A nonprofit independent licensee of the Blue Cross Blue Shield Association
MOTIVATIONAL
INTERVIEWING
1
LEARNING OBJECTIVES
 Define motivational interviewing (MI) spirit, including:
 Listing the three definitions of MI.
 Interpreting four key components to the MI
spirit: partnership, acceptance, compassion and
evocation.
 Explain and use core interviewing skills of OARS - open questions,
affirming, reflecting and summarizing.
 Describe the flow of MI: engaging, focusing, evoking and planning.
 Define motivation, ambivalence, sustain talk and discord. Identify
how the concepts relate to the stages of change and the flow of MI.
 Define change talk and the concepts of: DARNCAT - desire, ability,
reason and need; commitment, activation and taking steps; and
instilling discrepancies.
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ACTIVITY
The Health & Safety Quiz
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WHAT IS MI?
 Person-centered style
 Collaborative conversation
 Strengthens a individual’s own desire, ability, readiness, need and
commitment to change
 Addresses and explores ambivalence about change
 More focused and goal-directed
4
MI SPIRIT
 Readiness to change is not a trait, but a fluctuating product of
interpersonal interaction.
 Therapeutic relationship is more like a partnership or
companionship than expert/patient roles.
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MI STYLE AS PREDICTOR OF CHANGE
Wrestling
Wandering
Dancing
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MORE ON MI STYLE
 The helper’s style is a powerful determinant of the individual’s
resistance and change.
 An empathetic style is more likely to bring out self-motivated
responses and less resistance.
 Each person has powerful potential for change.
 The task of the helper is to release that potential and facilitate
the natural change process that is already inherent in the
individual.
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MI STYLE: EXPRESSING EMPATHY
 The crucial attitude is one of acceptance.
 Skilful reflective listening is fundamental to the individual feeling
understood and cared about.
 Ambivalence is normal; the case manager or counselor should
demonstrate an understanding of the individual’s perspective.
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MI ACCORDING TO BILL MILLER
MI is:
 Researched for over 30 years
 Has identifiable mechanism of action
 Verifiable as to whether it is being delivered competently
 Generalizable across a wide variety of problem areas
 Relatively brief, specifiable, grounded in testable theory
 Learnable by a broad range of providers
 Evidence-based (200+ published randomized clinical trials)
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THEORETICAL INFLUENCES ON MI
Carl Rogers
Leon Festinger
Daryl Bem
Jim Prochaska and
Carlo Di Clemente
• Theory of the Critical Conditions for
Change
• Cognitive Dissonance Theory
• Self-Perception Theory
• The Transtheoretical Stages of
Change
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MI: CHANGE TALK VS. SUSTAIN TALK
MI will increase change talk:
 The extent to which individuals verbally argue for change
(change talk) will be directly related to behavior change.
MI will diminish resistance to change-sustain talk:
 The extent to which individuals verbally defend status quo
(resistance) will be inversely related to behavior change.
Against Change
(resistance)
For Change
(change talk)
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TRADITIONAL APPROACH VS. MI
Traditional
Approach
MI
• Confrontation
• Collaboration
• Educating
• Evocation
• Authority
• Autonomy
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MI’S ACTIVE COMPONENTS
MI emphasizes two specific active components:
1. Relational component:
 Focused on empathy and the interpersonal spirit of MI.
2. Technical component:
 Involving differential evocation and reinforcement of change talk.
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EFFECTIVE RELATIONAL AND TECHNICAL
COMPONENTS
 MI style and spirit
 Open ended questions
 Affirmations of strengths and self-efficacy
 Reflection statements
 Motivation to change/change talk
 Pro’s, cons, ambivalence
 Instilling discrepancies
 Fostering a collaborative relationship/autonomy
 Change planning discussion
 Patient-centered discussion and feedback
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OARS
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FOUR COMMUNICATION SKILLS: OARS
 Using OARS during the four core processes helps identify
the individual’s perception of their problems, motivation,
change efforts and plans.
 Asking open-ended questions
 Giving affirmations
 Using reflective listening
 Making summary statements
 Also: providing information with permission from the individual
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OARS: OPEN-ENDED QUESTIONS
Open questions have the following characteristics:
 They ask the respondent to think and reflect.
 They will give opinions and feelings.
 They hand control of the conversation to the respondent.
You say:
 “What would you like from treatment?”
 “Tell me about your drinking…”
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OARS: OPEN-ENDED QUESTIONS ACTIVITY
Change the following closed to open-ended questions:
1. “Hello, are you having a good day?”
2. “Have you been taking your medication?”
3. “Did you miss your outpatient appointment again?”
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OARS: AFFIRMATIONS
 Verbally reinforce strengths, abilities or efforts to change behavior.
 Develop confidence by praising small steps taken in the direction of
change.
 Express appreciation of personal qualities that might facilitate
efforts to change.
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OARS: REFLECTING LISTENING
•
Reflective •
listening
•
says...
•
Reflective
listening
is NOT:
“I hear you.”
“I’m accepting, not judging you.”
“This is important.”
“Please tell me more.”
• Directing, warning, advising, persuading,
moralizing, agreeing, disagreeing,
labeling, interpreting, reassuring,
questioning, withdrawing.
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OARS: REFLECTIVE STATEMENTS
Repeat: Repeat a small portion of what was said:
 “It sounds like…”
 “What I hear you saying…”
Rephrase: Say close to what was said, substituting a few words:



“It seems as if…”
“I get the sense that…”
“It feels as though…”
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OARS: REFLECTIVE STATEMENTS
 Straight reflection: Make sure to take your opinion out of the
equation, just reflect.
 Amplified Reflection: Reflect back what the person has said in
amplified or exaggerated form – to state it in a more extreme
fashion.
 Double-sided reflection: Reflect back both of the individual’s
conflicting perspectives, usually requiring the use of previously
verbalized material. Use the conjunction “and” instead of “but”
when doing this.
“So, on the one hand it sounds like… and yet on the other hand…”
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OARS: REFLECTIVE STATEMENTS
Patient statement: “Using drugs is the only way I can cope.”
Simple reflection:
 “You use in order to deal with stress?”
Complex reflection:
 “You are afraid that you cannot handle life without using drugs?”
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OARS: DEEPENING REFLECTIVE STATEMENTS
Patient statement: “I want to quit smoking because I don’t want
another heart attack. I want to see my grandkids grow up.”
Content:
 “You see a connection between your smoking and your heart
disease and you’re ready to take action?”
Feelings:
 “You’re scared you might have another heart attack and die
prematurely?”
Meaning:
 “Your grandchildren mean a lot to you and you want to be there
for them?”
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OARS: SUMMARIZING
Benefits of summarizing:
 Allows individual to hear themselves a second time.
 Can be used to end session or transition to a new topic.
 Allows the interviewer to again reflect both sides of the ambivalence.
 Provides a summary of the conversation so far.
 Wraps up the discussion in one or two sentences:
“So far, you’ve expressed concern about your grandkids,
getting a job and finding a safer place to live.”
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OARS: ACTIVITY
Practice:
In the Moment
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OARS: PROVIDING INFORMATION WITH
PERMISSION
Providing information with permission:
 “Would it be ok if we discussed some of the benefits of quitting
[insert negative behavior - e.g., smoking, drinking a six pack every
night]?”
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USING OARS
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Practice Exercise
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Flow of MI:
The Four Core Processes
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FOUR CORE PROCESSES OF MI
1. Engaging
• The Relational Foundation
2. Focusing
• The Strategic Focus
3. Evoking
• The Transition to MI
4. Planning
• The Bridge to Change
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ENGAGING-STEP ONE
1.
Engaging
2.
Focusing
3.
Evoking
4.
Planning
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FOUR CORE PROCESSES: ENGAGING
 Focus on desires and goals
 Identify importance of goals
 Explore positivity of achievement
 Identify expectations
 Establish a sense of hope of change
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ENGAGING: SKILLS NEEDED
Therapeutic engagement is a prerequisite for everything
that follows:
 Use active listening skills
 Express accurate empathy
 Use OARS non-directivity
 Avoiding righting reflex or “fixing”
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ENGAGING: ASKING PERMISSION
Communicates respect:
You say:
 “Do you mind if we talk about [insert behavior]?”
 “Can we talk a bit about your [insert behavior]?”
 “I noticed in your medical history that you have hypertension, do
you mind if we talk about how different lifestyle choices affect
hypertension?”
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ENGAGEMENT: TRAPS TO AVOID
 Assessment trap
 Expert trap
 Premature focus trap
 Labeling trap
 Blaming trap
 Chat trap
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Practice Exercise
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FOCUSING-STEP TWO
Planning
Evoking
Focusing
Engaging
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2ND CORE PROCESS: FOCUSING
What is it?
 Pre-requisite for evoking and the third process.
 Developing motivation, identifying where they are in the
process of change and what are the barriers.
 Guiding towards a target behavior that is important.
 Helping identify a target area about which the individual is ambivalent
or struggling with change.
 Being transparent about what the target is: “Based on the concerns
you shared, in what direction are we headed?”
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FOCUSING: TECHNIQUES
 Using agenda setting or a bubble chart to narrow the focus.
 Asking: “Which one seems the hardest or most important to
work on right now?” vs. use it to check in on all of the areas.
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Practice Exercise
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EVOKING-STEP THREE
Planning
Evoking
Focusing
Engaging
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3RD CORE PROCESS: EVOKING
What is it?
 Drawing out the individual’s intrinsic motivation.
 Drawing out individual’s own ideas and reasons for change.
 Use elicit-provide-elicit technique and advice with permission.
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EVOKING: CHANGE TALK
Change talk helps with successful outcomes because it elicits
reasons for change from individuals vs. lecturing:
You say:
 “What would you like to see different about your current situation?”
 “What would be the good things about changing your current
situation?”
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EVOKING: QUESTIONS TO ASK
 “What would you like to see different about your current situation?”
 “What makes you think you need to change?”
 “What will happen if you don’t change?”
 “What would be the good things about changing your [insert
risky/problem behavior]?”
 “What would your life be like three years from now if you changed
your [insert risky/problem behavior]?”

“Why do you think others are concerned about your [insert
risky/problem behavior]?”
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EVOKING: BEING SUPPORTIVE
Emphasis is on being supportive as the individual wants to
change, but is struggling.
You say:
 “How can I help you get past some of the difficulties you are
experiencing?”
 “If you were to decide to change, what would you have to do
to make this happen?”
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EVOKING: PROVOKING EXTREMES
When there is little expressed desire for change, have the
individual describe a possible extreme consequence.
You say:
 “Suppose you don’t change, what is the WORST thing that might
happen?”
 “What is the BEST thing you could imagine that could result from
changing?”
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Practice Exercise
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PLANNING-STEP FOUR
Planning
Evoking
Focusing
Engaging
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FOUR CORE PROCESSES: PLANNING
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FOUR CORE PROCESSES: PLANNING
What is it?
 Working to develop commitment to change and formulating specific
plan of action
 Recognize it is ongoing and needs to be revisited
 Identify the characteristics of “negotiation of change”
You say:
 When saying “Yes” to moving ahead, “What will that look like?”
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PLANNING: INCREASE PLANNING
DISCUSSION
Examples of what to say:
 “Who would/would not be supportive of this change?”
 “What might they say or do? Let’s practice that conversation...”
 “You aren’t ready to make that change now, but if you decide to
in the future...”
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PATIENT-CENTERED PROBLEM DISCUSSION
Examples of what to say:
Ask permission to discuss topic:
 “I wonder if it would be ok with you if we talked about your
diabetes?”
Explain you will not insist on immediate action:
 “I’d like to get a better idea of how you feel about your
eating, and please don’t worry, I’m not going to lecture
you, ok?”
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Practice Exercise
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Motivation, Ambivalence,
Sustain Talk & Discord
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MOTIVATION, AMBIVALENCE,
SUSTAIN TALK
Motivation
Ambivalence
Sustain Talk
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MI WITH STAGES OF CHANGE
Not ready to change.
Change has occurred
in the past; focus is on
relapse prevention.
Pre-contemplation
Maintenance
Doing change, has
a support system;
removing barriers.
Action
Stages
of
Change
Considering change,
working through
pro’s/con’s.
Contemplation
Ready to start taking
action; making small
steps towards change.
Preparation
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WHAT IS SUSTAIN TALK & DISCORD
What is “sustain talk?”
 “The individual’s own motivations and verbalizations favoring the
status quo.”
What is “discord?”
 “Not being on the same wavelength.”
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WHY INDIVIDUALS DO NOT CHANGE?
 There is significant ambivalence
 Hot stove, or rolling the dice
 My problems are not that bad
 Blame and shame
 Attachment to habits, old behaviors
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FEELINGS ABOUT CHANGE
It’s not so much that we’re afraid of change or so in love with the old
ways, but it’s that place in between that we fear… It’s like being
between trapezes. It’s Linus when his blanket is in the dryer. There’s
nothing to hold on to.
- Marilyn Ferguson, author, philosopher
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BEHAVIORS CONNECTED TO SUSTAIN TALK
Individuals who present with sustain talk may exhibit the
following behaviors:
 Making excuses
 Challenging, hostile language (verbal and non-verbal)
 Minimizing importance or significance
 Blaming others
 Ignoring
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RESPONDING TO SUSTAIN TALK
Skills for responding to sustain talk:
 Reflective listening
 Emphasizing autonomy
 Reframing
 Agreeing with a twist
 Running head start
 Coming alongside
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IDENTIFYING DISCORD
Discord: Signals of disharmony in your collaborative relationship.
Signs of discord:
 Defending
 Squaring off
 Interrupting
 Disengagement
Tune your ear to hear signals of dissonance and
recognize them as important - Miller and Rollnick
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RESPONDING TO DISCORD
Skills for responding to discord:
 Reflection
 Apologizing
 Affirming
 Shifting focus
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SUSTAIN TALK & DISCORD
 Sustain talk is a normal part of the ambivalence and should not
be misinterpreted as “resistance.”
 Discord signals dissonance in your working relationship.
 Both can increase or decrease depending on how the interviewer
responds.
 Discord can arise for different reasons across the four processes
of MI.
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COMMON MISTAKE
When the individual senses the counselor is more invested in
change than they are, it destroys a healthy therapeutic
relationship.
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Practice Exercise
67
Change Talk:
DARNCAT
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CHANGE TALK: DARNCAT
DARN - desire, ability, reasons and need have something in common:
 They are pre-commitment forms of change talk.
 They are leading in the direction of change, but by themselves, they
do not trigger behavior change.
 To say: “I want to” isn’t to say “I am going to.”
 To say: “I can” is not the same as “I will.”
 To express reasons for change is not the same as agreeing to do it.
To say: “I need to” is still not saying “I intend to.”
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CHANGE TALK: DARNCAT
Actively listen for the individual’s change talk:
 DESIRE – “I want, I wish, I would like to…”
 ABILITY – “I can, I could, I would be able to…”
 REASON – “If I can…, then I can…”
 NEED – “I have to, I need to, I must…”
 COMMITMENT – “I will…, I am…”
 ACTIVATION – “I’m willing to…, I’m ready to…”
 TAKING STEPS – “I went to…, I called…”
70
CHANGE TALK: DESIRE FOR CHANGE
Desire statements tell you about the
individual’s preferences for change
or the status quo:
Individual would say:
 “I’d like to quit drinking if I could.”
 “I wish I could make my life better.”
 “I want to take better care of my kids.”
 “Getting in shape would make me feel so much better about myself.”
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CHANGE TALK: ABILITY TO CHANGE
Ability-related change talk signals motivational strength:
 “I definitely can” reflects much stronger confidence than
“I probably could”
Individual would say:
 “I think I could do that.”
 “That might be possible.”
 “I’m think I may be able to cut back on cigarettes.”
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CHANGE TALK: REASONS FOR CHANGE
Reasons are the specific arguments for change:
Individual would say:
 “To keep my truck driving license, I should probably cut down on
my drinking.”
 “My husband may leave me if I don’t go to therapy.”
73
CHANGE TALK: NEED FOR CHANGE
Statements about feeling obliged to change:
Individual would say:
 “I ought to make better food choices.”
 “I have to get some sleep.”
 “I really should get more exercise.”
74
CHANGE TALK: COMMITMENT TO CHANGE
Statements about the likelihood of change:
Individual with strong commitment would say:
 “I promise”
 “I will”
 “I intend to”
 “I am ready to”
Individual with lower levels of commitment would say:
 “I will think about it”
 “I’ll consider it”
 “I plan to”
 “I will try to”
75
CHANGE TALK: ACTIVATION TOWARDS CHANGE
Statements indicating movement towards change:
Individual would say:
 “I am willing to make better food choices.”
 “I am prepared to get more exercise.”
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CHANGE TALK: TAKING STEPS TOWARDS
CHANGE
Statements indicating movement towards change:
Individual would say:
 “I went to a support group meeting.”
 “I called three places about possible jobs.”
 “I bought some running shoes so I can exercise.”
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CHANGE TALK: STRATEGIES AND
TECHNIQUES
What MI strategies and techniques can we use when a
individual engages in change talk?
 Scaling exercises
 Circular questions
 Looking forward/looking back
 The miracle question
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Practice Exercise
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CHANGE TALK: SCALING EXERCISES
Importance/Confidence/Commitment Scale
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SCALING EXERCISES: SIX STEPS
A standard and complete application of scaling questions
contains the following six steps:
1. Explain the scaling question: “Imagine a scale from 0 to 10.
The 10 represents your desired situation and the 0 represents
the situation in which nothing of that desired situation has yet
been achieved.”
2. Ask: “Where are you now on this scale?”
3. Ask: “How did you manage to get there?”
4. Ask about a past success: “What was different, then? What
did you do differently? What worked well?”
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SCALING EXERCISES CONTINUED
5. Invite the individual to describe what the situation will be like
when they will be one step higher on the scale: “What will one
step higher on the scale look like? How will you notice you will have
reached one step higher on the scale? What will be different then?
What will you be able to do then?”
6. Ask about a small step forward: Invite them to name one step
forward they might take. “Has what we’ve discussed been helpful for
you for choosing a step forward? What might that step be? In what
situation might you take that step?”
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SCALING EXERCISES CONTINUED
Desired situation: what is your goal?
Past success: when have things been better?
Visualize moving one step higher on the scale:
what needs to happen to make that possible?
One step forward...
Current position: why are you here now?
What keeps you from being a lower score: what
are the past successes, solutions, resources or
useful circumstances that were helpful?
Nothing of the desired situation has yet been
achieved.
83
ELICITING CHANGE TALK TECHNIQUES
Examples of what to say:
Circular questions:
 “If your husband were here, what would he say?”
Looking forward or looking back:
 “If you were to look back on this decision five years from now,
how would that be different?”
 “Was there a time when this situation was better... How did
that look?”
 “If things were better than you could ever imagine, who would
be the first person in your life to notice...What would they
see?”
84
ELICITING CHANGE TALK
Examples of additional questions to ask:

“If you decided to change, what do you think would work for you?”

“What makes you think you can change, if you decided to?”

“What do you see in yourself in terms of ability that might be
encouraging, if you decided to change?”
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CHANGE TALK AND THE MIRACLE QUESTION
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EXPLORING PROS, CONS & AMBIVALENCE
 Address or explore positive and negative effects or results of
the individual’s behavior.
 Use decisional balancing by completing a cost-benefits
analysis, or develop a list of pros and cons.
 Express appreciation for ambivalence as a normal part of the
change process.
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EXAMPLE OF DECISIONAL BALANCE TREE
(PRO/CON ACTIVITY)
88
DECISIONAL BALANCE SHEET FOR
PROS/CONS
Considering a change about: _____________________.
Stay the Same
Change
Benefits of...
Costs of...
89
WHY INSTILL DISCREPANCIES?
When a discrepancy between present behavior and goals is
perceived, then motivation for change is created.
Function of instilling discrepancies is to:
 Heighten internal conflicts
 Increase awareness
 Create cognitive dissonance
90
EXAMPLES OF INSTILLING DISCREPANCIES





“On the one hand... On the other hand...”
“I’m confused, help me understand...”
“What were the risks of...”
“When faced with that decision again...”
“For you, were there not so good things about...”
91
HOW TO INSTILL DISCREPANCIES
“What are the good things about _____________?”
 “What else? Anything else that’s good about ______?”
“Okay, and what are the not so good things about ________?”
 “Tell me more... Anything else that’s not so good?”
“So on one hand, you say (insert the good things, be very brief)
and on the other hand (insert bad things, be more detailed)...”
 Is that correct?”
92
SUPPORTING AUTONOMY BY FOSTERING
A COLLABORATIVE ATMOSPHERE
 Convey in words or actions that this is a collaborative relationship.
 Emphasize greater importance of their own decisions, confidence
and perception.
 Verbalize respect for the individual’s autonomy and personal choices.
Examples:
 “What do you think you will do?”
 “What would you like to see happen?”
 “How do you want to proceed?”
 “What can we do together?”
93
MI EFFECTIVE VIDEOS
94
MI IS NOT
About Asking:
 “Why haven’t you changed?”
 “What keeps you doing this?”
 “Why do you have to _______?”
 “What were you thinking when you ______?”
 “Why can’t you _______?”
95
MI IS NOT


Giving unsolicited advice,
direction or feedback

Stages of change

Does not require use of
assessment feedback

A way of manipulating people
into doing what we want them
to do

A panacea or answer to all
clinical issues

A technique
Direct confrontation and
creating resistance

Being nice to people

Carl Rodgers’ non-directive
counseling approach
96
FIDELITY
 Fidelity: Degree to which our MI practices reproduce the original
style and intent.
 There is some flexibility, but results are most affective if we
follow the “recipe.”
 Motivational Interviewing Strategies & Techniques:
Rationales and examples:
 www.nova.edu/gsc/forms/mi_rationale_techniques.pdf
97
ANOTHER WAY TO LOOK AT MI
98
WHAT IS THE MOST IMPORTANT SKILL
FOR EFFECTIVE MI?
An empathic style seems to facilitate change. Its absence
deters change.
 Individuals who believe that they are likely to change do so.
 Individuals whose helpers believe that they are likely to change
do so.
 Those who are told that they are not expected to improve do
not.
99
CULTURAL COMPETENCE & MI
Embracing cultural competence can help to facilitate
change:
 Understanding and appreciate a patient's cultural background
can expand treatment opportunities
 Enhancing the sensitivity and capacity to treat patients from
other cultures improves a program's ability to treat all patients
100
MI FLOW
 People first talk about what they want to do (desire), why they
would change (reasons), how they could do it (ability) and how
important it is (need).
 When you evoke a persons own desire, ability, reasons, need and
commitment for change, you are fueling the human engines of
change.
101
MI IMPLEMENTATION & TIME
102
BENEFITS OF USING MI
 Effective across populations and cultures
 More realistic expectations
 Greater recognition of small accomplishments and greater success
over time
 Less staff frustration and burnout
 Actively involves the person in his/her own care
 Consistent with recovery transformation model
 Improves adherence to treatment plans and retention
 Instills hope
103
104
WHAT QUESTIONS DO YOU HAVE?
105
LEARNING OBJECTIVES
Can you:
 Define MI spirit and:
 List the three definitions of MI
 Interpret four key components to the MI spirit: partnership,
acceptance, compassion and evocation.
 Explain and use core interviewing skills of OARS - open questions,
affirming, reflecting and summarizing.
 Describe the flow of MI: engaging, focusing, evoking, and planning.
 Define motivation, ambivalence, sustain talk and discord; and
identify how the concepts relate to the stages of change and the flow
of MI.
 Define change talk and the concepts of: DARNCAT - desire, ability,
reason and need; commitment, activation and taking steps; and
instilling discrepancies.
106
PARTING THOUGHT…
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REFERENCES
Miller, W., & Rollnick, S. (2013). Motivational Interviewing : Helping people change (3rd ed.). New York:
Guilford Press.
Rollnick S., & Miller, W.R. (1995). What is motivational interviewing? Behavioural (sic) and Cognitive
Psychotherapy, 23, 325-334.
Sobell, L. C., & Sobell, M. B. (2008). Motivational
Interviewing strategies and techniques: Rationales
and examples. Retrieved from http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf
MINT: Excellence in Motivational Interviewing; The Motivational Network of Trainers; (2014)
http://www.motivationalinterviewing.org/sites/default/files/tnt_manual_2014_d10_20150205.pdf
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APPENDIX: LEARNING ACTIVITIES
The following activities are from the MINT Manual – Motivational
Interviewing Training New Trainers Manual
1.) Introduction: The Health and Safety Quiz
2.) OARS:
“In The Moment”
“Choosing Elements”
“Reflective Responses to Sentence Stems – Three Levels”
3.) Engaging: “Thinking Reflectively”
4.) Focusing: “3-Month Priorities”
5.) Evoking: “Evoking Confidence”
6.) Planning: “Round Robin”
7.) Sustain Talk and Discord:
“Batting Practice”
“Three Chairs Exercise”
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