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Introduction to Motivational Interviewing Workshop Motivational Interviewing is defined as: “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change" (Rollnick, 2008).

Oregon Coalition Against Domestic and Sexual Violence

Training materials and curriculum created by

Stéphanie Wahab, Ph.D., M.S.W. Associate Professor Portland State University School of Social Work P. O Box 751 Portland, Oregon 503-725-5083 (fax) 503-725-5545 [email protected]

Stéphanie Wahab Ph.D, 2009

TABLE OF CONTENTS

Theoretical Background Conceptual Models of Motivation ________________________________________ 4 Stages of Change ______________________________________________________6 Basic Principles of Motivational Interviewing _______________________________ 7 Motivational –Enhancing Interpersonal Style ________________________________8 Primary Ingredients: Skills OARS ______________________________________________________________9 Open-Ended Questions_________________________________________________10 Reflective listening ____________________________________________________12 Thomas Gordon’s 12 Roadblocks to Communication _________________________13 Summarizing _________________________________________________________14 Strategies Assessing Readiness to Change _________________________________________15 Exploring Ambivalence _______________________________________________17 Change Talk ________________________________________________________18 Eliciting and Enhancing Client Motivation & Change Talk____________________19 Working with Resistance ______________________________________________20 Exchanging Information _____________________________________________ _24 Options Tool________________________________________________________30 Additional Resources _________________________________________________32

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WHAT MOTIVATES PEOPLE TO CHANGE  If you are told what to do, there is a good chance that you will do the opposite. People want to feel in control.  Values and beliefs. The more central or core to you the value is, the more long-lasting and pervasive the change is likely to be. Support clients in making well thought out, committed decisions.  Your beliefs are more influenced by what you hear yourself say than by what others say to you. Encourage clients to say the kinds of things we usually tell them.  Ambivalence is a normal and natural part of the change process.  Decision-making can be facilitated by the weighing of the pros and cons of any choice.  Knowledge about how likely you are to incur harm or reap a benefit is an important element in deciding to change. Also important is the magnitude of the perceived harm or benefit. Provide personal feedback, advice, and/or education.  Before you can decide to change, you need to believe that there is something you can do that will effect the change. Voice confidence in client’s ability to change/adhere.  The interaction between therapist and client powerfully influences client resistance, compliance, and change. Never underestimate the power of relationship.  Brief interventions have the potential to produce similar outcomes to longer, more intensive interventions. Kaiser Permanente Northwest Division Center for Health Research, Denver, Colorado, 2000

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Conceptual Models That Inform MI Conflict and Ambivalence Animals, including people, tend to be immobilized by conflict. Approach-avoidance conflict seems to be particularly potent in its ability to hold people in repetitive cycles, with double approach-avoidance conflicts being still more tenacious (e.g., vacillating between a marital partner and an affair). In conflict situations, ambivalence (feeling at least two different ways about something, or wanting mutually exclusive goals) is a normal and defining condition of the state, and is a key obstacle to change. Decisional Balance The classic Janis and Mann (1977) decisional balance is a rational view, describing decision as a process of weighing cognitively the pros and cons of change. Change here depends on the pros (of change) outweighing the cons. Health Beliefs Health Beliefs models have emerged primarily from the public health field. An example is Ronald Rogers’ Protection Motivation Theory. Such models typically include two elements: (1) degree of perceived risk, often the cross-product of perceived probability and perceived severity, and (2) self-efficacy, the perceived availability of personally efficacious action. Motivation for change depends upon the presence of a sufficient degree of perceived risk, in combination with sufficient self-efficacy. Perceived risk without self-efficacy tends to result in defensive cognitive coping (e.g., denial, rationalization, projection) rather than behavior change. The first element of this change model can easily be converted to degree of perceived promise (for a positive goal), being the cross-product of perceived probability of reward and perceived value of reward. Reactance The Brehms’ (1981) reactance theory posits that perceived threats to personal freedom and choice will elicit behaviors designed to demonstrate and restore that freedom. When behavioral freedom and autonomy are threatened, the probability and the perceived desirability of the to-be-lost behavior will increase. This is consistent with the effects of more aggressive confrontational strategies, which tend to elicit resistance and are associated with lack of long-term behavior change (Miller, Benefield, & Tonigan, 1993). Self-Perception Theory Daryl Bem proposed self-perception theory as an alternative conceptual explanation for many of the empirical findings from cognitive dissonance research. Rather than postulating, as Festinger did, that there is an inherent Hullian drive to be internally consistent (cognitive dissonance), Bem proposed that people learn what they believe in the same way that others

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do: by hearing them (selves) talk. When people publicly take a position, their commitment to that position increases. The more a person argues on behalf of a position, the more committed he or she becomes of it. This is a way of understanding the countertherapeutic nature of the confrontational/denial trap, in which the therapist argues for change and the client argue against it. Self-Regulation Theory Yet another way of understanding what triggers change is found in self-regulation theory, originally described by Kanfer (for a recent review see Miller & Brown, 1991). In this view, behavior is regulated by cycles involving the monitoring of one’s own status, comparison of status with expectations, and “course correction” when status does not match goal or expectancy. To trigger change, one would seek to increase the discrepancy between status and goal, which could be accomplished either by increasing awareness of status (e.g., through feedback such as self-monitoring) or by affecting goal states (see the work of Miles Cox on goals in motivational counseling; chapter 19 in MI text). Rokeach’s Value Theory The New Mexico (Dept. of Psychology) group has been studying people who have undergone sudden transformations in personality (Miller & C’de Baca, 1994). They have been seeking conceptual models to understand why such dramatic shifts in behavior and identity (the fictional model is Ebenezer Scrooge) occur and endure. One promising model is found in Milton Rokeach’s 1973 classic volume on “The Nature of Human Values.” He conceptualizes personality as hierarchically organized, with immediate behaviors and cognitions at the most peripheral level. An individual’s attitudes, which number in the thousands, represent one organizational step inward. More central are beliefs, and behind these a set of a few dozen core personal values. Beyond these, Rokeach alluded to a most central sense of personal identity. The further “in” the shift occurs, the more sweeping will be the resulting change.

Source: Motivational Interviewing Workshop, October 22-23, 1999, Department of Psychology and enter on Alcoholism, Substance Abuse and Addictions (CASAA), The University of New Mexico.

Stages of Change

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The widely used transtheoretical model of Prochaska and DiClement (1982) describes several stages through which people normally pass in the process of changing. Change is conceptualized as a process. Precontemplation is the state in which people are not considering changing or initiating a behavior. They may be unaware that a problem exists. Contemplation is the stage characterized by ambivalence about changing or initiating a behavior. Action is the stage characterized by the taking of action in order to achieve change. Maintenance is the stage characterized by seeking to integrate and maintain a behavior that has been successfully changed or initiated. Relapse is the stage characterized by a recurrence of the undesired behavior or elimination of a desired behavior. Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones/ Irwin. Contemplation Precontemplation

Action Relapse

Maintenance

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Basic Principles of Motivational Interviewing Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy Express empathy  Acceptance facilitates change.  Skillful reflective listening is fundamental.  Ambivalence is normal. Develop discrepancy  The client rather than the counselor should present the arguments for change.  Change is motivated by perceived discrepancy between present behavior and important personal goals and values. Roll with resistance  Avoid arguing for change.  Resistance is not directly opposed.  New perspectives are invited but not imposed.  The client is a primary resource in finding answers and solutions.  Resistance is a signal to respond differently. 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 a self-fulfilling prophecy. Taken from Miller & Rollnick (2002). Motivational Interviewing: Preparing people for change. New York: The Guilford Press.

SPIRIT OF MI

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• • • • • •

Understanding Client Centered Collaborative Individualized Emphasizing Freedom of choice Respectful/accepting

KEY ELEMENTS 1. Understanding  Empathic, careful listening, attentive, non-judgmental, warm and supportive.  Seeking to see things from the client’s perspective. 2. Client -centered  Encouraging clients to be as active as possible in making decisions about health behavior change.  Eliciting motivation to change from the client, not imposing it from without.  Encouraging clients to do most of the talking. 3. Collaborative  Pursing common goals.  Sharing of agendas and responsibility.  Working together in partnership to determine the best course of action (a meeting between “experts”). 4. Individualized  Tailoring intervention approaches to match the client’s personal needs and readiness to change.  Moving at the client’s pace. 5. Emphasizing freedom of choice  Acknowledging that the decision if, when, and how to change is the client’s.  Avoiding “restrictive” messages (e.g. “you have to, “you must”, “you can’t”). 6. Respectful/accepting  Conveying respect by accepting whatever decisions a client makes about health behavior change.

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OPENING STRATEGIES: OARS Open-ended Questions Questions that cannot be answered “yes/no”, but which encourage clients to express their thoughts, feelings, or concerns.

Affirmation Expression of appreciation for client’s efforts or participation. Reflective Listening Accurate understanding of clients’ experience, communicated in a warm, nonjudgmental manner.

Summarizing Brining together of several of clients’ previously expressed thoughts, feelings, or concerns, often including the clinician’s understanding of how these fit together.

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Open-Ended Questions Goal  To encourage the client to think and talk about change. Key Elements  Ask the client specific open-ended questions to elicit “change talk”.  Ask questions in a way that is open and inviting. Avoid  Asking closed-ended questions (yes or no answers). Sample Questions Why do you wish to get and HIV test? Let’s suppose you decided to cut back on your needle sharing, how would your life be different? What brings you here today? What do you want to change? What do you like about sharing needles? What would need to be different for you to be safer when you have penetrative sex? What might get in your way of reaching your goals?

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QUESTION QUIZ Open ____

Closed ____

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2. What do you want to do about your smoking: stop, cut down, or stay the same?

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3. What brings you here today?

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4. Did the judge require you to attend treatment?

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5. What do you like about marijuana?

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6. Isn’t it important to you to have meaning in your life?

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7. In what ways is your diabetes a problem for you?

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8. How have you overcome other obstacles in the past?

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9. Have you ever thought about just walking as a simple way of exercising?

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10. Are you willing to try this for one week?

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11. Do you care about your health?

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12. What are the most important reasons why you want to make a change?

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13. Do you want to stay in this relationship?

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14. Where did you grow up?

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15. Is this an open question?

1. Where were you born?

Make up two OPEN questions of your own:

Give two examples of CLOSED questions you might ask:

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Reflective Listening    

Accurate reflection Gordon’s roadblocks to communication Nonverbal Thinking reflectively

Goals  To establish report.  To create a supportive environment for the client to think and talk about change.  To let the client know you are listening and understand.  To tap into the “natural change potential” of the client. Key elements  Demonstrate open and receptive non-verbal behaviors.  Let the client talk without interruption.  Employ minimal encouragers:         

Mm-hmmm I see Go on For instance Oh? And? Tell me more Really? What else?

 Use attentive silence to allow the client to think and process.  Listen without judgment or rebuttal. Avoid  Roadblocks to communication. [See handout on Gordon’s roadblocks to communication]

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Thomas Gordon’s 12 Roadblocks to Communication  Ordering, directing, or commanding  Warning or threatening  Giving advice, making suggestions, or providing solutions  Persuading with logic, arguing, or lecturing  Moralizing, preaching, or telling clients what they “should” do  Disagreeing, judging, criticizing, or blaming  Agreeing, approving, or praising  Shaming, ridiculing, or labeling  Interpreting or analyzing  Reassuring, sympathizing, or consoling  Questioning or probing  Withdrawing, distracting, humoring, or changing the subject Four Types of Reflective Listening Repeat- These reflections add nothing at all to what the client has said, but simply repeat or restate it using some or all of the same words. Rephrase- These reflections stay close to what the participant has said, slightly rephrase it, usually by substituting a synonym. It is the same thing said by the client, but in a slightly different way. Paraphrase- These reflections change, or add to what the client has said in a significant way, to infer the client’s meaning. Reflect Emotion- Regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimensions through feeling statements.

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Summarizing Goals     

To reinforce what the client has said, especially self-motivational statements. To show that you have been listening. To provide a mirror for the client to see themselves. To allow the client to hear her ‘change talk’. To tie together what has been said, to provide a transition link, and/or to bring closure to a conversation.

Key Elements  Summarize in a brief, concise manner.  Preface a summary statement with an introduction (ex. “let me see if I understand what you’ve told me so far”).  If a client has expressed ambivalence, it is useful to capture both sides of the ambivalence in the summary statement (“On the one hand………..on the other”).  End a summary statement with an invitation for the client to respond, such as: “How did I do? What have I missed?” Avoid  Rambling summaries.  Analyzing the meaning of what a client has said.

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Assessing Motivation, Confidence, and Readiness Goal  To determine a client’s readiness to change or initiate a behavior.  Reflect on process of change. Key Elements  Show the client the readiness to change ruler and ask her to indicate where she is in relation to the particular behavior.  Acknowledge and accept the client’s position on the ruler.  Ask specific open-ended questions to elicit “change talk.” Avoid  Showing bias or judging the client’s position on the ruler.  Rushing this process, as it is crucial to decision making. Key Questions/Statements “On a scale of 0-12, how ready are you right now to participate in the group activities? (0 = not ready at all, 12 = very ready). Key Follow-up Questions: Straight question: “Why did you pick a ___________?” Backwards question: “Why did you pick a 4 and not a 1?” Forwards question: “What would need to be different for you to move from a 2 to an 8?” Future question: “Let’s suppose you decided to participate, why would you want to?”

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PERSONAL RULERS WORKSHEET

Motivation Ruler 0 1 Not at all

2 3 Somewhat motivated

4 5 Fairly motivated

6 7 Motivated motivated

8 9 Very motivated

10 Extremely motivated

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6

8

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Confidence Ruler 0

1

Not at all

2

3

Somewhat confident

5

7

9

Fairly confident

Confident confident

Very confident

Extremely confident

4

6

8

10

Readiness Ruler 0 Not at all

1

2

3

Somewhat ready

Fairly ready

5

Ready ready

7

Very ready

9

Extremely ready

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Exploring Ambivalence Goals  The goal of exploring ambivalence is to help the client verbalize all the conflicting thoughts and feelings about the behavior change.  It is also to convey to the client a complete verbal picture of her/his uncertainty and ambivalence. “WHEN I HEAR MYSELF TALK, I LEARN MY BELIEFS” Key elements  Always ask permission to talk about a certain topic.  Begin by asking the client for their reasons for not changing the behavior, then ask about the reasons for change.  Summarize the reasons for not changing first, followed by the reasons for change.  Ask if you got it all.  Ask about the next step. “Where does this leave you now?” Avoid Using words like “problem” or “concern” unless the client uses them. Telling the client your perceptions of the reasons for change. Arguing with the client about the validity of their thoughts and feeling. Key questions “What are some of the things you like about drinking alcohol?” “What are some of the things you dislike about drinking alcohol?” “What are some of the reasons why you would want things to stay just the way they are?” “What are some of the reasons for making a change?” “What are the advantages/disadvantages to running away?” “What are the advantages/disadvantages of stealing?”

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Change Talk DARN-C language Desire: Desire is much like "wish hope" as it is the wish for better/different. "I wish I could quit smoking." (I Want to, prefer, wish). Bill, from your recent postings, which would you plant here: preferred self, ideal self, possible self? Ability: Ability deals with confidence and self-efficacy. "I could quit smoking cigarettes" (I Can, able, could, possible) Reasons: Reasons involve issues of incentive, motive or rational -contextual issues (I Should, why do it?). "Smoking really flares up my asthma." A way of making sense that involve more logical pronouncements “I should do it for this/that reason.” Need: Need seems to overlap with "Reasons" but deals more with "must" rather than "should" (I Must, importance, got to). Deals more with necessity and what is emotionally charged, rather than detached or dispassionate logic and rational. Need moves beyond logical reasons and moves into urgency. Commitment: All of the previous elements (DARN) have the component of strength/weakness to the verbiage. Commitment implies an agreement, intention, or obligation to change (I might, I will, I’m going to).

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Eliciting & Enhancing Client Motivation SKILLS: Evocative Questions Asking client for change talk (see “Confidence Talk on next page”). Elaboration Asking for examples and clarification of change talk. Typical Periods Asking clients to describe in detail a typical day, week, or other period of time, in order to elicit information about the place of problem behavior or symptoms in their lives. Looking Forward Asking clients to imagine what they would like their lives to be like at some time in the future, and then asking them what would need to change in order for them to be able to achieve this. Looking Back Asking clients to remember what things were like in their lives before they began to experience symptoms or engage in the problematic behavior, and to compare that to their lives in the present. Using Extremes Asking clients to imagine the worst possible consequences of not changing a behavior or their way of living, or the best possible outcome of making a change. Exploring Goals and Values Asking clients to tell you what is most important to them, then asking how current symptoms or problematic behavior fit with this. Decisional Balance Asking clients to describe the advantages (pros, “good things”) and then the disadvantages (cons, “not so good things”) of their current behavior or way of living, or the disadvantages and then the advantages of change. Importance and Confidence Asking clients to answer two scaling questions about how important change is to them, and how confident they are that they can change, and then discussing these ratings.

Recognizing Resistance 19

“Resistance” Behaviors ARGUMENT. The client contests the accuracy, expertise, or integrity of the counselor. Challenging. The client directly challenges the accuracy of what the counselor has said. Discounting. The client questions the counselor’s personal authority and expertise. Hostility. The client expresses direct hostility toward the counselor. INTERRUPTION. The client breaks in and interrupts the counselor in a defensive manner. Talking over. The client speaks while the counselor is still talking, without waiting for an appropriate pause or silence. Cutting off. The client breaks in with words obviously intended to cut the counselor off (e.g. ‘Now wait a minute. I’ve heard about enough.”) DENIAL. The client expresses an unwillingness to recognize problems, cooperate, accept responsibility, or take advice. Blaming. The client blames other people for problems. Disagreeing. The client disagrees with a suggestion that the client has made, offering no constructive alternative. This includes the familiar, “Yes, but...” which explains what is wrong with suggestions that are made. Excusing. The client makes excuses for his or her own behavior. Claiming Impunity. The client claims that he or she is not in any danger (e.g. from drinking). Minimizing. The client suggests that the counselor is exaggerating risks or dangers, and that it “really isn’t so bad.” Pessimism. The client makes general statements about self or others that are pessimistic, defeatist, or negativistic in tone. Reluctance. The client expresses reservations and reluctance about information or advice given. Unwillingness to change. The client expresses a lack of desire or an unwillingness to change, or an intention not to change. 20

IGNORING. counselor.

The client shows evidence of not following or, of ignoring the

Inattention. The client’s response indicates that he or she has not been following or attending to the counselor. Non-answer. In answering a counselor’s query, the client gives a response that is not an answer to the question. Side-tracking. The client changes the direction of the conversation that the client has been pursuing.

Source: Motivational Interviewing Workshop, October 22-23, 1999, Department of Psychology and enter on Alcoholism, Substance Abuse and Addictions (CASAA), The University of New Mexico.

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RESISTANCE STEMS 1. I’m not the one with the problem. If I drink, it’s just because my husband is always nagging me. (blaming) 2. Who are you to tell me what do to? What do you know about crack? You probably never even smoked a joint! (discounting) 3. Your little test here says I’m an alcoholic, but that can’t be right. I can quit drinking any time I feel like it. (disagreeing) 4.

I really like pot! I don’t want to quit! (unwillingness)

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I’ve tried to stop smoking before, and I just don’t think I can do it. (pessimism)

6. But everybody I know drinks! What am I going to tell my friends if I can’t have a drink when I want to? (reluctance) 7. My wife is always exaggerating! I haven’t ever been that bad! I’m the first to admit that I drink too much sometimes, but I’m no alcoholic! (minimizing) 8. I can really hold my liquor. I’m still standing when everybody else is under the table. (claiming impunity) 9. I don’t smoke any more than my friends do. What’s wrong with smoking a joint? (excusing) 10. I know you’re sitting there thinking that I’m a junkie, but it’s not like that. I just like getting high sometimes. (minimizing) 11. Why are you and my husband so stuck on my drinking? What about all of his problems? You’d drink, too, if you had a family like mine. (blaming, excusing) 12. I don’t know why my doctor sent me here? She said something about my blood test looking like I’m an alcoholic. Now, I suppose you’re gong to lecture me about my drinking. (challenging, hostility) 13. Everybody has to die sometime. Maybe smoking will do me in, but lots of people smoke all their lives and die of old age. Besides, they’ve never really proved that smoking causes cancer. (minimizing) 14. Tranquilizers aren’t really my problem. What I want to talk about is my son- now he’s a problem! (sidetracking)

Strategies for Working With Resistance

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       

Simple reflection- Reflect what is said (not always simple to do) Amplified reflection- Add some intensity Double sided reflection- Reflect the ambivalence Shifting focus- Change the focus/subject Reframing- Offer new meaning or interpretation Agreement with a twist- Reflection followed by a reframe Emphasize personal choice Siding with the negative

Goal  To minimize and manage client resistance. Key Elements  Recognize resistant behaviors as a signal to change strategies.  The clinician can generate resistance by: • Using a judgmental or confrontational approach. • Jumping ahead of where the client actually is on the readiness-to-change continuum. • Mis-assessing the client’s readiness to change. • Discounting the client’s feelings and thoughts.  When you encounter resistance, step back, listen, and try to understand things from the client’s perspective. Avoid  Arguing  Confronting  Persuading  Telling the client what to do and how to do it  Judging Tools Listen, listen, listen.

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Exchanging Information Goal  To share personalized feedback with the client in a neutral manner.  To offer your professional advice and opinions in a motivation-enhancing manner.  To offer new information to help support the client’s decision-making process. Key Elements     

Ask permission. Be clear, succinct, and non-judgmental. Elicit client response. Freedom of choice. Voice confidence.

Strategies Goal of providing feedback  To give personalized feedback in a natural manner  To offer your professional advice and opinions in a motivation-enhancing manner.  To offer new information to help support the client’s decision-making process. Avoid motivational interviewing –inconsistent behaviors. Ask them to talk about what types of behaviors might make an interaction between the physician and patient go less well. 1. Direct confrontation “You need to leave your partner.” “You keep putting yourself in a dangerous situation and if you don’t get out it will kill you.” 2. Unsolicited advise, health education, or recommendations prior to any indication from the patient that they are willing to hear such advice. “The best thing you can do for your kids in this situation is to not talk to him again.” “You simply have to eliminate alcohol for now until you get your situation in order.” 3. Asserting authority or expertise that tells the person what he or she must do. “As your counselor, I am telling you that you have to reduce your work schedule in order to take care of all this legal stuff.”

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“Housecleaning is not enough physical activity. You need consistent cardiovascular activity, like 20-30 minutes of walking each day. Otherwise, from my experience, you won’t lose weight and keep it off with the dietary changes you have made.” 4. Not empathically listening to the person and collaboratively working with him or her. “You really should let your Dr. know about side effects before you decide to stop taking your mediations.” “That may be, but I think it’s unlikely and more due to……..” 5. Being in a hurry. 6. “Why don’t you talk about that with the social worker. She’ll have more time to go over what you think you should do.” “Okay, I’ve got that part, but let’s move on because I have to cover a few more things before our time is up.”

Offering Advice- Elicit, Provide, Elicit • Ask for permission Example: “Might I share some advice with you?” • Emphasize freedom of choice and personal responsibility. Example: “This is what we recommend, but the final decision is yours.” • Voice confidence in the client’s ability to change/adhere. Example: “I’m confident that if you make a firm decision and commitment to take your medications regularly, you will be able to do so.” • Elicit client’s thoughts and feelings in response to advice. Example: “What do you think about my recommendation?” “Does this make sense?” “Any questions? “How is this information relevant to you?” “What do you think about this information?” “Is this information surprising to you?” “Were you already aware of this information?”

Providing Education, Elicit, Provide, Elicit

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•

Education is important but not sufficient for health behavior change.

• Ask client what she already knows. Example: “Tell me a bit about what you know about methadone.” • Avoid overwhelming clients with too much information. LESS IS MORE!!! Example: “You mentioned that you haven’t been taking your mediations regularly lately. I’m concerned because you’ve stated in the past that the meds. help you with your attention and concentration. In case this is helpful to you, the research tells us that antipsychotic medications can only work if you take them as they are prescribed. These are medications that need to be used on a continuous basis to help reduce your symptoms and prevent other symptoms from coming back.” • Check in frequently for understanding. Examples: What do you think about my recommendation?” “Does this make sense?” “Any questions? “How is this information relevant to you?” “What do you think about this information?” “Is this information surprising to you?” “Were you already aware of this information?”

Key Elements for providing advice and education     

Ask permission. Be clear, succinct, and non-judgmental. Elicit client response. Freedom of choice. Voice confidence.

Giving Feedback, Elicit, Provide, Elicit • Give the facts, leave the initial interpretation to the client. Example: “Our initial assessment of your liver function is that it is seriously compromised and that your overall health is seriously affected.” • Compare client’s feedback to norms, standards, historical data, and/or other clinical centers. Example: “Your cholesterol level has decreased by 30 points since the last time that we talked about your cholesterol.” •

Elicit client’s interpretation of the feedback. “Does this make sense?” “Any questions? “How is this information relevant to you?” 26

“What do you think about this information?” “Is this information surprising to you?” “Were you already aware of this information?”

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EXCHANGING INFORMATION WORKSHEET Write and “advice” statement for the scenario described below. 1. This client has been struggling with eating disorders however she has appeared to be eating well and healthily, for the most part, on the trip. You do have some suspicion based on recent conversations with her and others that she has been making herself throw up in the past couple of days. You think it would be a good idea for her to take a few minutes to reflect and talk about what is going on for her right now. Advice statement:

2. This client is frustrated b/c the group activities in the shelter make her feel really uncomfortable. She’s decided to stop her participation in the activities. Advice statement:

3. This client thinks that smoking pot every once in a while isn’t harmful to her health. Advice statement:

4. The client becomes verbally abusive when confronted. She gets angry, her forehead gets sweaty and she gets in your personal space and denies any problem. You care about her and want to support her in staying safe and protected. Advice statement:

5. This client wants to come out to her family but is afraid to. Advice statement:

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EXCHANGING INFORMATION WORKSHEET Write and “educational” statement for the scenario described below.

1. The client’s family members, who function as her primary support system, sabotage her medication compliance protocols because of questionable or blatantly incorrect information they have gleaned from the popular press.

Education statement:

2. This client tells you that she doesn’t think she can quit using pot because the pot helps her deal with the world better, especially when she feels stressed and anxious. Education statement:

3. This client wants to quit drinking, and has cut back from drinking a six pack to three hard alcohol drinks a day. The client doesn’t realize that the actual alcohol intake of the hard liquor is equivalent to the amount she was drinking in beer. Education statement:

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Offering Support/ Change Options Goal  To work with the client in deciding what to focus on. Key Elements  The Options tool consists of a group of several circles that list the options for discussion from the provider’s perspective. These circles are separated from two blank circles by a heavy line. The blank circles may be used to include options suggested by the client. It is important to have the blank circles. Options tools can be tailored to the area of focus and institutional resources available for support.  Show the client the appropriate options tool and ask if any of these behaviors/topics/issues might be of interest to her to discuss, or if there is something else that she/he would rather like to focus on that might be impacting his/her participation.  Invite the client to express his/her views on the subject.  Honor the client’s choice of behavior/topic/issue. Avoid  Setting the agenda on your own and/or pushing the client into premature focus on any one behavior of your choosing before he/she is ready.  Action planning unless specifically indicated by the client.  Problem solving for the client.  Giving advice.  Being a cheerleader for change.  Being judgmental about where he/she is. Sample Script “This worksheet represents some of the issues that may concern (be a part of) your life at the moment. What, if any, of these would you be interested in spending some time on? It could be one that you’ve been thinking about concerning ‘safer sex practices”. From my perspective it seems like issues around support sobriety has been important to you. However, it is up to you. Or maybe there is something else that you consider more important to discuss at this time. What do you think?”

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Options Worksheet

Self-care

Substance Use

Health

Violence Depression

Medication

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Additional Resources Clinical Demonstration and Training Videos Jennifer Hettema Motivational Interviewing Training Videos: http://www.mitrainingvideo.com/ Miller WR (1989). Motivational Interviewing. Available from the author of the Department of Psychology, University of New Mexico, Albuquerque, New Mexico 87131 Motivation for Change (1990). Two training videotapes available from Addiction Research Foundation, 33 Russell Street, Toronto M5S 2S1, Ontario, Canada. Miller WR, Rollnick S, directed by TB Moyers (1998). Motivational Interviewing. Series of six training tapes. Available from Delilah Yao, Department of Psychology, University of new Mexico, Albuquerque, New Mexico 87131-1161. Dyao@unm. Edu. European format available from European Addiction Training Institute, Stadhouderskade 125, 1074 AV Amsterdam, The Netherlands. Telephone: 31-20-675-2041; Fax: 31-20-675-4591. http://www.eati.org: [email protected]. Books Miller, W., & Rollnick. S. (2002). Motivational Interviewing: Preparing people for change. New York: The Guilford Press. Rollnick, S., Mason, P., Butler, C. (1999). Health Behavior Change: A guide for practitioners. New York: Churchill Livingstone. Arkowitz, H., Westra, H. A., Miller, W. M., & Rollnick, S. (2008). Motivational interviewing in the treatment of psychological problems. New York: Guildford Press.

Training in Motivational Interviewing Stephanie Wahab, Ph.D, Stephanie Wahab Training Inc. [email protected]

For a complete list of all publications on MI, including all clinical trials and problem areas go to the Motivational Interviewing Home Page- http://www.motivationalinterview.org/

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