Motivational Interviewing By: Tonia Stott, PhD What is Motivational Interviewing? A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller and Rollnick, 2002) Motivational Interviewing (MI) is a framework for practice a way of thinking and believing about people and when and how people change (spirit of MI) the combination of practice approaches and micro skills that are consistent with the spirit of MI What is Motivational Interviewing? The founders of MI are William Miller and Stephen Rollnick. They have been teaching and researching MI for about 30 years. They were heavily influenced by Carl Rogers, though they differ from a Rogerian approach in that MI is a directed way of working with clients, rather than a non-directive approach that follows clients as they wander. 1
What is Motivational Interviewing MI explores with clients their willingness, ability, and readiness for change. Through reflections and evocations, the approach aims to assist clients in resolving ambivalence about change, in clarifying their thoughts about change, and in organizing their thoughts around change. Spirit of MI The philosophical foundations of MI: People explore change when they understand the discrepancy between their own values and their actions. Clients changes have to be consistent with their values. If clients values are different from the practitioner s or what the client is supposed to change, MI will not result in real or lasting change. People change when they feel ready, able, and willing to change. Practitioners or interventionists cannot instill or create for clients the feelings of ability, willingness, or readiness, though practitioners can assist clients in recognizing and believing in their ability, willingness, and readiness. People explore the possibility of change when they feel supported in doing so, and when they feel they would be in control of what is changed, how it is changed, and when it is changed. The warmth and empathy practitioners display when working with clients is as important and possibly more important than what they say. An empathic, authentic relationship between practitioner and client gives the client room to explore change without feeling pressured. The fear of loss of control is often more powerful than any other motivating force, so if clients feel there could be a loss of control, they are much less likely to explore change. If practitioners try to control what is changed, how it is changed, and when it is changed, it is more likely to result in the client becoming more resistant to change than exploring change. Spirit of MI MI is not: A script or series of questions and statements that should be used the same way with all clients. A method of manipulating or tricking clients into agreeing with making change, even though they do not fully value the change. An exclusive technique. Other approaches and techniques could be used in concert with MI, if they are used in a spirit consistent with MI. A way proving to clients that they are wrong or that they should change. MI will not result in making or getting the client to do something or change something. Only the client is in control of the change. The practitioner assists the client with understanding what changes they want and how they could go about achieving those changes by focusing on change talk and not focusing talk that does not elicit change. 2
The Foundations of MI Collaboration the practitioner does not try to assume the expert role or to advance his/her own agenda of the solution. Rather the client and practitioner work in harmony in discussing problems, changes, and solutions. Practitioners can collaborate with clients on agenda setting. In the opening of any meeting with a client, the practitioner can ask the client what they would like to discuss during that time. Evocation the practitioner elicits from the client their values, beliefs about change, and plans for change. The practitioner does not prescribe it. Autonomy the client can choose to change or not, can choose what to change and not to change, when to change, and how to change. The practitioner respects the client s autonomy even if the choices are contrary to what the practitioner or the practitioner s agency thinks is best. General Principles of MI 1. Express empathy 2. Develop discrepancy (difference between what client values and what client does) 3. Roll with resistance 4. Support self-efficacy How MI Works A practitioner using an MI approach tries to be in harmony with the client. The practitioner does not say or do things that would elicit defensiveness or argument from clients in support of the status quo. The reason is that often when people argue in defense of a position, they become more committed to that position, so argument is counterproductive. When clients and practitioners are not working in harmony, it is referred to as dissonance in the practitioner-client relationship. In MI, if a client is resistant, this is a function of the client-practitioner relationship, as clients cannot resist something that is posing no force or pressure. When there is consonance or harmony, the client may be willing to explore the possibility of change. Through the exploration, the practitioner listens for change talk (talk of potential change, thoughts about change, willingness to change, advantages of changing, problems with the status quo, hope of change, etc.). When change talk manifests, the practitioner focuses on the change talk through employing specific skills. The skills are designed to assist clients in organizing their thoughts about change and clarifying their willingness, ability, and readiness for change. 3
How MI Works The most important skill in MI is listening. The practitioner needs to listen for change talk The practitioner needs to listen for indications of willingness, ability, and readiness for change The practitioner needs to fully listen to the client s perspectives, values, beliefs, and experiences Listening requires a degree of vulnerability (I don t actually have the power to fix very much) and humility (I can t completely know what is best for someone else) on the part of the practitioner There are many roadblocks that can prevent practitioners from listening. These roadblocks keep the practitioner s mind busy with trying to gain control of the conversation, proving they are right, placing themselves in the expert role, or placing themselves in a more powerful position. 1. Ordering, directing, commanding 2. Warning, cautioning, or threatening 3. Giving advice, making suggestions, or providing solutions 4. Persuading with logic, arguing, or lecturing 5. Telling people what they should do, moralizing 6. Disagreeing, judging, criticizing, or blaming 7. Agreeing, approving, or praising 8. Shaming, ridiculing, or labeling 9. Interpreting or analyzing 10. Reassuring, sympathizing, or consoling 11. Questioning or probing 12. Withdrawing, distracting, humoring, or changing the subject (Gordon, 1970 as quoted in Miller & Rollnick, 2002) Thomas Gordon s Roadblocks to Listening Skills of MI: OARS Open-ended (non-judgmental) questions Affirmations Reflective listening Summaries 4
Open-Ended Questions Using open-ended questions to honestly (not through trickery or manipulation) explore clients values and thoughts. If and What Questions I would like to know a little more about you and what your life is like, what is a typical day like for you? What would be the best thing about your life if you were not using meth? What worries you about your meth use? What do you think will happen if you keep using meth for the next five years? What would be the best thing about your life if you stopped using drugs? What would be the hardest thing about your life if you stopped using drugs? If you decided to stop using meth, how would you go about that? If you did decide that you wanted your change your discipline techniques, what would you do differently? Open-Ended Questions Readiness Scales Readiness Scales: Importance (willingness): On a scale of 1 to 10, with 1 being not important at all and 10 being very important, how important is it to you to stop using meth? Confidence (ability): If you did choose to stop using meth, on a scale of 1 to 10 with 1 being not confident at all, and 10 being very confident, how confident are you that you could stop? Readiness If you were to start following a plan to stop using meth, how soon would you want to start that plan, today, next week, next month, or next year? Trap to Avoid Question Answer Trap The question answer trap happens when a pattern develops of practitioner asking a question, client responding, practitioner asks question, client responds, etc. The reason this limits change talk is that the client may not become personally engaged in exploring change, rather the client waits for the expert to figure out the solution by simply asking enough questions. In question/answer patterns, the practitioner holds the power and responsibility for creating change. This is contrary to the spirit of MI. Generally, MI practitioners are encouraged to keep a 2 to 1 ratio of questions to reflections. 5
Affirmations Affirmations build clients sense of empowerment and self-efficacy. These are short statements specifically about the clients strengths that can be capitalized upon for change. Affirmations should be genuine and should be specific to behaviors. You have a lot of commitment to your family to have come here today despite your belief that there is nothing wrong. You are an independent person who is going to decide what is best for you. You don t let others make up your mind for you. You love your children and want to do what is best for them. You enjoy being with people and having a good time. reflect back to the client what you are hearing. aid you in ensuring you re understanding what the client is saying, but more importantly, they help the client clarify their thoughts. Though they said something and you reflected back what they said, after hearing it, they may change their mind slightly. This process of continuing to evaluate what specifically they think and feel assists clients in moving forward through ambivalence about change. should end in a period, not a question mark. Questions are useful to start a conversation or change a conversation, but questions interrupt the other person s thought processes., on the other hand, can keep the thought process going. can be simple, complex, amplified, understated, or double-sided. Different kinds of reflections can assist clients in clarifying their thoughts in different ways. Simple Reflection restates what the client said without much variation You feel that your use of drugs does not hurt anyone. It sounds like you have tried many times to leave your husband. You re wondering if you can get a job and support your children without prostituting. You don t know why your children were removed from your care. You believe that your Parent Aide doesn t understand how hard things are for you. 6
Complex test hypotheses or use words the client did not use to see if the statement rings true to client. Client: This is just too much, how am I supposed to do all this? This is like 3 pages long. I don t know even know what half this stuff means. SWer: You feel overwhelmed by the case plan tasks and are not sure where to start. Client: I can t work with that lady anymore. She s always saying this and that and how I do everything wrong. She doesn t understand what it s like and she thinks I have to be perfect and do everything just like her. Well I don t care about what she did with her kids and her perfect little life. SWer: The way the parent aid talks to you makes you feel like she doesn t respect you. Amplified reflections exaggerates or overstates what the client has said. This clarifies that things are not always a certain all or not all people respond to them that way, or there is no way they could ever do such a thing. It opens possibilities by allowing the client to explore exceptions. So, nothing bad has ever happened as a result of your substance use. You never get upset or angry with your children. You haven t learned anything at all from the parent aide classes. Understated reflections slightly lower the intensity of the client s statements in order to explore deeper meanings underlining the defensive emotion. Client: I love my kids and you all just ripped them away from me. How could you do this to them and call it protection? They hate that house and they look miserable. I didn t do anything wrong and this is all just bullshit. You re harming my kids because you believe some person at their school who barely knows them more than you believe us. They were fine with me. There was nothing wrong. SWer: You miss your children and you are confused about why they were removed from your care. Having a better understanding about why they were removed would be helpful to you. 7
Double-sided reflections mirror back to clients their ambivalence so it could be explored further. This is the one time to use the word but. Client: I love my husband and I don t want to leave him. I m tired of you people telling me how my marriage should be. So we fight, so what? He s not an abuser, I hit him as much as he hits me. Sure, sometimes he goes to far, but I should know better not to piss him off that much. SWer: You want to remain in the relationship with your husband but you understand that the violence in the relationship is not good for either of you. Summaries Summaries allows clients to hear how their thoughts have come together. Summaries come out of the narrative model. It assists clients with organizing their thoughts and reframing their experiences. You are angry about the removal of your children. You love them and you miss them. Taking care of them was hard, but you want them to come home as soon as possible. You do not think you have a substance abuse problem and you do not want to go to the evaluation. On the other hand you do understand that going to the evaluation is on your case plan and that whether or not you go will be reported to the court. You are willing to do anything for your kids, but you re just not sure you want to go to the evaluation, yet. Did I miss anything? Wrapping Up Concluding or wrapping up in an MI approach remains true to the spirit of MI in that the client is asked what she/he will do. Given what we have talked about, what will you do next? So, based on the choices available to you, what do you think you will do this week? How do you think you will decide what you are going to do about going to the evaluation or not? What will you do about this problem? 8