1. Evolution in MI-3 2. Three Puzzles Emerging from MI Research MINT Forum, Sheffield

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1 1. Evolution in MI-3 2. Three Puzzles Emerging from MI Research 2011 MINT Forum, Sheffield

2 1983

3 1991 MI-1

4 2002 MI-2

5 2008

6 2012 MI-3

7 2022 MI-4

8

9 X Generalized Principles of MI 1. Express Empathy 2. Develop Discrepancy 3. Avoid Argumentation 4. Roll with Resistance 5. Support Self-Efficacy

10 X Two Phases of MI Phase 1 Strengthen motivation for change Phase 2 Consolidate commitment to change

11 RESISTANCE

12 The Underlying Spirit of MI Partnership Acceptance Compassion Evocation

13 Behavior Change

14 Change is Broader than Behavior Decision to make a choice Forgiveness, Leaving or staying Attitude - to become a different person To be more Compassionate, Assertive etc. Resolution - Acceptance Complicated grief Finding peace regarding a decision Tolerance for anxiety, uncertainty etc.

15 Four Fundamental Processes in MI

16 Relational Motivational Foundation Interviewing 1. Engaging 2. Focusing 3. Evoking 4. Planning

17 The processes are somewhat linear.... Engaging necessarily comes first Focusing (identifying a change goal) is a prerequisite for Evoking Planning is logically a later step Engage Focus Evoke Plan

18 .... and yet also recursive Engaging skills (and re-engaging) continue throughout MI Focusing is not a one-time event; re-focusing 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

19 Four Foundational Planning Processes Evoking Focusing Engaging

20 Is it MI Yet?

21 Can it be MI without... Engaging? Focusing? Evoking? Planning? No No No Yes

22 So it becomes MI when.. 1. The communication style and spirit involve person-centered, empathic listening (Engage) AND 2. There is a particular identified target for change that is the topic of conversation (Focus) AND 3. The interviewer is evoking the person s own motivations (or plans) for change (Evoke)

23 A continuum of styles that can be used in all four processes Directing <=> Guiding <=> Following

24 Core counseling skills that can be used in all four processes Open questions Affirmation Reflection Summary Offering information and advice

25 Direction Language Directing as a counselor behavior Direction as focus Directional (not directive ) as a description of MI as goal-oriented

26 Three Essential Elements in any Definition of MI 1. MI is a particular kind of conversation about change (counseling, therapy, consultation, method of communication) 2. MI is collaborative (person-centered, partnership, honors autonomy, not expertrecipient) 3. MI is evocative, seeks to call forth the person s own motivation and commitment

27 DEFINITIONS OF MI Three levels of definition (of increasing specificity) 1. A layperson s definition (What s it for?) 2. A pragmatic practitioner s definition (Why would I use it?) 3. A technical therapeutic definition (How does it work?)

28 1. A layperson s definition (What s it for?) Motivational interviewing is a collaborative conversation style for strengthening a person s own motivation and commitment to change

29 2. A pragmatic practitioner s definition (Why would I use it?) Motivational interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change

30 3. A technical therapeutic definition (How does it work?) Motivational interviewing 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.

31 Counseling with Neutrality Neutrality is not a therapist attribute (like equanimity: composure, balance, emotional stability) Neutrality is the conscious clinical decision to try not to influence a client s direction of choice or change Neutrality can be about: Focusing (whether to pursue a change goal) Planning (how to pursue a change goal)

32 Counselor Aspiration Should I proceed strategically to favor the resolution of the client s ambivalence in a particular direction? or Do I want to maintain neutrality and not intentionally or inadvertently steer the person in one particular direction? MI was originally developed for the former situation

33 Engaging and Focusing Identification of Change Goal Aspiration A conscious choice Equipoise Evoking Planning Decisional Balance Both choices involve partnership, acceptance and compassion

34 Equipoise is where a classic decisional balance makes sense Giving intentionally balanced, equal attention to pros and cons in: Inquiry Elaboration Affirmation Reflection Summaries

35 2 x 2 Decisional Balance Grid PROs and CONs of Change Status Quo or Option A Change or Option B Advantages + Good things about Status Quo or Option A CON Good things about Change or Option B PRO Disadvantages - Less-good things about Status Quo or Option A PRO Less-good things about Change or Option B CON

36 Change Talk Change talk is any client speech that favors movement in the direction of change Previously called self-motivational statements (Miller & Rollnick, 1991) Change talk is by definition linked to a particular behavior change goal DARN CATs

37 Preparatory Change Talk Four Examples DARN DESIRE to change (want, like, wish.. ) ABILITY to change (can, could.. ) REASONS to change (if.. then) NEED to change (need, have to, got to..)

38 Mobilizing Change Talk Reflects resolution of ambivalence CATs COMMITMENT (intention, decision, promise) ACTIVATION (willing, ready, preparing) TAKING STEPS

39 Yet another metaphor MI Hill (Pre-) Contemplation Preparation Action

40 Responding to Change Talk All EARS E: Elaborating: Asking for elaboration, more detail, in what ways, an example, etc. A: Affirming commenting positively on the person s statement R: Reflecting, continuing the paragraph, etc. S: Summarizing collecting bouquets of change talk

41 Change Talk and Sustain Talk Opposite Sides of a Coin

42 Examples of Sustain Talk The other side of ambivalence I really like marijuana (D) I don t see how I could give up pot I have to smoke to be creative (A) (R) I don t think I need to quit (N) I intend to keep smoking and nobody can stop me (C) I m not ready to quit (A) I went back to smoking this week (T)

43 X What is Resistance? Sustain Talk Discord

44 Sustain Talk and Discord Sustain Talk is about the target behavior I really don t want to stop smoking I have to have my pills to make it through the day Discord is about your relationship You can t make me quit You don t understand how hard it is for me Both are highly responsive to counselor style

45 What is Discord? Behavior Interpersonal (It takes two to have discord) A signal of dissonance in your relationship Predictive of (non)change

46 Some Discord Signals Defensiveness Arguing Challenging Discounting Hostility Interrupting Talking over the counselor Ignoring Inattention Changing the subject

47

48 Three Puzzles

49 Three Puzzles Three inter-related issues arising from MI research and practice that you are likely to be confronted with in training

50 Three Puzzles 1. What is MI outcome research telling us? Negative clinical trials Adverse effects of MI Large provider effects

51 Three Puzzles 2. What are the active ingredients of MI? What to focus most on in training and quality assurance

52 Three Puzzles 3. What is good enough MI?

53 Practitioner: I m glad you came back to see me today. Mother: I must do this for my baby Practitioner: This baby is very important to you (listening) Mother: Yes. Practitioner: And you want it to be healthy (listening) Mother: Yes, I told my husband and he is supportive but there are some issues he is not helping me with he doesn t want to use the condoms Practitioner: What would be most helpful for us to start talking about? Is it condoms, your medication, your diet, or perhaps something else? Mother: I want to talk about the medication Practitioner: Yes, fine, we can come back to other things. The medication feels important to you (listening) Mother: Its very important, I want to know how to take these tablets so that I keep well Practitioner: What would you most like to know about the medicine? Mother: If I miss doses I worry that it will bring harm

54

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