An Introduction to Motivational Interviewing

1. An Introduction to Motivational Interviewing Richard L. Ogle, Ph.D. Professor & Chair Department of Psychology University of North Carolina Wilmington ogler@uncw.edu

2. Guiding Sentiments • If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be. —Johann Wolfgang Von Goethe • People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others. —Blaise Pascal • You are a midwife, assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say, “We did it ourselves.” —TAO TE CHING

3. Opening Conversation • Why are you here? • What do you want to learn? • In what specific situations would you like to use MI? • At what level do you want to engage?

4. Motivation • The probability of engaging in and maintaining a behavior over time. • What are the three key words? • Probability (0 – 1) not (0 or 1). • Engage • Maintain • Motivation is continuous not dichotomous • Fluctuating motivation can increase or decrease based on your behavior

5. Change • Change is more similar than different across behaviors • Change is a process that is continuous like a dimmer switch, not discrete like an on/off switch • Change depends on MOTIVATION. • Because of this, there are multiple ways and times that change can derail • Fortunately, there are multiple ways and times to facilitate the process

6. Stages of ChangeProchaska & DiClemente

7. Change Talk - DARN CAT • Client speech reflecting building motivation and correlated with behavioral change • Desire • Why a person would make a change. • Ability • How a person could you do it. • Reasons • What are good reasons to make the change? • Needs • How important is it and why? What are the negative that occur without change? • Commitment • What intentions are present? • Activation • What is the person ready or willing to do immediately? • Taking Steps • What have they already done?

8. Commitment Language Pattern A

9. Outcomes for Pattern A Group

10. Commitment Language Pattern B Amrhein et al., Journal of Consulting & Clinical Psychology 2003 71:862-878

11. Outcomes for Pattern B Group

12. Righting Reflex • Born of concern and caring • There’s a problem? Let’s fix it! • Fails to consider ambivalence in change process • May engender resistance

13. Ambivalence • Simultaneous feelings of approach and avoidance • Yes, but • I want to, but I can’t • The core of most motivational issues • Completely normal • Often uncomfortable • Can be chronic

14. Exercise • Talk about something real that you: • Want to change • Need to change • Should change • Have been thinking about changing • But, haven’t yet changed. • Not your deepest, darkest secret! • Listen carefully - goal to understand the dilemma • Ask these four questions: • Why would you want to make this change? • How might you go about it, in order to succeed? • What are the three best reasons to do it? • On a scale of 1-10, how important would you say it is to make this change? And why are you a ___ and not zero? • Summarize

15. Resistance • A result of a focus on only one side of an individual’s ambivalence • If you argue for change, your collaborator argues against it • It is relational. It is a signal that you are not meeting them where they are at; therefore, it is you responsibility to resolve • Sustain Talk • Speech about the target behavior that reflects only one side of ambivalence (status quo) • There is nothing inherently pathological about sustain talk • Discord • Speech reflecting a discord within the relationship/session • Denying • Arguing • Ignoring • Interrupting • Reluctance • May be concerned about the “unknowns” of change • Need to verbalize their reluctance & be heard • Rebellion • May have knowledge • May have highly invested energy in no change • Resignation • No energy for change • May feel overwhelmed & hopeless • Need to build hope • Rationalization • Has all of the answers • Utilizes “Harm Minimization”

16. Therapeutic Traps • Question-Answer Trap • Trap of Taking Sides • Expert Trap • Labeling Trap • Premature Focus Trap • Blaming Trap

17. Definitions of MI • Layperson’s Definition (Why would be do it) • MI is a collaborative conversational style for strengthening a persons own motivation and commitment to change • Practitioner’s Definition (Why you would use it) • MI is a person-centered counseling style for the common problem of ambivalence about change • Technical Definition (How it works) • MI 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.

18. A Brief History to This Point • MI is 31 years old this year • Description first published in a journal article in 1983. • First edition of book in 1991, second in 2002, third in 2013 • Over 1200 articles on MI • MI cited over 25,000 times • Over 200 RCT’s • Started as a vilified intervention in addictions and now is a best practice in all of behavioral health • Here are some things we know • MI is effective for a variety of behavioral targets • MI can be used in a variety of settings • MI is hard to standardize • Significant variability across counselors

19. Most Importantly, What We Know is… • MI training increases characteristic MI practice behaviors • OARS • Empathy • These behaviors affect particular types of client speech • Desire, Ability, Reasons, Need, Commitment, Activation, Taking Steps • The level and strength of these types of speech predict behavioral outcome • Findings are stronger in addictions than anywhere else

20. Spirit of MIhttp://www.youtube.com/watch?v=Vr-aZ4tdoac • Acceptance • Absolute worth • Autonomy • Accurate Empathy • Affirmation • Collaboration • Partners • Shared goals • Evocation • Pulling out instead of putting in • Compassion • For the other’s needs/self-interest • Services exist to benefit the people we serve • Change is fundamentally self change. Services facilitate • People are experts on themselves • We don’t have to make change happen • We don’t have to come up with all the good ideas • People have their own strengths, motivations, resources • Therefore change requires partnership • Understand, person’s own perspective, what is needed and how to accomplish it • Conversations about change should not be a struggle. Dancing, not wrestling • Motivation for change is not installed, but evoked • We cannot revoke people’s choice about their own behavior. People make their own decisions about what they will and will not do.

21. MI Principles • Express Empathy • Empathy alone is predictive of change • Roll w/Resistance • Verbal judo • Develop Discrepancy • Goals and values contrasted with current behavior • Support Self-Efficacy • R – Resist the righting reflex • U – Understand you client’s motivation • L – Listen to you client • E – Empower your client

22. Empathy • Multiple Components • Experience sharing (affective empathy) vicariously sharing targets’ internal states (“feeling with”), but knowing the target is the source of the emotional state in the self. • Mentalizing (cognitive empathy) explicitly considering targets' states and their sources, without necessarily sharing another's state. Perspective-taking. • Prosocial concern (compassion) feeling of concern for a target's suffering ("feeling for") that induces a motivation to alleviate that suffering. • http://www.youtube.com/watch?v=l7AWnfFRc7g • http://www.youtube.com/watch?v=1Evwgu369Jw

23. The Importance of Empathy and Rolling w/Resistance Miller, Benefield & Tonigan (1993) JCCP 61: 455-461

24. Developing Discrepancy • Finding, increasing or encouraging a discrepancy between present and desired states • Can be positive or negative in valence • Discontent with the status quo • Opportunity for betterment • Goldilocks Principle • Discrepancy within limit

25. Support Self-Efficacy • Perception of the degree to which someone feels confident he/she can accomplish a particular goal/task • Building confidence • Building on past successes • Translating things they do well in other life contexts to the behavior change context. • Affirming smaller steps and approximations

26. How Does MI Work • Empathy allows clients to reduce resistance and resolve ambivalence • Looking at the situation from their perspective • People feel understood; less resistant • Selective reinforcement of change talk • Focus on change talk • We learn what we believe when we hear ourselves speak • Therapist reinforces change talk that is consistent with therapeutic goals • Reinforcement further increases change talk and allows of client to experience build in motivation to change

27. Basic MI Tools • O - Open Questions • A - Affirmative Approach • R - Reflective Listening • S -Summaries • Your OARS propel you and steer you through the encounter • You have to do these well to do MI well • Everything in MI is rooted in OARS

28. Open Questions • Questions that cannot be answered “yes” or “no” or with a discrete answer. • Open questions generate more data – more data, more empathy • Open questions block momentum less than closed questions • Open questions lessen the “expert” or “investigator” feel of interactions

29. Opening Up Your Questions Do you drink? How much? Have you ever smoked a cigarette? Are you taking your medications as prescribed? Have you lost or gained weight in the last month? Are you sexually active? Do you always use birth control? How many alcoholic drinks do you have in a typical week? Did you take your insulin today? Do you get regular physical exercise? Is there a family history of heart disease? Have you ever been hospitalized or had surgery? On what day did your symptoms start?

30. Affirmation • Clients are often unsuccessful self-changers • Demoralized • Our role is to instill hope and a belief that the client can change • Empower the client – “can do” • Attributions • Focus on specific behaviors instead of attitudes or decisions • Focus on descriptions not evaluations • Attend to non-problem areas • Nurture a world-view of competence not deficit

31. Affirmation Exercise • Listen to the statement • Write down a few strengths • Write down an affirmation

32. Reflective Listening - Roadblocks to Listening • 1. Ordering, directing, or commanding • 2. Warning or threatening • 3. Giving advice, making suggestions, or providing solutions • 4. Persuading with logic, arguing, or lecturing • 5. Moralizing, preaching, or telling clients what they "should" do • 6. Disagreeing, judging, criticizing, or blaming • 7. Agreeing, approving, or praising • 8. Shaming, ridiculing, or labeling • 9. Interpreting or analyzing • 10. Reassuring, sympathizing, or consoling • 11. Questioning or probing • 12. Withdrawing, distracting, humoring, or changing the subject

33. Reflective Listening – What is it? • A statement – a hypothesis • Vocal inflection is downward • Keeps people “in the meaning/feeling” • A verbal mirror to reflect back • Exact words • Paraphrase • Meaning • Emotion

34. Reflection Exercises

35. Summaries • Groups of reflections that serve to • Remind you and client of what has been said • Highlight overarching themes – Linking • Transition when stuck or wanting to shift direction

36. Video • Listen for OARS

37. Rolling w/Resistance • Strategies • Reflection (Under/Over) • Reframe • Double-sided reflection • Emphasizing Personal Responsibility • Shifting Focus • Coming Alongside • Exercise

38. Exercise - Fishbowl • Practice OARS • Roll w/ resistance • Listen for Change talk

39. MI Processes • MI occurs throughout four ongoing processes of change conversations • Engaging • Focusing • Evoking • Planning • Often MI is about knowing how to skillfully and artfully move back and forth between each process

40. Engaging • The process by which counselor and client establish a helpful connection and a working relationship • How comfortable is this person talking to me? • How supportive and helpful am I being? • Do I understand this person’s perspective and concerns? • How comfortable do I feel with this conversation? • Does this feel like a collaborative partnership?

41. Understanding Values • Freely chosen core beliefs that drive and organize behavior that is intrinsically reinforcing. • Values represent what one wants their life to look like, stand for and be about • Global values • Domain-specific values – family, relationships, career, etc. • Values provide direction • Values are different from valuing • Values cannot be accomplished in-and-of-themselves • Instantiated moment by moment and over time • No matter what direction life takes, you still have your values

42. Values Assessment • Informal • “How do you hope your life will be different a few years from now?” • “Who do you respect in life and why?” • “Tell me what you care most about in life.” • Tombstone • Eulogy • Values Card-Sort • http://casaa.unm.edu/inst/Personal%20Values%20Card%20Sort%202.pdf • Batteries Exercise • Next Slide

44. Focusing • Process of clarifying direction – find the horizon point toward which to move. Agenda • What goals for change does this person really have? • Do I have different aspirations for change than this person? • Are we working together with a common purpose? • Does it feel like we are moving together, not in different directions? • Do I have a clear sense of where we are going? • Does this feel more like dancing than wrestling? • Sources – client, setting, your experience

45. Agenda Mapping • A short meta-conversation in which you step back with the client to consider the way ahead • Structuring • Consider options • Zoom in • Zoom out

46. Information Exchange: Elicit - Provide - Elicit • Elicit • What would you like to know/do about? • What do you already know/do about? • Provide • Provide information (not opinion) in manageable chunks • Confirming • New • Disconfirming • Elicit • What do you make of that? • What does this mean for you? • What more would you like to know?

47. Evoking • Eliciting client’s own motivations to change. Harness the client’s own thoughts and feelings about why and how they might do it • What are this persons reasons for change? • Is the reluctance more about confidence or importance? • What change talk am I hearing? • Am I steering to far or too fast in a particular direction? • Is the righting reflex pulling me to be the one arguing for change?

48. Explore Importance of Situation/Change • General: • How important is situation/issue, you need to make a decision or do something about it? • Importance Ruler • On a scale of 0 to 10, how important is this issue to you at this point in your life(0=not at all, 10=most important thing) • What makes it an X and not a Y? • What might make your rating a few points higher, a bit more important? • What can you specifically do to increase? • What might I, or others do to help it increase?

49. Explore Confidence about Changing • On a scale of 0 to 10, how confident are you that you could change if you decided to? • What makes it an X and not a Y? • What would make it a few points higher? • What can you specifically do to increase? • What might I, or others do to help it increase?

50. DARN CAT Client Exercise • Lets write down some statements about this change we are discussing. • D – Why do you want to make this change? • A – How could you do it? • R – What are good reasons to make the change? • N – How important is it and why? • C – What do you intend to do about it? • A – What are you ready or willing to do? • T – What have you already done? • Use your OARS to expand, explore and solidify.