Using Motivational Interviewing In the Therapeutic Process

TIP 35 by William R. Miller, PhD Motivational Interviewing:a therapeutic style intended to help clinicians work with clients to address the client’s continuous fluctuation between opposing behaviors and thoughts.

Three Components of MI Spirit Collaboration Evocation Autonomy Working in partnership Draw out ideas and solutions from individuals Decision making left to the person

Spirit of MI Motivation to change is elicited from the person, not externally It is the person’s task, not the counselor’s, to articulate and resolve ambivalence Direct persuasion is not an effective method for resolving ambivalence The counselor’s style is generally a quiet and eliciting one The counselor is directive only in helping the person to examine and resolve ambivalence Readiness to change is a fluctuating product of interpersonal interaction. The therapeutic relationship is more like a partnership or collaboration than expert/recipient role.

Characteristics of Motivational Interviewing Guiding, more than directing Dancing, rather than wrestling Listening, as much as telling Collaborative conversation Evokes from a person what he/she already has Honoring of a person’s autonomy Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care, 2008.

What do we know about Motivation? It is fundamental to change It fluctuates It can be modified It is influenced by external factors and social interactions It is very sensitive to interpersonal style There are internal and external sources We want to increase the probability of the person engaging in change behavior Motivating is an inherent part of our job

What is Ambivalence? I want to, but I don’t want to Natural phase in the process of change Normal aspect of human nature, not pathological Ambivalence is key issue to resolve for change to occur It is our friend

C hanging Extrinsic to Intrinsic Motivation Changing because I want to Know and explore values Core value discrepancy motivates change Explore life goals; discrepancy between where the person is and where he/she wants to be Choice/Self Determination Reframing the person’s negative statements

PRINCIPLES OF MOTIVATIONAL INTERVIEWING… “AREDS” A- Avoid Arguing R- ROLL WITH RESISTANCE E- EXPRESS EMPATHY D- DEVELOP DISCREPANCY S- SUPPORT SELF EFFICACY

MI Skills “AROSE” AFFIRMATIONS REFLECTIVE LISTENING OPEN ENDED QUESTIONS SUMMARIES ELICIT CHANGE TALK

Strategies To Elicit Change Talk Asking Evocative Questions Using Readiness Rulers Exploring the Decisional Balance Looking Back/Looking Forward Using hypotheticals Key Questions Source: S. Rollnick, W. Miller and C. Butler, Motivational Interviewing in Health Care, 2008.

Appropriate Motivational Strategies for Each Stage of Change Client's Stage of ChangeAppropriate Motivational Strategies for the Clinician Precontemplation The client is not yet considering change or is unwilling or unable to change. Establish rapport, ask permission, and build trust. Raise doubts or concerns in the client about. substance-using patterns Express concern and keep the door open.

Client's Stage of ChangeAppropriate Motivational Strategies for the Clinician Contemplation The client acknowledges concerns and is considering the possibility of change but is ambivalent and uncertain. Normalize ambivalence. Help the client "tip the decisional balance scales" toward change. Elicit and summarize self- motivational statements of intent and commitment from the client. Elicit ideas regarding the client's perceived self- efficacy and expectations regarding treatment.

Client's Stage of ChangeAppropriate Motivational Strategies for the Clinician Preparation The client is committed to and planning to make a change in the near future but is still considering what to do. 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 ChangeAppropriate Motivational Strategies for the Clinician Action The client is actively taking steps to change but has not yet reached a stable state. Engage the client in treatment and reinforce the importance of remaining in recovery. Acknowledge difficulties for the client in early stages of change. Help the client identify high-risk situations through a functional analysis and develop appropriate coping strategies to overcome these.

Client's Stage of ChangeAppropriate Motivational Strategies for the Clinician Maintenance The client has achieved initial goals such as abstinence and is now working to maintain gains. Support lifestyle changes. Affirm the client's resolve and self-efficacy. Help the client practice and use new coping strategies to avoid a return to use. Develop a "fire escape" plan if the client resumes substance use. Review long-term goals with the client.

Client's Stage of ChangeAppropriate Motivational Strategies for the Clinician Recurrence The client has experienced a recurrence of symptoms and must now cope with consequences and decide what to do next. Help the client reenter the change cycle and commend any willingness to reconsider positive change. Explore the meaning and reality of the recurrence as a learning opportunity. Assist the client in finding alternative coping strategies. Maintain supportive contact.

Skills Express EMPATHY through reflective listening. Develop discrepancy or inconsistencies between client goals and current behavior. Avoid argument and direct confrontation. Adjust to client’s resistance rather than opposing it directly. Support self- efficacy and optimism.

Expressing Empathy Acceptance facilitates change Skillful reflective listening is fundamental to expressing empathy Ambivalence is normal.

Develop Discrepancy Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes for the future. One useful tactic for helping a client perceive discrepancy is sometimes called the "Columbo approach" (Kanfer and Schefft, 1988).(Kanfer and Schefft, 1988)

Developing Discrepancy Developing awareness of consequences helps clients examine their behavior. A discrepancy between present behavior and important goals motivates change. The client should present the arguments for change. Source: Miller and Rollnick, 1991.Miller and Rollnick, 1991.

The Columbo Approach Using the Columbo approach, the clinician plays the role of a detective who is trying to solve a mystery but is having a difficult time because the clues don't add up. The "Columbo clinician" engages the client in solving the mystery.

Four Types of Client Resistance Arguing The client contests the accuracy, expertise, or integrity of the clinician.

“Resistance Continued” Interrupting The client breaks in and interrupts the clinician in a defensive manner.

“Resistance Continued” Denying The client expresses unwillingness to recognize problems, cooperate, accept responsibility, or take advice.

“Resistance Continued” Ignoring The client shows evidence of ignoring or not following the clinician.

Simple Reflection The simplest approach to responding to resistance is with nonresistance, by repeating the client's statement in a neutral form. This acknowledges and validates what the client has said and can elicit an opposite response.

Amplified Reflection Another strategy is to reflect the client's statement in an exaggerated form--to state it in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.

Double-sided Reflection A third strategy entails acknowledging what the client has said but then also stating contrary things she has said in the past. This requires the use of information that the client has offered previously, although perhaps not in the same session.

Shifting Focus You can defuse resistance by helping the client shift focus away from obstacles and barriers. This method offers an opportunity to affirm your client's personal choice regarding the conduct of his own life.

Agreement With a Twist A subtle strategy is to agree with the client, but with a slight twist or change of direction that propels the discussion forward.

Reframing A good strategy to use when a client denies personal problems is reframing--offering a new and positive interpretation of negative information provided by the client. Reframing "acknowledges the validity of the client's raw observations, but offers a new meaning...for them" (Miller and Rollnick, 1991, p. 107).(Miller and Rollnick, 1991, p. 107).

Rolling With Resistance Momentum can be used to good advantage. Perceptions can be shifted. New perspectives are invited but not imposed. The client is a valuable resource in finding solutions to problems. Source: Miller and Rollnick, Reprinted with permission.Miller and Rollnick, 1991.

Siding With the Negative One more strategy for adapting to client resistance is to "side with the negative"--to take up the negative voice in the discussion. If your client is ambivalent, your taking the negative side of the argument evokes a "Yes, but..." from the client, who then expresses the other (positive) side.

Self-Efficacy Belief in the possibility of change is an important motivator. The client is responsible for choosing and carrying out personal change. There is hope in the range of alternative approaches available. Source: Miller and Rollnick, Reprinted with permission.Miller and Rollnick, 1991.

Avoiding Arguments Arguments are counterproductive. Defending breeds defensiveness. Resistance is a signal to change strategies. Labeling is unnecessary. Source: Miller and Rollnick, Reprinted with permission.Miller and Rollnick, 1991.

Ask Open-Ended Questions Asking open-ended questions helps you understand your clients' point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response.

Listen Reflectively "Reflective listening is a way of checking rather than assuming that you know what is meant" (Miller and Rollnick, 1991, p. 75).(Miller and Rollnick, 1991, p. 75).

Summarize "Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on" (Miller and Rollnick, 1991, p. 78).(Miller and Rollnick, 1991, p. 78).

Affirm When it is done sincerely, affirming your client supports and promotes self-efficacy.

Four types of Motivational Statements Cognitive recognition of the problem (e.g., "I guess this is more serious than I thought.") Affective expression of concern about the perceived problem (e.g., "I'm really worried about what is happening to me.") A direct or implicit intention to change behavior (e.g., "I've got to do something about this.") Optimism about one's ability to change (e.g., "I know that if I try, I can really do it.")