Introduction to Motivational Interviewing

1. Introduction to Motivational Interviewing State of Hawaii, Department of Health, Adult Mental Health Division, Clinical Operations Team and Mental Health Services Research and Evaluation In Partnership with Substance Abuse and Mental Health Services Administration (SAMHSA) Evidence Based Practices Training and Implementation Grant

2. 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

3. 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

4. “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?

5. 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

6. Ambivalence Exercise • Find a partner. • 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.). • Select who will speak first. • The speaker presents what it is that you would like to do (but haven’t done yet). • The listener then argues strongly in favor of one of the options or sides. • Speaker, your job is to listen and note what you are thinking and feeling. • Switch roles.

7. Ambivalence Exercise What were your thoughts/feelings as the speaker? What happens when ambivalence collides with persuasion, prescription, convincing?

8. Motivational Interviewing is… “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002)

9. Spirit of Motivational Interviewing

10. 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.

11. 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.

12. 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.

13. 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?

14. 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.

15. 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.

16. 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.

17. 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.

18. Beliefs About Motivation(True or False?) • Until a person is motivated to change, there is not much we can do. • It usually takes a significant crisis (“hitting bottom”) to motivate a person to change. • Motivation is influenced by human connections. • Resistance to change arises from deep-seated defense mechanisms.

19. Beliefs About Motivation(True or False?) • People choose whether or not they will change. • Readiness for change involves a balancing of “pros” and “cons.” • Creating motivation for change usually requires confrontation. • Denial is not a client problem, it is a therapist skill problem.

21. 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

22. Open-Ended Questions Exercise: Turning closed-ended questions into open-ended ones

23. 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

24. Affirmations What is an affirmation? • Compliments, statements of appreciation and understanding • Praise positive behaviors • Support the person as they describe difficult situations OARS

25. 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.”

26. Affirmations Why affirm? • Supports and promotes self-efficacy, prevents discouragement • Builds rapport • Reinforces open exploration (client talk) Caveat: • Must be done sincerely OARS

27. 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

28. Express Empathy Empathy is distinct from… • Agreement • Warmth • Approval or praise • Reassurance, sympathy, or consolation • Advocacy

29. 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

30. Express Empathy Tips… • Good eye contact • Responsive facial expression • Body orientation • Verbal and non-verbal “encouragers” • Reflective listening/asking clarifying questions • Avoid expressing doubt/passing judgment

31. 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

32. The Bottom Line on Empathy Ambivalence is normal Our acceptance facilitates change Skillful reflective listening is fundamental to expressing empathy - Miller and Rollnick, 2002

33. Reflective Listening OARS

34. Thomas Gordon’s Model of Listening What the speaker means What the listener thinks the speaker means 1 4 Words the listener hears 2 3 Words the speaker says SPEAKER LISTENER

35. Reflective Listening “Reflective listening is a way of checking rather than assuming that you know what is meant.” (Miller and Rollnick, 2002) OARS

36. 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

37. 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

38. 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

39. Thinking Reflectively Exercise: • Split up into triads (1-speaker) (2-listeners). • Each person will take a turn being a speaker. • Each person will share a personal statement “One thing I like about myself is …” (e.g., I am organized. I am creative.) • The listeners respond with “Do you mean that…..” (generate at least 5 for each). • The speaker responds with only yes/no.

40. 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

41. 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...”

42. Reflections Are Statements Question: You’re thinking about stopping? (inflection goes up) Versus a statement: You’re thinking about stopping. (inflection goes down)

43. Reflective Listening Exercise: • Split up into triads (1-speaker) (2-listeners). • Each person will take a turn being a speaker. • 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…” • The listeners respond with reflections only. • The speaker can respond with yes/no and elaboration.

44. 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

45. Not Reflective Listening Thomas Gordon’s Roadblocks: • Ordering, directing, commanding • Warning, cautioning, threatening • Giving advice, making suggestions, providing solutions • Persuading with logic, arguing, lecturing • Telling what to do preaching • Disagreeing, judging, criticizing, blaming

46. Not Reflective Listening • Agreeing, approving, praising • Shaming, ridiculing, blaming • Interpreting or analyzing, [also labeling] • Reassuring, sympathizing, consoling • Questioning, probing • Withdrawing, distracting, humoring, changing the subject

47. 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

48. Summarizing Exercise (part 1): • Choose a partner. • Speaker: for 90 seconds talk about a habit, behavior, situation you are thinking about changing. • Listener: listen only and then give a summary of what you’ve been told. • Change roles and repeat.

49. Summarizing Exercise (part 2): • Change partners. • Speaker: once again tell your story for 90 seconds w/out interruption. • Listener: listen only and then give a summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story. • Change roles and repeat.

50. MI is Directive