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Motivational Interviewing

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Tom Dobson

on 8 August 2013

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Transcript of Motivational Interviewing

Thank you and please remember:

"People will forget what you said,
people will forget what do did,
but people will never forget
how you made them feel!"

Maya Angelou



Question-Answer Trap
Confrontation-Denial Trap
Expert Trap
Labeling Trap
Focus Trap
Blaming Trap
Chat Trap
Assessment Trap

Traps to Avoid
TRAPS TO AVOID
Elicit-Provide-Elicit
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
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 an information receptacle.
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
Pay-Off Matrix
Importance, Confidance and Readiness Rulers
Eliciting Change Talk
Forward Look
What do you hope your future will look like?
Goal Exploration
The purpose of this method is to uncover the values or goals the client considers most important. Then develop discrepancy.
Eliciting Change Talk
Elaboration
Give me an example.
How else does that affect your …
Extremes
Best and worst scenarios
Backward Look
What were things like before you…
Eliciting Change Talk
Eliciting Change Talk
The best summaries are succinct and easy to understand. Two to three sentences.

The worker decides what elements are important to summarize.

The aim is to summarize the elements that move the client forward.
Summarizing
Repeating
Rephrasing
Paraphrasing
Reflection of feeling
Levels of Reflective Listening
Reflections enhance clients understanding by expressing the element that is less clearly articulated or unexpressed but implicit within the message.
Reflective Listening
Reflective listening keeps the momentum moving forward and we use this momentum to elicit change talk and ultimately create change.
We try to use 3 reflections for every question asked.
Reflective Listening
Listening to what your client is saying is one of the key strategies. It is the key to the work.
As workers we want to vary our level of reflection. We want to move away from only simple reflections into deeper reflective listening. For example using reflections of affect.
Reflective Listening
Understood Empowered
Safe Hopeful
Want to talk more Comfortable
Open Interested
Accepted Want to come back
Respected Able to change
Engaged Cooperative
Positive Impact of Listening
Reflective Listening
- It must be hard for you to talk about this.
- You have lots of resources that will help you to deal with this problem
- It must have been difficult for you… and you made it!
- You showed that you really could.
- You have qualities of a leader. People look up to you.
- You are the kind of person who cares a lot for others.
- You are a person with high integrity!
Examples of Affirmations
Affirmations are a reflection of a clients abilities, strengths, efforts and/or a supportive statement. Affirmations have been associated with an increase in client change-talk and even commitment language.
Affirmations
Affirmations
What are the most important reasons why you want to quit smoking?
Give me an example of a time in your life when…
How does having employment makes things easier for you?
Describe a time when….
In what ways might taking the medication be beneficial to you?
Examples of Open Ended Questions
How can I help you with..?
Tell me about what’s been happening since we last met?
Tell me about your previous employment history?
What types of activities inspired you in the past?
What would be the benefits of going back to school?
Examples of Open Ended Questions
O-pen-Ended Questions

A-ffirmations

R-eflective Listening

S-ummarizing

OARS
Responding to Change Talk
T= Taking Steps= a specific action someone took toward change
Implementing Change Talk
CAT
A= Activating= I am ready to, I am willing to, I have been preparing to, I plan to, I am inclined to, I hope to,
Implementing Change Talk
CAT
C= Committing= I intend to, I made a decision to, I will, I promise, I am going to, I swear I am going,
Implementing Change Talk
CAT
C= Committing= I will, I am
A= Activating= I plan to…
T= Taking Steps= I did…
Implementing Change Talk

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)
Preparatory Change Talk
DARN

Preparatory Change Talk

Implementing Change Talk
Two kinds of Change Talk
I want to go back to school.
I have to get a job as I need more money.
I could probably put out some resumes this week.
I want to be able to provide for my family.
I want to start exercising regularly again.
I have to quit smoking.
Change Talk
Change talk is client speech that favours movement in the direction of change.

Specific to a particular target behaviour.

Occurs naturally when clients are ambivalent about change.
Change Talk
I really like marijuana.
I don’t see any reasons why I should go back to work.
I don’t see why it is so important to check my blood sugars every day.
There is no way I could get through the day without coffee or chocolate.
I intend to keep smoking and no one can stop me.
I don’t think I have to quit.
Sustain Talk
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
Stages of Change Interventions

You don’t have to make change happen.
Because… You can’t.




You don’t have to come up with all the answers.
Because…You probably don’t have the best ones.
Things to Remember
If change is to occur, clients need to be actively engaged in the process.
As workers we support the belief that our clients can change and that they are capable.
Empower your Client
As workers we create an atmosphere in which our clients can safely explore their conflicts and face difficult realities.
This atmosphere is created by being empathic and by communicating that empathy.
Listen to your Client
Motivation comes from within the client. We use MI to help find the motivation that lies within the client and to help them recognize that motivation.
Understanding Client’s Motivation
Angry, agitated and overwhelmed
Oppositional
Discounting
Defensive
Justifying
Not listened to or understood
Disengaged and helpless
Reactions to the Righting Reflex
Refers to the tendency of practitioners to try to actively fix their client’s problems, thereby reducing the likelihood of client change.

Righting Reflex fails to consider ambivalence.
Resist the Righting Reflex
R= Resist the righting reflex

U= Understand your client’s motivation

L= Listen to your client

E= Empower your client
MI Principles
Clients have within them the ability, capacity and potential for change.
Primary Belief in MI
Components of MI Spirit: Evocation
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.
"Anyone who willingly enters into the pain of a stranger is truly a remarkable person.“

H.J.M. Nouwen quote from In Memoriam: 
 
Components of MI Spirit: Compassion
Refers to the clinician and client working collaboratively together.
Working in partnership recognizes that clients are experts on themselves.
Components of MI Spirit: Partnership
Planning
Evoking
Focusing
Engaging
The Four Processes in MI
People Change When They Have Choice and Control.
MI Books
>1000 publications
>200 randomized clinical trials
Dozens of books and videotapes
Several coding systems for quality assurance.
Research on MI training
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 guiding style involves an approach in which the 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. (Rosengren, 2009)
Guiding Style
Motivational Interviewing is a collaborative, person-centred form of guiding to elicit and strengthen motivation for change.
MI Definition
Introduction to Motivational Interviewing
MI Spirit
Change Talk
OARS
Eliciting Change Talk
Wrap Up
Road Map
We are responsible
for the process/conversation
NOT the outcome.

So what happens when the Road looks like THIS?
We would like to acknowledge the contribution of the MINT membership for their inspiration and generous sharing of materials that allow us to bring the most up to date information and exercises to our MI training.
Thank You
MOTIVATIONAL INTERVIEWING
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.
Be careful when using “I” affirmations.
Affirmations
How would things be different if you had a job?
How would you like things to be different?
What steps do you think you need to take to make this happen?
What do you think you can do next?
When would you be most likely to..?
What are the good things about..and what are the not so good things about..?
Examples of Open Ended Questions
-Did/Do..
-Can/Could..
-Have..
-Are..
-Is..
-Can you..
-Why?
-How?

Closed Questions
D-esire
A-bility
R-eason
N-eed
C-ommitting
A-ctivating
T-aking S-teps
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.
Discord/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 Discord
What is sustained talk?
What is change talk?
Change Talk
Contemplation
Precontemplation
Preparation
Action
How Many of Your Clients Are Ready?
Stages of Change
Action
Preparation/Planning
Maintenance
Contemplation
Precontemplation
Remember:
NO FIXIN’
Absolute Worth
Autonomy
Accurate Empathy
Affirmation
Acceptance
Components of MI Spirit: Acceptance
MI
MI Principles
Change Talk
MI Spirit
OARS
Foundations of MI
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MI Trainers and Translations

We all want the road that is Straight and Easy
Adapted from Miller & Rollnick (2002) MI textbook, p. 53.
How Confident Ruler
0-------1--------2---------3--------4---------5---------6---------7---------8---------9--------10
Not At All Extremely Confident Confident
How Important Ruler
  0-------1--------2---------3--------4---------5---------6---------7---------8---------9--------10
Not At All Extremely Important Important
Importance and Confidence Rulers
So What is involved in helping to guide this process?
D.A.R.N. C.A.T.S
All personal break throughs begin with a change in beliefs!
" I feel heard by you "
ENGAGING
Therapeutic engagement is a prerequisite for everything that follows!
How comfortable is this person in talking to me?
How supportive and helpful am I being?
Do I understand this person's perspective and concerns?
How comfortable am I in this conversation?
Does this feel like a collaborative partnership?
The process of engaging leads to a focus on a particular agenda: what the person came to talk about. The focusing process helps to clarify a direction one intends to move.

What goals for change does the person really have?
Do I have different aspirations for change for this person?
Are we working together with a common purpose?
Does it feel like we are moving in same direction?
Do I have a clear sense of where we are going?
Does this feel like dancing or wrestling?
EVOKING
Evoking involves eliciting the clients own motivation for change, to harness their own ideas and feelings about why and how they might do it!

What are this person's own reason for change?
Is the reluctance more about confidence or importance of change?
What change talk am I hearing?
Am I steering too far or too fast in a particular direction?
Is the righting reflex pulling me to be the one arguing for change?
PLANNING
Planning encompasses both developing commitment to change and formulating a specific plan of action!
What would be a reasonable next step towards change?
What would help this person to move forward?
Am I remembering to evoke rather than prescribe a plan?
Am I offering needed information or advice with permission?
Am I retaining a sense of quiet curiosity about what will work best for this person?
FOCUSING
Full transcript