1. Motivational Interviewing
Phase 1: resolve ambivalence and build intrinsic motivation for change
Phase 2: strengthening commitment to change and developing a plan to acomplish it
Reason for motivational interviewing:
the client perceives less importance for a change that the councesllor does

2. Motivational Interviewing
Express empathy: acceptance, reflective listening, ambivalence
Develop discrepancy: the client rather than councellor should present the arguments for change
Roll with resistance: avoid arguing for change, new perspectives are invited but not imposed
Support self-efficacy: a person´s belief in the possibility of change is an important motivator; the client is responsible for choosing and carrying out change

3. Change and resistance
Two sides of one coin

4. Ambivalence A Decisional Balance Sheet
Continue to drink as before
Abstain from alcohol
Benefits:
helps me relax
Enjoy drinking with friends
Costs:
Could loose my family
Bad example for my children
Damaging my health
Spending too much money
Impairing my mental ability
Might loos my job
Waisting my time/life
Benefits:
Less family conflict
More time with my children
Feel better physically
Helps with money problems
Costs:
I enjoy getting high
What to do abyout my friends
How to deal with stress

5. Resistance Arguing: challenging, hostility
Interrupting: talking over, cutting off
Negating: blaming, disagreeing, excusing, minimizing, pesimism, unwillingness to change
Ignoring: inatention, nonanswer, no response
Client´s resistence behaviour is a signal of dissonance in the counseling

6. Change talk and resistance
Resistance talk
Disadvantages of status quo
Advantages of change
Intention to change
Optimism about change
Advantages of status quo
Disadvantages of change
Intention not o change
Pessimism about change

7. TRAPS
Question-Answer (Do you think you drink too much? What is your favourite drink?)
Taking Sides (Well it seems clear to me that you have a serious drinking problem. You are showing a lot of signs of alcoholism…What do you mean?)
Expert Trap (Conveying the impression of having all the answers)
Labelling trap (You are an alcoholic x So you are implying that I am an addict? No, I am really not concerned that much about labels. But it sounds like you are, that itś a worry for you.)
Premature focus trap (Pushing the client to talk about councellor´s own conception of the problem)
Blaming trap: Whose fault is the problem? Who is to blame?

8. Blame talk
„It sounds like you are worried about who is to blame here. I should explain that councelling is not about deciding who is at fault. That is what judges do, but not good concellors. Councelling has no-fault policy. I am not interested in looking for who si to blame but rather what is troubling you and what you might be able to do about it“

9. Opening session

10. Opening structure
„We have about an hour together now. In this time I want to get a beginning understaning of what brings you here. I will spend more time listening so that I can understand how you see things and what your concerns are. You must also have some hopes about what will and will not happen here and I will want to hear about those. Toward the end of this hour I will need to ask you some specific information that I need. What is on your mind?“

11. Diabetes management
„As you know there are a number of things that we could discuss today- such a s monitoring your blood sugar levels, healthy diet, exercies and your medication. What are you most concerned about? What would you like to talk about today? Perhaps there are other things that you feel are more important to discuss.“

12. Five early methods: OARS
Ask open questions
Affirm
Listen reflectively
Summarize
Elicit change talk

13. Open questions Questions that do not invite brief answers
Establish an atmosphere of acceptance and trust within which client will explore their concerns
„I would like to understand how you see things. What´s brought you here?“
„I understand that you have some concerns about….Tell me about them.“

14. Is it open or a closed question?
Practice
Is it open or a closed question?

15. 1. What do you like about drinking?
2. (4.) Are you willing to come back for a follow-up visit?
3. (5) What brings you here today?
4. (7) Have you ever thought about walking as a simple form of exercise?
5. (8). What do you want to do about your smoking: quit, cut down or stay the same?
6. (11). What possible long-term consequences of diabetes concern you most?
7. (12). Do you care about your health?

16. Inquisitive Neighbour
Practice
Inquisitive Neighbour

17. Questions: TRAPS Close Question-Answer Trap dia 01
Open Question followed by Close Question Trap dia 02

18. Questions: Invitation to dialogue
Open questions dia 03, dia 04

19. Listen reflectively

20. Identify reflective listening
P: I'm not able to exercise the way I need to.
D: Oh, I wouldn't worry about it. Lots of people don't even try.
P: I am not very good at putting things into words.
D: I think you have described the situation very well.
P: I was scared to death.
D: I can understand how those experiences must have frightened you, but I think it is very likely they'll respond to treatment.

21. Identify reflective listening
P: Work is almost unbearable. My supervisor watches me like a hawk and criticizes the tiniest little mistake I make.
D: Why not write her a memo and outline your grievances?
P: …crying…
Doctor: „Even now it brings tears to your eyes when you talk about your mother..
P: „I cannot fall asleep, after I told my wife about meeting with my new girlfriend, everything has changed.“
D: How do you think your wife felt when she found out about your affair?

22. What is not listening: Roadblocks
Message: Listen to me, I know the best
Ordering, directing or commanding
Warning, cautioning or threatening
Giving advice, making suggestions or providing solutions
Persuading with logic, arguing or lecturing
Telling people what they should do, moralizing
Disagreeing, judging criticizing or blaming
Shaming, ridiculing or labeling
Interpreting or analyzing
Questioning or probing
Withdrawing, distracting, humoring or changing the subject

23. What is not listening: Roadblocks
Shaming, ridiculing or labeling
Interpreting or analyzing
Questioning or probing
Withdrawing, distracting, humoring or changing the subject

24. Reflective listening
Reflexion is a reasonable guess as to what the speaker means
The listener has to hear the words accurately and then decode their meaning

25. „Continuing the paragraph“
P. I worry sometimes that I may be drinking too much for my own good.
D. You have been drinking quite a bit.
P. I don´t really think I dring that much. I can drink a lot and not feel it.
D. More that most people.
P. Yes, I can drink most people under the table.
D. And that´s what worries you.
P. Well, that and how I feel. The next morining I am usually in bad shape.
D. And that does not seem right to you.

26. Affirmation
The point is to notice and appropriately affirm the patient´s strengths and efforts

27. Give compliment to your neighbour…
Practice
Give compliment to your neighbour…

28. Statement of appreciation and understanding, compliments
Thanks for coming on time today.
I appreciate that you took a big step in coming here today.
You are clearly a resourceful person, to cope with such difficulties for so long.
That´s a good suggestion.
I have enjoyed talkong with you today and getting to know you a bit.
The point is to notice

29. How to make an enemy easily and quickly (dia5)
Identify 3 bad habits in communication

30. Change talk and resistance
Resistance talk
Disadvantages of status quo
Advantages of change
Intention to change
Optimism about change
Advantages of status quo
Disadvantages of change
Intention not o change
Pessimism about change

31. Responding to resistance with nonresistance
P: I just do not want to take pills. I ought to be able to handle it by my own.
Simple reflexion???
P: I couldn´t keep the weight off even if I lost it.
You do not think that medication would work for you
You do not want to rely on a drug. It seems to you like a crutch
You can´t see any way that yould work for you
You are rather discourade about trying again

32. Responding to resistance with nonresistance
Double-sided reflextion
P: I know it makes sense, but you don´t seem to understand how bad the pain is. When I even try to get out of the bed, let alone exercise, the pain in my back is terrible. I hurt all the time.
D: You think that in the long run exercise is likely to help you decrease your pain and at the same time you are suffering quite a lot and that makes it hard to get started walking or even to think about it.
Use and rather than but

33. How to be a patient´s sparingpartner (dia 6)
Identify OARS

34. Eliciting change talk

35. Recognizing disadvantages of the status quo (This is serious!)
Recognizing advantages of change (Probably I´d feel a lot better)
Expressing optimism about change ( I did quit smoking a few years ago. That was tough, and it took a few tries, but I did it.)
Expressing intention to change (I definitely don´t want to keep going the way I have been.)

36. Importance and confidence ruler
How important would you say it is important for you to …….?
On a scale from 0 to 10 where 0 is not at all important and 10 is extremely important, where sould you say you are?
And how confident would you say you are, that if you decide to…., you could do it? On the same scale, where 0 is not confident aa all and 10 is extremely confident, where would you say you are?

37. Importance and confidence ruler
Why are you at a …..and not zero?
What would it take for you to go from …..to ( a higher number?)

38. Methods for evoking change talk
Disadvantages of the stats quo:
What worries you about current situation?
Advantages of change:
What would be the good things about loosing weight?
Optimism about change:
What personal strenghts do you have that will help you succeed?
Intention to change
How important is this to you?

39. Signs of readiness for change
Decreased resistance
Decreased discussion about the problem
Resolve
Change talk
Questions about change
Envisioning
Experimenting between sessions

40. The patient is curious. What does it mean?
Information sharing
Dia 08
Crime and punishment
Elicit-provide-elicit:
Ask client what he knows (or wants to know) about an area of interest (elicit)
After describing, provide the information
Ask the client what is his view (elicit)
Dia 09
The patient is curious. What does it mean?

41. Identify 3 methods of motivational interview
Giving advice
Ask permission. Make sure the client is interested in what you are about to offer
Offer ideas, do not persuade.
Use a menu
Solicit what the client thinks
Dia 07
Identify 3 methods of motivational interview

42. Summary: how to motivate the patient for the change
Open questions
Reflective listening
Affirmation
Summarization
Change talk
Advice after permission
Choice offering

43. Source
Miller WR., Rollnick S. Motivational interviewing. Preparing people for change
Second edition, The Guilford Press, 2002