INTRODUCTION TO LEARNING MOTIVATIONAL INTERVIEWING

1. INTRODUCTION TO LEARNING MOTIVATIONAL INTERVIEWING Lynn S Massey, LMSW Health Services Research University of Michigan August 2013

2. Do you……. • Explain what the person could do differently to improve their health? • Advise / persuade / warn what will happen if they do not change? • Counsel the person about how to change? • Refer to a specialist? • Set goals for change?

3. Common Human Reactions to Being Listened to • Understood • Want to talk more • Liking the counselor • Open • Accepted • Respected • Engaged • Able to change • Safe • Empowered • Hopeful • Comfortable • Interested • Want to come back • Cooperative

4. Definitions

5. MI Definition-Layman’s Motivational Interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change.

6. Why do I want to learn MI? Motivational Interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change.

7. Technical Definition Motivational Interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for and commitment to a change goal by eliciting and exploring an individual's own arguments for change.

8. Eight Stages in Learning MI • The spirit of MI • OARS- client-centered counseling skills • Recognizing change talk • Eliciting and reinforcing change talk • Rolling with resistance • Developing a change plan • Consolidating client commitment • Integrating MI with other methods Miller, W.R., & Moyers, T. B. (2006). Eights stages in learning motivational interviewing. Journal of Teaching in the Addictions

9. Assumptions

10. Motivation • The probability that a person will enter into, continue, and adhere to a specific change strategy or plan • Motivation is a dynamic state (of readiness to change) • Part of clinician’s job • Occurs in an interpersonal context • “Noncompliance”, “resistance” and ”lack of motivation” are all partially due to therapists strategies

11. Ambivalence • Is normal, acceptable and understandable • Helps clinician to appreciate the complexity of the individual and their situation • To explore ambivalence is to work at the heart of motivation • Usually mistaken for resistance (yes, but…)

12. Spirit of MI

13. Definition • MI is not a set of methods to learn, but a therapeutic way to being and interacting with a person – not everyone will be able to do it • Context or interpersonal relationship within which the techniques are employed • Spirit of MI is necessary for expert use, but not to begin to learn MI – spirit of MI can emerge from therapist-client interactions using the method • The extent of initial curiosity and willingness to learn MI seems to be a good predictor for speed and ease of acquiring MI skills

14. The Spirit of MI • Is essential for the full and expert use of MI • Underlying assumption that “health is waiting inside” each person, and your role is to help it emerge (Humanistic Psychology) • Contrasted with the model that the patient is flawed • Therapists expression of spirit as measured by independent raters predicts client engagement, collaboration, and affect in sessions (Moyers et al, 2005)

15. Relational Components of MI • Empathy– genuine curiosity about client’s perspective (understanding) • MI Spirit: • Collaboration – fostering power sharing in the interaction • Evocation – elicitation / acceptance / understanding of client’s own ideas about change • Respect Autonomy – active fostering of client perception of choice

16. Collaboration • Fosters collaboration and power sharing so that client’s ideas impact the session • Encourages power sharing in the interaction in such a way that client’s ideas substantially influence the nature of the session • Builds rapport • Facilitates trust • Mutual understanding, not about the therapist being right.

17. Evocation • Accepting of the client’s own reasons for change and ideas about how change should happen • Doesn’t attempt to educate or direct if client resists • Proactively evokes client’s own reasons for change and ideas about how change should happen • The therapist’s job is to “draw out” the client’s own motivations and skills for change, not to tell them what to do or why they should do it

18. Autonomy • Accepting and supportive of client autonomy • The true power of change rests within the client • Ultimately it is up to the client to change • Clients are encouraged to take the lead on developing a “menu of options” as to how to achieve the desired change

19. Thumbs up Thumbs down C: I know my dad told you I’m depressed, but I’m not. Just because I don’t want to play football doesn’t mean I’m depressed. T: Your father is worrying needlessly. What do you think he’s seeing that makes him worry this way? Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren (2009)

20. Thumbs up Thumbs down C: They told me I have to have this surgery right away. But I don’t trust them, so I haven’t scheduled it yet. T: Why take the chance? They’re the experts, after all. Let’s call from this phone right now-maybe you can get in this week? Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren (2009)

21. MI Skills and Strategies

22. The Basics of MI • Client centered approach is necessary but not sufficient for behavior change • Client centeredness – the relational component- based on the Spirit of MI (collaboration, evocation, autonomy, respect) and Empathy • “It is not a goal unless it is a goal for the patient” • Change talk -the technical component – gives a voice to the person’s inner motivation based on what they value most

23. 4 Principles of MI 1) Express empathy – acceptance of people as they are frees them to change whereas non-acceptance immobilizes the change process 2) Develop discrepancy – between present behavior and broader goals and values; helping people get un-stuck 3) Roll with resistance – avoid arguing for change; new ideas/goals/options are not imposed; used as a signal 4) Support self-efficacy – belief in ability to change is a powerful predictor of change; counselor self-fulfilling prophesy

24. Basic Role of MI therapist • Is to help the client become his / her own advocate for change • Is to elicit rather than instill expertise on how to change • “Join with” a persons own intrinsic motivation to move towards more adaptive behavior (i.e. those that are in line with their values and goals)

25. Early strategies: OARS • Open Ended Questions “are you concerned about your health?” vs “to you, what are important reasons to cut down on your drinking?” • Affirmations “It really sounds like you have been committed to being the best father you can” • Reflective listening • Summary “Let me try to pull together what we have been talking about, let me know if I missed something; it sounds like on one hand you feel and were scared by the ER visit, but on the other hand, you don’t want to give up drinking completely”

26. Affirmations may include • Commenting positively on an attribute • You’re a strong person, a real survivor. • A statement of appreciation • I appreciate your openness and honesty today. • Catch the person doing something right • Thanks for coming in today! • A compliment • I like the way you said that. • An expression of hope, caring, or support • I hope this weekend goes well for you!

27. “If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be.” - Johann Wolfgang von Goethe

28. OARS Exercises • Open Ended Questions Quiz • Thinking Reflectively • Group Batting Practice • Forming Reflections • Miller tape with OARS coding • Structured Practice

29. What the listener hears What the speaker says What the listener thinks the speaker means What the speaker means

30. Communication errors 1) The speaker does not say exactly what is meant 2) The listener does not hear correctly 3) The listener gives a different interpretation to what the words mean

31. One thing that I like about myself is that….. • One thing you should know about me is….. • One thing about myself I’d like to change is…….

32. Listener • Listen carefully with a goal of understanding the dilemma • Give no advice. • Ask these four open questions and listen with interest: Why would you want to make this change? How might you go about it, in order to succeed? What are the three best reasons to do it? On a scale from 0 to 10, how important would you say it is for you to make this change? • Follow-up: And why are you at __ and not zero? • Give a short summary/reflection of the speaker’s motivations for change • Then ask: “So what do you think you’ll do?” and just listen

33. Reflective Listening: Overview • The essence is that it makes a guess as to what the speaker means • Statements rather than questions • “Continue the paragraph” – not just re-iteration • It is an active process (counselor decides what to reflect or ignore, what to emphasize, preferentially reflects change talk)

34. Complex Reflections • Adding content (interpretation or feeling) • Metaphor/Simile (picture language) • Amplification (stronger or weaker) • Double-sided (reflects two sides of person’s view) • Reframing (put situation in a different light) • Verbalization of unspoken emotion

35. Categories of Resistance • Arguing – challenging, discounting, hostility • Interruption – talking over, cutting off • Negating – blaming others, “yes, but”, excuse making, claiming impunity, minimizing, pessimism, reluctance, unwillingness to change • Ignoring – inattention, non-answers, no response to questions, side-tracking

36. Responding to Resistance • Simple Reflection – you feel stuck, etc. • Amplified Reflection –C: My wife thinks its worse than it is. T: It seems to you she has no reason for concern. • Double-sided Reflection - You don’t like the way this makes you feel sometimes, and you’re not sure how you might change things. • Reframing –C: I’ve tried to quit 3 times and failed. T: You’ve given it 3 good tries, and every try gets you closer. Its probably helped you learn some things that will and won’t work for you. • Emphasize personal choice and control – What you decide to do is completely up to you

37. Change Talk - DARN C • Disadvantages of Status Quo • Advantages of Change • Optimism about Change • Intention to Change • Desire • Ability • Reasons (to, not to) • Need • Commitment

38. The Flow of Change Talk MI Desire Ability Reasons Need Commitment Change

39. Eliciting Change Talk • Evocative Questions • Elaboration • Using Extremes • Looking Back • Looking Forward • Exploring Goals

40. Giving Information and Advice • Get permission • Qualify, honoring autonomy • Ask – Provide – Ask • For suggestions, offer several, not one

41. Thanks • Questions • Concerns • Motivationalinterviewing.com • Building Motivational Interviewing Skills a practitioner workbook by David Rosengren • Motivational Interviewing: Preparing people for change by William Miller and Stephen Rollnick (3rd edition) • lsmassey@med.umich.edu