Effecting change through the use of motivational interviewing
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Effecting Change through the Use of Motivational Interviewing. Thomas E. Freese, PhD Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs UCLA David Geffen School of Medicine, Dept. of Psychiatry www.psattc.org www.uclaisap.org.

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Effecting Change through the Use of Motivational Interviewing

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Effecting Change through the Use of Motivational Interviewing

Thomas E. Freese, PhD

Pacific Southwest Addiction Technology Transfer Center

UCLA Integrated Substance Abuse Programs

UCLA David Geffen School of Medicine, Dept. of Psychiatry



What are we talking about?

What does “increasing motivation” mean to you?

Understanding How People Change: Models

Traditional approach

Motivating for change

Traditional approach (1)

  • Change is motivated by discomfort.

  • If you can make people feel bad enough, they will change.

  • People have to “hit bottom” to be ready for change

  • Corollary: People don’t change if they haven’t suffered enough

The Stick

Traditional approach (2)

You better!

Or else!

If the stick is big enough,

there is no need for a carrot.

Traditional approach (3)

The Traditional Approach often used a Directing Style of helping.

Directing helping style

  • Tell them it’s important.

  • Show them how to do it.

  • Explain it to them, id how life could be better

  • Threaten them, instill fear.

  • Give them short term goals.

  • Make them a list.

  • Constantly remind them.

  • Tell them what you expect.

Directing Style of Helping

  • Might make sense if you believe that the client :

    • doesn’t know what they need to know.

    • does not know how to change.

    • Is indifferent to consequences of problem.

Directing Style of Helping

  • With these assumptions, it makes sense to:

    • use your expertise and teach them knowledge.

    • teach them skills for health promoting behavior.

    • give them hell, or otherwise make them feel something strongly enough so they will change.

Directing Style of Helping

Given that you are caring, compassionate, well-intended, and that your advice is sound…

…why does your directing helping style not work as well as you would hope?

Guiding Style of Helping

  • Respect their decisions.

  • Have them to describe what is working.

  • Ask them what their plan is.

  • Find out what’s important to them.

  • Have them talk about their health and their goals.

  • Have them list pros and cons.

  • Ask what their goals are for Tx.

Guiding Style of Helping

  • Motivational Interviewing can be considered a specialized subset of a Guiding style.

What is the problem?

It is NOT that…

  • they don’t want to see (denial)

  • they don’t care (no motivation)

    They are just in the early stages of change.

What is Motivational Interviewing?

It is:

A style of talking with people constructively about reducing their health risks and changing their behavior.

What is Motivational Interviewing?

It is designed to:

Enhance the client’s own motivation to change using strategies that are empathic and non-confrontational.

What is Motivational Interviewing?

You can recognize it by observing:

  • The powerful behavioral strategies for helping clients convince themselves that they ought to change

  • The “spirit of MI” style in which it is delivered

MI: Strategic goals

  • Resolve ambivalence

  • Avoid eliciting or strengthening resistance

  • Elicit “Change Talk” from the client

  • Enhance motivation and commitment for change

  • Help the consumer move through the Stages of Change

MI - The Spirit (1) : Style

  • Nonjudgmental and collaborative

  • Based on consumer and clinician partnership

  • Gently persuasive

  • More supportive than argumentative

  • Listens rather than tells

  • Communicates respect and acceptance for consumers and their feelings

MI - The Spirit (2) : Style

  • Explores consumer’s perceptions without labeling or correcting them

  • No teaching, modeling, skill-training

  • Resistance is seen as an interpersonal behavior pattern influenced by the clinician’s behavior

  • Resistance is met with reflection

MI - The Spirit (3) : Consumer

  • Responsibility for change is left with the consumer

  • Change arises from within rather than being imposed from without

  • Emphasis on consumer’s personal choice for deciding future behavior

  • Focus on eliciting the consumer’s own concerns

MI - The Spirit (4) : Clinician

  • Implies a strong sense of purpose

  • Seeks to create and amplify the consumer’s discrepancy in order to enhance motivation

  • Elicits possible change strategies from the consumer

  • Systematically directs consumer toward motivation for change

Important considerations

The clinician’s counselling style is one of the most important aspects of motivational interviewing:

  • Use reflective listening and empathy

  • Avoid confrontation

  • Work as a team against “the problem”

How does MI differ from traditional counseling?

1. Patient and practitioner are equal partners in relationship (collaborative effort between two experts)

Bring to mind the person in your life who has meant the most to you. The person who has:

Provided support

Helped resolve problems

Made you feel better

Helped to change your perspective


Ambivalence is Normal

Ambivalence is normal

  • People are almost always ambivalent about change –

    • Lack of motivation can be viewed as unresolved ambivalence.

How does MI differ from traditional or typical medical counseling?

  • AMBIVALENCE is the key issue to be

    resolved for change to occur.

  • People are more likely to change when they hear their own discussion of their ambivalence.

  • This discussion is called “change talk”

    in MI.

  • Getting patients to engage in “change talk” is a critical element of the MI process.

    *Glovsky and Rose, 2008

How can MI be helpful for us in working with our consumers/patients?

The successful MI therapist is able to inspire people to want to change

Use of MI can help engage and retain consumers in treatment

Using MI can help increase participation and involvement in treatment (thereby improving outcomes)

Definition of Motivation

The probability that a person will enter into, continue, and comply with change-directed behavior

Think about the most difficult change that you had to make in your life.

How much time did it take you to move from considering that change to actually taking action?


Motivational Interviewing

A patient-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

directive method


exploring and resolving ambivalence





What’s the Best Way to Facilitate Change?

Constructive behavior change comes from connecting with something valued, cherished and important

Intrinsic motivation for change comes out of an accepting, empowering, safe atmosphere where the painful present can be challenged

The Carrot

Where do I start?

What you dodepends on where the consumer is in the process of changing

The first step is to be able to identify where the consumer is coming from

Stages of ChangeProchaska & DiClemente








Helping People Change

Motivational Interviewing is the process of helping people move through the stages of change

1. Precontemplation


Not yet considering change or

is unwilling or unable to change.

Primary Task:

Raising Awareness

6. Recurrence


Experienced a recurrence

of the symptoms.

Primary Task:

Cope with consequences and

determine what to do next

2. Contemplation


Sees the possibility of change but

is ambivalent and uncertain.

Primary Task:

Resolving ambivalence/

Helping to choose change

Stages of Change:Primary Tasks

5. Maintenance


Has achieved the goals and is

working to maintain change.

Primary Task:

Develop new skills for

maintaining recovery

3. Determination


Committed to changing.

Still considering what to do.

Primary Task:

Help identify appropriate

change strategies

4. Action


Taking steps toward change but

hasn’t stabilized in the process.

Primary Task:

Help implement change strategies

and learn to eliminate

potential relapses

Precontemplation Stage


Not yet considering change or is unwilling or unable to change

Primary task–

Raising Awareness

Some Ways to Raise Awareness in the Precontemplation Stage

Offer factual information

Explore the meaning of events that brought the person in and the results of previous efforts

Explore pros and cons of targeted behaviors

Contemplation Stage

In this stage the consumer sees the possibility of change but is ambivalent and uncertain about beginning the process

Primary task–

Resolving ambivalence and helping the consumer choose to make the change

Possible Ways to Help the Consumer in the Contemplation Stage

Talk about the person’s sense of self-efficacy and expectations regarding what the change will entail

Summarize self-motivational statements

Continue exploration of pros and cons

Determination Stage

In this stage the consumer is committed to changing but is still considering exactly what to do and how to do it

Primary task–

Help consumer identify appropriate change strategies

Possible Ways to Help the Consumer in the Determination Stage

Offer a menu of options for change or treatment

Help consumer identify pros and cons of various treatment or change options

Identify and lower barriers to change

Help person enlist social support

Encourage person to publicly announce plans to change

Action Stage

In this stage the consumer is taking steps toward change but hasn’t stabilized in the process

Primary task–

Help implement the change strategies and learn to limit or eliminate potential relapses

Possible Ways to Help the Consumer in the Action Stage

Support a realistic view of change through small steps

Help person identify high-risk situations and develop appropriate coping strategies

Assist person in finding new reinforcers of positive change

Help access family and social support

Maintenance Stage


A stage in which the consumer has achieved the goals and is working to maintain them

Primary task–

consumer needs to develop new skills for maintaining recovery

Possible Ways to Help the Consumer in the Maintenance Stage

Help consumer identify and try alternative behaviors (drug-free sources of pleasure)

Maintain supportive contact

Encourage person to develop escape plan

Work to set new short and long term goals



consumer has experienced a recurrence of the symptoms

Primary task–

Must cope with the consequences and determine what to do next

How to Help the Consumer Who Has Experienced a Recurrence

Frame recurrence as a learningopportunity; recurrence does not equal failure!

Explore possible behavioral, psychological, social antecedents to the recurrence/relapse

Help person develop alternative coping strategies

Explain Stages of Change and encourage him/her to stay in the process

Maintain supportive contact

EXERCISE 1: Using the Stages of Change Treatment Matching Guide

37 year old client. Using opioids and alcohol.

Comes to you for help because they have been arrested for DUI. He was place on probation

Client says that he doesn’t think that he has a problem. That using drinking calms him down and makes him feel better. Willing to address opioids

Client states that he thinks that everyone should drink some.

Clients says he is ready to stop everything right now to get probation officer off his back.

Change Talk

  • Recognizing the problem

  • Expressing concern

  • Stating intention to change

  • Being optimistic about change

Moving Toward Change:the DARN Steps

Change Talk

  • Dig for change talk…

  • I’d like to hear you opinions about…

  • What are some things that bother you about drinking?

  • What role do you think alcohol played in your injury?

  • How would you like your drinking to be 5 years from now?

Change Talk is Happening When the Consumer Makes Statements that Indicate:

Recognition of a problem

A concern about the problem

Statements indicating an intention to change

Expressions of optimism about change

Building Motivation OARS(the microskills)

  • Open-ended questioning

  • Affirming

  • Reflective listening

  • Summarizing

The goal is to elicit and reinforce

self-motivational statements (Change Talk)

Open-Ended Questions

Solicits information in a neutral way

Helps person elaborate own view of the problem and brainstorm possible solutions

Helps therapist avoid prejudgments

Keeps communication moving forward

Allows consumer to do most of the talking

An open-ended question is one that requires more than a yes or no response


Focused on achievements of individual

Intended to:

Support person’s persistence

Encourage continued efforts

Assist person in seeing positives

Support individual’s proven strengths

Reflective Listening Key-Concepts

Listen to both what the person says and to what the person means

Check out assumptions

Create an environment of empathy (nonjudgmental)

You do not have to agree

Be aware of intonation (statement, not question)

Types of Reflective Statements

  • 1.Simple Reflection (repeat)

  • Amplified Reflection (rephrasing and

  • paraphrasing)

  • Double-Sided Reflection (rephrasing,

  • paraphrasing and reflecting feeling)

NIDA-SAMHSA Blending Initiative


Types of Reflective Statements

  • 1.Simple Reflection (repeat)

  • Amplified Reflection (amplify/exaggerate the consumer’s point)

  • Double-Sided Reflection (captures both sides of the ambivalence)

NIDA-SAMHSA Blending Initiative

Simple Reflections

  • Simple reflections: stay very close to the speaker’s original meaning

  • Client: I don’t know if I want to go to SAMHC or not.

  • Staff: You’re not really sure about going to SAMHC.

  • Client: It seems like being clean is getting easier.

  • Staff: It’s not such a struggle to stay clean anymore.

  • Client: I can’t wait to get my own place.

  • Staff: Moving out on your own is exciting.


  • Make a simple reflection…

  • Client: I don’t ever want to drink again.

  • Client: Some of the guys in the house are pretty cool.

  • Client: That Yvonna person who does our group is so awesome. She’s pretty much the most awesome person I’ve ever met.

Amplified Reflections

  • Complex reflections not only repeat the speaker’s meaning, they shape it.

  • “Put words in peoples’ mouths”

  • Goal is always to get client to give more change talk.

Making An Amplified Reflection

listen to the client statement, then…

  • 1.) note your target behavior

  • 2.) identify any change talk you


  • 3.) reflect the change talk.

    Be creative if necessary!


  • Client:“I don’t want to go back to prison but this is way too hard.”

    • What is the target behavior? Staying in the program.

    • What change talk did we hear? “I don’t want to go back to prison.”

      Staff: “You’re struggling here, but you won’t quit trying- prison is just not an option in your mind.”

      Client: ?


  • Client: “I’m not going to quit drinking. The drugs, fine, because I don’t want to keep getting in trouble.”

    • What is the target behavior? Abstinence.

    • What change talk did you hear? “I don’t want to keep getting in trouble.”

      Staff: “You’re tired of being in trouble with the law. You want to put that behind you.”

      Client: ?


  • Client: “Honestly, I think these meetings are stupid. It’s just a bunch of people sitting around romanticizing drugs. I don’t need to be doing that.”

    • What is the target behavior? attending support meetings

    • What change talk did you hear? The client doesn’t want to romanticize drug use.

      Staff: “You want real substance and support when you go to a meeting.”

      Client: ?

Double Sided Refections

  • So on the one hand you…..but on the other you want……..

  • End on the change talk.

  • I know I need to quit smoking for my health, but it’s so hard to stop.

  • So on the one hand you are worried about withdrawal from nicotine, but on the other hand you don’t want to die from smoking.

Reflective Listening Exercise

The Listener will using as many complex and double-sided reflections as possible. Remember:

note your target behavior;

find the emotion and/or the change talk;

reflect it- get creative.

What if…?

  • What if the client doesn’t say ANY change talk?

  • “Actions speak louder than words.” Do the client’s actions express any change talk? (Can you address any discrepancy between their words and their actions?)

    • Client: “This program is worthless. I don’t want anything to do with it.”

    • “On the one hand, you don’t really want to be here and you don’t think it will help you at all. On the other hand, you’re still sitting here in front of me. I’m wondering how that adds up.”

    • Client: ?

What If, Con’t

  • No, I mean it: What if the client gives you NO change talk? AT ALL?

  • Try reflecting the resistance. Can you get even MORE resistant than the client?

    • Client: “My PO wants me working and going to counseling and TASC. You guys want me going to all these meetings, making curfew, giving you all my money. My wife is always on my case. I’m gonna have to get loaded just to deal with you all!”

    • Staff: “It would be impossible to deal with all these people sober. In fact, nobody could do it!”

    • Client: ?

What If, Con’t

  • Consider the possibility that you are not talking about the right issue…













Medical Issues

To avoid this…








  • Summaries capture both sides of the ambivalence (“You say that ___________ but you also mentioned that ________________.”)

  • They demonstrate the clinician has been listening carefully.

  • Summaries also prompt clarification and further elaboration from the person.

  • They prepare consumers to move forward.

A summary is a series of reflections strung together

Four Principles ofMotivational Interviewing

1.Express empathy

2.Develop discrepancy

3.Avoid argumentation

4.Support self-efficacy

Use the Microskills of MI to:

Express Empathy

Acceptance facilitates change

Skillful reflective listening is fundamental

Ambivalence is normal

Empathic Listening

  • Respect Client Autonomy.

  • Respect Client Views.

  • Look at Problem Together – Client is not the problem.

  • Reflect what client is experiencing.

  • Genuinely care about your client.

  • Empower Client to Take Control of Their Lives.

  • Take care of your own crap!

  • Get your own therapist if needed!

  • Come to work with positive energy!

Use the Microskills of MI to:

Develop Discrepancy

Discrepancy between present behaviors and important goals or values motivates change

Awareness of consequences is important

Goal is to have the PERSON present reasons for change

Weighing the Decisional Balance

  • Strategies for weighing the pros and cons…

  • “What do you like about drinking?”

  • “What do you see as the downside of drinking?”

  • “What Else?”

  • Summarize both pros and cons…

  • “On the one hand you said..,

  • and on the other you said….”

Importance/Confidence/Readiness Scale

  • On a scale of 1–10…

  • How important is it for you to change your drinking?

  • How confident are you that you can change your drinking?

  • How ready are you to change your drinking?

  • For each ask…

  • Why didn’t you give it a lower number?

  • What would it take to raise that number?

1 2 3 4 5 6 7 8 9 10

The Decisional Balance

Avoid questions that inspire a yes/no answer.

The Payoff for Asking the Questions…

  • These questions will lead to a working treatment plan

    • Stage of change

    • Benefits of use

    • Consequences of use

    • Willingness to work on these issues

Use the Microskills of MI to:

Avoid Argumentation

Resistance is signal to change strategies

Labeling is unnecessary

Shift perceptions

Peoples’ attitudes are shaped by their words, not yours

Support Self-Efficacy

Belief that change is possible is an important motivator

Person is responsible for choosing and carrying out actions to change

There is hope in the range of alternative approaches available

Use the Microskills of MI to:

Support Self-Efficacy

Belief that change is possible is important motivator

Person is responsible for choosing and carrying out actions to change

There is hope in the range of alternative approaches available

The Feedback/Advice Sandwich

Ask Permission

Give Feedback/Advice

Ask for Response

Give them feedback and advice, but do it in a motivational way

When to Give Advice

  • Does the consumer already know what I have to say?

  • Have I elicited the consumer’s knowledge regarding this information?

  • Is what I’m about to say going to be helpful to the consumer (i.e., reduce resistance and/or increase change talk)

  • Summarize patients views (especially the pro)

  • Encourage them to share their views

  • What agreement was reached (repeat it)

Any time that you address substance use… “SEW” it up

Possible Ways to Help the Patient in the Determination Stage

  • Offer a menu of optionsfor change or treatment

  • Help client identify pros and consof various treatment or change options

  • Identify and lower barriersto change

  • Help person enlist social support

  • Encourage person to publicly announce plans to change

Focus on the client’s definition of the problem

Give advise to change

Explore options for change

Sew up the conversation

Let's Practice

How Do I Finish?

  • Develop a Change Plan with the consumer by:

    • Offering a menu of change options

    • Developing a behavior contract

    • Lowering barriers to action

    • Enlisting social support

    • Educating the consumer about treatment

You Are Using MI If You:

  • Talk less than your consumer does

  • Offer one refection for every three questions

  • Reflect with complexreflections more than half the time

  • Ask mostly open-ended questions

  • Avoid getting ahead of your consumer’s stage of readiness (warning, confronting, giving unwelcome advice, taking “good” side of the argument)

Sample MI Interview Questions

  • In looking over the good and not-so-good aspects of your alcohol/drug use, what do you notice?

  • Which benefits seem most important to you?

  • Which of the not-so-good things do you think cause the most problems for you?

  • If we could come up with healthier ways for you to get these same benefits, do you think it might be easier for you to cut down on your alcohol/drug use?

  • Which of the not-so-good things do you think affects your (MH dx) the most and might be the most important to try to reduce?

  • On a scale of 0-10, how ready are you to start working on these things?

Role Play of Motivational Interviewing Style

  • While observing notice examples of when the microskills (O.A.R.S.) are being used.

  • Were there any examples of Non-MI interventions?

  • What stage of change do you think the client is in? Why?

Strategies to Avoid

What techniques should I avoid?

Techniques to avoid when motivating clients:

  • Confrontation / denial

  • Closed questions

  • Clinician traps

  • Roadblocks to reflective listening

Clinician Traps

  • Question-Answer Trap

  • Confrontation-Denial Trap

  • Expert Trap

  • Labeling Trap

  • Premature-Focus Trap

  • Blaming Trap

Roadblocks 1

  • Ordering, directing, or commanding

  • Warning or threatening

  • Giving advice, making suggestions, providing solutions

  • Persuading with logic, arguing, lecturing

  • Moralising, preaching, telling them their duty

  • Judging, criticising, disagreeing, blaming

Roadblocks 2

  • Agreeing, approving, praising

  • Shaming, ridiculing, labeling, name-calling

  • Interpreting, analysing

  • Reassuring, sympathising, consoling

  • Questioning, probing

  • Withdrawing, distracting, humouring, changing the subject.

Some questions to ask yourself when in conversation with a client ...

  • What am I doing?

  • Where are we going, and who’s deciding?

  • What am I saying, and to what end?

  • Am I actively listening?

  • Are we dancing or wrestling?

The 3 Chairs exercise

Observe the activity and provide feedback.

Concluding Thoughts

  • Experiences and observations

  • One thing I can take away from this training and use tomorrow is…

Thomas E Freese, PhD

[email protected]

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