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motivational interviewing 2 days

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Tom Dobson

on 30 January 2014

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Transcript of motivational interviewing 2 days

This may seem redundant if the client is already committed to the change plan.
This is a good opportunity to review the plan and ask “Is this what you plan to do”?
If the client is not ready to choose commitment, then avoid the trap of pressing for it.
Instead of pressing forward, acknowledge the clients position. Then go back to your O.A.R.S.
Reaffirm Commitment
This is a good time to summarize again and then it’s time to go for a commitment to the plan.
It might be as easy as asking directly something like, “Is this what you want to do?” and the client saying, “Yes.”
What else might we do at this time?
Building a Plan and Getting
Handout on Building a Plan
Building a Plan and Getting Commitment
Planning is a negotiated process in MI. As a guide, we assist clients in thinking through the steps of an option, difficulties they might encounter, how they might address these, what resources they might bring to this process, and how to evaluate the plan. Its
important to express concern if there is something in the plan that appears unworkable.
Arrive at a Plan
This is an area that a workers expertise can be of great benefit to clients. Caution is still to remain MI adherent.

Practice E-P-E = Elicit-Provide-Elicit
Sort Options
Practice with Goals
One of you is the worker and the other is the client
Determine 2-3 areas the client wants to work on
Establish general goal statements
Measure each goal statement against SMART (Handout 5-27) and amend as necessary
Switch roles after 10 minutes (the trainer will alert you)
Practice with Goals
What are some other things for us to remember as we set goals? (cont’d)
Keep the big picture in mind
Remember that there are a number of options available, not one single “right” approach; it’s a matter of what works well for this client.
Guide the client toward a treatment strategy which you believe is best suited to them to reduce the possibility of discouragement and failure.
Set Goals
How would you like your life to be different?
What would you like to see change?
If things were better, what would be different?
What would you like to have more of or Less of?
Set goals
S = Specific
M = Measurable
A = Attainable/Agreed to
R = Revisitable, Realistic
T = Tiered/Timely
Set goals
Whose Goals are these?

Set clear goals

Set goals
Underestimating ambivalence


Insufficient direction
Speed Counselling
Dodge Ball
Client: I’m having a lot of problems at home. You’d miss some family meetings too if you had to deal with the stress I am always under. I know they’re mandated, but sometimes I feel stuck.
Clinician: That makes a lot of sense. Your home situation is tough and missing meetings that are there to help you isn’t making matters any better for you, your family, or your legal situation.
Agreement with a Twist
Clinician: You’ve thought a lot about this and want to figure out how to assert yourself without screaming at him.
Client: Yeah, he can start by letting me take care of myself and give me some space. That’s what I want to say to him.
Clinician: He wants to help, but doesn’t know how to go about it.
Client: If he tells me one more time he wants to get into treatment with me to help me with my problems, I’m going to scream.
Reframing (Providing a different perspective)
Client: “Why are you giving me this booklet? Are you telling me I have to stop smoking?.”

Clinician: “It’s just information. What you do with it is completely up to you. The decision to stop smoking is up to you.”
Emphasizing personal choice
and control
Double-sided reflection

Client: “I know I shouldn’t hang around with those guys, but we grew up together and I just can’t walk away from them. They aren’t all bad..”
Clinician: “So you feel loyal to some of these guys, especially the ones who aren’t all that bad. On the other hand, you have some concerns about what might happen if you keep hanging with them.”
Handling Resistance Examples
Simple reflection:

Client: “Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint!”

Clinician: “It’s hard to imagine how I could possibly understand.”

Amplified reflection:

Client: “I couldn’t just give up drinking. All of my friends drink.”

Clinician: “You couldn’t handle your friend’s reaction if you quit.”
When people perceive their freedom of choice is being threatened, they tend to react by asserting their liberty.
Emphasizing Personal Choice
and Control
Acknowledges the validity of what the person’s has said and offers new meaning or interpretation for them.
Shift the person’s attention away from what seems to be a stumbling block or barrier. Such detouring can be a good way to address or at least postpone dissonance when encountering a particular difficult issue.
Shifting Focus
Using reflective listening to capture both sides of the ambivalence.
If the person’s recent statement manifests only the resistance side of the argument, a D.S reflection acknowledges what the client has said and adds to it the other side of their own ambivalence.
Double-Sided Reflections
Reflecting back what the person has said in an amplified or exaggerated form.
To state it in an even more extreme fashion. If successful, this will encourage the person to back off a bit and will elicit the other side of ambivalence. (must be done empathically)
Amplified Reflections
A simple acknowledgement of the person’s disagreement, feeling, or perception can permit further exploration rather than continued defensiveness.
Simple Reflections
Simple Reflection.
Amplified Reflection.
Double sided reflection.
Shifting Focus.
Agreeing with a Twist.
Emphasizing Personal Choice and Control.
Handling Resistance
Resistance lies at the very heart of human change!
If you speak the same lines, as others have done, the script will come to the same conclusion.
You have an opportunity rewrite our role.
Resistance is a key to successful treatment if you can recognize it for what it is:
In expressing resistance, the client is probably rehearsing a script that has been played out many times before. There is an expected role for you to play.
Prochaska and DiClemente might say that the worker is using inappropriate strategies for the stage of change that the client is in. That means the worker has to go back to where the client is and start working from that point.
Now pretend you are the client and answer the
fallowing questions-

Where are you now in your work with your practitioner?
Where would you like to be?
What’s getting in the way of that happening?
Whats your perspective?
Where are you now in your work with this client?
Where would you like to be?
What’s getting in the way of that happening?
Sustain Talk: Is about the target behaviour-
I really don’t want to stop smoking.
I have to have these pills to make it through the day.
Resistance: Is about the relationship-
You can’t make me quit.
You don’t understand how hard it is for me.

Both are highly responsive to counsellor style.

Miller and Rollnick 2010
Sustain Talk and Resistance

In pairs, practice at least 2 traps – either avoiding it or getting out of it.
For the first trap,1 person is the worker and the other person is the client.
For the next trap, switch roles and practice for a different trap.
Take 3-4 minutes per rehearsal (total of 7-8 min)
Scenario: a first or second meeting to build motivation to reduce substance use.
Behaviour Rehearsal
If a client starts to blame, the worker can refocus the discussion by reflecting back their concern and framing it in the context of the client’s reason for counselling and what they want to do about that.
Make a brief structuring statement at the beginning of the counselling session which clearly sets out the purpose of the counselling.
To Avoid the Blaming Trap
Sometimes a client focuses on who’s to blame or who’s at fault for the situation or problem
Blame is irrelevant and non-productive in counselling.
The Blaming Trap
Avoid an argument about the “proper” topic for
discussion and exploration focus on the client’s concerns... and trust that you will be able to explore other topics.
( remember there maybe a reason that they are avoiding your topic)
Continue to build trust using empathetic listening.
To Avoid the Focus Trap
Don’t label a client (I don’t care about labels; they’re not important. What is important …)
Discourage a client from self-labeling
Explore the consequences of their behaviour.
To Avoid the Labeling Trap
The danger in labeling a client is that it:
carries a stigma
can easily evoke resistance
The worker insisting on labeling can easily fall into confrontation-denial trap.
If the client doesn’t raise labeling, the worker shouldn’t either, but if a client has already accepted a label, the worker can also just accept it.
The Labeling Trap
If a worker conveys the impression that they have all the answers, the client is put in a passive role. If the client is not engaged in the process, it’s unlikely that they will resolve their ambivalence and decide to change. It can also affect your therapeutic relationship.
The Expert Trap
Use reflective listening.
Elicit self-motivating statements.
Explore the consequences of what the client is doing without judgement.
To Avoid the Confrontation-Denial
The worker listens to a client,
They then announce that the client has a problem.
Then sets out some specific action for the client to take.
Client is usually reluctant to acknowledge the problem (it isn’t that bad … I don’t need to change that much).
Almost every time the worker argues for one side, the client argues for the other side.
This is the most important trap to avoid and it can emerge any time the worker argues with a client.
The Confrontation-Denial Trap
Have clients complete a pre-counselling questionnaire.
(It will give you specific information you need at the beginning)
You can still ask other questions in later sessions
Use reflective listening after asking an open-ended question.
Avoid asking 3 questions in a row.
To Avoid the Question-Answer
Using closed questions
Ones that require only a one word or single phrase response from the client.
This Often happens because:
We workers need to gather information about the client or
We Workers feel anxious about our work loads needing to get as much done as possible.
It reduces our interaction with the client.
It prevents the client from exploring and offering self-motivational statements.
It can also build a clients anxiety and resistance to our efforts to support.
The Question-Answer Trap
Question-Answer Trap
Confrontation-Denial Trap
Expert Trap
Labeling Trap
Focus Trap
Blaming Trap
Traps to Avoid
A very effective method to elicit change talk.
Explores positives and negatives of the client staying where they’re at versus making a change.
Its very helpful in clarifying both sides of the client’s ambivalence.
The client might know many of the points on both sides but never have put them all together.
It also lays the ground work to develop discrepancies.
Pay-Off Matrix
What else is..
Miracle question( Where do you see yourself in 5 years?)
How will being creative support your recovery?
Linking behaviors to past values......"What values are important to you"
Eliciting Change Talk

The purpose of this method is to uncover the values or goals the client considers most important. Then develop discrepancy.
You haven’t actually convinced me that you have got a real problem.
Confidence rulers
Pay-Off matrix
Eliciting Change Talk
Some examples:
Give me an example.
For example … (voice fading away)
Such as …(voice fading away)
How else does that affect your...
How much does this concern you?
Simply asking the client to elaborate on a specific topic.
Early in the process, for example, it’s helpful to ask a client to describe a typical day.
This enables details about behaviour and mood changes, substance use related to the changes, and other areas of concern to emerge fairly naturally.
There is a range of methods we can use to elicit change talk we’re going to explore that range, including the pay-off matrix mentioned in an early session

Eliciting Change Talk
Eliciting Change Talk
Identify your most important values?
What does each value mean?
Inquire about how the client is living out this value?
Inquire about how the client is not living out this value?
Note the links between the problem behaviour and values.
Exploring Values
Values Card sort exercise
Exploring Values
Explore your clients values to elicit reasons for change.
Exploring Values
After we have selectively picked some flowers, we now summarize them to make a bouquet.
Clients often need help organizing all the information or material.
Summaries help clients see the types of flowers, the relations between the flowers and the elements still needed.
Providing Bouquets
Giving equal weight to sustain/change talk is what clients already know. This is what keeps people stuck.
We are listening for the things clients tell us about change and we use targeted reflective listening to pick out the
flowers (change statements)
that are of value to the client.
Picking the flowers
Examples of Evocative Questions:
What concerns you now about your current level of use?
What worries you about how ODSP works with it’s clients?
How would you like things to be different for you with relationships?
How would things be better if you changed?
Evocative Questions
We ask questions that directly identify reasons for change.
We want to use questions that guide the conversation toward change talk vs sustain talk.
Evocative Questions
There are four approaches to resolving ambivalence

Evocative Questions

Picking the flowers

Providing Bouquets

Exploring Values
To resolve ambivalence we want to focus on change talk. Selectively elicit and reinforce the talk that is directed towards change versus focusing on the sustained talk.
People resolve ambivalence by talking themselves into changing.
Definition= “simultaneous and contradictory attitudes or feelings toward a person, object or action.” (seen as attraction and repulsion).
A continual fluctuation.
Uncertainty as to which approach to follow.
Merriam-Websters Dictionary

“People are generally better persuaded by the reasons which they themselves have discovered than by those which have come into the minds of others”

Pascal’s Pansees, 17th Century

Start by asking clients what they already know about an area (elicit)
Once you have heard what they know, then the worker can add to it. (provide)
Ask the client their view on what has been provided. (elicit)
Strategies for Information Sharing
and Advice Giving
Give clients implicit or explicit permission to disagree with you. Example
“This may or may not be of concern to you”.
“I don’t know if this makes sense to you and I would like to hear what you think about..”
“You may not agree with me on this..”
Principles of Information Sharing
and Advice Giving
Offer information, don’t impose it.
Find out if clients want the information before you give it.
Ask permission, especially if clients haven’t asked for the information
Provide information in the context of other clients
Principles of Information Sharing and Advice Giving
Information Sharing and Advice Giving
Change Talk Exercise
Reducing emotional arousal
Affirmations sensitive to emotional state and Culture
Ambivalence around behaviours related to voice hearing and unusual beliefs
Integrates values and develops discrepancy
Makes explicit links between psychosis and substance use.
Adapting MI for Psychosis?
Martino et al. (2002)
Targets ambivalence surrounding treatment & medication & substance use
Increased emphasis on affirming clients
Avoid reflecting hopelessness
Reduce reflection on disturbing life experiences
Frequent short reflections
Frequent summaries
Simple verbal and visual materials
Sensitive to the Pacing
Adapting MI for Psychosis?
It selectively elicits questions.
it`s selective in it`s reflections.
It`s Selective in it`s elaborations
It`s Selective in it`s summaries
It`s Selective in it`s affirmations

Miller and Rollnick 2010
How Motivational Interviewing is Directional
Summarizing Clinician:

“I’d like to try to pull together what you’ve said so far. Let me know if I miss anything. You came in here primarily because your wife is concerned about your drinking, but you are not so sure that drinking is a problem. On the one hand alcohol helps you to feel better in the short-run, but on the other hand you think that drinking makes you more depressed and tired overall. Does that sound about right?”

Example of a Summary
It’s important to check that your summary is an accurate reflection of what the client is saying. Ask questions like:
Is that a fair summary?
What have I left out?
How does that sound?
Some examples of how a summary might begin:
So far you’ve said that ….
On the one hand you’ve talked about…. On the other hand you’ve said…
I’d like to try to pull together what you’ve said ….
I just want to make sure I understand everything. You’ve been saying….

Is used when we are going to change the direction of a session.
This summary might be a bit of a longer technique. It is used to resolve ambivalence. (similar to develop discrepancy)
Important when using summaries to use the conjunction “
” rather than “

” negates everything after it. “
” allows both concepts to be held simultaneously.

They seek to contrast ideas heard in the present moment with ideas presented previously.
This technique is used to resolve ambivalence. (similar to develop discrepancy)
It’s helpful to summarize periodically throughout a session.
3 types of summaries that you can use are:


In Summarizing:
The best summaries are succinct.
Two to three sentences.
Easy to understand.
The worker decides what elements are important to summarize.
The aim is to summarize those elements that move the client forward.
- We make summary statements to
link together discussions and comments and
to reinforce what has been said.
-Summaries show that you’ve been listening closely.
and they help a client to continue in the process of change.
-Last, and perhaps most important, summaries enable a client to hear their own self-motivational statements again.
Directing or ordering
Warning or threatening
Giving advice or solutions
Persuading, arguing or lecturing
Preaching or “should-ing”
Judging, criticizing or blaming
Shaming, ridiculing or labeling
Reassuring or consoling
Questioning or probing continuously

These are often referred to as “roadblocks”
What Reflective Listening is NOT
Excerpt from Miller and Rollnick’s video series on MI
4 Early Strategies or Actions
Reflection of feeling
Levels of Reflective Listening
In its simplest form, reflective listening is merely repeating a few words to keep the speaker moving.
A more advanced form substitutes the listener’s words for the speaker’s words .
Sometimes the most effective and also the most difficult reflective listening mirrors how the speaker seems to feel rather than what they are actually saying.
Reflective Listening
Reflective listening keeps the momentum moving forward and we use this momentum to elicit change talk and ultimately create change.
Reflective Listening
We try to use 3 reflections for every question asked.
Reflections enhance clients understanding by expressing the element that is less clearly articulated or unexpressed but implicit within the message.
Reflective Listening
Reflective listening is especially important after a client has responded to an open-ended question.
Change talk statements should always be reflected back so the client hears them twice.
Reflective Listening
The listener forms a reasonable guess about meaning and makes a statement about it, not a question
A statement reduces resistance
The reflective listener sorts through the various meanings that a statement might have and chooses the one they think is most likely
Key components of reflective listening
Want to talk more
Common Human Reactions to Being
Listened To
What is reflective listening?


You have qualities of a leader...People look up to you!
You are the kind of person who cares a lot for others!
Examples of Affirmations
It must be hard for you to talk about this!
You have lots of resources that will help you to deal with this problem!
You showed that you really could!
It must have been difficult for you… and you made it!
Examples of Affirmations
Sound like-
sincere compliments
appreciation comments
statements of understanding
statements that legitimize/validate the clients current emotional state

Examples of Affirmations
Affirmations strengthen the psychological immune system (Sherman & Cohen, 2006).
Making the person feel ”seen” as a person (not just as a client).
As a worker we want individuals to know that they are a significant person, this makes change more likely.
Reinforce and strengthen important alternative domains.
What are some Affirmations that you'd Like to Hear?
4 Early Strategies or Actions
What are some Affirmations you can give to your clients?
4 Early Strategies or Actions
Affirm the Client
Can you meet with me once a week for the next 10 weeks?

How do you feel about meeting again next week?
Open Ended Questions Handout
Possible Responses
Do other people in your immediately family use drugs or alcohol?

What does your family think about using drugs or alcohol?
Open Ended Questions Handout
Possible Responses
How old were you when you first started using?

Tell me about when you first started using.
Open Ended Questions Handout
Possible Responses
You’re here to talk about how much you use drugs, right?

I assume from the fact that you’re here that you have some things you want to talk over. What would you like to discuss?
Open Ended Questions Handout
Possible Responses

You’re here to talk about how much you use drugs, right?

How old were you when you first started using?
Are you in touch with your family?

Do other people in your immediately family use drugs or alcohol?

Can you meet with me once a week for the next 10 weeks?
Open Ended Questions
Instructions: Convert these questions into open-ended questions or statements.
Handout: Open-Ended Questions
What were you hoping we’d be able to accomplish today?
What were you hoping to be able to accomplish today?
Open Ended Question
What brings you here today?
Tell me about what’s been happening since we last met?
So what makes you feel that it might be time for a change?
What do you like about drinking?
What are the most important reasons why you want to stop injecting?
Examples of Open Ended Questions
Sets the tone for non judgmental exploration of client problems.
Gets the client talking
Allows for the client to do most of the talking.
Important especially after you have heard change talk.
Open-Ended Questions
What’s so great about open-ended questions? Why do we want to use them?
4 Strategies or Actions
Ask Open-Ended Questions
Strategy #1
Ask Open-Ended Questions
-Open-ended questions
- Affirm the client
- Reflective listening
-Summarize the proceedings


Responding to Change Talk
I know my urine was dirty for marijuana. I smoked for years and only stopped two weeks ago. I’d like to see a clean urine too.
I’ve had enough of life on the streets. If I don’t stay out of trouble, I’ll be dead before I know it.
I can’t wait to stop seeing you. Don’t get me wrong, but the day probation is out of my life will be the day I can truly get on with my life.
What does pot have to do with it. I go to for psychiatric treatment. That’s what I need. I hardly ever smoke pot, anyway.
Recognizing Change Talk (cont.)
I want to come to see you more often. It’s just that most of the time I can’t get a ride.
I don’t need to stop drinking. I need to cut down on my drinking, for sure. But I don’t need to stop.
If the judge keeps continuing my case, he’ll drive me to do something to land my ass in jail. I don’t need any more programs, I need to stay near my family.
That program might be good at helping some people, but not me. I can change by myself
Recognizing Change Talk
Underestimating ambivalence

Over directing

Insufficient direction
= Committing= I will, I am
= Activating= I plan to, ready to…
= Taking Steps= I did…
Implementing Change Talk
…usually precedes change.
“I want to but I don’t want to”
D= DESIRE to change (want, like, wish . . )
A= ABILITY to change (can, could)
R= REASONS to change (if . . then)
N= NEED to change (need, have to, got to . .)
There is four kinds
Change Talk

Preparatory Change Talk

Implementing Change Talk

There are two kinds of Change Talk
Change talk is client speech that favors movement in the direction of change.

Specific to a particular target behavior.

Occurs naturally when clients are ambivalent about change.
Change Talk

Sustain talk sounds like-

I really like marijuana.
I don’t see how I could give up pot.
I need to smoke to be creative.
I intend to keep smoking and no one can
can stop me.
I don’t think I have to quit.
Sustain Talk
What is sustained talk?

What is change talk?
Change Talk
Recognizing Change Talk
Frequency of change talk during MI sessions predicts better outcomes in alcohol consumers, homeless drug-using adolescents and emergency room patients. (Moyers et al, Baer et al, Gaume et al)
Change Talk
Research has indicated that when the worker uses MI consistent strategies(OARS, support for autonomy, and empathy) this has been associated with increased levels of change talk.
This change talk then predicts better treatment outcomes.
Change Talk
Sustain Talk
Change Talk

Support self-efficacy
An effective alternative to arguing
involves reframing a client’s statement in a way which offers new information and a new perspective.
The client is welcome to take or leave the new information or new perspective.
We expect there to be some resistance.
Roll with resistance
The natural response of anyone who is challenged about a behavior over which they are ambivalent, is to argue the counter position.
Identifies the difference between where the client is and where s/he wants to be
or the difference between current behaviour and important personal goals
sometimes called cognitive dissonance
Develop discrepancy
Develop discrepancy
Begins with respectful listening to understand the client’s perspective (without judgment, criticism or blame).
Becomes a response which indicates that the client’s perspective is understandable, comprehensible and (at least for the client) valid.
Express empathy
Express empathy
Principles of Motivational Interviewing


Think about an inspiring person in your life whom motivated you to excel and to try harder than you otherwise would have.
Answer the following questions-
What was their name?
What characteristics did they have?
What inspired you to be your best?
How did you respond to their efforts?
MI Spirit Exercise


Involves drawing out ideas and solutions from within clients.
We recognize that clients have experience with their own challenges and the things that help and hinder the process of change.
MI Spirit

Refers to the clinician and client working in partnership.
A collaborative stance recognizes that clients are experts on themselves, and their past experiences with change.
MI Spirit

MI clinicians are like guides.
Decision making is left to the client.
We recognize that clients are ultimately responsible for choosing their own paths.
Being the author of your own life.
MI Spirit
"Anyone who willingly enters into the pain of a stranger is truly a remarkable person.“

H.J.M. Nouwen quote from In Memoriam: 

C = Compassion
A = Autonomy
C = Collaboration
E = Evocation
Components of MI Spirit
People only change when the pain of change is less than the pain of staying the same.
Saunders’ Law of Behavior Change
Motivation is not a trait!
The clinician shares the responsibility for enhancing their clients’ motivation for change. Clients are not responsible for coming to their practitioner motivated for change. Motivation is malleable and is formed in the context of relationships
The guiding style involves an approach in which a client and counselor work as a team. They “walk” together, but the practitioner “points out routes  and options, serving as a resource about what is possible, what others have done, and what the risks and benefits might be of each approach.

As the practitioner points out possible paths, the client receives assistance in choosing the directions that fits best for the client. (Rosenberg, 2009)
Guiding Style
Motivational Interviewing is a collaborative, person-centered form of guiding the conversation to elicit and strengthen ones motivation for change.
MI Definition
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 for change.
Three Essential Elements
in any Definition of MI
What is motivational interviewing?

How would you define MI?
Motivational Interviewing
1. Getting the spirit of MI
2. Using client-centered skills (OARS)
3. Recognizing change talk
4. Eliciting and reinforcing change talk
5. Rolling with resistance
6. Developing a change plan
7. Consolidating client commitment
8. Integrating MI with other intervention methods

Miller, W. R., & Moyers, T. B. (2006). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions
Eight Stages in Learning MI
The basis of this training is Miller and Rollnick’s book Motivational Interviewing – Preparing people to change addictive behavior
Introduction to Motivational Interviewing
>1000 publications
>200 randomized clinical trials
Dozens of books and videotapes
Several coding systems for quality assurance.
Research on MI training
Motivational Interviewing

It may not be that we are poor
at our jobs and our skills are not proficient; instead, we need to read our clients' reactions to what we say and work with them, dance with them, and be flexible in our skills and expectations and change them quickly to meet the clients needs.
We would like to acknowledge the contribution of the MINT membership, for the inspiration and generous sharing of materials that allows us to bring the most up to date information and exercises to our MI training.
Thank You
If you had a reminder sign on the wall behind or above the client’s head, What would you put on the your sign to remind you about MI?
Reminder Sign
Building a Plan
Miller and Rollnick Video Clip
Building a Plan and Getting Commitment
Building a Plan and Getting Commitment
What are some other things for us to remember as we set goals?
Work closely with the client.
Go with the goals that are most important to the client, even if you know there’s a problem with those goals.
Define acceptable and attainable goals for the client.
Set Goals
S = Set goals
O = Sort options
A = Arrive at a plan
R = Reaffirm commitment
Four Elements to consider when Negotiating a Treatment Plan
Offer initial agreement, but with a slight twist or change of direction.
Agreement with a twist is basically a reflection followed by a reframe.
Agreeing with a Twist

Think about a client whom you are working with that you feel has been difficult. Answer the following questions.
Sometimes the client and worker want to focus on different topics.
worker wants to explore alcohol/drug use and related problems and client wants to cover off broader issues.
If the worker insists on their choice, the client can become resistant or defensive.
The Focus Trap
Recognize and remind the client that, the client is the expert for their life.
Engage the client in exploring their ambivalence.
If you don’t have the answer, say so, then find it and convey it to the client.
To Avoid the Expert Trap
Adapted from Miller & Rollnick (2002) MI textbook, p. 53.
How Confident Ruler
Not At All Extremely Confident Confident
How Important Ruler
Not At All Extremely Important Important
Importance and Confidence Rulers
How else does that affect your …
Best and worst scenarios
Backward Look:
What were things like before you…
Forward Look:
What do you hope your future will look like?
Eliciting Change Talk
Use a menu of options
Invite clients to decide what the information means for them.
Give information that is factually based or normatively based, not just opinion.
Remember that your client is a person, not a information receptacle.
Principles of Information Sharing
and Advice Giving

primary purpose is to gather information and present it back to the client, and to keep the conversation moving. Usually ends in a what else?
Affirmations are a way to anchor clients to their strengths and inner resources as they work towards change.
Affirmations need to be genuine, show appreciation, and demonstrate understanding.
Affirmations focus on descriptions not on evaluations.
Are you in touch with your family?

What can you tell me about your relationship with your family?
Open Ended Questions Handout
Possible Responses
I think I could quit.
I have to do something about my drinking.
I am probably going to quit.
I want to get my kids back, and I can’t do that if I am using.
I want to stop smoking crack.
I don’t want to feel like this everyday.
Change Talk
Sounds Like-
Talk that indicates the client is not willing to change.
They are happy with the status quo and have no desire to change at his time.
There is a desire for the benefits of continued behaviour.
Sustain Talk
Encompasses hope and a sense of client personal responsibility
Only the client can make the change happen; no one else can do that
It also demonstrates a belief in the client’s ability to change.
Clients build confidence in their ability to cope with the tasks or challenges
critical to their motivation.

Support self-efficacy
Roll with resistance
Four over-arching principles:
Express empathy
Develop discrepancy
Roll with resistance
Support self-efficacy
Motivational Interviewing
Four main principles
MI Principles
MI Spirit
Change Talk
Foundations of MI
Assumes that people are ambivalent about change and must work towards their own decision concerning the change.
Aims to produce an internal drive to change, using non-confrontational techniques.
Effects change by shifting the decisional balance (negative consequences of the behaviour are elicited from the client so that the client sees and accepts the advantages of change)
Motivational Interviewing
Sign (U.S.)
MI Trainers and Translations




Strategy #4
( Pre)
Mobilizing Change Talk
Preparatory Change Talk
MI Hill
Motivational Mountain
In Combination with Other services,
Group Treatment
Couples Treatment
Parents and Families
Criminal Justice/Probation
Adolescents and Young Adults
Medication Adherence
Eating Disorders
Treatment Engagement and Retention
HIV-risk Behaviors
Diet & Exercise (diabetic, hypertension, cardiac pts.)
Dual Diagnosis (psychosis, depression)
Alcohol/Drug (cannabis, cocaine, heroin, nicotine)
MI Principles
MI Spirit
Change Talk
Foundations of MI
Tom Dobson
Strategy #2
You are a person with very high integrity!
Strategy #3
Want to come back
Able to change
Full transcript