Motivational Interviewing: Motivational Interviewing: Working with The Working with The Resistant ClientResistant Client

Dr Louise A. Stanger Ed. D, Dr Louise A. Stanger Ed. D, LCSW, BRI II, CIPLCSW, BRI II, CIP

MINT Trainer of TrainersMINT Trainer of Trainers Faculty SDSUFaculty SDSU Director All About Director All About

InterventionsInterventions

ObjectivesObjectives

To experience and practice the basics of MI To learn MI Style and Principles To directly experience the MI approach and

contrast with others To see how it integrates into everyday practice

Getting To Know You Getting To Know You

Hello, Tell us about Hello, Tell us about Yourself ?Yourself ?

What brought you here What brought you here today ?today ?

What do you want to get What do you want to get out of training ?out of training ?

What is Motivation?What is Motivation?

Probability of Probability of behavior change or behavior change or movement toward or movement toward or against goalagainst goal

Extrinsic…….Extrinsic…….

Intrinsic ……Intrinsic ……

Personal Goal : Personal Goal :

Choose a personal goalChoose a personal goal

Develop an action PlanDevelop an action Plan

Action

Thinking

Idea

SO…………………..SO…………………..

How realistic is this plan for you & how soon will you How realistic is this plan for you & how soon will you start?start?

How faithful will you be to the plan?.. Be Honest!How faithful will you be to the plan?.. Be Honest! Will it be easy or hard?Will it be easy or hard? How long will you do this plan for?How long will you do this plan for? How will you view yourself if you stop, do it partially , How will you view yourself if you stop, do it partially ,

stop & start, never start at all?stop & start, never start at all? Can others help you and how will you respond to Can others help you and how will you respond to

reminders?reminders?

Second ThoughtsSecond Thoughts

AfterthoughtsAfterthoughts

How was this for youHow was this for you Is the process of change Is the process of change

simple or complexsimple or complex Is change linearIs change linear Is it all or nothing for Is it all or nothing for

you?you? Motivation >>>Motivation >>> Confidence >>>>Confidence >>>>

When do People Change When do People Change

Stages of Change Stages of Change

Readiness to ChangeReadiness to Change

In between the cravings In between the cravings

Find the Spaces Inbetween Find the Spaces Inbetween Omar Manejawa MDOmar Manejawa MD

Cravings – MyopicCravings – Myopic

Spaces- ChangeSpaces- Change

Habits -ActionsHabits -Actions

Stages Of Change Stages Of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

PrecontemplationPrecontemplation

Person is not seeing need for lifestyle changePerson is not seeing need for lifestyle change Client believes there is no problemClient believes there is no problem May feel forced into treatment.May feel forced into treatment. Response to resisistanceResponse to resisistance

What does this sound like? What does this sound like?

Counselors Task : PrecontemplationCounselors Task : Precontemplation

Raise DoubtRaise Doubt

Increase the person’s perception of risks and Increase the person’s perception of risks and problems with current behaviorproblems with current behavior

2. Contemplation 2. Contemplation

Person is considering Person is considering making a change and has making a change and has not decided yetnot decided yet

Response to resistance Response to resistance Estimates put 80% of Estimates put 80% of

people either people either precontemplative or precontemplative or contemplativecontemplative

Maybe I willl …………Maybe I willl …………

Task : Contemplation Task : Contemplation

Client is considering changeClient is considering change

Client not fully convinced he / she will make Client not fully convinced he / she will make change- eovke responses to change change- eovke responses to change

Tip the Balance –strengthen self efficacy Tip the Balance –strengthen self efficacy

Case example :Lisa visits CVSCase example :Lisa visits CVS

Preparation Preparation

Person has decided to Person has decided to change and is change and is considering how to Make considering how to Make changes changes

Motivation fluctuates as Motivation fluctuates as does ambivalencedoes ambivalence

MI used to elicit change MI used to elicit change talk talk

Action Action

Person is actively doing Person is actively doing something to changesomething to change

May experience setbacksMay experience setbacks

Encourage action, set Encourage action, set example, give homework example, give homework

MaintenanceMaintenance

Person is maintaining activity over timePerson is maintaining activity over time

Some temptation to return to former behavior Some temptation to return to former behavior or small lapses ( TRIGGER LANE )or small lapses ( TRIGGER LANE )

Change has existed over 6 months or more Change has existed over 6 months or more

RELAPSE & RECYCLERELAPSE & RECYCLE

Restart, reboot the processesRestart, reboot the processes

Help the person renew the process of Help the person renew the process of contemplation, determination, and action w/o contemplation, determination, and action w/o getting stuck in Shameville !getting stuck in Shameville !

What is Motivational Interviewing?What is Motivational Interviewing?

A directive client-centered counseling approach A directive client-centered counseling approach for eliciting behavior change by helping clients for eliciting behavior change by helping clients to explore and resolve ambivalence.to explore and resolve ambivalence.

Rollnick and Miller 1995Rollnick and Miller 1995

MI StyleMI Style

Process not TechniqueProcess not Technique CollaborativeCollaborative

Evocation- elicit clients Evocation- elicit clients internal viewpointinternal viewpoint

Autonomy Autonomy

Roll With ResistanceRoll With Resistance

MI SpiritMI Spirit

Rogerian approachRogerian approach Coupled with a directionCoupled with a direction EqualitarianEqualitarian Warm, Empathetic, Affirming & RespectfulWarm, Empathetic, Affirming & Respectful Guiding & eliciting vs. instructing & persuadingGuiding & eliciting vs. instructing & persuading Video- Join Up (Horse Whisper)Video- Join Up (Horse Whisper)

Characteristics of MICharacteristics of MI

Counselor is active and directiveCounselor is active and directive Counselor helps shape behaviorCounselor helps shape behavior MI strategy is specific and systematicMI strategy is specific and systematic Consistent with principles of client choice and Consistent with principles of client choice and

empowermentempowerment Consistent with cultural sensitivity in that client Consistent with cultural sensitivity in that client

leads and counselors agenda is not imposedleads and counselors agenda is not imposed

Traps to Avoid Traps to Avoid Question-AnswerQuestion-Answer

Labeling Trap – dx codesLabeling Trap – dx codes

Premature Focus Trap-start with Premature Focus Trap-start with clients concern not yoursclients concern not yours

Expert Expert

Taking sidesTaking sides

Blaming Others _ who is to Blaming Others _ who is to blame is not as important as blame is not as important as to what your concerns areto what your concerns are

MI PrinciplesMI PrinciplesEE-DD-RR-SSEE-DD-RR-SS

Express EmpathyExpress Empathy

Develop Discrepancy- help one get unstuck from Develop Discrepancy- help one get unstuck from ambivalent feelings ambivalent feelings

Roll with Resistance ( get out of the way )Roll with Resistance ( get out of the way )

Support Self Efficacy ( Bandura) The capacity of a Support Self Efficacy ( Bandura) The capacity of a person to believe they can carryspecific act or behavior person to believe they can carryspecific act or behavior

Guiding Strategies Guiding Strategies

How to Express EmpathyHow to Express Empathy How to Develop DiscrepancyHow to Develop Discrepancy How to Roll With ResistanceHow to Roll With Resistance How to Elicit Self-MotivationHow to Elicit Self-Motivation Brief NegotiationBrief Negotiation

How to Express Empathy How to Express Empathy Use your Oars Use your Oars

Open Ended QuestionsOpen Ended Questions

AffirmationsAffirmations

Reflections Reflections

SummariesSummaries

Open and Closed EndedOpen and Closed Ended

What types of things do you What types of things do you want to talk aboutwant to talk about

Tell me about…Tell me about… How do you think smoking How do you think smoking

pot is related to the problems pot is related to the problems you talk about in your you talk about in your marriagemarriage

What brings you here What brings you here today?/today?/

Don’t yuu think your wife Don’t yuu think your wife and kids are hurt enough by and kids are hurt enough by your drinking ?your drinking ?

Isn’t your friends idea that Isn’t your friends idea that you quit ?you quit ?

Are there good things about Are there good things about your drug use?your drug use?

How long have you been How long have you been concerned about x ?concerned about x ?

Mining for AffirmationsMining for AffirmationsGroup ExerciseGroup Exercise

20 Strengths 20 Strengths

Groups of 5-with 5 Groups of 5-with 5 strengths strengths

Identify open ended Identify open ended question to elicit strength question to elicit strength and an affirmation you and an affirmation you might offer in response might offer in response to a strengthto a strength

Affirm your clientAffirm your client

I appreciate your honestyI appreciate your honesty I can see that caring for I can see that caring for

your children is your children is important to youimportant to you

It shows courage and It shows courage and commitment to come commitment to come back to meetings back to meetings

You have good ideasYou have good ideas

Listening Exercise Listening Exercise

Break up in dyadsBreak up in dyads

Practice Listening – 3 Practice Listening – 3 minutesminutes

DebriefDebrief

12 Roadblocks to Listening 12 Roadblocks to Listening

1. Ordering, directing, 1. Ordering, directing, commandingcommanding

2. Warning or threatening2. Warning or threatening 3. Giving advice, suggestions, 3. Giving advice, suggestions,

solutionssolutions 4. Persuading with logic, 4. Persuading with logic,

arguing,arguing, 5. Moralizing, preaching 5. Moralizing, preaching 6.Disagreening, judging, 6.Disagreening, judging,

criticizing , blaming criticizing , blaming

12 Roadblocks to Listening12 Roadblocks to Listening

7.Agreeing, approving, 7.Agreeing, approving, praisingpraising

8. Shaming, ridiculing or 8. Shaming, ridiculing or labelinglabeling

9. Interpreting or analyzing9. Interpreting or analyzing 10. Reassuring, sympathizing10. Reassuring, sympathizing 11. Questioning or probing 11. Questioning or probing 12.Withdrawing, distracting 12.Withdrawing, distracting

Assumptions To AvoidAssumptions To Avoid

Person OUGHT to changePerson OUGHT to change Person WANTS to changePerson WANTS to change Persons health is prime Persons health is prime

motivation factormotivation factor If she/he decides not to If she/he decides not to

change consultation is a change consultation is a failurefailure

Individuals are either Individuals are either motivated to change or they motivated to change or they are notare not

Now is the right time to Now is the right time to consider changeconsider change

A tough approach is A tough approach is always the best approachalways the best approach

I am the expert and I am the expert and know bestknow best

A egotiation approach is A egotiation approach is always best always best

Persuasion Exercise Persuasion Exercise

Grps of 2Grps of 2 Identify change you are consideringIdentify change you are considering Counselors roleCounselors role

1. Explain why perosn should make this change1. Explain why perosn should make this change 2. Give three specific benefits that result from change2. Give three specific benefits that result from change 3. Tell the person how they can change3. Tell the person how they can change 4. Emphasize its important for them to make change/include 4. Emphasize its important for them to make change/include

negative consequencesnegative consequences 5. Tell persuade the person to do it5. Tell persuade the person to do it And if you encounter resitance try harder And if you encounter resitance try harder

Listen ReflectivelyListen Reflectively

Being quiet and actively Being quiet and actively listening listening

Responding with a Responding with a statement that accurately statement that accurately reflects the essence of reflects the essence of what the client meant what the client meant

Listen carefully think Listen carefully think ReflectionsReflections

Reflections Reflections

Think in terms of forming an Think in terms of forming an hypotheses or best guess at hypotheses or best guess at what client is sayingwhat client is saying

Take a guess –Do you Take a guess –Do you mean…mean…

You have to differentiate You have to differentiate

between a question and a between a question and a statement statement

Voice goes down at end of Voice goes down at end of statement rather then up with statement rather then up with a questiona question

““You're angry with your You're angry with your mother …mother …

A statement does not require A statement does not require an answer .an answer .

Used strategically emaphsize, Used strategically emaphsize, clients view , feelings, clients view , feelings, ambivalence, emotion change ambivalence, emotion change talk talk

Level of Reflection Level of Reflection

Repeating repeat what someone has just saidRepeating repeat what someone has just said Rephrase – substitute a few different words Rephrase – substitute a few different words Paraphrasing-make a fairly major restatement Paraphrasing-make a fairly major restatement

inferring what you think a person has saidinferring what you think a person has said Reflecting feeling – special kind of paraphrase Reflecting feeling – special kind of paraphrase

where you are not necessarily relecting content where you are not necessarily relecting content rather feelingrather feeling

Simple ReflectionSimple Reflection

Client: She is driving me Client: She is driving me crazy trying to get me to crazy trying to get me to do quit do quit

Counselor; Her methods Counselor; Her methods are really bothering youare really bothering you

Client: I don’t have Client: I don’t have anything to sayanything to say

Counselor- You are not Counselor- You are not feeling talkative today feeling talkative today

Amplified Reflections Amplified Reflections

Exaggerate what client Exaggerate what client says be careful not to be says be careful not to be sarcasticsarcastic

All my friends smoke All my friends smoke weed and I don’t see weed and I don’t see giving it up giving it up

So you are likely to keep So you are likely to keep smoking foreversmoking forever

Doubled Sided Reflection Doubled Sided Reflection ((meant to capture both sides of ambivalencemeant to capture both sides of ambivalence ) )

C- It would stink to lose my job over a dumb policy C- It would stink to lose my job over a dumb policy because I have been using, because I have been using, but but do way do I want to quit do way do I want to quit partying just because of thatpartying just because of that

Co- Co- On the one handOn the one hand you value your job because it allows you value your job because it allows you to live comfortably and on the other hand you also you to live comfortably and on the other hand you also enjoy using drugs with your friends enjoy using drugs with your friends

C -It would be hard to stick to a plan (workout)……….C -It would be hard to stick to a plan (workout)………. CO--------CO--------

Other strategies for Handing Other strategies for Handing ResistanceResistance

ClarificationClarification

Shift focus away from Shift focus away from stumbling blockstumbling block

Emphasize Personal Emphasize Personal Choice and ControlChoice and Control

Provide SummariesProvide Summaries

Communicate what you have tracked what the Communicate what you have tracked what the client has said so that you have understanding of client has said so that you have understanding of what is being saidwhat is being said

Helps structure session so you do not get Helps structure session so you do not get sidetracked sidetracked

Provide opportunity to emphasize statements a Provide opportunity to emphasize statements a client has made about change talk gives client client has made about change talk gives client another opportunity to hear what she has said another opportunity to hear what she has said in context provided by the counselorin context provided by the counselor

Example Example

So Sally , let me know if I heard you correctly. So Sally , let me know if I heard you correctly. You care about your children and you are You care about your children and you are hoping social services does not intervene. You hoping social services does not intervene. You believe you need to change your realtionships believe you need to change your realtionships that involve using and aren’t quite sure how to that involve using and aren’t quite sure how to do that? do that?

Or what else would you add ?......Or what else would you add ?......

Exploring Ambivalence Exploring Ambivalence

The Existence of The Existence of conflicting emotions or conflicting emotions or thoughts about a person thoughts about a person object or idea object or idea

Protagonist Exercise Protagonist Exercise

Decisional Balance WorksheetDecisional Balance Worksheet((Fill in what you are considering as change )Fill in what you are considering as change )

Good things about Good things about Changing behaviorChanging behavior

Good things about changing Good things about changing behaviorbehavior

Not so good things about Not so good things about behavior behavior

Not so good things about Not so good things about changing behaviorchanging behavior

Protagonists' Exercise Protagonists' Exercise

Explore Roles for Explore Roles for resolving ambivalenceresolving ambivalence

Break up in groups of 6Break up in groups of 6 Client is to discuss an Client is to discuss an

issue on which he/she is issue on which he/she is ambivalentambivalent

Four counselors are Four counselors are assigned a role & each assigned a role & each has 3 minuteshas 3 minutes

1 observer1 observer

Protagonists' ExerciseProtagonists' Exercise

#1- argues for one side #1- argues for one side of ambivalenceof ambivalence

#2 argues other side of #2 argues other side of ambivalenceambivalence

#3 communicates #3 communicates disinterest- “I really don’t disinterest- “I really don’t care what you to”care what you to”

#4 show interest in how #4 show interest in how the person is doing the person is doing

Eliciting Change Talk Eliciting Change Talk

Desire StatementsDesire Statements I’d like toI’d like to quit drinking if quit drinking if

I couldI could I wish I couldI wish I could make my make my

life betterlife better I want toI want to ………. ……….

Getting in shape would Getting in shape would make me feel……. make me feel…….

Ability StatementsAbility Statements I I thinkthink I can do that I can do that That That mightmight be possible be possible I’m thinkingI’m thinking I might be I might be

able to……..able to……..

If I had someone to help If I had someone to help me , me , I probablyI probably could could …..…..

Eliciting Change TalkEliciting Change Talk

REASON StatementsREASON Statements

I have to quit smoking I have to quit smoking becausebecause of my asthma of my asthma

To keep my truck license I To keep my truck license I probably shouldprobably should cut down on cut down on my meth and drinkingmy meth and drinking

My kids may be taken from My kids may be taken from me if I keep usingme if I keep using

I don’t like my kids to see me I don’t like my kids to see me this way this way

NEED NEED Statements Statements

It’s really important to my It’s really important to my health to change my diethealth to change my diet

Something has to change or Something has to change or my marriage will breakmy marriage will break

I will die if I keep using like I will die if I keep using like thisthis

Do You Swear????Do You Swear????

Person 1: “I want to”Person 1: “I want to” Person 2: “ I could”Person 2: “ I could” Person 3: “ I have good Person 3: “ I have good

reasons to”reasons to” Person 4 : “ I need to”Person 4 : “ I need to”

Person 5: I willPerson 5: I will

DARN (DARN (Desire, Ability , Reason, Need) Desire, Ability , Reason, Need)

What do you think you will What do you think you will do ?do ?

What does this mean about What does this mean about your habit ?your habit ?

What are your options?What are your options? What's the next step for you?What's the next step for you? What are some good things What are some good things

about making a change ?about making a change ? Where does this leave you?Where does this leave you?

On A Scale of 1-10On A Scale of 1-10

Not at all Important Not at all Important Very ImportantVery Important

Not at all Confident Not at all Confident

You picked a 7 , why wasn’t You picked a 7 , why wasn’t a lower scorea lower score

Very Confident Very Confident

You picked a seven why You picked a seven why wasn’t a higher score wasn’t a higher score

ResistanceResistance

TraditionalTraditional Client not getting itClient not getting it

MI ViewMI View Counselor may not be Counselor may not be

getting itgetting it

Case Example – Lisa Case Example – Lisa

Signs of Resistance Signs of Resistance ArguingArguing ChallengingChallenging DiscountingDiscounting HostilityHostility

Ignoring Ignoring -Inattention-Inattention-Non-answer-Non-answer-No response-No response-Sidetracking-Sidetracking

DenyingDenying BlamingBlaming DisagreeingDisagreeing Excuses Excuses Claiming impunityClaiming impunity MinimizingMinimizing PessimismPessimism ReluctanceReluctance Unwilling to change Unwilling to change

•InterruptingInterrupting Taking OverTaking Over Cutting OffCutting Off

Ten Strategies for Evoking Change Ten Strategies for Evoking Change

1. 1. Ask Evocative questionsAsk Evocative questions Why would you want to make this change? (Desire)Why would you want to make this change? (Desire) How might you go about that ? (Ability)How might you go about that ? (Ability) What are the three best reasons for doing that ? What are the three best reasons for doing that ?

(Reasons)(Reasons) How important is it for you to make this change? How important is it for you to make this change?

(Need)(Need) So what do you think you will do? (Commitment)So what do you think you will do? (Commitment)

Ten Strategies for Evoking ChangeTen Strategies for Evoking Change

2. 2. Ask for ElaborationAsk for Elaboration When change talk emerges ask for more detail. In When change talk emerges ask for more detail. In

what ways?what ways? 3. Ask For Examples3. Ask For Examples

Ask for specific examples, when was the last time that Ask for specific examples, when was the last time that happened ? give me an examplehappened ? give me an example

4. Look Back4. Look BackAsk about a time before current concern emerged. Ask about a time before current concern emerged.

How were things better? different?How were things better? different?

Ten Strategies for Evoking ChangeTen Strategies for Evoking Change

5. Looking Forward-5. Looking Forward-

What would happen if things What would happen if things stay the same/ If you are stay the same/ If you are 100% successful in making 100% successful in making changes you want what changes you want what would life look like ?would life look like ?

6. Extremes6. Extremes

What is the worst thing that What is the worst thing that could happen? What is the could happen? What is the best thing that could happen best thing that could happen

Ten Strategies for Evoking ChangeTen Strategies for Evoking Change

7. 7. Use Change RulersUse Change Rulers On a scale of On a scale of

1-------------------101-------------------10

8. 8. Explore Goals and Explore Goals and ValuesValues What are the persons What are the persons

values and goals values and goals

9. 9. Join upJoin up –Come along –Come along side side

Ten Strategies for Evoking ChangeTen Strategies for Evoking Change

10. Responding to 10. Responding to Change Talk (Change Talk (EARSEARS))

EXPLOREEXPLORE

AFFIRMAFFIRM

SUMMARIZESUMMARIZE

Closing Skills –Closing Skills –

55 44 33 22 11

I guaranteeI guarantee

I willI will

I promiseI promise

I vowI vow

I shallI shall

I give my I give my wordword

I assumeI assume

I dedicate I dedicate myselfmyself

I knowI know

I am devoted I am devoted toto

I pledge toI pledge to

I agree toI agree to

I intend toI intend to

I am ready toI am ready to

I look forward I look forward toto

I consent toI consent to

I plan toI plan to

I resolve toI resolve to

I expect toI expect to

I concede toI concede to

I declare my I declare my intention tointention to

I favorI favor

I endorseI endorse

I believeI believe

I acceptI accept

I volunteerI volunteer

I aimI aim

I aspireI aspire

I proposeI propose

I am I am predisposedpredisposed

I anticipateI anticipate

I predict I predict

I presume I presume

I mean toI mean to

I forseeI forsee

I envisageI envisage

I assumeI assume

I betI bet

I hop esoI hop eso

I will tryI will try

I think I willI think I will

I suppose I I suppose I willwill

I imagine I I imagine I willwill

I guessI guess

I will wager I will wager

Setting a Course of Action Setting a Course of Action

Set Specific Short term goalsSet Specific Short term goals Consider Your optionsConsider Your options Establish a PlanEstablish a Plan Establish Monitoring ( CBT) Establish Monitoring ( CBT)

10 Things MI is not10 Things MI is not

Based on transtheoretical Based on transtheoretical modelmodel

TrickeryTrickery A specific techniqueA specific technique Decisional balance Decisional balance

(equally exploring pros (equally exploring pros and consand cons

Assessment feedbackAssessment feedback

CBTCBT Just clinet centeredJust clinet centered Easy tpo learnEasy tpo learn What yu are already What yu are already

doingdoing Panacea for every clinical Panacea for every clinical

challengechallenge

Traditional Assumptions of Traditional Assumptions of Motivation & ChangeMotivation & Change

Symptoms are weaknesses that need to be fixed.Symptoms are weaknesses that need to be fixed. Client is damaged, Counselor fixes clientClient is damaged, Counselor fixes client Doctor knows bestDoctor knows best Only client has control over motivationOnly client has control over motivation Client must hit “Rock Bottom”Client must hit “Rock Bottom” Change is linear and static, “on-off switch”Change is linear and static, “on-off switch” No motivation=No treatment. ( Ping-Pong for Dually No motivation=No treatment. ( Ping-Pong for Dually

Diagnosed clients)Diagnosed clients) Double Standard of Efficacy.Double Standard of Efficacy.

Non-Directive Counseling vs. MINon-Directive Counseling vs. MI Non-Directive CounselingNon-Directive Counseling Client determines content 7 Client determines content 7

directiondirection Counselor avoids advice Counselor avoids advice

giving 7 feedbackgiving 7 feedback High use of empathic High use of empathic

reflectionreflection Explores clients conflicts Explores clients conflicts

and emotionsand emotions

Motivational InterviewingMotivational Interviewing Systematically directs client Systematically directs client

towards motivation for towards motivation for changechange

Counselor offers advice & Counselor offers advice & feedback when appropriate feedback when appropriate & solicited& solicited

Empathic reflection used Empathic reflection used selectively to reinforce selectively to reinforce processprocess

Seeks to create & amplify Seeks to create & amplify clients discrepancy in order clients discrepancy in order to enhance motivation.to enhance motivation.

Skills Training/ CBT vs. MISkills Training/ CBT vs. MI CBT/ Skills TrainingCBT/ Skills Training Assumes Client is motivatedAssumes Client is motivated Seeks to modify maladaptive cognitionsSeeks to modify maladaptive cognitions Treatment provides specific coping Treatment provides specific coping

strategiesstrategies Teaches through instruction, modeling Teaches through instruction, modeling

practice & feedbackpractice & feedback Specific problem solving strategies are Specific problem solving strategies are

taught.taught.

Role Plays Role Plays

Role Plays Role Plays