1. MOTIVATIONAL INTERVIEWING AS A COUNSELING STYLE
NAOMI C. SANCHEZ,RP,MS PSYCH, Ph.D.

2. SOURCE: ENHANCING MOTIVATION FOR CHANGE IN SUBSTANCE ABUSE TREATMENT (Matrix Intensive Outpatient Program Training) .

3. “…THE TONGUE OF THE WISE BRINGS HEALING.” PROVERBS 12:18

4. “…THE TAMED TONGUE SUBDUES THE ADVERSARY.” Washington Gladden

5. Helping people change Start “where the client is”
Helping people change involves increasing their awareness of their need to change and helping them to start moving through the stages of change.
Start “where the client is”
Positive approaches are more effective than confrontation – particularly in an outpatient setting.
Instructions
Remind participants that Motivational Interviewing is just one of many approaches to helping people change. The trainer is not implying that other approaches (i.e., confrontational) are wrong or should never be used. Clarify the concept that you are presenting one more tool to be available in the clinician’s arsenal of approaches to use when circumstances indicate. In order to have the tool available, it is necessary to become proficient in its use.

6. The Concept of Motivation (1)
“Motivation can be defined as the probability that a person will enter into, continue, and adhere to a specific change strategy” (Council of Philosophical Studies, 1981)
Motivation is a key to change
Motivation is multidimensional
Motivation is dynamic and fluctuating

7. The Concept of Motivation (2)
Motivation is influenced by the clinician’s style
Motivation can be modified
The clinician’s task is to elicit and enhance motivation
“Lack of motivation” is a challenge for the clinician’s therapeutic skills, not a fault for which to blame our clients

8. General Motivational Strategies
giving ADVICE
removing BARRIERS
providing CHOICE
decreasing DESIRABILITY
practicing EMPATHY
providing FEEDBACK
clarifying GOALS
active HELPING
Notes
(Source: Miller, W. & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change addictive behaviour. New York: the Guildford Press)

9. The Concept of Ambivalence (2)
Ambivalence is normal
clients usually enter treatment with fluctuating and conflicting motivations
they “want to change and don’t want to change”
“working with ambivalence is working with the heart of the problem”

11. OUR INTERPRETATION of Motivation
Clients were considered motivated if they-
Agreed to participate in a program’s course of treatment;
Were compliant with treatment activities; and
Accepted the label of “alcoholic” or “drug dependent”

12. Clients were considered unmotivated if they-
Resisted a diagnosis; or
Refused to adhere to a program’s treatment protocol.

13. Motivation for change is related to the level of probability that a person who uses substances will-
Enter treatment;
Continue in treatment; and
Adhere to a specific change strategy.

14. WHAT IS MOTIVATION ? A reason to desire or act
That which gives purpose and direction to behavior
Static – either does or does not have
Dynamic – changeable and can be influenced

15. According to the view of motivation as static
A clinician has little chance of influencing a client’s motivation.
If a client is not motivated to change, it is the client’s problem (or even fault).

16. According to the view of motivation as dynamic
Purposeful;
Intentional;
Positive; and
Changeable.

17. The client ultimately is responsible for change
Belief inherent in the view of motivation as dynamic and in motivational approaches in general is that-
The client ultimately is responsible for change
This responsibility is shared with the clinician through a therapeutic partnership.

18. The Spirit of Motivational Interviewing
Collaboration
Evocation
Autonomy

19. Why Enhance Motivation?
Motivation- enhancing approaches are associated with …..
Greater participation in treatment;

20. Positive treatment outcomes such as-
Reduction in consumption of substances;
Increased rates of abstinence from substance;
Positive social adjustment;
Successful referrals to treatment; and
A positive attitude toward change and a commitment to change.

21. 3 Critical Elements of Motivation
ABILITY refers to the extent to which the person has the necessary skills, resources, and confidence to carry out a change.
WILLINGNESS involves the importance a person places on changing- how much a change is wanted or desired.
READINESS represents a final step in which the person decides to change a particular behavior.

22. 7 Assumptions About the Nature of Motivation
Is a key to change;
Is multidimensional;
Is dynamic and fluctuating;
Is influenced by social interactions;
Can be modified;
Is influenced by the clinician’s style; and
The clinician’s task is to elicit and enhance motivation.

23. Individual’s motivation to change can be influenced strongly by;
Family;
Friends;
Emotions;
Community support.

24. Situations/Experiences that might prompt a Person to Begin Thinking about Changing
Distress levels

25. 2. Critical life events, such as-
Spiritual inspiration or religious conversion;
Traumatic accident or severe illness;
Death of a loved one;
Being fired;
Becoming pregnant; or
Getting married.

26. What one thinks about the effect of substances on his or her life;
Recognition of the harm or hurt one has inflicted on the others or oneself;
Positive and negative external incentives, such as-
Supportive and empathic friends;
Rewards; and
Coercion of various types.

27. Assumption 6: Motivation is Influenced by Clinician’s Style
Clinician style may be one of the most important, and most often ignored, variables for predicting client response to an intervention, accounting for more of the variance than client characteristics.

28. .
A review of the literature on clinician characteristics associated with substance abuse treatment effectiveness found that the ability to establish a helping alliance and good interpersonal skills were more important than a clinician’s professional training or experience.

29. Desirable Attributes of Clinicians
Non- possessive warmth;
Friendliness;
Genuineness;
Respect;
Ability to affirm;
Empathy.

30. Assumption 7: The Clinician’s Task is to Elicit and Enhance Motivation
Recognizing behavior that is not in their best interest;
Regarding positive change to be in their best interest;

31. Assumption 7: The Clinician’s Task is to Elicit and Enhance Motivation
Feeling competent to change;
Developing a plan for change;
Beginning to take action; and
Continuing to use strategies that discourage a return to the old behavior.

32. Motivational Interviewing

34. Motivational Interviewing (MI)
“MI is a directive, client-centered method for enhancing intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

35. Motivational Interviewing (MI)
“MI is a way of being with a client, not just a set of techniques for doing counseling” (Miller and Rollnick, 1991)

36. MI: Strategic goals Resolve ambivalence
Avoid eliciting or strengthening resistance
Elicit “Change Talk” from the client
Enhance motivation and commitment for change
Help the client go through the Stages of Change

37. MI - The Spirit (1) : Style
nonjudgmental and collaborative
based on client and clinician partnership
gently persuasive
more supportive than argumentative
listens rather than tells
communicates respect and acceptance for clients and their feelings

38. MI - The Spirit (2) : Style
explores client’s perceptions without labeling or correcting them
no teaching, modeling, skill-training
resistance is seen as an interpersonal behavior pattern influenced by the clinician’s behavior
resistance is met with reflection

39. MI - The Spirit (3) : Client
Responsibility for change is left with the client
Change arises from within rather than imposed from without
Emphasis on client’s personal choice for deciding future behavior
Focus on eliciting the client’s own concerns

40. MI - The Spirit (4) : Clinician
Implies a strong sense of purpose
Seeks to create and amplify the client’s discrepancy in order to enhance motivation
Elicits possible change strategies from the client
Systematically directs client toward motivation for change

41. Important considerations
The clinician’s counselling style is one of the most important aspects of motivational interviewing:
Use reflective listening and empathy
Avoid confrontation
Work as a team against “the problem”
Notes
The success of motivational interviewing is subject to the client’s awareness of the personal consequences of their own drug use patterns. The intervention should elicit from clients their concerns about drug use and arguments for change. The clinician should focus on the attitudes and values of the client, assist the client to make their own decisions, and attempt to direct their motivation towards positive behaviour change.
(Source: Adapted from Addy and Ritter, 2000)

42. Determination/ Preparation
Motivating for change
Maintenance
Action
Determination/ Preparation
Notes
The clinician’s counselling style is one of the most important aspects of effective motivational interviewing, and can be a powerful determinant of client resistance and change. Based on the assumption that ambivalence is normal and acceptance facilitates change, the counsellor should use reflective listening to express empathy. In motivational interviewing, a client should never feel they are being confronted by the clinician. Rather, they should feel like a collaborative effort is being made against “the problem.”
(Source: Adapted from Addy & Ritter, 2000)
Contemplation
Pre-contemplation

43. Determination/ Preparation
Motivating for change
Maintenance
Relapse Prevention
Action
Options Menu
Determination/ Preparation
Develop Discrepancy
Notes
The clinician’s counselling style is one of the most important aspects of effective motivational interviewing, and can be a powerful determinant of client resistance and change. Based on the assumption that ambivalence is normal and acceptance facilitates change, the counsellor should use reflective listening to express empathy. In motivational interviewing, a client should never feel they are being confronted by the clinician. Rather, they should feel like a collaborative effort is being made against “the problem.”
(Source: Adapted from Addy & Ritter, 2000)
Contemplation
Education
Pre-contemplation

44. Stages of Readiness “Principles”
Motivation exists along a continuum of readiness;
Clients progress through stages in a spiral (not linear);
When enhancing motivation, if the clinicians use strategies in a stage other than the one the client is in, the result could be treatment noncompliance;
Will describe typical client attitudes and actions at each stage and suggest strategies & techniques clinicians can use to move clients from one stage to the next.
Explain the relapse process

45. Relapse is an event, not a stage.
If clinicians push clients at a faster pace than they are ready to take, the therapeutic alliance may break down;
Relapse is an event, not a stage.
Will describe typical client attitudes and actions at each stage and suggest strategies & techniques clinicians can use to move clients from one stage to the next.
Explain the relapse process

46. Stage of Change Model Prochaska & DiClemente (1992)
PRECONTEMPLATION
CONTEMPLATION
PREPARATION
ACTION
MAINTENANCE

47. Stage 1: Pre-Contemplation
Individual is unaware, unable, unwilling
to change. No intent to change.
Indicators: argue, interrupt, deny, ignore, avoid reading, talking, or thinking about the behavior…
Individual is traditionally characterized as resistant, unmotivated.

48. Stage 1: Pre-Contemplation: Clinical Tools
Establish rapport
Determine why the client has come to you.
Introduce ambivalence about recovery – why it might be a good idea, e.g., “why do you think other people decide to manage their disorders?”
Give information on risks, pros & cons of use
Acknowledge the client’s thoughts, feelings, fears, and concerns.
Keep the interview informal
Ask permission
Build trust
Explore the meaning of events that brought the client to treatment or the results of previous treatments
Elicit client’s perception of the problem
Providing personalized feedback about assessment findings (if applicable)
Helping significant other intervene
Examine discrepancies between the client’s and others’ perceptions of the problem behavior
Express concern
Keep the door open.
Effective catalysts for change:
Consciousness raising
Environmental reevaluation
Emotional arousal and dramatic relief.

49. Stage 2: Contemplation
Individual is ambivalent or uncertain regarding behavior change.
Indicators: Individual meets clinician “half way,” willing to look at pros and cons of behavior change
Individual is traditionally characterized as unpredictable, time intensive.

50. Stage 2: Contemplation Clinical Tools
Discuss & weigh pros/cons of recovery
Emphasize client's free choice & responsibility
Elicit self-motivational statements
Discuss the client’s goals in life, how will recovery affect these?
Reduce the fear of recovery through example and problem solving
Ask questions that clarify motivation e.g., “what’s most important to you… why?”
Normalize ambivalence
Help the client “tip the decisional balance scales” toward change by:
Changing extrinsic to intrinsic motivation
Examine the client’s personal values in relation to change
Elicit self-motivational statements of intent and commitment from the client
Elicit ideas regarding the client’s perceived self-efficacy and expectations regarding treatment
Summarize self-motivational statements.
Effective catalysts for change:
Self-reevaluation
Emotional arousal and dramatic relief
Environmental re-evaluation
“When you want to keep your motivation for doing something, what are some of the things you say to yourself?”

51. Stage 3: Preparation
Individual shifts from thinking about behavior change to planning first steps.
Indicators: Individual asks questions, considers options, demonstrates openness in considering behavior change.
Individual is traditionally characterized as compliant, “coming along,”, “good to work with.”

52. Stage 3: Preparation Clinical Tools
Support efforts to change
Clarify goals & identify successful strategies
Structure plan of action with client based on client’s history and willingness, allowing client to decide
Encourage client to commit to action
Give client clear, consistent and unequivocal message about recovery
With permission, offer expertise and advice
Consider and lower barriers to change
Help the client enlist social support
Explore treatment expectancies & client’s role
Elicit from the client what has worked in the past either for him or others whom s/he knows.
Assist client negotiate finances, child care, work, transportation, other potential barriers.
Have the client publicly announce plans to change get into treatment..
Effective catalysts for change:
Self-liberation
Counterconditioning
Helping relationships

53. Stage 4: Action
Individual demonstrates steps toward behavior change such as periods of abstinence.
Indicators: Individual is receptive to clinical interventions. Treatment compliance is normal. Demonstrated behavior change affects positive outcomes in other areas (i.e., relationships at home and work).
Individual is traditionally characterized as “successful,” “working the program.”

54. Stage 4: Action Clinical Tools
Seek commitment to specific behavioral change at each session
Acknowledge difficulties, support even minimal progress
Identify risky situations, triggers & coping strategies
Help client find new reinforcers
Support perseverance (“Sticking to the plan”)
Engage the client in treatment
Reinforce the importance of remaining in recovery
Support a realistic view of change through small steps.
Help the client assess whether s/he has strong family and social support.
Effective catalyst for change:
Counterconditioning
Stimulus control
Reinforcement management
Helping relationships
Self-liberation
At this stage, clients are receptive to the full range of counselor techniques, but client motivation often wax and wane along a spiral.
If relapse occurs, the counselor “backs up” and applies techniques from earlier stage.
For example, “Relapse is an event, but not an cat of magic, se let’s look at what was going on just before you resumed using. One we identify some of what you were thinking and feeling, we can devise some ways to choose differently.”

55. Stage 5: Maintenance Individual sustains treatment goals.
Indicators: Individual has made behavior changes, practices stable abstinence, met treatment goals, and practices healthy coping strategies.
Individual is traditionally characterized as “ready for successful discharge,” “no longer needing treatment,” “ready for aftercare.”

56. Stage 5: Maintenance Clinical Tools
Support and affirm changes
Rehearse new coping strategies and countermeasures to triggers
Review personal growth long-term goals
Encourage client to contribute to recovery of others
Help client identify and sample drug-free sources of pleasure (new reinforcers)
Affirm the client’s resolve and self-efficacy
Help the client practice & use new coping strategies to avoid relapse
Explain to the client you are available to talk between sessions
Together develop a “fire escape” plan if client relapses
Such as:
Treatment Plan
Awareness of risky situations
Coping strategies for each situation
Participation in 12-Step programs
Pursuit of hobbies & cultural activities
Volunteer opportunities
The counselor reminds the client of progress.
Effective catalysts for change:
Helping relationships
Environmental reevaluation
Self-liberation
Reinforcement management

57. Appropriate Motivational Strategies for Each Stage of Change
Client's Stage of Change
Appropriate Motivational Strategies for the Clinician
Stage 1: 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

58. Client's Stage of Change
Appropriate Motivational Strategies for the Clinician
Stage 2: 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.

59. Client's Stage of Change
Appropriate Motivational Strategies for the Clinician
Stage 3: 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.
Offer a menu of options for change or treatment.
With permission, offer expertise and advice.
Elicit from the client what has worked in the past either for him or others whom he knows.
Assist the client to negotiate finances, child care, work, transportation, or other potential barriers.
Have the client publicly announce plans to change.

60. Client's Stage of Change
Appropriate Motivational Strategies for the Clinician
Stage 4: 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.
Support a realistic view of change through small steps.
Assist the client in finding new reinforcers of positive change.
Help the client assess whether she has strong family and social support.

61. Client's Stage of Change
Appropriate Motivational Strategies for the Clinician
Stage 5: 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.
Help the client identify and sample drug-free sources of pleasure (i.e., new reinforcers).
Maintain supportive contact (e.g., explain to the client that you are available to talk between sessions).

62. “I WILL GIVE THEM AN UNDIVIDED HEART AND PUT A NEW SPIRIT IN THEM
“I WILL GIVE THEM AN UNDIVIDED HEART AND PUT A NEW SPIRIT IN THEM.” Ezekiel 11:19

63. GOD BLESS YOU!