1. Motivational Interviewing (MI) With Clients Resistant to Change Mary T
Motivational Interviewing (MI) With Clients Resistant to Change Mary T. Curtis, CAP
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2. Agenda Explore Change…Motivation…Resistance Brief Overview of MI
The Therapist’s Role in MI
Strategies…Roll With Resistance

3. How Does Behavior Change?
Behavior A Behavior B

4. Introspective Exercise
Think of a behavior you’ve tried to change
How much time elapsed between:
The first time you engaged in the behavior, and
The first time you recognized risk or consequences?
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5. Introspective Exercise
How much time elapsed between:
The first time you recognized risk or negative consequences, and
The first time you made an earnest attempt to change the behavior?
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6. Introspective Exercise
Did you ever experience some success in changing your behavior?
What helped you achieve the success?
Did you ever experience a resumption of or increase in the undesired behavior after experiencing some success?
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7. Introspective Exercise
What did you discover about change?
Did motivation play a role in your change?
Where did you find your motivation?
Is motivation enough?
Did you experience any resistance?
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8. Stages of Change James Prochaska, PhD., and Carlo DiClemente, PhD.
Precontemplation
Contemplation
Preparation
Action
Maintenance
James Prochaska, PhD., and Carlo DiClemente, PhD.

9. Change Change is fluid Change is a process
Change is influenced by motivation
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10. Motivation Motivation is key to change
Motivation is a dynamic & fluctuating state
Motivation can be modified
There are intrinsic and extrinsic motivators
It can be influenced by relationships
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11. Motivational Interviewing (MI) was developed in the late 1980’s by William Miller, PhD. and Stephen Rollnic, PhD. MI is now an established evidence-based practice in the treatment of individuals with substance use disorders.
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12. Eight Stages in Learning MI
1. The spirit of MI
2. OARS – Client-centered counseling skills
3. Recognizing and reinforcing change talk
4. Eliciting and strengthening change talk
5. Rolling with resistance
6. Developing a change plan
7. Consolidating client commitment
8. Shifting flexibly between MI and other methods
Miller, W. R., & Moyers, T. B. (in press). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions.

13. “…a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” (Miller & Rollnick, 2009)
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14. Motivational Interviewing
The Why: Enhance Motivation for Change
The How: Identifying, exploring and resolving ambivalence about behavior change.

15. The Spirit of MI Autonomy...Collaboration…Evocation
“…a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.”
Autonomy...Collaboration…Evocation
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16. The Spirit of MI Guiding, more than directing
Dancing, rather than wrestling
Listening, as much as telling
Collaborative conversation
Evokes from a person what he/she already has
Motivation is elicited from the person
Honoring of a person’s autonomy
Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care, 2008.
The counselor is directive only in helping the person to examine and resolve ambivalence
The relationship is collaborative more of partner rather than expert/recepient
Meet the person where they are at

17. Principles of MI Express Empathy Support Self-Efficacy
There are five distinct principles:
Express Empathy
Support Self-Efficacy
Create Discrepancy
Avoid Arguments
Roll with Resistance
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18. ACTIVITY...COLLABORATION
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19. Therapeutic Alliance
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20. There are necessary qualities a Therapist brings to a helping-relationship in order for it to be effective.
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21. Necessary Qualities Skillset Be Present Effective Listener
Skilled Communicator
Emotionally Intelligent
Skilled in MI concepts, principles and strategies.

22. Necessary Qualities Willing Accepting Committed Collaborative
Mindset
Willing
Accepting
Committed
Collaborative
Empathetic
Compassionate

23. Therapists and Client Motivation
Style/personality influence outcomes
Empathic therapists have better outcomes
Expectations influence outcomes
Differences in drop-out rates
Differences in outcome rates
Simple actions decrease drop-out

24. The Professional’s Role
“Therapists adopting a hostile-confrontational style tend to elicit more withdrawal, lower involvement, distancing, and resistance.”
“For those (women) with low self-image, confrontational group therapy appeared to have a detrimental effect.”
(Waltman,1995, Journal of Substance Abuse Treatment)

25. MI Strategies
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26. OARS-Opening Strategy
Open-ended questions
Affirmations
Reflections
Summaries
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27. Change Talk Client identifies that behavior might be problematic
Client expresses concern about a behavior
Client expresses a desire to change the behavior

28. Change Talk
MI uses an acronym to identify types of “change-talk”. The acronym is DARN-C.
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29. The Flow of Change Talk MI Desire Ability Reasons Need Commitment

30. Change Talk Preparatory Change Talk Desire (I want to change)
Ability (I can change)
Reason (It’s important to change)
Need (I should change)
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31. Change Talk Preparatory Change Talk Desire (I want to change)
Ability (I can change)
Reason (It’s important to change)
Need (I should change)
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32. Change Talk Implementing Change Talk Commitment (I will make changes.)
Activation (I am ready, prepared, willing)
Taking steps (I am taking actions to…)
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33. Eliciting Change Talk Importance/Confidence Ruler Exploring problem
Looking backward / Looking forward
Exploring values and discrepancy with behavior
Considering pros and cons (decisional balance)
Exploring Extremes
Planning and Committing
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34. Resistance
In Motivational Interviewing “Resistance” is defined as a misalliance in the counselor-client relationship and not an inherent “symptom” of addiction.
Normal, natural and to be expected
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35. Resistance Argue Deny a problem Accuse Interrupt Disagree
Passively resist though minimal answers
Overtly comply due to mandate
Become angry
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36. Resistance—Sustain Talk
MI currently uses the term “sustain-talk” to describe client communication that indicates a desire, plan or commitment to staying the same.
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37. Resistance—Sustain Talk
“I don’t have a problem, it is all a mistake.”
“You people are just out to make money on this.”
“My wife thinks everyone has a problem because her father is an alcoholic.”
“I know I need to cut down, but I can do it on my own.”
“Coming to this program makes me feel worse, when do I get discharged?”
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38. Resistance—Responding
Roll with Resistance
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39. Summary A style…a way of interacting with clients.
The goal is to resolve the client’s ambivalence and guide them in the direction of making a positive change.
Goal oriented and solution focused.
Includes techniques to elicit “change talk” and “Sustain Talk.”
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40. Resistance—Responding
Reflective Techniques:
Simple Reflection
Double-sided Reflection
Amplified Reflection
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41. Simple Reflection
A simple reflection, mirrors or reflects back to the client the content, feeling or meaning of his/her communication.
Client: “I know I made a mistake but the hoops they are making me jump through here are getting ridiculous.”
Therapist: “You are pretty upset about all this. It seems like everyone is overreacting to a mistake.”
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42. Double-Sided Reflection
Attempts to reflect back both sides of the ambivalence the client experiences so that the client hears back both the “sustain-talk” in his/her communication and the “change-talk.” An example is…
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43. Double-Sided Reflection
Client: “I know that I made a mistake, but the hoops they are making me jump through are ridiculous.”
Counselor: “You made a mistake and it sounds like you feel badly about that, but you also think that people are asking you to do too much.”
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44. Amplified Reflection
Takes what the client said and increases the intensity of the “sustain-talk.” When hearing an amplification of what was communicated, a client will often reconsider what he/she said and clarify. An example is…
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45. Amplified Reflection
Client: “I know I made a mistake, but the hoops they are making me jump through are ridiculous.”
Counselor: “You don’t agree with any of what they are making you do.”
A client may respond to this, “No, I know I need to do some things to make this right but I am frustrated with this contract.”
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46. Strategic Techniques Shifting Focus Coming Along Side
Emphasizing Personal Choice and Control
Reframe
Agreement With a Twist
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47. Shifting Focus
Shifting focus attempts to get around a “stuck” point by simply side-stepping. An example, using the same client statement is:
Client: “I know I made a mistake, but the hoops they are making me jump through are getting ridiculous.”
Counselor: “You are upset by all of these hoops. Can you tell me more about the mistake you think you make?
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48. Coming Alongside
This technique is used to align with the client. An example of coming along side is:
Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”
Counselor: “You may be at your limit and might not be able to keep up with all this.”
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49. Emphasize Personal Choice & Control
Clients ultimately always choose a course of action and this technique simply acknowledges this fact. Acknowledging this can sometimes help a client recognize that they are making a choice. An example is:
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50. Emphasize Personal Choice and Control
Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”
Counselor: “You don’t like what others are asking you to do, but so far you are choosing to follow-through with what they are asking. It takes a lot of fortitude to do that. Tell me what motivates you.”
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51. Agreement With A Twist
This is a complex technique that combines a reflection with a reframe. This gives the client confirmation that they were “heard” and then offers another perspective on their communication. It is similar to a reframe and an example is:
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52. Agreement With A Twist
Client: “I know that I made a mistake, but the hoops that they are making me jump through are getting ridiculous.”
Counselor: “You are feeling frustrated with all these expectations. You are also anxious to be successful?”
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53. Summary A style…a way of interacting with clients.
The goal is to resolve the client’s ambivalence and guide them in the direction of making a positive change.
Goal oriented and solution focused.
Includes techniques to elicit “change talk” and “Sustain Talk.”
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54. Strategies – Elicit Change Talk
OARS
Exploring the Problem
Looking Backward
Looking Forward
Considering Importance
Importance/Confidence Ruler
Exploring Values
Considering Pros and Cons
Planning and Committing
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55. Strategies – Decreasing Sustain-Talk
Simple Reflection
Double-sided Reflection
Amplified Reflection
Shifting Focus
Coming Along-Side
Emphasize Personal Choice and Control
Reframe
Agreement with a twist
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56. Sources
Center for Substance Abuse Treatment (1999). Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) 35. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Miller, W. R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. 2nd Edition. New York: Guilford Press.
Miller, W.R. & Rollnick, S. (2010). What's new since MI-2? Presentation at the International Conference on Motivational Interviewing (ICMI). Stockholm, June 6, Accessed at conference-workshop.pdf
Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
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57. Why Motivational Interviewing?
Evidence-based >120 clinical trials
Relatively brief
Grounded in testable theory
With specifiable mechanisms of action
Generalizable across problem areas
Complementary to other treatment methods
Verifiable – Is it being delivered properly?
Can be delivered by non-specialists