Motivational Interviewing
May 6, 2010
Motivational Interviewing (MI)
A little background…
Chris Dunn,
Dunn Ph.D.
Ph D
University of Washington
Kari Stephens, Ph.D.
University of Washington
MI Definition
D fi iti
Definition
Rationale
for style
Learning
MI
Theory
Spirit
Rationale for MI Style
“ client-centered, directive method for
enhancing intrinsic motivation to change
by exploring and resolving
ambivalence”
(Miller and Rollnick, 2002)
MI Theory
If not listened to:
If listened to:
Secretive
Frank
Angry, annoyed
Understood, accepted
Avoidant
Exploring
Oppositional
Cooperative
Discounting
Concerned
Spirit of MI
Do
Reactance
Theory
Avoid client “pushback”
Self-perception
Theory
When clients argue for change,
they come to believe in their
argument
Don’t
Draw out
“What would you would like to
change about your drinking?”
• Implant the right ideas
Value Theory
Allow the freedom not to
change
“How ready are you to change?”
• Push for commitment
Clients will change if the status
quo violates their deep values
Humanistic
Theory
Clients will change under
conditions of positive regard,
acceptance, and empathy
Collaborate
“What do you think you’ll do?”
“You really need to stop
drinking.”
“If you delay getting sober,
you could die.”
• Dictate
“I would urge you to quit
drinking.”
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Motivational Interviewing
May 6, 2010
MI cowboy
Ambivalence
Feeling two ways
about something
Cullum, L. The New Yorker. May 9, 2005.
“Of course we can’t make you do anything you don’t want
to do…But we’re all headed to Dodge City and we’d like you
to join us.”
Both sides already
there
A communication trap!
– Argue one side,
person defends the
other
Common prior to habit
change (common
during habit change).
Common with respect
to alcohol.
Defense of status quo
makes change less
likely
Ambivalence Example
MI
Inconsistent
MI
Spirit
My client struggles
with ambivalence
about change. One
moment, she wants
to take the plunge,
and the next moment,
she’s stuck again.
She’s working hard to
resolve this.
She’s manipulative.
She tells me she
wants to change,
because she thinks it’s
what I want to hear.
But she’s really not
motivated.
Learning MI
Techniques
Listening
Li
t i
Skills
Spirit
Motivationalinterview.org
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Motivational Interviewing
May 6, 2010
Agree on a target behavior to talk about
Agree on a target behavior to talk about
Draw out client’s story about that target
behavior
Draw out client’s story about that target
behavior
Ask
s for
o C
Change
a ge Talk
a a
and
d highlight
g g it
Share assessment results relevant to
target behavior
Explore options for changing target
behavior
Try for a commitment to do something
about target behavior
Target Behavior: Example
MI
Spirit
There are a couple
of things we could
t lk about,
talk
b t like
lik
taking your meds,
doing BA,
substance use, or
looking for work.
Would it be okay if
we discussed…?
MI Microskills
MI
Inconsistent
OARS
Today, we are
going to talk about
your drug abuse...
Openended
Questions
Affirmations
Reflections
Summaries
***Use at All Times
Open-Ended Questions: Examples
Open-ended Questions
**Rule of thumb: 3 reflections for every
question
MI
Spirit
Agree on a target behavior to talk about
Of all the issues we have discussed, which one would you
like to talk about?
Draw out client’s story about that target behavior
Tell me how alcohol fits into your typical lifestyle?
Ask for Change Talk and highlight it
What are some of your concerns about using meth?
Sets the
Creates
tone for MI
momentum
work
Focus
broadly
Avoids
“Question
& Answer
Trap”
Share assessment results relevant to target behavior
What do you think about the feedback that this questionnaire
suggests your symptoms of depression are worse?
Explore options for changing target behavior
What sorts of things have you thought of trying?
Try for a commitment to do something about target behavior
What barriers might come up, and how would you deal with
them?
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Motivational Interviewing
May 6, 2010
Affirmations: Examples
Affirmations
MI
Spirit
Why we use them
Agree on a target behavior to talk about
I appreciate your honesty about not wanting to discuss that.
• Clients are often demoralized
• Orients people to their strengths
Draw out client’s story about that target behavior
You’ve been working hard on this for a long time!
What to do
Share assessment results relevant to target behavior
One of your strengths that showed up on the assessment
was your drive to protect other people.
Explore options for changing target behavior
I believe that when you make up your mind to take action,
you will be successful.
Ask for Change Talk and highlight it
You have been doing some pretty serious thinking about this.
• Hard to do genuinely, be genuine
• Probe partial successes
• Reframe resistance into an affirmation (find
the good news in resistance)
Reflections
Reflections: Examples
More than paying
attention

Those who can’t
reflect can’t do MI

Can be:
 Used to attend
selectively
 Used to focus
Try for a commitment to do something about target behavior
You’re doing a great job of thinking through this.
MI
Spirit
It sounds like you are feeling…
It sounds like you are not happy with…
It sounds like you are a bit uncomfortable about…
So you are saying that you are having trouble…
More than
repeating
words
Hypothesis
testing
session
So you are saying that you are no so sure about …
You’re not ready to…
You’re having a problem with…
 Used to highlight
Change talk
You’re feeling that…
Way of thinking
It’s been difficult for you…
You’re struggling with…
What a pisser!
Summaries
What - special, compound reflections
• Structure:
• Indicate you’re about to summarize
• Be selective
• Note ambivalence & attend to change statements
• Be concise!
• End with the good news
When
• Use to change directions or ask a key question
• Use to end
• Use when you don’t know what else to do!
Summaries: Examples
MI
Spirit
Ask for Change Talk and highlight it
So, if I’ve got it right, there are some things you
enjoy about drinking, and at the same time, you
pretty
y strong
g reasons for wanting
g to
have some p
change.
Try for a commitment to do something about
target behavior
Let me see if I understand you correctly. You’re
really not ready to quit drinking entirely, but you
would like to try cutting down to no more than
two drinks per day. Is that about right?
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Motivational Interviewing
May 6, 2010
What is Change Talk
MI
Spirit
Agree on a target behavior to talk about
Draw out client’s story about that target
behavior
Agree on a target behavior to talk about
I really need to talk about quitting smoking, because that’s
going to kill me.
Draw out client’s story about that target behavior
I don’t want to get cancer like my mother did.
Ask for Change Talk and highlight it
Hmm, I didn’t realize it was that bad…
Ask for Change Talk and highlight it
Share assessment results relevant to target behavior
I think I’d like to try quitting for a while.
Explore options for changing target behavior
I think I’d like to try quitting for a while.
Try for a commitment to do something about target behavior
I am definitely going to do this; I have no choice.
Finding Change Talk
in Ambivalence
Client
“I really don’t want to stop
smoking, but I know that I
should. I’ve tried before
y hard.”
and it’s really
***Just ask for it!
MI
Spirit
I’d like to hear you opinions about…
What are some things that bother you
about drinking?
MI
Spirit
Therapist
“You really don’t want to
quit.”
“It’s pretty clear to you
that you ought to quit.”
“You’re not sure if you
can quit.”
Eliciting Change Talk: Pros/Cons
MI
Spirit
Eliciting Change Talk: Examples
What role do you think alcohol played in
your arrest?
How would you like your drinking to be 5
years from now?
What to do when you hear Change Talk
What do you like about ____?
Elaborate
What Else?
What do you see as the downside of _____?
?
Affirm
What Else?
Summarize
both pros and cons
“On the one hand you
said…, on the other
hand you said…”
Reflect
• What else? What makes you say
that? What makes you feel that
way?
• I admire your open-mindedness…
open mindedness
• You’re doing some serious thinking
here…
• Sounds like you’re thinking about
making a change…
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Motivational Interviewing
May 6, 2010
Assessment Results
Agree on a target behavior to talk about
Draw out client’s story about that target
behavior
Ask for Change Talk and highlight it
Share assessment results relevant to
target behavior
Why share them?
• To make it more important to client that he/she
change
• To increase his/her concern with the status quo
• To show client that target behavior is not normal
Tips
•
•
•
•
•
Compose a sound bite to convey your message.
Expect push-back.
Don’t argue with “yeah, buts.”
Don’t defend the assessment process.
Just deliver the message and reflect client’s
responses.
Explore Options
Agree on a target behavior to talk about
Draw out client’s story about that target
behavior
Offer a
menu
• What have you considered trying?
• What have you done before?
• Would you like to hear any ideas from
me?
Ask
s for
o C
Change
a ge Talk
a a
and
d highlight
g g it
Share assessment results relevant to
target behavior
Explore options for changing target
behavior
In the
hypothetical
Try for a commitment to do something
about target behavior
Menu of Options: Drinking Example
MI
Spirit
Make no change whatsoever
Cut down
Don’t cut down but never drive after
Quit entirely
See a counselor
• If you wanted
to…
• If you decided
to…
• If the time
were right…
• How would you
do it?
• How would you
go about it?
• What would you
do?
Giving Advice: Example
MI
Spirit
There’s something
that concerns me.
Would it be ok if I
shared my
concerns with you?
OK if I offer a
suggestion?
MI
Inconsistent
The best thing for
you to do is to quit
right away.
Don’t do that,
because it will….
(Others that the client thinks of?)
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Motivational Interviewing
Giving Advice:
May 6, 2010
Giving Advice
Without Telling Someone What to Do
MI
Spirit
Provide Clear Information or Feedback
• The results of your test suggest that…
• What happens to some people is that…
• My recommendation would be that…
Elicit their reaction
• What do you think?
• What are your thoughts?
Ask:
• What do
you know
about the
effects of…
of
Tell:
• The results of
your tests
suggest that…
• What happens to
some people is
that…
• What
concerns do
you have
about…?
Ask:
• What do
you think?
• How does
that sound
to you?
• As your
doctor/counselor/
nurse, I strongly
urge you to…
Closing on Good Terms
S
Summarize
patient’s
views
E
Encouraging
remarks
W
What
agreement
was reached
is repeated
Especially
the prochange part
of what they
said
References

If you would like more information about
Motivational Interviewing, please go to:
Motivationalinterview.org
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