11/14/2013
Helping People Change with Motivational Interviewing
Susan M. Russell, LISW-S, LICDC-CS, ACSW
What is Motivational Interviewing? “Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.” Miller and Rollnick (2013)
Motivational Interviewing 3rd Edition: Helping People Change (2013) William Miller and Stephen Rollnick
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Motivational Interviewing Theory Carl Rogers’ theory of the “critical conditions for change” Leon Festinger’s cognitive dissonance theory Daryl Bem’s self-perception theory The transtheoretical stages of change of Jim Prochaska and Carlo DiClemente
Why learn Motivational Interviewing? What are the advantages for you and your practice?
More importantly… What are the advantages for your clients?
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Motivational Interviewing Reduces the tendency to view our clients as “resistant” Reduces provider burnout Increases collaboration between client and treatment provider Increases “change talk”
Is it compatible with our social work values? Motivational Interviewing is: • • •
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Client-centered Collaborative Embraces the view of client as expert and partner Therapist is encouraged to use non-value laden responses
The NASW Code of Ethics Service Social justice Client self determination Dignity and worth of the person Importance of human relationships Integrity Competence
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What is meant by the Motivational Interviewing Spirit? Think of a time when you had a problem or concern. Think of a person who was helpful to you during that time. What characteristics did the person have? How did they interact with you?
Think of the same or another problem Call to mind a person who was not helpful during this time. What were some of this person’s characteristics? What did your interactions with this person feel like to you?
Spirit of Motivational Interviewing Collaboration - Counseling involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change.
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Contrasted with… Confrontation – Counseling involves overriding the client’s impaired perspectives by imposing awareness and acceptance of “reality” that the client cannot see or will not admit.
Spirit of Motivational Interviewing Evocation – The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values.
Contrasted with… Education – The client is presumed to lack key knowledge, insight, and / or skills that are necessary for change to occur. The counselor seeks to address these deficits by providing the requisite enlightenment.
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Spirit of Motivational Interviewing Autonomy – The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice.
Contrasted with … Authority – The counselor tells the client what he or she must do.
Four General Principles of MI Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy
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Express Empathy Acceptance facilitates change. Skillful listening is fundamental. Ambivalence is normal.
Develop Discrepancy The client rather than the counselor should present the arguments for change. Change is motivated by a perceived discrepancy between the present behavior and important personal goals or values.
Roll with Resistance Avoid arguing for change. Resistance is not directly opposed. New perspectives are invited, but not imposed. The client is the primary resource in finding answers and solutions. Resistance is a signal to respond differently.
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Support Self-Efficacy A person’s belief in the possibility of change is an important motivator. The client, not the counselor, is responsible for choosing and carrying out change. The counselor’s own belief in the person’s ability to change becomes of self-fulfilling prophecy.
Four Processes of Motivational Interviewing Engaging Focusing Evoking Planning
DVD Segment 2013 Motivational Interviewing: Helping People Change
John with William Miller, PhD
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What did you notice … About Dr. Miller’s approach? His responses to John’s silences? How does he engage him in further conversation?
Motivational Interviewing Skills OARS Open Questions Affirmations Reflections Summary Statements
Practice Session Choose a partner and experience a “real-play” of a behavior change you would like to make, but one you have ambivalence around Some suggestions might be exercising, healthier diet, etc.
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Let’s Discuss the Experience What worked well for you? How did it feel being the “counselor”? How did it feel being the “counseled”? What can you take from this experience?
The “Traps” to Avoid The Question – Answer Trap The Trap of Taking Sides The Expert Trap Labeling Trap Premature Focus Trap Blaming Trap
Charting Our Course We must chart our course if we hope to reach our goals, know when to change tack, and when to hold steady.
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How to learn Motivational Interviewing? Eight tasks of learning MI include: 1. The Overall Spirit of MI 2. OARS – Client Centered Counseling Skills 3. Recognizing Change Talk and Sustain Talk 4. Eliciting and Strengthening Change Talk
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6. 7. 8.
Rolling with Sustain Talk and Resistance Developing a Change Plan Consolidating Commitment Transition and Blending
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Recognizing Change Talk Any talk that favors movement toward change DARNCAT, desire, ability, reason, need, commitment, action, taking steps
Recognizing Change Talk Desire – want, wish, like Ability – can, could, able Reason – specific reason for change Need – need to, have to, must
DARNCAT continued Commitment – will, intend to Action – ready to, willing to Taking Steps – reporting recent specific action
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Drumming for Change • Participants will drum or clap when they hear change talk
Eliciting Change Talk Ten strategies for evoking or eliciting change talk. 1.
Ask evocative questions:
1. Ask Evocative Questions Why would you want to make this change? (Desire) How might you go about it in order to succeed? (Ability)
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1. Ask Evocative Questions What are the best reasons for you to do it? (Reason) How important is it for your to make this change? (Need) So what do you think you’ll do?
2. Ask for Elaboration When a change talk theme emerges ask for more detail. In what ways…?
3. Ask for Examples When change talk themes emerge, ask for specific examples. Could you give me an example? What else?
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4. Look Back Ask about a time before the current concern emerged. What were things like then? Better? Different?
5. Look Forward Ask what may happen if things continue as they are (status quo). If you were 100% successful in making the changes you want, what would be different? How would you like your life to be five years from now?
6. Query Extremes What are the worst things that might happen if you do not make this change? What are the best things that might happen if you do make this change?
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7. Use Change Rulers Ask on a scale of 0 – 10 how important is it to you to make this change?
Use Change Rulers Why are you at 3 – 4 and not 0? What could move you to a higher number? On a scale of 0 – 10 how confident are you that you can make this change or how committed are you to making this change? Explore responses.
Explore Goals and Values Ask for the person’s goals and values. You might use a values card sort. If there is a target behavior, ask how this behavior impacts the person’s goals.
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Come Alongside Explicitly side with the negative (status quo) side of ambivalence. Perhaps (target behavior) is so important to you that you won’t give it up, no matter what the cost.
Responding to Change Talk EARS Explore – Ask for Elaboration Affirm – Express agreement, appreciation, encouragement Reflect – Offer a simple or complex reflection Summarize – change talk is also collected in a “bouquet” summary.
Sustain Talk and Change Talk 2 sides of the same coin Sustain talk is normal
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Resistance vs Sustain Talk Resistance is interpersonal behavior, signal of dissonance, predictive of nonchange, and highly responsive to counselor style (discounting, interrupting, and arguing).
Techniques for Responding to Resistance Simple reflection Amplified reflection Double-sided reflection
Other Responses Shifting Focus Reframing Emphasizing Personal Control Coming Alongside Agreement with a Twist Decisional Balance
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Developing a Change Plan Transition from Phase 1 to Phase 2 Recognizing Readiness Testing the Water: Recapitulation and key question Negotiating a Change Plan as a Form of Eliciting and Guiding Elicit – Provide - Elicit
Developing a Change Plan Generate Alternatives Giving Information and Advice with Permission Honing Down Specifics Beware Pressing for a Change Plan Strengthening Confidence
Resources: Motivational Interviewing: Training New Trainers (TNT) Resources for Trainers November 11, 2008 OARS DARN CAT – Christina Delos Reyes, MD DVD Motivational Interviewing: Helping People Change
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