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Reflections on Motivational Interviewing

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  1. Reflections on Motivational Interviewing Cardiff September 27, 2011

  2. 1983

  3. MI-1 1991

  4. MI-2 2002

  5. 2008

  6. MI-3 2012

  7. MI-4 2022

  8. X Generalized Principles of MI Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Support Self-Efficacy

  9. X Two Phases of MI Phase 1 Strengthen motivation for change Phase 2 Consolidate commitment to change

  10. RESISTANCE

  11. The Underlying Spirit of MI Partnership Evocation Acceptance Compassion

  12. Change is Broader than Behavior • 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.

  13. Four Fundamental Processes in MI

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

  15. 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 Focus Evoke Plan

  16. . . . . 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

  17. Four Foundational Processes

  18. Is it MI Yet?

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

  20. So it becomes 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) AND 3. The interviewer is evoking the person’s own motivations (or plans) for change (Evoke)

  21. A continuum of styles that can be used in all four processes

  22. Core counseling skills that can be used in all four processes Open questions Affirmation Reflection Summary Offering information and advice

  23. Direction Language “Directing” as a counselor behavior “Direction” as focus “Directional” (not “directive”) as a description of MI as goal-oriented

  24. 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

  25. 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?) Definitions of MI

  26. 1. A layperson’s definition(What’s it for?) Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change

  27. 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

  28. 3. A technical therapeutic definition (How does it work?) Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is 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.

  29. Counseling with Neutrality • Neutality is not a therapist attribute (like equanimity: composure, balance, emotional stability) • Neutrality is the conscious clinical decision to try not to influence a client’s direction of choice or change • Neutrality can be about: • Focusing (whether to pursue a change goal) • Planning (how to pursue a change goal)

  30. Counselor Aspiration Should I proceed strategically to favor the resolution of the client’s ambivalence in a particular direction? or Do I want to maintain neutrality and not intentionally or inadvertently steer the person in one particular direction? MI was originally developed for the former situation

  31. Engaging and Focusing Identification of Change Goal A conscious choice Aspiration Equipoise Evoking Planning Decisional Balance Both choices involve partnership, acceptance and compassion

  32. Equipoise is where a classic decisional balance makes sense Giving intentionally balanced, equal attention to pros and cons in: Inquiry Elaboration Affirmation Reflection Summaries

  33. 2 x 2 Decisional Balance Grid PROs and CONs of Change

  34. 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

  35. Preparatory Change TalkFour Examples 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 . .)

  36. Mobilizing Change TalkReflects resolution of ambivalence CATs • COMMITMENT (intention, decision, promise) • ACTIVATION (willing, ready, preparing) • TAKING STEPS

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

  38. Responding to Change TalkAll 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

  39. Change Talk and Sustain Talk Opposite Sides of a Coin

  40. Examples of Sustain TalkThe 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)

  41. What is “Resistance”? Sustain Talk Discord X

  42. Sustain Talk and Discord • 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 • 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 counselor style

  43. What is Discord? Behavior Interpersonal (It takes two to have discord) A signal of dissonance in your relationship Predictive of (non)change

  44. Some Discord Signals • Defensiveness • Arguing • Challenging Discounting Hostility • Interrupting • Talking over the counselor • Ignoring • Inattention Changing the subject

  45. MI in Child Protection Services

  46. Dual Roles in CPS • To facilitate change in the caregivers • To protect and serve the children’s best interests Similar to dual roles in probation/parole Fulfilling role #1 serves role #2

  47. The Righting Reflex • “Righting” is serious business in CPS • Passion or anxiety to protect can easily create an adversarial role in which: • The worker advocates for change • The client is defensive and “resistive” • This is the quintessential clinical dilemma for which MI was developed

  48. Engaging • An early and important task in MI • Promoted primarily by OARS • Can occur relatively quickly • An opposite style from fact-questioning • Research question: Does MI-based engaging yield critical information more honestly and quickly than asking questions?

  49. Focusing • Sometimes the worker must set the focus: • Violence • Attending school • Substance abuse Challenge: How to avoid “rapid focus” problems and unconstructive adversarial interactions when you must address it? One key: Engage first