Motivational Interviewing Mary Dugan, Ph.D., LCSW Amanda Anderson Shelly Evans & Jennifer Bartlett Marla Gamble
Objectives • MI Definitions • Processes of MI • OARS • Change Talk • Resistance • Learning to use MI
MI: A way to talk about behavior change • Person-centered • Directional method • Enhances internal motivation for change • Explores and resolves ambivalence • Empirically supported
Motivational Interviewing . . . . . is a clinical method that overlaps humanistic and cognitive therapies . . . is not behavior therapy although there is some use of reinforcement to elicit and shape client speech . . . Has a strong focus on acceptance and commitment as interpersonal transactions
MI is an Evidence Based Practice • On the federal NREPP list • Being vetted by American Psychological Association • Strongest evidence in alcohol and drug abuse • Good outcomes for alcohol, drugs, hypertension, bulimia, and compliance in diabetes • Support for smoking, physical activity, and adherence with hyperlipidemia treatment • AMIs (Adaptations of MI) were superior to placebo controls and equal to active treatments. • Noonan and Moyers (1997); Dunn (2003)
Broader than Behavior Change • 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.
Three Essential Elements in any Definition of MI MI is a particular kind of conversation about change(counseling, therapy, consultation, method of communication) MI is collaborative(person-centered, partnership, honors autonomy, not expert-recipient) MI is evocative, seeks to call forth the person’s own motivation and commitment
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?) Definitions of MI
1. A layperson’s definition(What’s it for?) Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change
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
3. A technical therapeutic definition (How does it work?) Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change
Relational Motivational Foundation Interviewing 1. Engaging 2. Focusing 3. Evoking 4. Planning
4 Fundamental Processes in MI Engaging – The Relational Foundation Person-centered style Listen – understand dilemma and values OARS core skills Learn this first
4 Fundamental Processes in MI Engaging – The Relational Foundation Focusing – Strategic Centering Agenda setting Finding a focus Information & advice
4 Fundamental Processes in MI Engaging – The Relational Foundation Focusing – Strategic Centering Evoking – The Transition to MI Selective eliciting Selective responding Selective summaries
4 Fundamental Processes in MI 1. Engaging – The Relational Foundation 2. Focusing – Strategic Centering 3. Evoking – The Transition to MI 4. Planning – The Bridge to Change Replacing prior Phase I and Phase II Negotiating a change plan Consolidating commitment
Can it be MI without . . . No No No Yes Engaging ? Focusing ? Evoking ? Planning ?
So it’s 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 for change (Evoke)
The 4 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
. . . . 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
Engaging – The Relational Foundation • Best Developed Process • Person-centered style • Listen – understand dilemma and values MI SPIRIT OARS core skills
The “Spirit” of Motivational Interviewing Collaboration Evocation Autonomy Compassion
Steve Rollnick (Sophia, Bulgaria 2007) How do we help people solve problems?
Direct manage, prescribe, lead, tell, show the way, take charge of, preside, govern, rule, have authority, exert authority, reign, take the reins, take command, point towards; conduct, determine, steer one’s course, pull the stroke oar.
Follow Go along with, allow, permit, be responsive, have faith in, go after, attend, take in, shadow, understand, observe.
A widespread dichotomy Direct Manage Prescribe Lead Tell Follow Permit Let be Allow Go along
Guide Enlighten, shepherd, encourage, motivate, support, lay before, look after, support, take along, accompany, awaken, promote autonomy, elicit solutions
Guiding: a neglected style Follow Permit Let be Allow Direct Manage Prescribe Lead Guide Shepherd Encourage Motivate
Fundamental MI skills • Open Questions • Affirmation • Reflective Listening • Summarizing • Elicit
What does open-ended mean? • Questions can’t be answered yes or no • Questions that can’t be answered with one or two words • Questions that are not rhetorical
Open-Ended Questions • Probe widely for information • Help uncover the individual’s priorities and values • Avoid socially desirable responses • Draw people out
Some Guidelines with Questions Ask fewer questions! No more than three questions in a row Ask MORE OPEN than closed questions TWO REFLECTIONS for each question
Affirmations • Affirm a person’s struggles, achievements, values, and feelings • Emphasize a strength • Notice and appreciate a positive action • Should be genuine • Express positive regard and caring • Examples • “It takes courage to face such difficult problems” • “This is hard work you’re doing” • “You really care a lot about your family” • “Your anger is understandable”
Bridge the gap by reflection What the speaker means What the listener thinks the speaker means 1 4 What the listener hears 2 3 What the speaker says The Function of Reflection R
Reflective Listening • A critical MI skill • Mirrors what the individual says • Is non-threatening • Deepens the conversation • Helps people understand themselves
MI Listening Method • Reflective listening encourages disclosure and exploration. • Listen carefully • Generate hypothesis about content, meaning, emotion • Put your hypothesis in form of a statement • Keep voice inflection neutral/down at end • Listen to individual’s clarification • Restate hypothesis of the clarified content
Reflective listening stems • So you feel like.. • It sounds like you…. • You’re wondering if… • In other words you’re saying…. • Let me see if I heard you correctly…. • What I hear you saying… • Ask for clarification- I want to understand, help me to understand what you’re saying • You’re feeling. . . • It seems that you …. • So you….
Reflections First, train yourself to think reflectively What does this person really mean? How does this fit with cultural competence? Reflective listening is a way to check in with the patient. Can be a guess about what they really meant.
Summarization • “What you’ve said is important.” • “I value what you say.” • “Here are the salient points.” • “Did I hear you correctly?” • “We covered that well. Now let's talk about ...”
Using Summaries • After a minimum of 3 reflections • Good for moving the conversation or transitioning to the next topic