An introduction to Motivational Interviewing

1. An introduction to Motivational Interviewing Daniel W. M. Maitland, Ph.D. Assistant ProfessorTexas A&M University-Corpus Christi

2. General outline Experiential in nature. You will be learning by doing. MI Style & Spirit Underlying principles Stages of change Rowing your OARS Exploring Ambivalence Rolling with resistance Change talk

3. What is MI?

4. MI Style Collaborative Evocation Person centered Effect of style on client behavior Resistance & change talk: opposite sides of same coin Respect for client autonomy

5. MI Principles • Express Empathy • The capacity for participation in another’s feelings or ideas • Develop Discrepancy • Roll with resistance • Support Self-Efficacy

6. Fostering collaboration Treat therapy as a joint effort Emphasize the importance of the client’s perceptive The client chooses if and how to change Verbalize respect for client’s autonomy

7. Evocation • Avoid traps • Question-Answer • Labeling • Premature Focus • Taking Sides • Blaming • Expert

8. Let practice! – What traps are occurring?

9. Stages of change • Precontemplation • A person not seeing the need for change • Contemplation • Considering change • Preparation • Decided to make change, considering how • Action • A person is actively doing something to change • Maintenance • Working to maintain implemented change • Lapses & Relapses Prochaska & DiClemente, 1984

10. Doing something different – row your OARS

11. Open ended questions • Gets the clients talking • Less yes/no responses • Don’t elicit terse answers or very specific pieces of information • Helps client avoid passive role • Use what and how questions • Consider requests • Tell me… • Describe…

12. Self practice – Convert these to open ended questions • 9. Have you ever witnessed or experienced yourself a life-threatening • accident or physical or sexual assault? • 10. Have you ever been incarcerated? • 11. Have you felt sad, lifeless, or exhausted most of the day every day for the • last two weeks? • 12. Do you carry a gun or a knife on you? • 13. Have you paid your rent this month? • 14. Do you have enough access to food? • 15. Are you thinking about harming yourself or others? 1. What is the last grade in school that you were able to complete? 2. How many cigarettes do you smoke per day? 3. Have you ever had a sexually transmitted infection or an abortion? 4. Don’t you think it would be a good idea to stop smoking cigarettes? 5. In the last week, how many alcoholic drinks have you had? 6. Did anyone in your family growing up have a mental illness? 7. When is the last time you were tested for HIV? 8. Do you physically discipline your child?

13. Affirmations Focus on confidence in client’s ability to achieve change Use compliments or praise Acknowledge qualities that promote change Recognize effort or small steps Reframe difficulties (dropping out of treatment just to come back again later) Must be genuine!

14. Affirmation practice Example: Trudy smokes two packs of cigarettes a day. She knows it isn’t good for her and is fed up with people reminding her of it. Over time, she has come to realize that her smoking has moved from a social habit to a harmful addiction. She feels guilty about her smoking and tries to hide it from her family. At some point, she will stop, but just not yet. With everything else going on in her life, this is one area she feels is her own. Strengths: • Independent, doesn’t let others unduly influence her. • Aware of changes in her behavior and is bothered by it. • Wants to be more healthy Affirmation: You are somebody who makes up her own mind. You’re aware of the negative effects of smoking and when you’re ready to make a change you’ll do what’s needed to be successful. • Think of three people • One you like • One you are neutral about • One you dislike • Think of several affirmations related to a particular strength or quality • Frequently start with you • More specific is better • Share those with a partner

15. Reflections • A hypothesis as to what the talker is getting at • Said as a statement not a question • Voice tone turns down at the end = reflection • Voice tone turns up at the end = question • Integrates underlying feeling, values, and unsaid portions • Endeavor for accuracy • Encourage client to explore or elaborate

16. Types and levels of reflection

17. Reflection activity Group of 3-6 (or your table) practice reflecting what a speaker says Designate 1 speaker to talk about a topic (favorite activity, person who inspires them, decision they’re facing, challenging situation, dilemma, etc) for 30-45 seconds Go around circle creating reflective statements using the techniques on last slide. After several rounds choose a new speaker

18. Directive reflecting Change what you’re emphasizing Can steer the client from the proverbial back seat “It’s been fun, but something has got to give. I just can’t go on like this anymore.” - You’ve enjoyed yourself. - You’re worried about what might happen. - It’s time for a change.

19. Short practice alone Adapted from Rosengren, DB. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook • Come up with 3 responses to each quote below • Each emphasizes a different aspect of the statement • I know I could do some things differently, but if she would just back off, then the situation would be a whole lot less tense; then these things wouldn’t happen. • So, I’m not too worried, but it’s been over a year since I’ve had an HIV test. • I know I’m not perfect, but why do they have to always tell me what to do. I’m not 3! • I don’t think I have a drinking problem. It’s just that my partner is overly sensitive because her dad was an alcoholic.

20. Summarize • Purposes • Tracking • Creates structure • Emphasize specific elements • Special form of reflection • Assures clear communication • Useful as a transition • Reflects ambivalence & highlights change talk

21. Basic framework & types of summaries • Basic Framework for Offering Summaries • 1. Indicate you’re summarizing • 2. Give summary • 3. Invite response “What’d I miss?” • Types of summaries • Collecting • Linking • Transitional

22. Summary practice In a group of 3 to 6 or at your table Have a Speaker and Interviewer engage in 3 minute MI conversation. Then, 1. Have a person in the circle (other than the Interviewer) provide a collecting summary followed by a brief response from the Speaker about the general accuracy 2. A second person in the circle then offers a linking summary followed by a brief response 3. A third person then provides a transitional summary followed by a brief response 4. Debrief 5. Repeat the exercise with a different Speaker and Interviewer engaging in a 3 minute conversation.

23. Exploring ambivalence People do not usually come to therapy ready to change Want to change and for things to stay the same Ambivalence is natural Ambivalence fluctuates

24. Resistance • What does resistance look and feel like? • Arguing • Interrupting • Negating or “Denial” • Ignoring • What is resistance? • A cue to change strategies • A normal reaction to having freedoms decreased or denied • An interpersonal process

25. How do you roll with resistance? Reflections Shift focus Reframe Agreement with a twist Emphasize personal choice and control Come alongside

26. Change talk – DARN-C • Desire • Do you want to make this change? • Ability • Do you have the tools to make this change? • Reason • Why do you want to make this change? • Need • How important is the change? • Commitment • What action will you take to make this happen?

27. Methods for evoking change talk • Asking evocative questions • What worries you about your current situation? • Why would you want to make this change? • How might you go about it, in order to succeed? • Using importance ruler • On a scale of 0 to 10, how important is it for you to make this change? Tell me about being at ___ compared to (several numbers lower)? What would it take to move from ___ to (next highest number)? And how I might I help you with that? • Exploring extremes • What’s the worst that could happen? The best? • Looking back • What was life like before ____ • Looking forward • How would you like things to be different in the future regarding _____? • Exploring goals and values • What’s most important to you in life? What are the rules you’d live by? How does this fit with your personal goals?

28. Let’s see it in action

29. Now you put it together Groups of 4. 8 minutes for exercise. 1 speaker, 1 interviewer, 2 observers Topic is “One thing in my life or about myself I want to change” Interviewer: Use OARS to evoke DARN-C statements. Avoid traps. (Pause and consult observers if you need help!) Observer 1: Track occurrence of OARS – write down good examples Observer 2: Track DARN-C – write down good examples

30. Debrief and repeat as time allows Interviewer: Talk about what you died well and 1 thing you could improve on Speaker: Tell the interviewer all the things they did well, suggest 1 improvement Observers: Share your count of OARS/DARN-C, Share good examples.

31. Thank you – Any questions? Daniel W. M. Maitland Assistant Professor, Texas A&M University – Corpus Christi Daniel.Maitland@TAMUCC.edu