Motivational Interviewing
Overview
Module 12
Blake Beecher, PhD
Eastern Washington University
Learning Objectives:
1.
2.
3.
4.
Spirit of MI, DEARS
OARS practice
Stages of Change informed Intervention
Eliciting, recognizing, and sustaining change talk
You would think . . .
that having had a heart attack would be enough to
persuade a man to quit smoking, change his
diet, exercise more, and take his medication
that hangovers, damaged relationships, an auto
crash, and memory blackouts would be enough
to convince a woman to stop drinking
losing one’s life savings and children’s inheritance
in slot machines would be enough to help a man
to quit gambling
You would think . . .
that the very real threats of blindness,
amputations and other complications
from diabetes would be enough to
motivate weight loss and glycemic
control
that time spent in the dehumanizing
privations of prison would dissuade
people from re-offending
And yet so often it is not enough for
people to change: What is the Key to
change?
Client Motivation is a Key to Change
Successful treatment outcomes are predicted by:
Pretreatment motivation measures
Treatment attendance
Treatment adherence/compliance
Counselor ratings of motivation and
prognosis
That is, more “motivated” clients do better
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.
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.
Client Motivation is Greatly Influenced
by the Counselor
Clients’ motivation, retention and outcome vary with
the particular counselor to whom they are
assigned
Counselor style strongly drives client resistance
(confrontation drives it up, empathic listening
brings it down)
That is, the counselor is one of the biggest
determinants of client motivation and change
Readiness for What?
Rather than asking: “Why isn’t this
person motivated?”
Ask: “What is this person motivated
for?”
Potential Pitfall: Assuming you know.
The Righting Reflex:
NOT Motivational Interviewing
If following the righting instinct, you will
ineffectively 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?
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.
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.
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.
You take one side; I another
When you strong argue one side, the ambivalent
naturally argue the other
The stronger the argument the less likely
change occurs
Common Human Reactions to the Righting Reflex
Angry, agitated
Oppositional
Discounting
Defensive
Justifying
Not understood
Not heard
Procrastinate
 Afraid
 Helpless, overwhelmed
 Ashamed
 Trapped
 Disengaged
 Don’t come back – avoid
 Uncomfortable
 Resistant
Common Human Reactions to Being Listened to
Understood
Want to talk more
Liking the counselor
Open
Accepted
Respected
Engaged
Able to change
Safe
Empowered
Hopeful
Comfortable
Interested
Want to come back
Cooperative
A Change of Role
You don’t have to make change happen
You can’t
You don’t have to come up with all the
answers
You probably don’t have the best ones
You’re not wrestling
You’re dancing
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
Ambivalence Exercise
1. Find a partner.
2. Each of you write down something you are interested in
doing but have mixed feelings about (e.g., studying,
buying a new car, quitting smoking, exercising, etc.).
3. Select who will speak first.
4. The speaker presents what it is that s/he 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.
Ambivalence Exercise
What were your thoughts/feelings as the
speaker?
What happens when ambivalence collides
with persuasion, prescription,
convincing?
Motivational Interviewing
Motivational interviewing is a semi-directive, client-centered
counseling style that enhances motivation for change by
helping the client clarify and resolve ambivalence about
behavior change.
The goal of motivational interviewing is to create and amplify
discrepancy between present behavior and broader goals.
Create cognitive dissonance between
Where one
Is now
Where one
wants to be
MI is Semi-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
Uses empathic reflection
noncontingently
Avoids interjecting counselor’s
advice/feedback
Seeks to evoke and amplify
discrepancy to enhance
motivation for change
Uses reflection selectively to
reinforce motivation for change
Offers feedback where
appropriate
Two Phases of MI
Phase I: Building Motivation to Change
Phase II: Strengthening commitment to
change
Appropriate Motivational Strategies for Each Stage of
Change
Client's Stage of Change
Appropriate Motivational
Strategies for the Clinician
Precontemplation
Establish rapport, ask
permission, and build trust.
Raise doubts or concerns
in the client about
problematic patterns
Express concern and
keep the door open.
The client is not yet
considering change or is
unwilling or unable to
change.
Client's Stage of Change
Contemplation
Appropriate Motivational Strategies
for the Clinician
Normalize ambivalence.
Help the client "tip the
decisional balance scales"
The client acknowledges toward change.
Elicit and summarize selfconcerns and is
considering the possibility motivational statements of
intent and commitment from
of change but is
ambivalent and uncertain. the client.
Elicit ideas regarding the
client's perceived self-efficacy
and expectations regarding
treatment.
Client's Stage of Change
Preparation
The client is committed
to and planning to make
a change in the near
future but is still
considering what to do.
Appropriate Motivational Strategies for
the Clinician
Explore treatment
expectancies and the client's
role.
Clarify the client's own goals.
Negotiate a change--or
treatment--plan and behavior
contract.
Consider and lower barriers
to change.
Help the client enlist social
support.
Client's Stage of Change
Action
Appropriate Motivational Strategies for the
Clinician
Engage the client in treatment
and reinforce the importance of
retaining behavior change.
Acknowledge difficulties for the
The client is actively
client in early stages of change.
taking steps to change Help the client identify high-risk
but has not yet
situations through a functional
reached a stable state. analysis and develop
appropriate coping strategies to
overcome these.
Client's Stage of Change
Maintenance
The client has achieved
initial goals such as
abstinence and is now
working to maintain
gains.
Appropriate Motivational Strategies for
the Clinician
Support lifestyle changes.
Affirm the client's resolve
and self-efficacy.
Help the client practice and
use new coping strategies to
avoid a relapse.
Develop a "fire escape" plan
if the client resumes
problematic behaviors.
Review long-term goals with
the client.
Client's Stage of Change
Recurrence
Appropriate Motivational Strategies for
the Clinician
Help the client reenter the
change cycle and commend
any willingness to reconsider
positive change.
The client has
experienced a recurrence
Explore the meaning and
of symptoms and must
reality of the recurrence as a
now cope with
learning opportunity.
consequences and decide
Assist the client in finding
what to do next.
alternative coping strategies.
Maintain supportive contact.
3 Critical Components
of Motivation: Readiness Ruler - WAR
Willing:
The importance of change:
desires, wants or wills
change
Able: Confidence for change;
feels willing but unable- “I
wish I could” may use
defense mech.
Ready:
A matter of priorities; “I want
to but not now.”
Able
Five Principles of MI-- DEARS
Develop Discrepancy
 Person rather than the counselor should present the arguments
for change
 Change is motivated by a perceived discrepancy between
present behavior and important personal goals or values
Express Empathy
 Research indicating importance of empathy
 Skillful reflective listening is fundamental
 Ambivalence is normal
Five Principles of MI
Avoid Argumentation
Confrontation increases client resistance
to change
Labeling is unnecessary
Five Principles of MI
Roll with Resistance
▫ Provider’s role is to reduce resistance,
since this is correlated with poorer
outcomes
▫ If resistance increases, providers shift to
different strategies
▫ The person’s objections or minimization do
not demand a response
▫ The person is a primary resource in finding
answers and solutions
Five Principles of MI
Support Self-Efficacy
▫ A person’s belief in the possibility of change
is an important motivator
▫ The person, not the counselor, is
responsible for choosing and carrying out
change
▫ The counselor’s own belief in the person’s
ability to change becomes a self-fulfilling
prophecy
What Is Resistance?
Verbal and non-verbal behaviors
Expected and normal
Function of interpersonal communication
Continued resistance predictive of reduced
change
Resistance is highly responsive to counselor
style
Getting resistance? Change strategies.
Types of Resistance
Argument
 Challenging
 Discounting
 Hostility
Interruption
 Talking over
 Cutting off
Ignoring




Inattention
Non-response
Non-answer
Side-tracking
Denial







Blaming
Disagreeing
Excusing
Reluctance
Minimizing
Pessimism
Unwillingness to change
 Claiming immunity
 WHAT ELSE?????
Resistance and Persuasion
Many older approaches to behavior change
relied on the counselor to persuade or
even intimidate client into changing
These approaches often elicit reactance
and reduce the chances that a resistant
client will consider changing a problem
behavior
Dancing vs. Wrestling
Many MI proponents use the
metaphor of dancing with
clients to illustrate this
method of gently moving
with them around the
ambivalence of change
The Importance of Values “The
Hook”
If Values are not identified, there is no
discrepancy—a main component of MI
What makes their life worth living?
What do they value in their life that is
affected by the problem?
What is most important to them?
What gives their life meaning?
Areas of Values
1. Family/Parenting 7.
2. Love/Intimate
8.
relationships
3. Friends/Social
9.
connectedness
4. Work/Career
5. Education/Training
6. Recreation/Fun
Spirituality
Citizenship/
Community Life
Health/Physical Self
Care
Case # 1
Juan is a 40 year old unemployed plumber who would like
to get back to work, but has difficulty working due to
obesity and uncontrolled diabetes. Juan has tried to alter
his diet and take his medication consistently a few times
in the past, but has slipped back each time has made any
changes. He is in the clinic due to his diabetes and you
received a referral to meet with him.
Case # 2
Gina is a 42 year-old part time college student. She is a
single mother with 4 kids and is working part time. She
has hypertension, anxiety, and depression, and receives
her medication from the clinic for all three. She comes to
the clinic frequently stressed about her health problems
and her life situation.
Case # 3
Rafael is a 29 year old man who is HIV+.
He reports to you that he is having regular unprotected
sex. He tells you that he usually goes to church right
afterwards and prays for forgiveness but “can’t seem to
stop” himself from continuing this behavior. He also
remarks that although he has been feeling “fine” he visits
his primary care doctor frequently.
The “Spirit of MI”1
Too much focus on the techniques of MI results in a
loss of its essential style, “sprit” or way of being
• Motivation elicited from the client, not imposed
from without
• Client's task, not the counselor's, to articulate +
resolve ambivalence
• Persuasion is not an effective method for
resolving ambivalence
“Spirit of MI”2
• Readiness to change not a client trait, but a
fluctuating product of interpersonal interaction
• The therapeutic relationship is a partnership
rather than expert/recipient roles
“Spirit of MI”3
Central therapist behaviors
• Understand the person's frame of reference via
reflective listening
• Express acceptance and affirmation
• Eliciting + reinforcing the client's self motivational
statements expressions of problem recognition
• Monitoring the client's degree of readiness to change +
ensuring that resistance is not generated
• Affirming the client's freedom of choice and selfdirection
Motivational Interviewing
Techniques
Open-ended
Questions
Reflective
Listening
Affirm
Summarize
Elicit
Change Talk
Core Components
Express
Empathy
Avoid
Argumentation
Roll with
Resistance
Develop
Discrepancy
Support
Self-efficacy
Spirit
Collaboration
Evocation
Autonomy
MI Research Support in Health Settings4, 5, 6
Substance use decrease
Treatment adherence increase
Treatment engagement increase
HIV risk reduction
Diet and exercise
Gambling decrease
Healthy behavioral change
Motivational interviewing consistently outperforms traditional
advice giving in the treatment of a broad range of behavioral
problems and diseases.
Hettema, J. et al., 2005; Lundahl & Burke 2009; Ruback, S. et al., 2005
References
1. Miller, W.R. & Rollnick, S. (2002). Motivational interviewing (2nd ed.): Preparing people
for change. New York: Guilford Press.
2. Miller, W.R. & Rollnick, S. (2002). Motivational interviewing (2nd ed.): Preparing people
for change. New York: Guilford Press.
3. Miller, W.R. & Rollnick, S. (2002). Motivational interviewing (2nd ed.): Preparing people
for change. New York: Guilford Press.
4. 4. Hettema, J., Steele, J., & Miller, W. (2005). Motivational Interviewing. Annual Review of
Clinical Psychology, 91–111.
5. 5. Lundahl, B. W., & Burke, B. L. (2009). The effectiveness and applicability of
motivational interviewing: A practice-friendly review of four meta-analyses. Journal of
Clinical Psychology: In session, 65, 1232-1245.
6. 6. Ruback, S., Sandbaek, A., Lauritzen, T., & Christensen, B. (2005). Motivational
interviewing: A systematic review and meta-analyses. British Journal of General Practice,
April, 305-312.
7. Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance
Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services
Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 35.)
Available from: http://www.ncbi.nlm.nih.gov/books/NBK64967/