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Transcript of Introduction to Motivational Interviewing State of Hawaii, Department of Health, Adult Mental Health...
![Page 1: Introduction to Motivational Interviewing State of Hawaii, Department of Health, Adult Mental Health Division, Clinical Operations Team and Mental Health.](https://reader034.fdocuments.net/reader034/viewer/2022051516/56649de65503460f94ade7f9/html5/thumbnails/1.jpg)
Introduction to Motivational Interviewing
State of Hawaii, Department of Health, Adult Mental Health Division, Clinical Operations Team and
Mental Health Services Research and EvaluationIn Partnership with
Substance Abuse and Mental Health Services Administration (SAMHSA)
Evidence Based Practices Training and Implementation Grant
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Acknowledgement
Material contained within this training was largely based on the work of William R. Miller and Stephen Rollnick in their groundbreaking book titled, Motivational Interviewing: Preparing People for Change
Published by Guilford Press, 2002
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Beliefs About Motivation (True or False?)
• Handout Quiz: Beliefs About Motivation– Complete the true/false quiz and hang onto it– We will review the answers later
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“Motivation can be understood not as something that one has, but as something that one does.
It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy.”
What is Motivation?
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Ambivalence
“I want to change, but I don’t want to change.”
• Very few decisions in life are made with 100% certainty
• Ambivalence is normal and part of the change process for everyone
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Ambivalence Exercise1. Find a partner.2. Each of you write down something you are interested in
doing but have mixed feelings about (e.g., buying a new car, quitting smoking, exercising, etc.).
3. Select who will speak first.4. The speaker presents what it is that you would like to do (but
haven’t done yet).5. The listener then argues strongly in favor of one of the
options or sides.6. Speaker, your job is to listen and note what you are thinking
and feeling.7. Switch roles.
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Ambivalence Exercise
What were your thoughts/feelings as the speaker?
What happens when ambivalence collides with persuasion, prescription, convincing?
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Motivational Interviewing is…
“a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”
(Miller & Rollnick, 2002)
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Spirit of Motivational Interviewing
MI Mirror Image
Collaboration vs. Confrontation
Evocation vs. Education
Autonomy vs. Authority
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Spirit of Motivational Interviewing
• Motivations to change are elicited from within the client, not imposed from outside.
• It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence.
• Direct persuasion is not an effective method for resolving ambivalence.
• Readiness to change is not a client trait, but fluctuating product of interpersonal interaction.
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Spirit of Motivational Interviewing
• The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.
• Positive atmosphere that is conducive but not coercive for change.
• The counselor is directive in helping the client to examine and resolve ambivalence.
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NOT Motivational Interviewing
The Righting Reflex• Human beings have a built in desire to set things
right/to solve the problem.
• When the righting reflex collides with ambivalence, the client defends the status quo.
• If a person argues on behalf of one position, he or she becomes more committed to it.
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NOT Motivational Interviewing
If following the righting instinct, you will ask:
• Why don’t you want to change?• Why don’t you try… ?
– Okay then, how about…
• What makes you think you are not at risk?• How can you tell me you don’t have a problem?
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NOT Motivational Interviewing
• Argues that person has a problem and needs to change – emphasis on acceptance of problem/diagnosis.
• Offers direct advice or prescribes solutions (e.g., coping strategies) without actively encouraging person to make his/her choices.
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NOT Motivational Interviewing
• Uses authoritative/expert stance and leaves client in passive role.
• Does most of talking or if acts as unidirectional information system – focus on imparting information.
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NOT Motivational Interviewing
• Identifies and modifies maladaptive cognitions.
• Allows the client to determine the content and direction of the counseling.
• Behaves in a punitive or coercive manner.
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Assumptions to Avoid• Person OUGHT to change.
• Health is the person’s prime motivating factor.
• People are either motivated or not.
• Now is the right time to consider change.
• I am the expert; therefore, the person must follow my advice.
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Beliefs About Motivation (True or False?)
1. Until a person is motivated to change, there is not much we can do.
2. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change.
3. Motivation is influenced by human connections.
4. Resistance to change arises from deep-seated defense mechanisms.
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Beliefs About Motivation (True or False?)
5. People choose whether or not they will change.
6. Readiness for change involves a balancing of “pros” and “cons.”
7. Creating motivation for change usually requires confrontation.
8. Denial is not a client problem, it is a therapist skill problem.
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MI Principles
Express Empathy
Develop Discrepancy Roll with Resistance
Support Self-Efficacy
MI Methods
Open-Ended Questions Affirmations
Reflective Listening Summaries
Elicit Change Talk
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Open-Ended Questions
What are open-ended questions?
• Gather broad descriptive information• Require more of a response than a simple yes/no or
fill in the blank • Often start with words like:
– “How…” – “What…” – “Tell me about…”
• Usually go from general to specific
OARS
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Open-Ended Questions
Exercise:Turning closed-ended questions into open-ended ones
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Open-Ended Questions
• Why open-ended questions?– Avoid the question-answer trap
• Puts client in a passive role• No opportunity for client to explore ambivalence
OARS
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Affirmations
What is an affirmation?
• Compliments, statements of appreciation and understanding– Praise positive behaviors– Support the person as they describe difficult
situations
OARS
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Affirmations
• Examples:– “I appreciate how hard it must have been for you
to decide to come here. You took a big step.”– “I’ve enjoyed talking with you today, and getting
to know you a bit.”– “You seem to be a very giving person. You are
always helping your friends.”
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Affirmations
Why affirm?• Supports and promotes self-efficacy, prevents
discouragement• Builds rapport• Reinforces open exploration (client talk)
Caveat:• Must be done sincerely
OARS
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Express Empathy
What is empathy?• Reflects an accurate understanding
– Assume the person’s perspectives are understandable, comprehensible, and valid
– Seek to understand the person’s feelings and perspectives without judging
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Express Empathy
Empathy is distinct from… • Agreement • Warmth• Approval or praise• Reassurance, sympathy, or consolation• Advocacy
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Express Empathy
Why is empathy important in MI and IDDT?
• Communicates acceptance which facilitates change• Encourages a collaborative alliance which also
promotes change
• Leads to an understanding of each person’s unique perspective, feelings, and values which make up the material we need to facilitate change
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Express Empathy
Tips…Good eye contactResponsive facial expressionBody orientationVerbal and non-verbal “encouragers”Reflective listening/asking clarifying questionsAvoid expressing doubt/passing judgment
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Empathy is NOT…
• The sharing of common past experiences• Giving advice, making suggestions, or
providing solutions • Demonstrated through a flurry of questions• Demonstrated through self-disclosure
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The Bottom Line on Empathy
• Ambivalence is normal • Our acceptance facilitates change• Skillful reflective listening is fundamental to
expressing empathy- Miller and Rollnick, 2002
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Reflective Listening
OARS
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SPEAKER LISTENER
Words the speaker
says
Words the listener hears
What thespeaker means
What the listenerthinks the speaker
means1
32
4
Thomas Gordon’s Model of Listening
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Reflective Listening
“Reflective listening is a way of checking rather than assuming that you know what is meant.”
(Miller and Rollnick, 2002)
OARS
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Reflective Listening
• Why listen reflectively?– Demonstrates that you have accurately heard and
understood the client– Strengthens the empathic relationship– Encourages further exploration of problems and
feelings• Avoid the premature-focus trap
– Can be used strategically to facilitate change
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Reflective Listening
In motivational interviewing,• About half of all practitioner responses are
reflections • 2-3 reflections are offered per question asked
In ordinary counseling, • Reflections constitute a small proportion of all
responses • Questions outnumber reflections 10 to 1
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Learning Reflective Listening
• Reflective listening begins with thinking reflectively
• Thinking reflectively requires a continual awareness that what you think people mean may not be what they really mean
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Thinking Reflectively
Exercise:1. Split up into triads (1-speaker) (2-listeners).2. Each person will take a turn being a speaker.3. Each person will share a personal statement
“One thing I like about myself is …”(e.g., I am organized. I am creative.)
4. The listeners respond with “Do you mean that…..” (generate at least 5 for each).
5. The speaker responds with only yes/no.
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Reflective Listening
• A reflection is two things:– A hypothesis as to what the speaker
means– A statement
• Statements are less likely than questions to evoke resistance
OARS
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Reflections Are Statements
“DO YOU MEAN……?”
• Use a statement to reflect your understanding
• Inflection turns down at the end“You...” “So you...”“Its...” “Its like...”“You feel...”
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Reflections Are Statements
• Question:– You’re thinking about stopping? (inflection goes
up)
• Versus a statement:– You’re thinking about stopping. (inflection goes
down)
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Reflective Listening
Exercise:1. Split up into triads (1-speaker) (2-listeners).2. Each person will take a turn being a speaker.3. Each person will share a personal statement
“One thing I like about myself is …”OR“One thing about myself I’d like to change is…”
4. The listeners respond with reflections only.5. The speaker can respond with yes/no and elaboration.
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Levels of Reflection
• Simple Reflection – stays close– Repeating– Rephrasing (substitutes synonyms)
• Complex Reflection – makes a guess– Paraphrasing – major restatement, infers
meaning, “continuing the paragraph’– Reflection of feeling - deepest
OARS
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Not Reflective Listening
Thomas Gordon’s Roadblocks:1. Ordering, directing, commanding2. Warning, cautioning, threatening3. Giving advice, making suggestions, providing
solutions4. Persuading with logic, arguing, lecturing5. Telling what to do preaching6. Disagreeing, judging, criticizing, blaming
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Not Reflective Listening
7. Agreeing, approving, praising8. Shaming, ridiculing, blaming9. Interpreting or analyzing, [also labeling]10. Reassuring, sympathizing, consoling11. Questioning, probing12. Withdrawing, distracting, humoring, changing
the subject
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Summaries
• Pull together what has transpired thus far in a session
• Strategic use: practitioner selects what information should be included & what can be minimized or left out
• Additional information can also be incorporated into summary – e.g., past conversations, assessment results, collateral reports etc.
OARS
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Summarizing
Exercise (part 1): 1. Choose a partner.2. Speaker: for 90 seconds talk about a habit,
behavior, situation you are thinking about changing.
3. Listener: listen only and then give a summary of what you’ve been told.
4. Change roles and repeat.
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Summarizing
Exercise (part 2): 1. Change partners.2. Speaker: once again tell your story for 90
seconds w/out interruption.3. Listener: listen only and then give a
summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story.
4. Change roles and repeat.
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MI is Directive
Nondirective/ Rogerian Motivational Interviewing
Allows client to determine content and direction of counseling
Systematically directs client toward motivation for change
Explores client’s conflicts and emotions without specific goals for change
Seeks to evoke and amplify discrepancy to enhance motivation for change
Uses empathic reflection noncontingently
Uses reflection selectively to reinforce motivation for change
Avoids interjecting counselor’s advice/feedback
Offers feedback where appropriate
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Develop Discrepancy
The logic…• Motivation arises from a discrepancy between
actual and desired states• We can help with motivation by creating and
amplifying discrepancy
In short…• We want to help clients see the contrast
between what they want and what they do
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Develop Discrepancy
Ambivalence Over Time in Treatment
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Develop Discrepancy
• Explore goals and values with which substance use may conflictLong term recovery goalsValuesDreams Past preferred activitiesAdmired people
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Develop Discrepancy
• Client verbalization of negative consequences amplifies discrepancy– Payoff matrix/decisional balance exercise
Advantages
Disadvantages
Using Substances
Not Using Substances
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Change and Resistance
Opposite sides of a coin–Resistance–Change talk
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Resistance
What is resistance?How is resistance expressed?
• Negating– Blaming, disagreeing, excusing,
minimizing, unwillingness to change• Ignoring
– Inattention, sidetracking, nonanswer• Arguing
– Challenging, discounting, hostility• Interrupting
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Resistance
• Counselor behaviors that elicit resistance– Arguing for change (the trap of taking sides)– Assuming the expert role/claiming preeminence– Labeling– Being in a hurry– Criticizing, shaming, or blaming
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Resistance
• Resistance is a product of the interpersonal relationship
• Hence, there are things we can do to diminish resistance
• Resistance is a signal to respond differently, it is valuable feedback
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Change Talk
• Generally falls into one of these four categories:– Disadvantages of the status quo– Advantages of change– Optimism for change– Intention to change
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Change Talk
• Disadvantages of the status quo“I can see that in the long run, this is going to do me in if I
don’t make a change.”“I am ruining my family life.”
• Advantages of change“My boys would like it. They’re always after me to quit.”“Probably I’d feel a lot better.”“At least it would get the courts off my back.”
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Change Talk
• Optimism About Change“I think I could probably do it if I decided to.”“I did quit smoking a few years ago. That was tough, and it
took a few tries, but I did it.”“My family would be there to support me.”
• Intention to Change“I definitely don’t want to keep going the way I have been.”“I’ve got to do something.”
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Recognizing Resistance and Change Talk
Exercise (part 1):1. Form groups of three.2. One person is the speaker: talk about
something you are trying to change.3. One is the listener: persuade your partner to
make the change (NOT MI).4. One is the recorder: listen for resistance and
change talk and record.
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Recognizing Resistance and Change Talk
Exercise (part 2):1. Switch roles.2. Speaker: talk about something you are trying
to change.3. Listener: use OARS.4. Recorder: listen for resistance and
change talk and record.
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In its simplest form, the implicit theory of MI posits:
1a. MI will increase client change talk. 1b. MI will diminish client resistance.2a. The extent to which clients verbally defend the
status quo (resistance) will be inversely related to behavior change.
2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change.
Miller, W.R. (2004) Toward a Theory of Motivational Interviewing. motivationalinterviewing.org
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Responding to Resistance
• Roll with it!
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Roll with Resistance
• Counselor behaviors that defuse resistance – strategies to use– Reflections– Shifting focus– Emphasizing personal control– (Agreement with a twist)– (Reframing)– (Coming alongside)
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Reflections
• Simple & Complex Reflections– Repeating, rephrasing, paraphrasing, reflection of
feeling
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Double-Sided Reflection
• Captures both sides of the ambivalence
– Client: Okay, maybe I’ve got some problems with gambling, but it’s not like I’m addicted to it.
– Interviewer: You see that your gambling is causing problems for you and your family, and it’s also important that people not think of you as some kind of addict.
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Amplified Reflection
• Exaggerated to encourage some retreat
– Client: I couldn’t just give up drinking. What would my friends think?
– Interviewer: You couldn’t handle your friends’ reaction if you quit.
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Shifting Focus
• Shift the person’s attention away from what seems to be a stumbling block in the way of progress.
– Client: You’re probably going to give me a diet that I need to stick to, and tell me that I have to get some of these exercise machines or go to a gym every day.
– Interviewer: I don’t know enough about you yet for us to even start talking about what makes sense for you to do. What we need to do right now is…
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Emphasizing Personal Control
• Assuring the client that it is he/she who in the end will determine what will happen
– Client: Why are you giving me this booklet? Are you telling me I have to use condoms?
– Interviewer: It’s just information. What you do with it is completely up to you. Naturally, no one can make you use condoms.
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Roll with Resistance
Exercise:• Get into groups of three.• Decide who will be the client, the counselor, and the
recorder. • Client: choose and read a resistant scenario or make up
your own.• Counselor: test out alternative strategies for responding.• Recorder: note strategies used and client response, what
seemed to work best?• Switch roles and use a new scenario.
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Roll with Resistance
Exercise Scenarios:• “Who are you to tell me what to do? What do you know
about crack? You probably never even smoked a joint!
• “Cocaine is not really my problem. What I want to talk about is my roommate—now he’s a problem!”
• “Look, I’ve been in detox dozens of times before. I’m hopeless. I just want to dry out and go home.”
• “I really like pot! It’s the only good thing about my day and I don’t want to quit!”
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Responding to Change Talk
• Elaborating • Reflecting• Summarizing• Affirming
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Elaborating
• Ask for clarification– “In what ways? When?”
• Ask for a specific example– “Give me an example. Tell me about the last time that
happened.”
• Straightforward encouragement to continue– “What else?”– “What else have you noticed or wondered about your
_____?”
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Reflecting
• Selectively reflecting• If the reflection evokes the other side
(resistance) then recover with a double sided reflection
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Summarizing
• Consciously selective• Gather together “bouquets” of change
statements and offer them back
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Affirming
• Simply comment positively– “That’s a good point”– “That sounds like a good idea”– “I think that could work”– “I can see how that would concern you”
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Eliciting Change Talk
• Asking evocative questions• Using the importance ruler• Exploring the decisional balance• Describe a typical day• (Querying extremes)• (Looking back)• (Looking forward)
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Asking Evocative Questions
• Use open questions to explore client’s own concerns
• Assume the person is feeling ambivalent and has at least some concerns
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Asking Evocative Questions
• What hassles have you had in relation to your drug use?
• In what ways has your drinking been a problem for you?
• What is there about your drinking that you or other people might see as a reason for concern?
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Using the Importance Ruler1.
2. “Why are you at a ___ and not a zero?”
“On a scale from 0 to 10, how important to you is it to change your ______ ?” Not at all Extremely Important Unsure Important
0 1 2 3 4 5 6 7 8 9 10
Importance Ruler
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Exploring the Decisional Balance
• Asking about both the positives and negatives of the behavior
• Asking about the pros and cons of change• Doing the payoff matrix
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Describe a Typical Day
• Ask the person to walk you through a typical day
• Areas of concern often emerge naturally
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Change Talk
Exercise:• Get into groups of three.• Each person selects a role: speaker, listener, recorder.• This is the first session.• Speakers, your job is to come in considering that you want to make a
change either in yourself or in your life but still feel very ambivalent about.
• Listeners, your job is to open up the session and practice using OARS and strategies for eliciting change talk as best you can.
• Observers, your job is to note the open ended questions, reflective listening statements, affirmations, summaries and strategies to elicit change talk.
• Switch roles.
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Support Self-Efficacy
What is self-efficacy?
• Extent to which the person feels ABLE to change
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Support Self-Efficacy
• People cannot be ready to change until they perceive both that they want to and are able to do so
• The client, not the counselor, is responsible for choosing and carrying out the change
• Our own belief in the person’s ability to change becomes a self-fulfilling prophecy
• We can support self-efficacy in the spirit of MI
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Responding to Confidence Talk
• Elaborating• Reflecting• Summarizing• Affirming• Raising possible problems and challenges
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Responding to Confidence Talk
• Elaborating– Straightforward encouragement to continue
• “Why else do you think you could succeed?”• “How else could you do it?
• Reflecting– Selectively reflect themes, experiences, ideas &
preferences that suggest the client’s perceived ability to make the change
• “I quit once before.” “You can do it again.”
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Responding to Confidence Talk
• Summarizing– Consciously selective– Gather together “bouquets” of confidence
statements and offer them back
• Affirming– Simply comment positively
• “I think that could work”• “I bet your family believes you can do this”
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Responding to Confidence Talk
• Raising possible challenges – Stimulate further thought and specificity
• “What might you do if _____?”• “How could you respond if _____?”• “What do you think would happen if _____?”
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Eliciting Confidence Talk
Strategies:• Evocative questions• Confidence ruler• Reviewing past successes• Exploring personal strengths & supports• Brainstorming• Reframing• Giving information & advice• Hypothetical change
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Support Self-Efficacy
Traps:• “I’ll take over now, thank you”
• Abandons MI and responds to low confidence with a prescription
• “There, there you will be fine” • Not taking the confidence issue seriously
• Gloom a deux• Sharing the client’s hopelessness and helplessness
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Take Home Messages
• Do a payoff matrix• Elaborate change talk• When in doubt, reflect
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Learning MI – Next Steps
• What is one MI skill you are committed to developing in the next month?
• What are some of the barriers you see to using MI?
• How ready are you to start using some MI strategies and techniques?
• What specific plans do you have to continue learning MI?
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Resources for Learning Motivational Interviewing
• Motivational Interviewing (2002) Miller & Rollnick
• www.motivationalinterview.com (Training tapes, articles, bibliographies, training opportunities)
• Enhancing Motivation for Change in Substance Abuse Treatment, Tip 35