An Introduction to Motivational Interviewing Richard L. Ogle, Ph.D. Professor & Chair Department of Psychology University of North Carolina Wilmington Guiding Sentiments 0 If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be. Johann Wolfgang Von Goethe 0 People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others. Blaise Pascal 0 You are a midwife, assisting at someone elses birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say, We did it ourselves. TAO TE CHING Opening Conversation 0 Why are you here? 0 What do you want to learn? 0 In what specific situations would you like to use MI? 0 At what level do you want to engage? Motivation 0 The probability of engaging in and maintaining a behavior over time. 0 What are the three key words? 0 Probability (0 1) not (0 or 1). 0 Engage 0 Maintain 0 Motivation is continuous not dichotomous 0 Fluctuating motivation can increase or decrease based on your behavior Change Change is more similar than different across behaviors Change is a process that is continuous like a dimmer switch, not discrete like an on/off switch Change depends on MOTIVATION. Because of this, there are multiple ways and times that change can derail Fortunately, there are multiple ways and times to facilitate the process Stages of Change Prochaska & DiClemente Change Talk - DARN CAT 0 Client speech reflecting building motivation and correlated with behavioral change 0 Desire 0 Why a person would make a change. 0 Ability 0 How a person could you do it. 0 Reasons 0 What are good reasons to make the change? 0 Needs 0 How important is it and why? What are the negative that occur without change? 0 Commitment 0 What intentions are present? 0 Activation 0 What is the person ready or willing to do immediately? 0 Taking Steps 0 What have they already done? Commitment Language Pattern A Outcomes for Pattern A Group Commitment Language Pattern B Amrhein et al., Journal of Consulting & Clinical Psychology : Outcomes for Pattern B Group Righting Reflex 0 Born of concern and caring 0 Theres a problem? Lets fix it! 0 Fails to consider ambivalence in change process 0 May engender resistance Ambivalence 0 Simultaneous feelings of approach and avoidance 0 Yes, but 0 I want to, but I cant 0 The core of most motivational issues 0 Completely normal 0 Often uncomfortable 0 Can be chronic Exercise 0 Talk about something real that you: 0 Want to change 0 Need to change 0 Should change 0 Have been thinking about changing 0 But, havent yet changed. 0 Not your deepest, darkest secret! 0 Listen carefully - goal to understand the dilemma 0 Ask these four questions: 0 Why would you want to make this change? 0 How might you go about it, in order to succeed? 0 What are the three best reasons to do it? 0 On a scale of 1-10, how important would you say it is to make this change? And why are you a ___ and not zero? 0 Summarize Resistance 0 A result of a focus on only one side of an individuals ambivalence 0 If you argue for change, your collaborator argues against it 0 It is relational. It is a signal that you are not meeting them where they are at; therefore, it is you responsibility to resolve 0 Sustain Talk 0 Speech about the target behavior that reflects only one side of ambivalence (status quo) 0 There is nothing inherently pathological about sustain talk 0 Discord 0 Speech reflecting a discord within the relationship/session 0 Denying 0 Arguing 0 Ignoring 0 Interrupting 0 Reluctance 0 May be concerned about the unknowns of change 0 Need to verbalize their reluctance & be heard 0 Rebellion 0 May have knowledge 0 May have highly invested energy in no change 0 Resignation 0 No energy for change 0 May feel overwhelmed & hopeless 0 Need to build hope 0 Rationalization 0 Has all of the answers 0 Utilizes Harm Minimization Therapeutic Traps 0 Question-Answer Trap 0 Trap of Taking Sides 0 Expert Trap 0 Labeling Trap 0 Premature Focus Trap 0 Blaming Trap Definitions of MI 0 Laypersons Definition (Why would be do it) 0 MI is a collaborative conversational style for strengthening a persons own motivation and commitment to change 0 Practitioners Definition (Why you would use it) 0 MI is a person-centered counseling style for the common problem of ambivalence about change 0 Technical Definition (How it works) 0 MI is a collaborative, goal oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the persons own reasons for change within an atmosphere of acceptance and compassion. A Brief History to This Point 0 MI is 31 years old this year 0 Description first published in a journal article in First edition of book in 1991, second in 2002, third in Over 1200 articles on MI 0 MI cited over 25,000 times 0 Over 200 RCTs 0 Started as a vilified intervention in addictions and now is a best practice in all of behavioral health 0 Here are some things we know 0 MI is effective for a variety of behavioral targets 0 MI can be used in a variety of settings 0 MI is hard to standardize 0 Significant variability across counselors Most Importantly, What We Know is 0 MI training increases characteristic MI practice behaviors 0 OARS 0 Empathy 0 These behaviors affect particular types of client speech 0 Desire, Ability, Reasons, Need, Commitment, Activation, Taking Steps 0 The level and strength of these types of speech predict behavioral outcome 0 Findings are stronger in addictions than anywhere else Spirit of MI 0 Acceptance 0 Absolute worth 0 Autonomy 0 Accurate Empathy 0 Affirmation 0 Collaboration 0 Partners 0 Shared goals 0 Evocation 0 Pulling out instead of putting in 0 Compassion 0 For the others needs/self- interest 0 Services exist to benefit the people we serve 0 Change is fundamentally self change. Services facilitate 0 People are experts on themselves 0 We dont have to make change happen 0 We dont have to come up with all the good ideas 0 People have their own strengths, motivations, resources 0 Therefore change requires partnership 0 Understand, persons own perspective, what is needed and how to accomplish it 0 Conversations about change should not be a struggle. Dancing, not wrestling 0 Motivation for change is not installed, but evoked 0 We cannot revoke peoples choice about their own behavior. People make their own decisions about what they will and will not do. MI Principles 0 Express Empathy 0 Empathy alone is predictive of change 0 Roll w/Resistance 0 Verbal judo 0 Develop Discrepancy 0 Goals and values contrasted with current behavior 0 Support Self-Efficacy 0 R Resist the righting reflex 0 U Understand you clients motivation 0 L Listen to you client 0 E Empower your client Empathy 0 Multiple Components 0 Experience sharing (affective empathy) vicariously sharing targets internal states (feeling with), but knowing the target is the source of the emotional state in the self. 0 Mentalizing (cognitive empathy) explicitly considering targets' states and their sources, without necessarily sharing another's state. Perspective-taking. 0 Prosocial concern (compassion) feeling of concern for a target's suffering ("feeling for") that induces a motivation to alleviate that suffering The Importance of Empathy and Rolling w/Resistance Miller, Benefield & Tonigan (1993) JCCP 61: Developing Discrepancy 0 Finding, increasing or encouraging a discrepancy between present and desired states 0 Can be positive or negative in valence 0 Discontent with the status quo 0 Opportunity for betterment 0 Goldilocks Principle 0 Discrepancy within limit Support Self-Efficacy 0 Perception of the degree to which someone feels confident he/she can accomplish a particular goal/task 0 Building confidence 0 Building on past successes 0 Translating things they do well in other life contexts to the behavior change context. 0 Affirming smaller steps and approximations How Does MI Work 0 Empathy allows clients to reduce resistance and resolve ambivalence 0 Looking at the situation from their perspective 0 People feel understood; less resistant 0 Selective reinforcement of change talk 0 Focus on change talk 0 We learn what we believe when we hear ourselves speak 0 Therapist reinforces change talk that is consistent with therapeutic goals 0 Reinforcement further increases change talk and allows of client to experience build in motivation to change Basic MI Tools 0 O - Open Questions 0 A - Affirmative Approach 0 R - Reflective Listening 0 S -Summaries 0 Your OARS propel you and steer you through the encounter 0 You have to do these well to do MI well 0 Everything in MI is rooted in OARS Open Questions 0 Questions that cannot be answered yes or no or with a discrete answer. 0 Open questions generate more data more data, more empathy 0 Open questions block momentum less than closed questions 0 Open questions lessen the expert or investigator feel of interactions Opening Up Your Questions Do you drink? How much? Have you ever smoked a cigarette? Are you taking your medications as prescribed? Have you lost or gained weight in the last month? Are you sexually active? Do you always use birth control? How many alcoholic drinks do you have in a typical week? Did you take your insulin today? Do you get regular physical exercise? Is there a family history of heart disease? Have you ever been hospitalized or had surgery? On what day did your symptoms start? Affirmation 0 Clients are often unsuccessful self-changers 0 Demoralized 0 Our role is to instill hope and a belief that the client can change 0 Empower the client can do 0 Attributions 0 Focus on specific behaviors instead of attitudes or decisions 0 Focus on descriptions not evaluations 0 Attend to non-problem areas 0 Nurture a world-view of competence not deficit Affirmation Exercise 0 Listen to the statement 0 Write down a few strengths 0 Write down an affirmation Reflective Listening - Roadblocks to Listening 1. Ordering, directing, or commanding 2. Warning or threatening 3. Giving advice, making suggestions, or providing solutions 4. Persuading with logic, arguing, or lecturing 5. Moralizing, preaching, or telling clients what they "should" do 6. Disagreeing, judging, criticizing, or blaming 7. Agreeing, approving, or praising 8. Shaming, ridiculing, or labeling 9. Interpreting or analyzing 10. Reassuring, sympathizing, or consoling 11. Questioning or probing 12. Withdrawing, distracting, humoring, or changing the subject Reflective Listening What is it? 0 A statement a hypothesis 0 Vocal inflection is downward 0 Keeps people in the meaning/feeling 0 A verbal mirror to reflect back 0 Exact words 0 Paraphrase 0 Meaning 0 Emotion Reflection Exercises Summaries 0 Groups of reflections that serve to 0 Remind you and client of what has been said 0 Highlight overarching themes Linking 0 Transition when stuck or wanting to shift direction Video 0 Listen for OARS Rolling w/Resistance 0 Strategies 0 Reflection (Under/Over) 0 Reframe 0 Double-sided reflection 0 Emphasizing Personal Responsibility 0 Shifting Focus 0 Coming Alongside 0 Exercise Exercise - Fishbowl 0 Practice OARS 0 Roll w/ resistance 0 Listen for Change talk MI Processes 0 MI occurs throughout four ongoing processes of change conversations 0 Engaging 0 Focusing 0 Evoking 0 Planning 0 Often MI is about knowing how to skillfully and artfully move back and forth between each process Engaging 0 The process by which counselor and client establish a helpful connection and a working relationship 0 How comfortable is this person talking to me? 0 How supportive and helpful am I being? 0 Do I understand this persons perspective and concerns? 0 How comfortable do I feel with this conversation? 0 Does this feel like a collaborative partnership? Understanding Values 0 Freely chosen core beliefs that drive and organize behavior that is intrinsically reinforcing. 0 Values represent what one wants their life to look like, stand for and be about 0 Global values 0 Domain-specific values family, relationships, career, etc. 0 Values provide direction 0 Values are different from valuing 0 Values cannot be accomplished in-and-of-themselves 0 Instantiated moment by moment and over time 0 No matter what direction life takes, you still have your values Values Assessment 0 Informal 0 How do you hope your life will be different a few years from now? 0 Who do you respect in life and why? 0 Tell me what you care most about in life. 0 Tombstone 0 Eulogy 0 Values Card-Sort 0Sort%202.pdfSort%202.pdf 0 Batteries Exercise 0 Next Slide Focusing 0 Process of clarifying direction find the horizon point toward which to move. Agenda 0 What goals for change does this person really have? 0 Do I have different aspirations for change than this person? 0 Are we working together with a common purpose? 0 Does it feel like we are moving together, not in different directions? 0 Do I have a clear sense of where we are going? 0 Does this feel more like dancing than wrestling? 0 Sources client, setting, your experience Agenda Mapping 0 A short meta-conversation in which you step back with the client to consider the way ahead 0 Structuring 0 Consider options 0 Zoom in 0 Zoom out Information Exchange: Elicit - Provide - Elicit 0 Elicit 0 What would you like to know/do about? 0 What do you already know/do about? 0 Provide 0 Provide information (not opinion) in manageable chunks 0 Confirming 0 New 0 Disconfirming 0 Elicit 0 What do you make of that? 0 What does this mean for you? 0 What more would you like to know? Evoking 0 Eliciting clients own motivations to change. Harness the clients own thoughts and feelings about why and how they might do it 0 What are this persons reasons for change? 0 Is the reluctance more about confidence or importance? 0 What change talk am I hearing? 0 Am I steering to far or too fast in a particular direction? 0 Is the righting reflex pulling me to be the one arguing for change? Explore Importance of Situation/Change General: How important is situation/issue, you need to make a decision or do something about it? Importance Ruler On a scale of 0 to 10, how important is this issue to you at this point in your life(0=not at all, 10=most important thing) What makes it an X and not a Y? What might make your rating a few points higher, a bit more important? What can you specifically do to increase? What might I, or others do to help it increase? Explore Confidence about Changing On a scale of 0 to 10, how confident are you that you could change if you decided to? What makes it an X and not a Y? What would make it a few points higher? What can you specifically do to increase? What might I, or others do to help it increase? DARN CAT Client Exercise 0 Lets write down some statements about this change we are discussing. 0 D Why do you want to make this change? 0 A How could you do it? 0 R What are good reasons to make the change? 0 N How important is it and why? 0 C What do you intend to do about it? 0 A What are you ready or willing to do? 0 T What have you already done? 0 Use your OARS to expand, explore and solidify. Decisional Balance 0 Not changing: 0 What concerns you the most about the possibility of not making a change? 0 What might some benefits be of not addressing this, not making any changes? 0 Changing: 0 What might you lose, have to give up, or risk, if you make a change? What might not be so good? 0 What good things might happen if you did something about it, made a change? Exercise Decisional Balance ff Pros of Status Quo Cons of Status Quo Cons of Change Pros of Change Looking Forward 0 In general, what things are most important to you? 0 Family? Cutting back on work? Getting some fun or excitement back in your life? Feeling better about yourself? Getting more involved in your community? Your spirituality? Having a partner? Being financially prepared? Autonomy? 0 Thinking about what s important for you for the future, how does this current issue fit in? 0 What is likely to be the outcome if you don t make any decisions, do anything about it? What do you think things will be like a year from now, or five? 0 What might be the outcome if you were successful at making some changes? How might things be in a year from now, or five? Looking Back 0 How long has it been going on? 0 How did it come about? 0 Did it start all at once or gradually? 0 What were things like before? 0 How were things better now? 0 How are things worse? Building on Strengths 0 What strengths might you draw on to make a change? 0 Are you determined? Flexible? Careful? Organized? Creative? Resourceful? Stubborn? 0 How have these strengths helped you before? 0 What things might be changed in your environment to help you succeed? What might help you get ready? 0 How might others help? Remembering Successes 0 What have you been successful at changing in the past? No matter how small... 0 What initiated you making this change? 0 What did you do to get started, what did you do to stick with your decision to change? 0 What barriers or obstacles did you run into? How did you get past them? 0 How easy was it? How did you feel after making that change? How do you feel about it now? 0 What other changes have you made? Other Strategies 0 Typical Day 0 Others Concerns 0 Normative Feedback How to Reinforce Change Talk (EARS) Elaborate In what ways? Give me an example? What else? Why else? How else? Affirm Sounds like a good idea I think you could do that It is really important to you to Reflect Summarize Collect the flowers of change talk and give back a bouquet of change talk back to the client. Give them what you want them to hear; not everything. Exercise 0 Listening for change-talk Planning 0 The process of developing commitment to change and a specific plan of action 0 What would be a reasonable next step toward change? 0 What would help this person to move forward? 0 Am I remembering to evoke rather that prescribe a plan? 0 Am I offering needed info and advice with permission? 0 Am I retaining a sense of quiet curiosity about what will work best for this person? MI and Planning 0 Moving from evoking to planning 0 Comes from a sense of the interaction less resistance, more curiosity, more change talk, more optimism 0 Summarize 0 Change-talk focused 0 Key question 0 A questions that elicits what a client wants to do in relation to the problem of concern 0 What do you think you will do? 0 What are you thinking at this point about ______? 0 What changes, if any, or you thinking about making? 0 What are your options? 0 It sounds like things cant stay the way they are, what do you think you might do? 0 What are some of the good things about making a change? MI Change Planning 0 Lots of freedom in how to do this, but do follow these 6 steps 0 Confirm the goal 0 State goals in behavioral terms 0 Avoid dead person goals 0 Itemize options 0 Elicit the clients hunches and preferences 0 Plan strategy 0 What are the steps and how will they know its working 0 Summarize and strengthen commitment 0 Troubleshoot raise concerns you have Behavior Change Plan 0 What, specifically, would you like to be different? 0 What, specifically, could you do to get started? 0 If the first step is successful, then what? 0 Who else could you ask for support, assistance, if anyone? What could you ask for? 0 What would be signs that things are going well? 0 How would you know if you were off-track? 0 What would you do if you got off-track? Supporting Change 0 Subsequent treatment should integrate the processes of: 0 Replanning 0 Reminding 0 Refocusing 0 Reengaging4E53AF4293F2F Opening the Session 0 Set the Agenda 0 Spirit 0 What will be talked about 0 Your role 0 Open Question 0 Pick up your OARS and start paddling 0 Perceptions of being there 0 Perceptions of the issues 0 Important current activities, requirements, and/or needs 0 Paddle in order to build rapport (Joining) and elicit change talk Managing the Middle 0 Assess/Understand Values 0 Card Sort or Batteries Exercise 0 Use EVOKING strategies 0 Develop Discrepancy 0 Support Self-Efficacy 0 Provide information/feedback if necessary 0 Elicit-Provide-Elicit Wrapping Up an MI Session 0 If using MI brings you to a point where a client is making statements related to change or increased importance/confidence 0 Summarize & Key Question 0 Behavior Change Plan 0 Summarize & Elicit Commitment 0 If client is stuck/ambivalent 0 Reflect the continued ambivalence in terms of Importance/Confidence 0 Summarize Exercise Fishbowl 0 Goal 0 Practice OARS 0 Listen for change talk 0 Reinforce change talk 0 Practice process-based exercises Questions Specific MI Applications Treatment Engagement 0 Turn your assessment into and MI-informed assessment 0 There are number of questions I will need to ask you today, but first I would just like to know what brings you here today, what are your biggest concerns and how you hope we might be able to help you. 0 Listen with empathy and to detect the process where you need to start 0 Ask for permission to move into the assessment phase 0 Use open-ended questions to replace closed prompts on your assessment. 0 Listen for change talk 0 Summarize and transition through each domain 0 Use EPE for information exchange 0 Use importance/confidence 0 Summarize at the end Treatment Enhancement 0 Boosts the effects of larger treatments 0 Motivational Enhancement Therapy 0 Now being integrated with other treatment formats 0 CBT 0 Now being developed to treat specific disorders 0 Depression, OCD, eating disorders, GAD Medication Compliance 0 Assessing motivation for adherence. 0 Discussing previous adherence 0 Anticipating adherence difficulties 0 Personalized feedback 0 Informally assessing antidepressant knowledge 0 Adherence plan 0 Discussing goals/values 0 Exploring of both sides of motivation/eliciting commitment. 0 Exploration of previous concerns and result of nonadherence. 0 Discuss and prepare for motivational issues that may arise. 0 Feedback on dose-taking, reinforcement of adherence, and exploration of missed doses. 0 Targeted information exchange 0 Articulate patients reasons for adhering to treatment, anticipated barriers, and plan 0 Mailed to participants 1 week after the intervention to provide additional information. 0 Discussing adherence in alignment with sources of motivation. Components Purpose Interian, A, Martinez, I, Rios, L.I., Krejci, J, Guarnaccia, P.J. (2010). Adaptation of a Motivational Interviewing Intervention to Improve Antidepressant Adherence Among Latinos. Cultural Diversity and Ethnic Minority Psychology, 16(2), MI and Suicidal Ideation 0 Phase 1: Exploring the present problem and the motivation to die. 0 Focus in on eliciting the ambivalence around suicide. 0 Phase 2: Building motivation to live. 0 Focus is on gently shifting toward the living side of the ambivalence 0 Phase 3: Strengthening commitment to live. 0 Focus is on moving reasons to commitment and planning for the next stage of treatment. Take Home 0 Learning MI involves 10 steps of understanding 0 Understand and invoke the underlying spirit 0 Develop skill and comfort with reflective listening 0 Learn to identify from clients agenda, goals that can become foci of the conversation 0 Understand EPE as information exchange 0 Learn to recognize change talk and sustain talk 0 Learn to evoke change talk 0 Learn to strengthen change talk 0 Learn to respond to sustain talk in ways that do not amplify it 0 Understand the timing when moving into planning 0 Cant just get good at MI-consistent behaviors must eliminate MI- inconsistent behaviors 0 Advice or info without permission 0 Confronting by disagreeing, arguing, correcting, shaming, blaming, criticizing, etc. 0 Directing by giving orders, commands or imperatives, or otherwise challenging autonomy 0 One never stops learning MI