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Motivational Interviewing. November 16, 2009 Nurse Practitioners Roundtable The Homestead, Hot Springs,VA Cecilia van Zyl-Knab, LCSW, MINT Motivation4Change. You would think . . . .

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Motivational interviewing


November 16, 2009

Nurse Practitioners Roundtable

The Homestead, Hot Springs,VA

Cecilia van Zyl-Knab, LCSW, MINT


You would think

You would think . . .

  • that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication

  • that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking

And yet so often it is not enough what is the key

And yet so often it is not enough: What is the Key?

Client motivation is a key to change

Client Motivation is a Key to Change

  • Substance abuse treatment outcomes are predicted by:

    • Pretreatment motivation measures

    • Treatment attendance

    • Treatment adherence/compliance

    • Counselor ratings of motivation and prognosis

  • That is, more “motivated” clients do better

And client motivation is greatly influenced by the counselor

And Client Motivation is Greatly Influenced by the Counselor:

  • Clients’ motivation, retention and outcome vary with the particular counselor to whom they are assigned

  • Counselor style strongly drives client resistance (confrontation drives it up, empathic listening brings it down)

  • That is, the counselor is one of the biggest determinants of client motivation and change

Readiness for what

Readiness for What?

  • Rather than asking: “Why isn’t this person motivated?”

  • Ask: “What is this person motivated for?”

  • Potential Pitfall: Assuming you know.



  • Research specifically has not found overuse of denial, or any other typical patterns of defensive styles among people with SUDs

If it s not personality then what behaviors cause counselors to perceive clients as being in denial

If it’s not personality, then what behaviorscause counselors to perceive clients as being in “denial”?

  • Disagreeing with the counselor

  • Resisting a diagnosis/label

  • Declining help

  • Showing little distress

  • Disavowing a need for counseling or change

  • Being non-compliant with treatment prescriptions


  • Not changing

In contrast counselors tend to perceive clients as being motivated when they

In contrast, counselors tend to perceive clients as being “motivated” when they:

  • Agree with the counselor

  • Accept the counselor’s diagnosis/label

  • Express a desire for help

  • Show distress

  • Voice a need for the counselor/counseling

  • Comply with the counselor’s treatment plan


  • Change

In other words client motivation is evident in

In other words, client motivation is evident in:

  • Low resistance

  • Openness and collaboration

  • Expressing emotion

  • Adhering to a change plan


  • Changing

    All of which are strongly influenced, for better or worse, by what the counselor does



The Dilemma of Change

Stages of change prochaska diclemente

Stages of ChangeProchaska & DiClemente

Contemplation stage

Contemplation Stage

  • It is easy to think that someone in this stage is ready to make a change.

  • Work place smokers survey: 70-80% contemplation, but only 3-5% attracted to programs for change

  • Some studies: Relationship between contemplation & higher levels of depression

Cognitive behavioral change

Cognitive & Behavioral Change:

  • Seems that cognitive and experiential processes of change more important in earlier stages (consciousness raising, self evaluation, environmental re-evaluation)

  • Behavioral processes more important in later stages of change (efficacy)

The righting reflex

The Righting Reflex

You take one side i another

You take one side; I another

  • When you strong argue one side, the ambivalent naturally argue the other

  • The stronger the argument the less likely change occurs

Common human reactions to the righting reflex

Angry, agitated





Not understood

Not heard



 Helpless, overwhelmed




Don’t come back – avoid

 Uncomfortable

 Resistant

Common Human Reactions to the Righting Reflex

Common human reactions to being listened to


Want to talk more

Liking the counselor





Able to change






Want to come back


Common Human Reactions to Being Listened to

A change of role

A Change of Role

  • You don’t have to make change happen

    You can’t

  • You don’t have to come up with all the answers

    You probably don’t have the best ones

  • You’re not wrestling

    You’re dancing

Motivational interviewing definition

Motivational Interviewing Definition:

  • Motivational interviewing is

  • a person-centered,

  • directive

  • method of communication

  • for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

The spirit of motivational interviewing

The Spirit of Motivational Interviewing

  • Collaboration

  • Evocation

    • Docere and Ducere

  • Autonomy

Docere and ducere

Docere and Ducere

  • Two Latin verbs regarding education

  • Evoking vs. Imparting information

  • Docere - lead / impart knowledge or info

  • Ducere - to draw forth or evoke from within

  • Spirit of MI: Ability to draw forth rather than

    pulling the client toward the goal

Thank you

Thank You!

  • Upcoming 2 Day Training: Richmond, VA

  • January 14 & 15, 2010 for more info visit:


Reference list

Reference List:

  • Miller, W. R., Rollnick, S. (2002). Motivational Interviewing, Preparing People for Change. 2nd Ed. Guilford Press.

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