An Introduction An Introduction to Motivational to Motivational InterviewingInterviewing

Richard L. Ogle, Ph.D.Professor & ChairDepartment of PsychologyUniversity of North Carolina Wilmingtonogler@uncw.edu

Guiding Sentiments0 If you treat an individual as he is, he will stay as he is, but if you treat him as if

he were what he ought to be and could be, he will become what he ought to be and could be.

—Johann Wolfgang Von Goethe

0 People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others.

—Blaise Pascal

0 You are a midwife, assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say, “We did it ourselves.”

—TAO TE CHING

Opening Conversation

0Why are you here?0What do you want to learn?0 In what specific situations would you like to use MI?0At what level do you want to engage?

Motivation

0The probability of engaging in and maintaining a behavior over time.

0What are the three key words?0 Probability (0 – 1) not (0 or 1).0 Engage0 Maintain

0Motivation is continuous not dichotomous0Fluctuating motivation can increase or decrease

based on your behavior

Change

Change is more similar than different across behaviors

Change is a process that is continuous like a dimmer switch, not discrete like an on/off switch

Change depends on MOTIVATION.Because of this, there are multiple ways and times

that change can derailFortunately, there are multiple ways and times to

facilitate the process

Stages of ChangeProchaska & DiClemente

Change Talk - DARN CAT0 Client speech reflecting building motivation and correlated with behavioral

change0 Desire

0 Why a person would make a change.0 Ability

0 How a person could you do it.0 Reasons

0 What are good reasons to make the change?0 Needs

0 How important is it and why? What are the negative that occur without change?0 Commitment

0 What intentions are present?0 Activation

0 What is the person ready or willing to do immediately?0 Taking Steps

0 What have they already done?

Commitment Language Pattern A

Outcomes for Pattern A Group

Commitment Language Pattern B

Amrhein et al., Journal of Consulting & Clinical Psychology 2003 71:862-878

Outcomes for Pattern B Group

Righting Reflex

0Born of concern and caring0There’s a problem? Let’s fix it!0Fails to consider ambivalence in change process0May engender resistance

Ambivalence

0Simultaneous feelings of approach and avoidance0 Yes, but0 I want to, but I can’t

0The core of most motivational issues0 Completely normal0 Often uncomfortable

0Can be chronic

Exercise0Talk about something

real that you:0 Want to change0 Need to change0 Should change0 Have been thinking

about changing

0But, haven’t yet changed.0Not your deepest,

darkest secret!

0 Listen carefully - goal to understand the dilemma

0 Ask these four questions:0 Why would you want to

make this change?0 How might you go about it,

in order to succeed?0 What are the three best

reasons to do it?0 On a scale of 1-10, how

important would you say it is to make this change? And why are you a ___ and not zero?

0 Summarize

Resistance0 A result of a focus on only one

side of an individual’s ambivalence0 If you argue for change, your

collaborator argues against it0 It is relational. It is a signal

that you are not meeting them where they are at; therefore, it is you responsibility to resolve0 Sustain Talk

0 Speech about the target behavior that reflects only one side of ambivalence (status quo)0 There is nothing inherently

pathological about sustain talk 0 Discord

0 Speech reflecting a discord within the relationship/session0 Denying0 Arguing0 Ignoring0 Interrupting

0 Reluctance0 May be concerned about the

“unknowns” of change0 Need to verbalize their

reluctance & be heard0 Rebellion

0 May have knowledge0 May have highly invested

energy in no change0 Resignation

0 No energy for change0 May feel overwhelmed &

hopeless0 Need to build hope

0 Rationalization0 Has all of the answers0 Utilizes “Harm Minimization”

Therapeutic Traps

0Question-Answer Trap0Trap of Taking Sides0Expert Trap0Labeling Trap0Premature Focus Trap0Blaming Trap

Definitions of MI0 Layperson’s Definition (Why

would be do it)0 MI is a collaborative conversational

style for strengthening a persons own motivation and commitment to change

0 Practitioner’s Definition (Why you would use it)0 MI is a person-centered counseling

style for the common problem of ambivalence about change

0 Technical Definition (How it works)0 MI is a collaborative, goal oriented

style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

A Brief History to This Point0 MI is 31 years old this year

0 Description first published in a journal article in 1983.

0 First edition of book in 1991, second in 2002, third in 2013

0 Over 1200 articles on MI0 MI cited over 25,000 times0 Over 200 RCT’s

0 Started as a vilified intervention in addictions and now is a best practice in all of behavioral health

0Here are some things we know0 MI is effective for a

variety of behavioral targets

0 MI can be used in a variety of settings

0 MI is hard to standardize0Significant variability

across counselors

Most Importantly, What We Know is…

0 MI training increases characteristic MI practice behaviors0 OARS0 Empathy

0 These behaviors affect particular types of client speech0 Desire, Ability, Reasons, Need, Commitment, Activation,

Taking Steps

0 The level and strength of these types of speech predict behavioral outcome0 Findings are stronger in addictions than anywhere else

Spirit of MIhttp://www.youtube.com/watch?v=Vr-aZ4tdoac

0 Acceptance0 Absolute worth0 Autonomy0 Accurate Empathy0 Affirmation

0 Collaboration0 Partners0 Shared goals

0 Evocation0 Pulling out instead of putting in

0 Compassion0 For the other’s needs/self-

interest

0 Services exist to benefit the people we serve0 Change is fundamentally self change. Services

facilitate0 People are experts on themselves0 We don’t have to make change happen0 We don’t have to come up with all the good

ideas0 People have their own strengths, motivations,

resources0 Therefore change requires partnership0 Understand, person’s own perspective, what

is needed and how to accomplish it0 Conversations about change should not be a

struggle. Dancing, not wrestling0 Motivation for change is not installed, but

evoked0 We cannot revoke people’s choice about their

own behavior. People make their own decisions about what they will and will not do.

MI Principles

0Express Empathy0 Empathy alone is

predictive of change0Roll w/Resistance

0 Verbal judo0Develop Discrepancy

0 Goals and values contrasted with current behavior

0Support Self-Efficacy

0R – Resist the righting reflex

0U – Understand you client’s motivation

0L – Listen to you client0E – Empower your client

Empathy0Multiple Components

0 Experience sharing (affective empathy) vicariously sharing targets’ internal states (“feeling with”), but knowing the target is the source of the emotional state in the self.

0 Mentalizing (cognitive empathy) explicitly considering targets' states and their sources, without necessarily sharing another's state. Perspective-taking.

0 Prosocial concern (compassion) feeling of concern for a target's suffering ("feeling for") that induces a motivation to alleviate that suffering.

0http://www.youtube.com/watch?v=l7AWnfFRc7g 0http://www.youtube.com/watch?v=1Evwgu369Jw

The Importance of Empathy and Rolling w/Resistance

Miller, Benefield & Tonigan (1993) JCCP 61: 455-461

Developing Discrepancy

0Finding, increasing or encouraging a discrepancy between present and desired states

0Can be positive or negative in valence0 Discontent with the status quo0 Opportunity for betterment

0Goldilocks Principle0Discrepancy within limit

Support Self-Efficacy

0Perception of the degree to which someone feels confident he/she can accomplish a particular goal/task0 Building confidence

0Building on past successes0Translating things they do well in other life contexts

to the behavior change context.0Affirming smaller steps and approximations

How Does MI Work

0Empathy allows clients to reduce resistance and resolve ambivalence0 Looking at the situation from their perspective

0People feel understood; less resistant

0 Selective reinforcement of change talk0Focus on change talk0We learn what we believe when we hear ourselves speak0Therapist reinforces change talk that is consistent with

therapeutic goals0Reinforcement further increases change talk and allows of

client to experience build in motivation to change

Basic MI Tools

0O - Open Questions0A - Affirmative

Approach0R - Reflective

Listening0S -Summaries

0Your OARS propel you and steer you through the encounter

0You have to do these well to do MI well

0Everything in MI is rooted in OARS

Open Questions

0Questions that cannot be answered “yes” or “no” or with a discrete answer.

0Open questions generate more data – more data, more empathy

0Open questions block momentum less than closed questions

0Open questions lessen the “expert” or “investigator” feel of interactions

Opening Up Your Questions

Do you drink? How much?Have you ever smoked a cigarette?Are you taking your medications as prescribed?Have you lost or gained weight in the last month?Are you sexually active?Do you always use birth control?How many alcoholic drinks do you have in a typical week?Did you take your insulin today?Do you get regular physical exercise?Is there a family history of heart disease?Have you ever been hospitalized or had surgery?On what day did your symptoms start?

Affirmation0Clients are often unsuccessful self-changers

0 Demoralized

0Our role is to instill hope and a belief that the client can change0 Empower the client – “can do”

0Attributions 0 Focus on specific behaviors instead of attitudes or decisions0 Focus on descriptions not evaluations0 Attend to non-problem areas0 Nurture a world-view of competence not deficit

Affirmation Exercise

0Listen to the statement0Write down a few strengths0Write down an affirmation

Reflective Listening - Roadblocks to Listening

1. Ordering, directing, or commanding2. Warning or threatening3. Giving advice, making suggestions, or providing solutions4. Persuading with logic, arguing, or lecturing5. Moralizing, preaching, or telling clients what they "should" do6. Disagreeing, judging, criticizing, or blaming7. Agreeing, approving, or praising8. Shaming, ridiculing, or labeling9. Interpreting or analyzing10. Reassuring, sympathizing, or consoling11. Questioning or probing12. Withdrawing, distracting, humoring, or changing the subject

Reflective Listening – What is it?

0A statement – a hypothesis0 Vocal inflection is downward0 Keeps people “in the meaning/feeling”

0A verbal mirror to reflect back0 Exact words0 Paraphrase0 Meaning0 Emotion

Reflection Exercises

Summaries

0Groups of reflections that serve to0 Remind you and client of what has been said0 Highlight overarching themes – Linking0 Transition when stuck or wanting to shift direction

Video

0Listen for OARS

Rolling w/Resistance0Strategies

0 Reflection (Under/Over)0 Reframe0 Double-sided reflection0 Emphasizing Personal Responsibility0 Shifting Focus0 Coming Alongside

0Exercise

Exercise - Fishbowl

0Practice OARS0Roll w/ resistance0Listen for Change talk

MI Processes

0MI occurs throughout four ongoing processes of change conversations0 Engaging0 Focusing0 Evoking0 Planning

0Often MI is about knowing how to skillfully and artfully move back and forth between each process

Engaging

0The process by which counselor and client establish a helpful connection and a working relationship0 How comfortable is this person talking to me?0 How supportive and helpful am I being?0 Do I understand this person’s perspective and concerns?0 How comfortable do I feel with this conversation?0 Does this feel like a collaborative partnership?

Understanding Values0 Freely chosen core beliefs that drive and organize behavior

that is intrinsically reinforcing.0 Values represent what one wants their life to look like, stand for

and be about0Global values0Domain-specific values – family, relationships, career, etc.

0 Values provide direction0 Values are different from valuing0 Values cannot be accomplished in-and-of-themselves

0 Instantiated moment by moment and over time0 No matter what direction life takes, you still have your values

Values Assessment0 Informal

0 “How do you hope your life will be different a few years from now?”

0 “Who do you respect in life and why?”0 “Tell me what you care most about in life.”

0 Tombstone0 Eulogy0 Values Card-Sort

0 http://casaa.unm.edu/inst/Personal%20Values%20Card%20Sort%202.pdf

0 Batteries Exercise0 Next Slide

Focusing

0Process of clarifying direction – find the horizon point toward which to move. Agenda0 What goals for change does this person really have?0 Do I have different aspirations for change than this

person?0 Are we working together with a common purpose?0 Does it feel like we are moving together, not in different

directions?0 Do I have a clear sense of where we are going?0 Does this feel more like dancing than wrestling?0 Sources – client, setting, your experience

Agenda Mapping

0A short meta-conversation in which you step back with the client to consider the way ahead0 Structuring0 Consider options0 Zoom in0 Zoom out

Information Exchange: Elicit - Provide - Elicit

0 Elicit0 What would you like to know/do about?0 What do you already know/do about?

0 Provide0 Provide information (not opinion) in manageable

chunks0Confirming0New0Disconfirming

0 Elicit0 What do you make of that?0 What does this mean for you?0 What more would you like to know?

Evoking

0Eliciting client’s own motivations to change. Harness the client’s own thoughts and feelings about why and how they might do it0 What are this persons reasons for change?0 Is the reluctance more about confidence or importance?0 What change talk am I hearing?0 Am I steering to far or too fast in a particular direction?0 Is the righting reflex pulling me to be the one arguing for

change?

Explore Importance of Situation/Change

General:How important is situation/issue, you need to make a

decision or do something about it?Importance Ruler

On a scale of 0 to 10, how important is this issue to you at this point in your life(0=not at all, 10=most important thing)

What makes it an X and not a Y?What might make your rating a few points higher, a bit more

important?What can you specifically do to increase?What might I, or others do to help it increase?

Explore Confidence about Changing

On a scale of 0 to 10, how confident are you that you could change if you decided to?

What makes it an X and not a Y?

What would make it a few points higher?

What can you specifically do to increase?

What might I, or others do to help it increase?

DARN CAT Client Exercise

0Lets write down some statements about this change we are discussing.0 D – Why do you want to make this change?0 A – How could you do it?0 R – What are good reasons to make the change?0 N – How important is it and why?0 C – What do you intend to do about it?0 A – What are you ready or willing to do?0 T – What have you already done?

0Use your OARS to expand, explore and solidify.

Decisional Balance0Not changing:

0 What concerns you the most about the possibility of not making a change?

0 What might some benefits be of not addressing this, not making any changes?

0Changing:0 What might you lose, have to give up, or risk, if you make a

change? What might not be so good?0 What good things might happen if you did something about it,

made a change?

Exercise – Decisional Balance

ff

Pros of Status Quo

Cons of Status Quo

Cons of Change

Pros of Change

Looking Forward0 In general, what things are most important to you?

0 Family? Cutting back on work? Getting some fun or excitement back in your life? Feeling better about yourself? Getting more involved in your community? Your spirituality? Having a partner? Being financially prepared? Autonomy?

0 Thinking about what’s important for you for the future, how does this current issue fit in?

0 What is likely to be the outcome if you don’t make any decisions, do anything about it? What do you think things will be like a year from now, or five?

0 What might be the outcome if you were successful at making some changes? How might things be in a year from now, or five?

Looking Back0How long has it been going on? 0How did it come about? 0Did it start all at once or gradually?0What were things like before? 0How were things better now? 0How are things worse?

Building on Strengths

0What strengths might you draw on to make a change?

0Are you determined? Flexible? Careful? Organized? Creative? Resourceful? Stubborn?

0How have these strengths helped you before?0What things might be changed in your environment to help

you succeed? What might help you get ready?0How might others help?

Remembering Successes0What have you been successful at changing in the past? No

matter how small...0 What initiated you making this change? 0 What did you do to get started, what did you do to stick with

your decision to change?0 What barriers or obstacles did you run into? How did you get

past them?0 How easy was it? How did you feel after making that change?

How do you feel about it now?0 What other changes have you made?

Other Strategies

0Typical Day

0Other’s Concerns

0Normative Feedback

How to Reinforce Change Talk (EARS)

Elaborate“In what ways?”“Give me an example?”“What else?”“Why else?”“How else?”

Affirm“Sounds like a good idea”“I think you could do that”“It is really important to you to…”

ReflectSummarize

Collect the flowers of change talk and give back a bouquet of change talk back to the client. Give them what you want them to hear; not everything.

Exercise0Listening for change-talk

Planning0The process of developing commitment to change and

a specific plan of action0 What would be a reasonable next step toward change?0 What would help this person to move forward?0 Am I remembering to evoke rather that prescribe a

plan?0 Am I offering needed info and advice with permission?0 Am I retaining a sense of quiet curiosity about what will

work best for this person?

MI and Planning0 Moving from evoking to planning

0Comes from a sense of the interaction – less resistance, more curiosity, more change talk, more optimism

0 Summarize 0Change-talk focused

0 Key question0A questions that elicits what a client wants to do in relation to

the problem of concern0What do you think you will do?0What are you thinking at this point about ______?0What changes, if any, or you thinking about making?0What are your options?0 It sounds like things can’t stay the way they are, what do you

think you might do?0What are some of the good things about making a change?

MI Change Planning0Lots of freedom in how to do this, but do follow these 6

steps0 Confirm the goal

0State goals in behavioral terms0Avoid “dead person” goals

0 Itemize options0 Elicit the client’s hunches and preferences0 Plan strategy

0What are the steps and how will they know it’s working

0 Summarize and strengthen commitment0 Troubleshoot – raise concerns you have

Behavior Change Plan

0What, specifically, would you like to be different?0What, specifically, could you do to get started?0If the first step is successful, then what?0Who else could you ask for support, assistance, if

anyone? What could you ask for?0What would be signs that things are going well?0How would you know if you were off-track?0What would you do if you got off-track?

Supporting Change

0Subsequent treatment should integrate the processes of:0Replanning0Reminding0Refocusing0Reengaging

http://www.youtube.com/watch?v=K1jJYON92m8&list=PLB234E53AF4293F2F

Opening the Session

0Set the Agenda0 Spirit0 What will be talked about0 Your role

0Open Question0 Pick up your OARS and start paddling

0Perceptions of being there0Perceptions of the issues0 Important current activities, requirements, and/or needs

0Paddle in order to build rapport (Joining) and elicit change talk

Managing the Middle

0Assess/Understand Values0 Card Sort or Batteries Exercise

0Use EVOKING strategies0 Develop Discrepancy0 Support Self-Efficacy

0Provide information/feedback if necessary0 Elicit-Provide-Elicit

Wrapping Up an MI Session0 If using MI brings you to a point where a client is making

statements related to change or increased importance/confidence0 Summarize & Key Question0 Behavior Change Plan0 Summarize & Elicit Commitment

0 If client is stuck/ambivalent0 Reflect the continued ambivalence in terms of

Importance/Confidence0 Summarize

Exercise – Fishbowl

0Goal0 Practice OARS0 Listen for change talk0 Reinforce change talk0 Practice process-based exercises

Questions

Specific MI Applications

Treatment Engagement0Turn your assessment into and MI-informed assessment

0“There are number of questions I will need to ask you today, but first I would just like to know what brings you here today, what are your biggest concerns and how you hope we might be able to help you.”0Listen with empathy and to detect the process where you need to start

0Ask for permission to move into the assessment phase0Use open-ended questions to replace closed prompts on your assessment.0Listen for change talk0Summarize and transition through each domain

0Use EPE for information exchange0Use importance/confidence0Summarize at the end

Treatment Enhancement0 Boosts the effects of larger treatments0 Motivational Enhancement Therapy0 Now being integrated with other treatment formats

0CBT

0 Now being developed to treat specific disorders0Depression, OCD, eating disorders, GAD

Medication Compliance

0 Assessing motivation for adherence.

0 Discussing previous adherence

0 Anticipating adherence difficulties

0 Personalized feedback0 Informally assessing

antidepressant knowledge

0 Adherence plan0 Discussing

goals/values

0 Exploring of both sides of motivation/eliciting commitment.

0 Exploration of previous concerns and result of nonadherence.

0 Discuss and prepare for motivational issues that may arise.

0 Feedback on dose-taking, reinforcement of adherence, and exploration of missed doses.

0 Targeted information exchange0 Articulate patient’s reasons for

adhering to treatment, anticipated barriers, and plan

0 Mailed to participants 1 week after the intervention to provide additional information.

0 Discussing adherence in alignment with sources of motivation.

Components Purpose

Interian, A, Martinez, I, Rios, L.I., Krejci, J, Guarnaccia, P.J. (2010). Adaptation of a Motivational Interviewing Intervention to Improve Antidepressant Adherence Among Latinos. Cultural Diversity and Ethnic Minority Psychology, 16(2), 215-225

MI and Suicidal Ideation

0Phase 1: Exploring the present problem and the motivation to die.0 Focus in on eliciting the ambivalence around suicide.

0Phase 2: Building motivation to live.0 Focus is on gently shifting toward the living side of the

ambivalence

0Phase 3: Strengthening commitment to live.0 Focus is on moving reasons to commitment and

planning for the next stage of treatment.

Take Home0 Learning MI involves 10 steps of understanding

0 Understand and invoke the underlying spirit0 Develop skill and comfort with reflective listening0 Learn to identify from client’s agenda, goals that can become foci of the

conversation0 Understand EPE as information exchange0 Learn to recognize change talk and sustain talk0 Learn to evoke change talk0 Learn to strengthen change talk0 Learn to respond to sustain talk in ways that do not amplify it0 Understand the timing when moving into planning

0 Can’t just get good at MI-consistent behaviors must eliminate MI-inconsistent behaviors

0 Advice or info without permission0 Confronting by disagreeing, arguing, correcting, shaming, blaming,

criticizing, etc.0 Directing by giving orders, commands or imperatives, or otherwise

challenging autonomy 0 One never stops learning MI