1. Motivational Interviewing
Dr Karen Meechan
Msc Addictions 28/01/2014

2. Aims of Session To Understand the spirit of MI
Understand the fundamental skills required for MI
Understand the four foundational processes of MI

3. Opening Exercise
Think of something (that you don’t mind disclosing) that you feel in two minds about changing
Split into pairs
Person 1: Share your dilemma with your partner
Person 2: Argue strongly in favour of change. Whatever the person says - do not deviate from this position
Why are we doing this exercise?
Illustratates where it came from

4. Issues Raised? Ambivalence about change is normal
Motivation fluctuates: it is dynamic
Motivation can be influenced by the way we are talked to, and talk about it: it is interpersonal
‘Resistance’ can be generated in the interaction
The Righting Reflex influences us as therapists
The more we say something the more we believe it (Self-Perception Theory, Bem 1967)
Confidence to change is crucial (Self-Efficacy)
What is resistance?
Behaviour
• Interpersonal (It takes two to resist)
• A signal of dissonance
• Predictive of (non)change
Righting reflex
Desire to stop someone going down wrong path
BUT it has a paradoxical effect
A counsellor arguing for change forces the client to voice the other side: “why I shouldn’t change”

5. Blaise Pascal – 17th century
“People are generally better persuaded by the reasons which they themselves have discovered, than by those that have come into the minds of others”
Blaise Pascal – 17th century
Why? People are better convinced by ideas they have come up with
People always have ideas of their own
They know what has meaning or will work for them
It is much more satisfying to come up with an idea yourself
Let the client take the best lines

6. Motivational Interviewing Origins
Key people: William Miller and Steve Rollnick
USA: Culture of conflict in treatment
‘Resistance’ attributed to the pathology of patients, ie.
“Addicts lack motivation and always deny the severity of the problem”
William Miller was interested in how the behaviour of counsellors might influence their clients’ behaviour
Direct persuasion elicits resistance and denial can be experimentally manipulated
Challenging traditional ideas of drug users and treatment.
In the 1980’s Milller did a series of experiments that looked at therapist characteristics as a predictor of alcohol consumption in people with drink problems. They found that those clients who saw a therapist rated as having rogerian counselling skills were more likely to be abstinent.
Moreover, therapists classified as having a ‘confrontational’ or telling style worked with clients who did not reduce their drinking as much.
Research on therapist variables: (Miller 1998, Addiction 93 (2) )
1 Found that certain therapeutic styles led clients to leave treatment more than others.
2 Denial can be experimentally manipulated by therapist behaviour.
3 High levels of resistance were associated with a more confrontational style.
4 At one year follow up it was found that the more the therapist had confronted the more the client drank.
5 Empathy ratings predicted the two thirds of variance in clients drinking at 6 months.
MI not founded on theory
Broadly grounded in Rogers’ client-centered counseling approach
Original description based on implicit principles derived from intuitive practice
MI principles were stated prior to empirical support or theory (1983)
Need to be aware of our own attitudes, beliefs, thoughts and feelings about drug users – these will influence our behaviour and impede the practice of MI

7. A Definition of MI
“A client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”
Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing –
Preparing People for Change (2nd edition). NY: Guilford Press
“Having a quiet and constructive discussion about change in which the client drives the process as much as possible”
Rollnick, S. and Allison, J. (2004) Motivational Interviewing in N. Heather and T. Stockwell (Eds), Treatment and Prevention of Alcohol Problems. Chichester: Wiley
Guide people to their own reasons

8. The Spirit of MI Fundamental approach of MI
Collaboration. Counselling involves a partnership that honours the client’s expertise and perspectives. The counsellor provides an atmosphere that is conducive rather than coercive to change.
Evocation. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals and values.
Autonomy. The counsellor affirms the client’s right and capacity for self direction and facilitates informed choice.
Compassion – MI-3
Mirror-image opposite approach to counselling
Confrontation. Counselling involves over-riding the client’s impaired perspectives by imposing awareness and acceptance of reality that the client cannot see or will not admit.
Education. The client is presumed to lack key knowledge, insight, and or/skills that are necessary for change to occur. The counsellor seeks to address these deficits by providing the requisite enlightenment.
Authority. The counsellor tells the client what he or she must do.
Collaboration models Rogerian person centred approach empathy
Evocation
Compassion
Acceptance
Hope
Belief
People who believe they can change do
People whose counsellors believe they can change do

9. Summary of MI
Not just a set of techniques. It is a clinical style – a way of being with clients
Provides way of having conversations about behaviour change
These conversations can be inherently ‘thorny’
Aims to resolve ambivalence (which is normal not pathological)
Minimises ‘resistance’
Builds client’s internal motivation for change 9

10. Motivation: “Ready, Willing and Able”
Willing: Importance of
change - Why?
Ready: A matter
of priorities
Importance and confidence = motivation
Able: Confidence for change - How?

11. Principles of MI Express empathy Roll with resistance
Support self-efficacy
Develop discrepancy 11 11

12. Four Foundational Processes in MI
The Bridge to Change
Planning
The Transition to MI
Evoking
Processes are somewhat linear
Engaging comes first – the relatonal foundation
Guiding (ie. identifying a change goal) is a prerequisite for Evoking
Planning is logically a step later
Yet also recursive:
engaging skills continue throughout
Focussing is not a one time event, refocussing is needed and focus may change
Evoking can begin very early
“Testing the water” on planning may indicate a need for more of the above.
NB. Idea of Phases in first 2 MI books has been displaced in MI-3 but still think it useful to guide your thinking …
Flow is: Resolving ambivalence, Building motivation, Strengthening commitment to change, Developing an action plan to accomplish change
Useful to hold idea that 1st you have to make the decision that you want to change, then think about how you are going to do it.
So, in MI-3 …. Engaging comes first, the relational foundation:
person centred style,
listen to understand dilemna and values
OARS core skills…..
The Strategic Focus
Guiding
The Relational Foundation
Engaging

13. Engaging Therapeutic Empathy +
The OARS – Fundamental strategies used in MI (also basic conversation, communication and counselling skills)
Ask Open Questions
Affirm
Listen Reflectively
Summarise
Affirmations are a way of feeding back to a person some strength that they have
Not about telling someone they’ve done well
They should affirm who the person is in a positive way
The rule is they must be authentic
Builds rapport
Helps build self-esteem and self-efficacy (often lacking)
Always be on the look out for positive attributes

14. Guiding
The strategic (directional) focus of MI • Finding a direction and developing changes or goals • Agenda setting • Giving information and advice (ask-provide-ask) MI is a guiding style, but not all guiding is MI Engaging and Guiding are MI-consistent practice, but not yet (in themselves) MI

15. Evoking
• The bridge to MI • There is a clear change goal • Selective eliciting (OARS) – Recognizing change talk – Eliciting change talk (e.g., selective questions) – Responding to change talk (e.g. selective reflection) – Summarizing change talk – Using the importance and confidence ruler
Rulers help to give you an idea whether it is importance or confidence that you need to focus on
Importance and confidence ruler; Use to elicit change talk

16. Change Continuum (Prochaska and DiClemente, 1982)
(if you assume the client is more to the right then they are - you are likely to encounter ‘sustain talk’)
No change
Change
Precontemplation
LINK TOO PSYCHOLOGICAL MODELS
Contemplation
Decision
Action

17. What is Unique to MI?
Attuned to and guided by certain types of natural language (change talk)
Intentional, differential evoking and strengthening of change talk
Strategic-directional use of client-centered counseling methods (reflection, summary)
Change talk is any client speech that favours movement in the direction of change
Desire Action Reason Need DARN Commitment Action Taking steps CAT

18. Applications in the Research
Substance misuse, sexual health, dietary change, weight loss, voice therapy, gambling, physical activity promotion, medication adherence, diabetes, depression, anxiety, OCD, eating disorders, dual diagnosis, chronic leg ulceration, criminal justice, vascular risk, stroke rehabilitation, chronic pain, self-care, domestic violence, child health, oral health
Whole issue of 2009 Journal Clinical Psychology (65, 11) about MI, including how it can be integrated with other psychotherapeutic approaches to treat mental health problems

19. Evidence Base
A lot of research (700 Psychinfo citations ), using variations of MI (eg. MET) and combined with other therapies, elements of MI only
Applied to many clinical problems
Lundahl et al. (2010): Meta Analysis of MI. Significantly better than TAU/no treatment, as good as other approaches (eg CBT, 12 step), shorter treatment, effects are durable over time, severity of problem does not affect effectiveness
Ashton (2005): Consistently beneficial for less committed clients but can worsen outcomes to those already committed
Moyers et al. (2009): Client change talk, once mobilised by therapist behaviour during MI sessions (eg. reflecting change talk when occurs) leads to reduced drinking 19

20. References
Ashton, M. (2005). The motivational hallo. Drug and Alcohol Findings, 13,
Bem, D.J. (1967). Self-perception theory: an alternative interpretation of cognitive dissonance phenomena. Psychological Review 73,
Lundahl, B.W, Kunz, C., Brownell, C. et al. (2010). A meta analysis of motivational intervewing: twenty five years of empirical studies. Research on Social Work Practice, 20 (2),
Miller W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People to Change (2nd Ed). New York: Guilford Press.
Prochaska, J.O. and DiClemente, C.C. (1982). Transtheoretical therapy: Towards a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19,
Rollnick, S. and Allison, J. (2004) Motivational Interviewing in N. Heather and T. Stockwell (Eds), Treatment and Prevention of Alcohol Problems. Chichester: Wiley
Moyers, T. B., Martin, T., Houck, J.M. et al. (2009). From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing. Journal of Consulting and Clinical Psychology, 77, 6,

21. Further Reading Website resource: www.motivationalinterview.org
Miller, W. (1998) Why do people change addictive behaviour? The 1996 H. David Archibald Lecture Addiction 93 (2),
Miller, W.R. and Rollnick, S. (2009) Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy 37,
Pilling, S., Hesketh, K. and Mitcheson, L. (2010). Routes to Recovery: Psychosocial Interventions fo Drug Misuse. London: BPS and NTA.
Rollnick, S., Miller, W. and Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behaviour. London: Guildford Press.