client’s own expertise
Dancing versus wrestling
Avoiding the “expert trap”
Non-judgmental
Active collaborative conversation
Joint decision-making process

9. Acceptance Absolute worth Affirmation Accurate empathy
Autonomy support

10. Absolute Worth Unconditional positive regard (Rogers)
Dignity and worth of the person (NASW Code of Ethics)

11. Affirmation
Seek and acknowledge strengths, including change talk, resources, and values
Building blocks

12. Accurate Empathy
“to sense the person’s inner world of private personal meanings…” (Rogers, 1989, pp )
Anticipating
Experiencing
Communicating

13. Autonomy Support Responsibility : Resistance trade off
People can and will make own decision
Paradoxical nature of behavior change
Support both self-determination and self-efficacy
Detachment from outcomes

14. Compassion To benevolently seek and value the well-being of others
To give priority to the person’s needs
Never exploit
Not necessarily to “suffer with.”

15. Evocation
Elicit and activate person’s own resources, rationale and motivation for behavior change
The person’s side of ambivalence that favors change
Includes their goals, values, and aspirations that relate to target behavior

16. Four Processes/Methods and Flow of MI
Engaging
Focusing
Evoking
Planning

17. Engaging Meet where patient is Discord and sustain talk be prevalent
Empathize
Establish trust and rapport
Verbally and non-verbally

18. Focusing
Focus and structure conversation on an identified target behavior
Redirect discourse toward target behavior when necessary
Discuss possible change rather than history

19. Evoking Patient’s own ideas about change
Change talk side of ambivalence

20. Planning Decision making Action steps and target behaviors prioritized
Implementation intentions (Gollwitzer)

21. Techniques: OARS Open questions Affirmations
Reflections: Simple and complex
Summaries

22. Technique: Exchanging Information Elicit-Provide-Elicit
Ask permission
Clarify information needs and gaps
“May I ask what you already know about…”
Provide
Prioritize
Support autonomy
Don’t prescribe the person’s response
Ask for person’s interpretation, understanding, or response

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

24. Mobilizing Change (and Sustain) Talk reflects resolution of ambivalence
COMMITMENT (intention, decision)
ACTIVATION (ready, prepared, willing)
TAKING STEPS

25. Commitment-Behavior Change Model in Groups: Participant Desire, Ability, Reasons, and Need (DARN) change talk mediate Commitment Language, which in turn mediates their impact on health behavior.
Desire
Ability
(Self-efficacy)
Reasons
Need
Commitment
Activation
Taking Steps
Health behavior
From “How Does Motivational Interviewing Work? What Client Talk Reveals,” by P. C. Amrhein, 2004, Journal of Cognitive Psychotherapy: An International Quarterly, 18, 4, p Copyright 2004 by the Springer Publishing Company. Adapted with permission.

26. Supplemental Slides

27. 12 Tasks in Learning MI 1. Understanding the spirit of MI
2. Developing skill and comfort with reflective listening and the client-centered OARS skills
3. Identifying change goals/target behaviors
4. Giving information in an MI adherent manner
5. Recognizing change and sustain talk
6. Evoking and reinforcing change talk
7. Responding to, reinforcing, and strengthening change talk
8. Responding to sustain talk and discord so as to not amplify it
9. Developing hope and confidence
10. Timing and negotiating a change plan
11. Strengthening commitment
12. Flexibly integrating MI with other skills and practices
(Miller & Moyers, 2006; Miller & Rollnick, 2013)

28. Discord
Interpersonal behavior that reflects dissonance in the working relationship: Arguing, interrupting, discounting, or ignoring

29. Motivational Interviewing Defined
Lay Definition: A collaborative conversation style for strengthening a person’s own motivation and commitment to change
Used in many contexts by many different professional or paraprofessional people

30. Motivational Interviewing Defined
Clinical Definition: A person-centered counseling style for addressing the common problem of ambivalence about change
Why should I as a clinician learn MI?
How would I use it?

31. Motivational Interviewing Defined
Technical Definition: A collaborative, goal-oriented style of communication with particular attention to the language of change, designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion
How does it work?

32. Continuum of Communication Styles
Directing Guiding Following

33. Directing Parameters of the working relationship
Exceptions to confidentiality
The nonnegotiables
Providing information

34. Following Understanding and taking an interest in the other person
Being curious and showing respect
Super listening

35. Guiding
Focus and structure conversation on an identified target behavior
Redirect discourse toward target behavior when necessary
Discuss possible change rather than history
Elicit/emphasize/reinforce change talk

36. What Good Listening Is Not * (Roadblocks: Thomas Gordon)
Asking questions
Agreeing, approving, or praising
Advising, suggesting, providing solutions
Arguing, persuading with logic, lecturing
Analyzing or interpreting
Assuring, sympathizing, or consoling

37. What Good Listening is Not (Roadblocks, from Thomas Gordon)
Ordering, directing, or commanding
Warning, cautioning, or threatening
Moralizing, telling what they “should” do
Disagreeing, judging, criticizing, or blaming
Shaming, ridiculing, or labeling
Withdrawing, distracting, humoring, or changing the subject

38. Hypothesized Relationship Among Process and Outcome Variables in MI
Therapist Empathy & MI Spirit
Client Preparatory Change Talk & Diminished Resistance
Training in MI
Behavior Change
Therapist Use of MI-Consistent Methods
Commitment to Behavior Change
From Miller and Rose (2009) Toward a Theory of Motivational Interviewing., 64, p American Psychologist

39. Ten Things that MI is Not (Miller & Rollnick, 2008)
1. Based on the transtheoretical model of change 2. A way of tricking people into doing what you want them to do 3. A specific technique (MI is a counseling method; no specific
technique is essential) 4. Decisional balance, equally exploring pros and cons of
change 5. Assessment feedback 6. A form of cognitive-behavior therapy 7. Just client-centered therapy 8. Easy to learn 9. What you were already doing 10. A panacea for every clinical challenge

40. Evidence-Base for MI: Effects across Samples
25% no effect
50% small but meaningful effect
25% moderate to strong effect
Average MI intervention: 99 minutes
(Lundahl et al., in press)
Brief MI in health care: 5-15 minutes
(Martino et al., 2007)

41. Reflections * Forming Reflections Are statements rather than questions
Make a guess about the client’s meaning (rather than asking)
Yield more information and better understanding
Often a question can be turned into a reflection

42. Forming Reflections X X X X
A reflection states an hypothesis, makes a guess about what the person means
Form a statement, not a question
Think of your question: Do you mean that you ?
Cut the question words Do you mean that You . .
Inflect your voice down at the end
There’s no penalty for missing
In general, a reflection should not be longer than the client’s statement. X X X X

43. Giving Information/Educating59
Collaboration:
Giving Information/Educating
Neutral language
“Folks have found…”
“Others have benefited from…”
“Doctors recommend…”
Conditional words
“Might consider” vs. “ought to,” “should”
Avoid the “I” and “Y” words
“I think…”
“You should…”
Gary S. Rose, Ph.D.