Motivational Interviewing: Empowering Self-Directed Behavioral Change

1. Motivational Interviewing: Empowering Self-Directed Behavioral Change “A desire to be in charge of our own lives, a need for control, is born in each of us. It is essential to our mental health, and our success, that we take control.” Robert F. Bennett

2. A Brief History of Motivational Interviewing • MI: a counseling modality, evolved from Carl Rogers’sClient-Centered Therapy (Rogers, 1951) and Prochaska’s Stages of Change Theory (Prochaska & DiClemente, 1984). • Developed by William Miller and Stephen Rollnick (Miller & Rollnick, 2002) as a treatment protocol to reverse adult alcohol and substance abuse. • Adapted for use with adolescent cannabis users • Further adapted for other risk behaviors such as smoking cessation, medical treatment protocols, and now, • Academic environment: adult literacy, traditional education and underachievement applications to improve persistence and academic performance

3. What is Motivation and Where Does it Come From? External –vs- Internal Motivation: The difference between the “gold-star” reward system of reinforcement and internally-driven goal setting and acquisition. Self-Determination Theory (Deci & Ryan, 1985) The internal dynamics of human motivation. Illuminates the function of attributional mechanisms that fuel goal setting and behavior-modification and empowers the individual to effect behavioral change by redirecting intrinsic motivation.

4. Behavior… to Change • “Behavior is the result of an interaction between [a] situational pull and personal tendencies” (Miller & Rollnick, 2002, pp.287) • Possible Selves • Values Create discrepancy

5. Possible Selves? Self-knowledge delineated by both the personal and the social context. It represents an individual’s ideals of • What they might become, • What they would like to become, • What they are afraid of becoming (Markus & Nurius, 1986).

6. Values: How important? • “Rules for living; important, desirable or worthwhile needs and wants; fundamental ideas about what is right and wrong, good and bad; stimuli which can induce positive or negative emotional states; and preferred events (Fraenkel, 1980). • “What is prized or held in high esteem (values) implies standards of appropriate human behavior (morals) compatible with principles (ethics) governing what is good for the person and for the society to which the individual belongs” (Irwin, 1988).

7. Congruence –v- Discrepancy • Discrepancy, like Piaget’s notion of Disequilibrium, is the energy behind change. • Self seeks congruence between Possible selves and the present self…but you need a conductor to encourage orchestration… • Motivational Interviewing works to reveal ambivalence, elevate discrepancy, and elicitchangetalk —in the direction of a self-identified Possible Self.

8. Goal Setting and Goal Acquisition… Motivational Interviewer

9. How Does it Work? • Motivational Interviewing is • a counseling modality that effects behavioral change by: • Developing discrepancy and ambivalence; • Encouraging CHANGE TALK; and • Calling upon internal or intrapsychic mechanisms such as Resilience (Henderson & Milstein, 1996), • Personal Values (Miller and Rose, 2009), and • Intrinsic Motivation (Miller & Rollnick, 2002) • to empower the individual.

11. MI: a Variety of Applications • Adult In-Patient and Out-Patient Drug Abuse Treatment (Miller, W. R., 1995) • Correctional Settings (William R. Miller; reprinted from the MINUET) • Adolescent Outpatient Substance Abuse Treatment (Lauren Aubrey Lawendowski, 1998) • Emergency Room Interventions:Adolescents with alcohol-related injuries (Nancy Barnett)

12. MI: a Variety of Applications • Dual Diagnosis Treatment (Kathleen Sciacca, 1997) • High-Risk Sexual Practices (by Douglass Fisher and Rosemary Ryan) • Adolescents engaged in risk-behaviors (Chris Dunn) • Smoking Cessation Treatment (Mary M Velasquez, Jacklyn Hecht, Virginia P Quinn, Karen M Emmons, Carlo C DiClemente, Patricia Dolan-Mullen) (pdf link to article in Tobacco Control, 2000) • Eating Disorders (Motivational Interviewing for Eating Disorders, Janet Treasure, Dr. Ulrike Schmidt and Gill Todd, Eating Disorder South London & Maudsley NHS Trust)

13. Some important data on MI: • Project MATCH, 1997(Journal of Studies on Alcohol, 58:7-29) • Design Randomized clinical trial • Population Outpatient and aftercare • Nation US (9 sites) • N 1,726 adults • MI 4 session • Comparison 12 session CBT or TSF • Follow-up 15 months post-treatment • (Miller, W. R., 1995)

14. 4 Principles of MI • 1) Express “Empathy” • Communicate understanding & genuine caring • “Unconditional positive regard” • “Non-possessive warmth” • Impact upon client – Validation, connection, & empowerment (willingness to take more control & responsibility) • “Pacing” is the 1st step toward “Leading”

15. 4 Principles of MI • 2) Develop “Discrepancy” • Help to reveal the gap between client’s goals, values, and current behavior • Allow natural unfolding of psychic tension • Discomfort provides opportunity for change – “No pain, no gain” • Co-create plan that resolves tension via change (i.e., return to balance at new level and/or lifestyle change)

16. 4 Principles of MI • 3) Roll with “Resistance” • A signal to do something different (e.g., relent, stop “fight”, don’t personalize) • “1-Up” position produces “1-Down” result • Client’s energy must stay aligned with his/her desires, not our own, or we both lose • Client ALWAYS makes the argument for change, or lasting change will not occur

17. 4 Principles of MI • 4) Support “Self-Efficacy” • Explore & reframe past change efforts, both successes & failures (e.g., “Failing Forward”) • Elicit & attend to client’s own views/ideas of why & how to change • Avoid explicit direction & confrontation • Elicit commitment to a simple course of action • Liberate client’s actual, unrealized power

18. How It Works • Client-centered, directive style elicits increased change talk & decreased resistance • Resolution of ambivalence is promoted by accurate empathy • Direction of resolution is influenced by the coach’s selective reinforcement of the client’s speech

19. The 2 Phases of MI • Phase 1 • Increasing readiness for change • Focus upon the “Why” of change, how it is personally meaningful • Promote general sense of ability to change • Phase 2 • Strengthening commitment to change • Focus upon the “How” of change & plans

20. The MI “Spirit” • Autonomy-support • Acceptance that client might choose not to change • Collaboration • Negotiation vs. an authoritarian stance • Evocation • Drawing out the client’s ideas & motivation

21. Fundamentals of MI:“OARS” • Open-Ended Questions • Affirmations • Reflections • Summaries

22. Fundamentals of MI:“OARS” • Open-Ended Questions • Avoid “Yes” or “No” response • Elicit broader answers • Use client’s own words • Avoid bias/prejudgment • Make few assumptions • Not judgmental or preachy • Don’t label emotions

23. Open: To what extent…? How often…? Why…? Tell me about… Help me understand… What, if any…? What else…? Closed: Did you..? Will you…? Can you…? Is it…? Open-Ended Starters

24. Fundamentals of MI:“OARS” • Affirmations • Recognition of client’s strengths & qualities • Your “vote of confidence” • Reality based appraisal • Positive truths, based upon past successes & future potential

25. Fundamentals of MI:“OARS” • Reflections • Keep the conversation client-centered & equal • Focus in on 1 part of a complex statement • Reflect both sides of client’s ambivalence

26. Fundamentals of MI:“OARS” • Summaries • Capture essence of client’s motivational conflict • Link current & previous topics • Transition from 1 topic to another

28. Bibliography Burke, B., Arkowitz, H., & Menchola, M. (2003). The efficacy of Motivational Interviewing: A meta-analysis. Journal of Consulting and Clinical Psychology, 71(5), 843–861. Deci, E.L., & Ryan, R.M. (1985). Intrinsic motivation and self-determination in human behavior. New York: Plenum. Henderson, N., & Milstein, M. (1996). Resiliency in schools. Thousand Oaks, CA: Corwin Press, Inc. Markus, H. & Nurius, P. (1986). Possible selves. American Psychologist, 41(9), 954-969. McCambridge, J. & Strang, J. (2004). The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: Results from a multi-site cluster randomized trial. Addiction, 99, 39-52. Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. 2nd ed. New York: The Guildford Press Oyserman, D., Terry, K., & Bybee, D.(2002). A possible selves intervention to enhance school Involvement. Journal of Adolescence, 25(3), 313-326. Project MATCH. (1997). Journal of Studies on Alcohol, 58, 7-29.