Introduction to Motivational Interviewing

1. Introduction to Motivational Interviewing State of Hawaii, Department of Health, Adult Mental Health Division, Clinical Operations Team and Mental Health Services Research and Evaluation In Partnership with Substance Abuse and Mental Health Services Administration (SAMHSA) Evidence Based Practices Training and Implementation Grant Trainers who want to provide detailed training for motivational counseling should read Miller and Rollnick�s book, Motivational Interviewing. Trainers who want to provide detailed training for motivational counseling should read Miller and Rollnick�s book, Motivational Interviewing.

2. Acknowledgement Material contained within this training was largely based on the work of William R. Miller and Stephen Rollnick in their groundbreaking book titled, Motivational Interviewing: Preparing People for Change Published by Guilford Press, 2002

3. Beliefs About Motivation (True or False?) Handout Quiz: Beliefs About Motivation Complete the true/false quiz and hang onto it We will review the answers later [Handout the quiz: H1 Beliefs About Motivation. Instruct participants to complete the true/false quiz and hang onto it to be reviewed later.][Handout the quiz: H1 Beliefs About Motivation. Instruct participants to complete the true/false quiz and hang onto it to be reviewed later.]

4. �Motivation can be understood not as something that one has, but as something that one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy.� What is Motivation? The first thing we need talk about in an introduction to motivational interviewing is motivation. From a motivational interviewing perspective motivation: �can be understood not as something that one has (it is not a personal attribute), but as something that one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy.� This is a quote from Bill Miller the co-author of Motivational Interviewing, the book pictured here. When we talk about substance abuse we often wonder what is getting in the way of motivation for change, why do people get stuck/continue to engage in unhealthy behaviors?The first thing we need talk about in an introduction to motivational interviewing is motivation. From a motivational interviewing perspective motivation: �can be understood not as something that one has (it is not a personal attribute), but as something that one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy.� This is a quote from Bill Miller the co-author of Motivational Interviewing, the book pictured here. When we talk about substance abuse we often wonder what is getting in the way of motivation for change, why do people get stuck/continue to engage in unhealthy behaviors?

5. Ambivalence �I want to change, but I don�t want to change.� Very few decisions in life are made with 100% certainty Ambivalence is normal and part of the change process for everyone From a motivational interviewing perspective, the answer is ambivalence. Ambivalence simply means that although the person wants change, he or she also wants to stay the same. It is important to note that just because a person is not ready for change, this does not mean they do not want to change; they just also want to stay the same. Very few decisions in life are made with 100% certainty � most people have mixed feelings about change at least at first. Ambivalence is normal and part of the change process for everyone � rather than view ambivalence and resistance as �pathological� we need to understand that they are a normal part of the change process and work with them. Misinterpretation of ambivalence as pathological often leads to the therapist concluding that there is something wrong with the person�s judgment, knowledge base, or reasoning which then leads to the conclusion that a person needs to be educated about and persuaded to take a specific course of action, which increases resistance. A key assumption of motivational interviewing is that most people are not completely ready for change. If they were, it would be appropriate to promote skills development and other action-related tasks. From a motivational interviewing perspective, the answer is ambivalence. Ambivalence simply means that although the person wants change, he or she also wants to stay the same. It is important to note that just because a person is not ready for change, this does not mean they do not want to change; they just also want to stay the same. Very few decisions in life are made with 100% certainty � most people have mixed feelings about change at least at first. Ambivalence is normal and part of the change process for everyone � rather than view ambivalence and resistance as �pathological� we need to understand that they are a normal part of the change process and work with them. Misinterpretation of ambivalence as pathological often leads to the therapist concluding that there is something wrong with the person�s judgment, knowledge base, or reasoning which then leads to the conclusion that a person needs to be educated about and persuaded to take a specific course of action, which increases resistance. A key assumption of motivational interviewing is that most people are not completely ready for change. If they were, it would be appropriate to promote skills development and other action-related tasks.

6. Ambivalence Exercise Find a partner. Each of you write down something you are interested in doing but have mixed feelings about (e.g., buying a new car, quitting smoking, exercising, etc.). Select who will speak first. The speaker presents what it is that you would like to do (but haven�t done yet). The listener then argues strongly in favor of one of the options or sides. Speaker, your job is to listen and note what you are thinking and feeling. Switch roles. To demonstrate how this ambivalence can play out in our interactions with others we are going to do an exercise. [Exercise: Instruct participants to: Find a partner. Each of you write down something you are interested in doing but have mixed feelings about (e.g., buying a new car, quitting smoking, exercising, etc.). Select who will speak first. The speaker presents what it is that you would like to do (but haven�t done yet). The listener then argues strongly in favor of one of the options or sides. Speaker, your job is to listen and note what you are thinking and feeling. Switch roles.] To demonstrate how this ambivalence can play out in our interactions with others we are going to do an exercise. [Exercise: Instruct participants to: Find a partner. Each of you write down something you are interested in doing but have mixed feelings about (e.g., buying a new car, quitting smoking, exercising, etc.). Select who will speak first. The speaker presents what it is that you would like to do (but haven�t done yet). The listener then argues strongly in favor of one of the options or sides. Speaker, your job is to listen and note what you are thinking and feeling. Switch roles.]

7. Ambivalence Exercise What were your thoughts/feelings as the speaker? What happens when ambivalence collides with persuasion, prescription, convincing? Debrief the exercise. What were your thoughts/feelings as the speaker? What happens when ambivalence collides with persuasion, prescription, convincing? So, how does this exercise apply to motivational interviewing: If the counselor resists the impulse to voice the reason/argue for change but instead helps the person explore the reasons to stay the same several things typically happen: 1. Person perceives that the counselor is empathetic, interested in her or him. 2. The person may be surprised to find that the expected outcome of the encounter (being coerced or judged) is not occurring. 3. Counselor has the opportunity to learn about the thoughts, feelings, and behavior patterns that underlie the maintenance of problem behavior or present barriers to resolution. 4. If the counselor helps the client explore the many good reasons that he or she is persisting in the behavior, the client feels a reduced need to protect that side of ambivalence. This approach to ambivalence is part of MI. Debrief the exercise. What were your thoughts/feelings as the speaker? What happens when ambivalence collides with persuasion, prescription, convincing? So, how does this exercise apply to motivational interviewing: If the counselor resists the impulse to voice the reason/argue for change but instead helps the person explore the reasons to stay the same several things typically happen: 1. Person perceives that the counselor is empathetic, interested in her or him. 2. The person may be surprised to find that the expected outcome of the encounter (being coerced or judged) is not occurring. 3. Counselor has the opportunity to learn about the thoughts, feelings, and behavior patterns that underlie the maintenance of problem behavior or present barriers to resolution. 4. If the counselor helps the client explore the many good reasons that he or she is persisting in the behavior, the client feels a reduced need to protect that side of ambivalence. This approach to ambivalence is part of MI.

8. Motivational Interviewing is� �a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence� (Miller & Rollnick, 2002) What is motivational interviewing? �a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence� Each part of this definition is important for a full understanding of MI: �client-centered� The focus is on the person�s present interests and concerns and on the person�s own experiences and values. The focus is NOT on teaching coping skills, reshaping cognitions, or excavating the past. �directive� We intentionally work to help people resolve ambivalence, generally in the direction of change. In MI we selectively respond to the consumer�s talk/speech in a way that moves the person toward change. �method� Motivational interviewing is a style of or approach to communication, it is a way of being with a client, NOT just a set of techniques for doing counseling. �intrinsic motivation� Motivation to change is elicited from the client/from within the person. MI is NOT a strategy to impose change through extrinsic means or contingencies (e.g., legal, financial, threatened loss of job or family). MI relies upon identifying and mobilizing the client's intrinsic values and goals to stimulate behavior change.� �by exploring and resolving ambivalence� The operational assumption in MI is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. MI assumes ambivalence can be resolved by working with your client's intrinsic motivations and values. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere.� What is motivational interviewing? �a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence� Each part of this definition is important for a full understanding of MI: �client-centered� The focus is on the person�s present interests and concerns and on the person�s own experiences and values. The focus is NOT on teaching coping skills, reshaping cognitions, or excavating the past. �directive� We intentionally work to help people resolve ambivalence, generally in the direction of change. In MI we selectively respond to the consumer�s talk/speech in a way that moves the person toward change. �method� Motivational interviewing is a style of or approach to communication, it is a way of being with a client, NOT just a set of techniques for doing counseling. �intrinsic motivation� Motivation to change is elicited from the client/from within the person. MI is NOT a strategy to impose change through extrinsic means or contingencies (e.g., legal, financial, threatened loss of job or family). MI relies upon identifying and mobilizing the client's intrinsic values and goals to stimulate behavior change.� �by exploring and resolving ambivalence� The operational assumption in MI is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. MI assumes ambivalence can be resolved by working with your client's intrinsic motivations and values. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere.�

9. Spirit of Motivational Interviewing Collaboration: In MI there is a partner-like relationship, NOT an authoritarian one-up stance. The counselor honors the client�s experiences and perceptions. This creates an atmosphere conducive versus coercive to change. Confrontation, on the other hand, overrides the person�s impaired perspective and imposes awareness and acceptance of �reality� that the person does not see or admit. Evocation: In MI the resources and motivation for change are presumed to reside within the client. It is the counselor�s job to find intrinsic motivation and evoke it, call it forth. The style is one of eliciting things (e.g., wisdom, motivation) from the person NOT imparting, inserting, or installing them. Education, on the other hand, presumes that the person lacks key knowledge, insight or skills that are necessary for the change to occur. The counselor provides the requisite enlightenment. Autonomy: In MI responsibility for change is left with the person, their autonomy is respected. The counselor affirms the person�s right and capacity for self-direction. The approach is empowering to consumers. Authority, on the other hand, takes the responsibility and power away from the person and the counselor tells the person what they must do.Collaboration: In MI there is a partner-like relationship, NOT an authoritarian one-up stance. The counselor honors the client�s experiences and perceptions. This creates an atmosphere conducive versus coercive to change. Confrontation, on the other hand, overrides the person�s impaired perspective and imposes awareness and acceptance of �reality� that the person does not see or admit. Evocation: In MI the resources and motivation for change are presumed to reside within the client. It is the counselor�s job to find intrinsic motivation and evoke it, call it forth. The style is one of eliciting things (e.g., wisdom, motivation) from the person NOT imparting, inserting, or installing them. Education, on the other hand, presumes that the person lacks key knowledge, insight or skills that are necessary for the change to occur. The counselor provides the requisite enlightenment. Autonomy: In MI responsibility for change is left with the person, their autonomy is respected. The counselor affirms the person�s right and capacity for self-direction. The approach is empowering to consumers. Authority, on the other hand, takes the responsibility and power away from the person and the counselor tells the person what they must do.

10. Spirit of Motivational Interviewing Motivations to change are elicited from within the client, not imposed from outside. It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. Direct persuasion is not an effective method for resolving ambivalence. Readiness to change is not a client trait, but fluctuating product of interpersonal interaction. Motivations to change are elicited from the client, not imposed from outside. This is different from other motivational approaches that have emphasized coercion, persuasion, constructive confrontation, or the use of external contingencies (e.g., threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies on identifying and mobilizing the client�s intrinsic values, including cultural values and goals to stimulate behavior change. It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between 2 courses of action, each of which has perceived benefits and costs. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict, for example, �If I stop smoking I will feel better about myself, but I may also put on weight which will make me feel unhappy and unattractive.� The counselor�s task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that triggers change. Direct persuasion is not an effective method for resolving ambivalence. It is tempting to try to be �helpful� by persuading the client of the urgency of the problem about the benefits of change. It is fairly clear, however, that these tactics generally increase client resistance and diminish the probability of change. Readiness to change is not a client trait, but fluctuating product of interpersonal interaction. The therapist is therefore highly attentive and responsive to the client's motivational signs. Resistance and "denial" are seen not as client traits, but as feedback regarding therapist behavior. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies. Motivations to change are elicited from the client, not imposed from outside. This is different from other motivational approaches that have emphasized coercion, persuasion, constructive confrontation, or the use of external contingencies (e.g., threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies on identifying and mobilizing the client�s intrinsic values, including cultural values and goals to stimulate behavior change. It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between 2 courses of action, each of which has perceived benefits and costs. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict, for example, �If I stop smoking I will feel better about myself, but I may also put on weight which will make me feel unhappy and unattractive.� The counselor�s task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that triggers change. Direct persuasion is not an effective method for resolving ambivalence. It is tempting to try to be �helpful� by persuading the client of the urgency of the problem about the benefits of change. It is fairly clear, however, that these tactics generally increase client resistance and diminish the probability of change. Readiness to change is not a client trait, but fluctuating product of interpersonal interaction. The therapist is therefore highly attentive and responsive to the client's motivational signs. Resistance and "denial" are seen not as client traits, but as feedback regarding therapist behavior. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.

11. Spirit of Motivational Interviewing The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. Positive atmosphere that is conducive but not coercive for change. The counselor is directive in helping the client to examine and resolve ambivalence. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client's autonomy and freedom of choice (and consequences) regarding his or her own behaviour.� This creates a positive atmosphere that is conducive but not coercive for change. The counselor is directive in helping the client to examine and resolve ambivalence. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere; it is directive in this way.� The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client's autonomy and freedom of choice (and consequences) regarding his or her own behaviour.� This creates a positive atmosphere that is conducive but not coercive for change. The counselor is directive in helping the client to examine and resolve ambivalence. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere; it is directive in this way.�

12. NOT Motivational Interviewing The Righting Reflex Human beings have a built in desire to set things right/to solve the problem. When the righting reflex collides with ambivalence, the client defends the status quo. If a person argues on behalf of one position, he or she becomes more committed to it. The righting reflex is a term that refers to the seemingly built-in desire of humans to set things right (more generally it refers to an animal�s ability to �land on its feet,� e.g., a cat). When presented with a problem, someone else�s problem, we have the tendency to offer solutions. When this instinct meets ambivalence, however, we know what happens, the person defends the status quo/argues against change. The major problem with this phenomenon is that the more a person argues on behalf of one position, the more committed to it he/she becomes. This an important principle demonstrated in social psychology. We can literally talk ourselves into (and out of) things. On the flip side, the more we can elicit change statements/talk from people, the more committed to change they become.The righting reflex is a term that refers to the seemingly built-in desire of humans to set things right (more generally it refers to an animal�s ability to �land on its feet,� e.g., a cat). When presented with a problem, someone else�s problem, we have the tendency to offer solutions. When this instinct meets ambivalence, however, we know what happens, the person defends the status quo/argues against change. The major problem with this phenomenon is that the more a person argues on behalf of one position, the more committed to it he/she becomes. This an important principle demonstrated in social psychology. We can literally talk ourselves into (and out of) things. On the flip side, the more we can elicit change statements/talk from people, the more committed to change they become.

13. NOT Motivational Interviewing If following the righting instinct, you will ask: Why don�t you want to change? Why don�t you try� ? Okay then, how about� What makes you think you are not at risk? How can you tell me you don�t have a problem? The righting reflex and responses that follow (advise, teach, persuade) are not necessarily bad responses, they are just misfit to the problem of unresolved ambivalence and resistance. Some things we might hear ourselves say if following the righting reflex include: Why don�t you want to change? Why don�t you try� ? � and when we hear, �yes, but�� Okay then, how about� What makes you think you are not at risk? How can you tell me you don�t have a problem? The righting reflex is not MI.The righting reflex and responses that follow (advise, teach, persuade) are not necessarily bad responses, they are just misfit to the problem of unresolved ambivalence and resistance. Some things we might hear ourselves say if following the righting reflex include: Why don�t you want to change? Why don�t you try� ? � and when we hear, �yes, but�� Okay then, how about� What makes you think you are not at risk? How can you tell me you don�t have a problem? The righting reflex is not MI.

14. NOT Motivational Interviewing Argues that person has a problem and needs to change � emphasis on acceptance of problem/diagnosis. Offers direct advice or prescribes solutions (e.g., coping strategies) without actively encouraging person to make his/her choices. Motivational interviewing is distinct from other therapies/interventions. It is probably most distinct from a confrontation of denial approach, but is also distinct from skills training approaches and from strictly client-centered therapy. The intervention is not MI if it: Argues that person has a problem and needs to change � emphasis on acceptance of problem. This is more confrontation of denial. MI de-emphasizes labels as unnecessary of change to occur. Offers direct advice or prescribes solutions (e.g., coping strategies) without actively encouraging person to make his/her choices � this is also used in more confrontational approaches, but also in skills training approaches. MI elicits solutions from the client. Motivational interviewing is distinct from other therapies/interventions. It is probably most distinct from a confrontation of denial approach, but is also distinct from skills training approaches and from strictly client-centered therapy. The intervention is not MI if it: Argues that person has a problem and needs to change � emphasis on acceptance of problem. This is more confrontation of denial. MI de-emphasizes labels as unnecessary of change to occur. Offers direct advice or prescribes solutions (e.g., coping strategies) without actively encouraging person to make his/her choices � this is also used in more confrontational approaches, but also in skills training approaches. MI elicits solutions from the client.

15. NOT Motivational Interviewing Uses authoritative/expert stance and leaves client in passive role. Does most of talking or if acts as unidirectional information system � focus on imparting information. The intervention is not MI if: Uses authoritative/expert stance and leaves client in passive role � MI is a collaborative and eliciting approach. Does most of talking or if acts as unidirectional information system � this is used in skills training approaches where the focus is on instruction/teaching coping, problem-solving etc. In MI the client does most of the talking, we are not imparting information, knowledge or even motivation, we are eliciting it from the client.The intervention is not MI if: Uses authoritative/expert stance and leaves client in passive role � MI is a collaborative and eliciting approach. Does most of talking or if acts as unidirectional information system � this is used in skills training approaches where the focus is on instruction/teaching coping, problem-solving etc. In MI the client does most of the talking, we are not imparting information, knowledge or even motivation, we are eliciting it from the client.

16. NOT Motivational Interviewing Identifies and modifies maladaptive cognitions. Allows the client to determine the content and direction of the counseling. Behaves in a punitive or coercive manner. The intervention is not MI if: Identifies and modifies maladaptive cognitions � this is generally a cognitive behavioral approach. In MI we explore and reflect perceptions without labeling or correcting them. Allows the client to determine the content and direction of the counseling � in strictly client centered therapy, the therapist follows the client in a non-directive way. In MI, the counselor systematically directs the client toward motivation for change, reflection/reinforcement is used selectively. Behaves in a punitive or coercive manner � MI emphasizes acceptance and non-judgment of the person. External contingencies are not used, rather the focus is on internal or intrinsic motivation. The intervention is not MI if: Identifies and modifies maladaptive cognitions � this is generally a cognitive behavioral approach. In MI we explore and reflect perceptions without labeling or correcting them. Allows the client to determine the content and direction of the counseling � in strictly client centered therapy, the therapist follows the client in a non-directive way. In MI, the counselor systematically directs the client toward motivation for change, reflection/reinforcement is used selectively. Behaves in a punitive or coercive manner � MI emphasizes acceptance and non-judgment of the person. External contingencies are not used, rather the focus is on internal or intrinsic motivation.

17. Assumptions to Avoid Person OUGHT to change. Health is the person�s prime motivating factor. People are either motivated or not. Now is the right time to consider change. I am the expert; therefore, the person must follow my advice. There are some common assumptions, assumptions we all get stuck in sometimes, that get in the way of practicing MI. These include: Person OUGHT to change. Health is the person�s prime motivating factor. People are either motivated or not. Now is the right time to consider change. I am the expert; therefore, the person must follow my advice. How much of this list is our motives? How much do you practice behaviors which fall short of �healthy�? (e.g., junk food, not exercising, lax on doctor visits)There are some common assumptions, assumptions we all get stuck in sometimes, that get in the way of practicing MI. These include: Person OUGHT to change. Health is the person�s prime motivating factor. People are either motivated or not. Now is the right time to consider change. I am the expert; therefore, the person must follow my advice. How much of this list is our motives? How much do you practice behaviors which fall short of �healthy�? (e.g., junk food, not exercising, lax on doctor visits)

18. Beliefs About Motivation (True or False?) Until a person is motivated to change, there is not much we can do. It usually takes a significant crisis (�hitting bottom�) to motivate a person to change. Motivation is influenced by human connections. Resistance to change arises from deep-seated defense mechanisms. Until a person is motivated to change, there is not much we can do � False � motivation is accessible and can be modified or enhanced at many points in the change process. Clients may not have to "hit bottom" or experience terrible, irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image. It usually takes a significant crisis (�hitting bottom�) to motivate a person to change � False � Sometimes this is how it happens, BUT clients do not have to "hit bottom" or experience irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image. There are several types of experiences that may have effects, either increasing or decreasing motivation. Experiences such as: Distress levels: e.g., increased anxiety about the problem. Critical life events: e.g., spiritual inspiration/religious conversion through traumatic accidents or severe illnesses, deaths of loved ones, being fired, becoming pregnant, or getting married. Cognitive evaluation or appraisal, of the impact of substances in one�s life, can lead to change. This weighing of the pros and cons of substance use accounts for 30 to 60 percent of the changes reported in natural recovery studies. Recognizing negative consequences and the harm or hurt one has inflicted on others or oneself helps motivate some people to change. Helping clients see the connection between substance use and adverse consequences to themselves or others is an important motivational strategy. Positive and negative external incentives: Supportive and empathic friends, rewards, or coercion of various types may stimulate motivation for change. Motivation is influenced by human connections � True � Motivation belongs to one person, yet it can be understood to result from the interactions between the individual and other people or environmental factors. A person�s readiness for change fluctuates over time and depends a lot on the situation; it is not a static personal attribute. Motivation can vacillate between conflicting objectives. Motivation also varies in intensity, faltering in response to doubts and increasing as these are resolved. Motivation to change can be strongly influenced by family, friends, emotions, and community support. Resistance to change arises from deep-seated defense mechanisms � False � Denial, rationalization, resistance, and arguing, as assertions of personal freedom, are common defense mechanisms that many people use instinctively to protect themselves emotionally. When clients are labeled pejoratively as alcoholic or manipulative or resistant, given no voice in selecting treatment goals, or directed authoritatively to do or not to do something, the result is a predictable--and quite normal--response of defiance. Additionally, ambivalence is normal. Until a person is motivated to change, there is not much we can do � False � motivation is accessible and can be modified or enhanced at many points in the change process. Clients may not have to "hit bottom" or experience terrible, irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image. It usually takes a significant crisis (�hitting bottom�) to motivate a person to change � False � Sometimes this is how it happens, BUT clients do not have to "hit bottom" or experience irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image. There are several types of experiences that may have effects, either increasing or decreasing motivation. Experiences such as: Distress levels: e.g., increased anxiety about the problem. Critical life events: e.g., spiritual inspiration/religious conversion through traumatic accidents or severe illnesses, deaths of loved ones, being fired, becoming pregnant, or getting married. Cognitive evaluation or appraisal, of the impact of substances in one�s life, can lead to change. This weighing of the pros and cons of substance use accounts for 30 to 60 percent of the changes reported in natural recovery studies. Recognizing negative consequences and the harm or hurt one has inflicted on others or oneself helps motivate some people to change. Helping clients see the connection between substance use and adverse consequences to themselves or others is an important motivational strategy. Positive and negative external incentives: Supportive and empathic friends, rewards, or coercion of various types may stimulate motivation for change. Motivation is influenced by human connections � True � Motivation belongs to one person, yet it can be understood to result from the interactions between the individual and other people or environmental factors. A person�s readiness for change fluctuates over time and depends a lot on the situation; it is not a static personal attribute. Motivation can vacillate between conflicting objectives. Motivation also varies in intensity, faltering in response to doubts and increasing as these are resolved. Motivation to change can be strongly influenced by family, friends, emotions, and community support. Resistance to change arises from deep-seated defense mechanisms � False � Denial, rationalization, resistance, and arguing, as assertions of personal freedom, are common defense mechanisms that many people use instinctively to protect themselves emotionally. When clients are labeled pejoratively as alcoholic or manipulative or resistant, given no voice in selecting treatment goals, or directed authoritatively to do or not to do something, the result is a predictable--and quite normal--response of defiance. Additionally, ambivalence is normal.

19. Beliefs About Motivation (True or False?) People choose whether or not they will change. Readiness for change involves a balancing of �pros� and �cons.� Creating motivation for change usually requires confrontation. Denial is not a client problem, it is a therapist skill problem. People choose whether or not they will change � ultimately True � Although change is the responsibility of the client and many people change their excessive substance-using behavior on their own without therapeutic intervention, you can enhance your client's motivation for beneficial change at each stage of the change process. Readiness for change involves a balancing of �pros� and �cons� � True � Ambivalence needs to be resolved before the change can progress. Creating motivation for change usually requires confrontation � False � confrontation may promote resistance rather than motivation to change or cooperate. Research suggests that the more frequently clinicians use adversarial confrontational techniques with substance-using clients, the less likely clients will change. Denial is not a client problem, it is a therapist skill problem � True � MI views denial and resistance as behaviors evoked by environmental conditions, not as traits characteristic of substance abusers.� A direct comparison of counselor styles suggested that a confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client-centered, supportive, and empathic style that uses reflective listening and gentle persuasion. People choose whether or not they will change � ultimately True � Although change is the responsibility of the client and many people change their excessive substance-using behavior on their own without therapeutic intervention, you can enhance your client's motivation for beneficial change at each stage of the change process. Readiness for change involves a balancing of �pros� and �cons� � True � Ambivalence needs to be resolved before the change can progress. Creating motivation for change usually requires confrontation � False � confrontation may promote resistance rather than motivation to change or cooperate. Research suggests that the more frequently clinicians use adversarial confrontational techniques with substance-using clients, the less likely clients will change. Denial is not a client problem, it is a therapist skill problem � True � MI views denial and resistance as behaviors evoked by environmental conditions, not as traits characteristic of substance abusers.� A direct comparison of counselor styles suggested that a confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client-centered, supportive, and empathic style that uses reflective listening and gentle persuasion.

20. There are four broad guiding principles in motivational interviewing: express empathy, develop discrepancy, roll with resistance, and support self-efficacy. These principles are one-step from the spirit of MI toward more specific practice. We will discuss each of these today. We will also discuss some of the more specific methods of motivational interviewing. Open questions, affirmations, reflective listening, and summaries are the primary skills necessary to practice motivational interviewing. These skills provide the foundation of motivational interviewing. Change occurs when people give voice to their own reasons for change. These skills encourage the client to explore their problems; they get the client talking. These skills can be useful from the first session and throughout the process of motivational interviewing. They are summarized by the acronym OARS. The OARS are derived largely from client-centered counseling, but, as we will see later, in MI they are used for a particular purpose: helping people to explore their ambivalence and clarify reasons to change. Eliciting change talk is another essential method in MI which we will discuss in more detail toward the end of our day. We are going to start out discussing open-ended questions and affirmations, then jump over to expressing empathy. Then finish up the OARS with discussion of reflective listening and summaries. Then we�ll move back to the principles of developing discrepancy and rolling with resistance, address eliciting change talk and finish up with supporting self-efficacy. [Direct participants attention to the handout: H2 MI Strategies and Principles summary] There are four broad guiding principles in motivational interviewing: express empathy, develop discrepancy, roll with resistance, and support self-efficacy. These principles are one-step from the spirit of MI toward more specific practice. We will discuss each of these today. We will also discuss some of the more specific methods of motivational interviewing. Open questions, affirmations, reflective listening, and summaries are the primary skills necessary to practice motivational interviewing. These skills provide the foundation of motivational interviewing. Change occurs when people give voice to their own reasons for change. These skills encourage the client to explore their problems; they get the client talking. These skills can be useful from the first session and throughout the process of motivational interviewing. They are summarized by the acronym OARS. The OARS are derived largely from client-centered counseling, but, as we will see later, in MI they are used for a particular purpose: helping people to explore their ambivalence and clarify reasons to change. Eliciting change talk is another essential method in MI which we will discuss in more detail toward the end of our day. We are going to start out discussing open-ended questions and affirmations, then jump over to expressing empathy. Then finish up the OARS with discussion of reflective listening and summaries. Then we�ll move back to the principles of developing discrepancy and rolling with resistance, address eliciting change talk and finish up with supporting self-efficacy. [Direct participants attention to the handout: H2 MI Strategies and Principles summary]

21. Open-Ended Questions What are open-ended questions? Gather broad descriptive information Require more of a response than a simple yes/no or fill in the blank Often start with words like: �How�� �What�� �Tell me about�� Usually go from general to specific Does anyone know, what are open-ended questions? Open questions gather broad descriptive information. They require more of a response than a simple yes/no or fill in the blank. Open questions often start with words like, �How�� �What�� �Tell me about�� �Describe�� Finally, open questions usually start out general and then get more specific. Open questions encourage the client to do most of the talking, help us avoid premature judgments, and keep communication moving forward. Closed questions on the other hand gather very narrow specific information, tend to solicit yes or no answers or one or two word answers, and convey that agenda is about some other ends than the client (our own need to gather info, curiosity, complete a form). Example of an open question: What reason�s might you have to cut down on your drinking? By asking open-ended questions, the stage is set to utilize aspects of reflective listening, affirmations, and summarizing. Does anyone know, what are open-ended questions? Open questions gather broad descriptive information. They require more of a response than a simple yes/no or fill in the blank. Open questions often start with words like, �How�� �What�� �Tell me about�� �Describe�� Finally, open questions usually start out general and then get more specific. Open questions encourage the client to do most of the talking, help us avoid premature judgments, and keep communication moving forward. Closed questions on the other hand gather very narrow specific information, tend to solicit yes or no answers or one or two word answers, and convey that agenda is about some other ends than the client (our own need to gather info, curiosity, complete a form). Example of an open question: What reason�s might you have to cut down on your drinking? By asking open-ended questions, the stage is set to utilize aspects of reflective listening, affirmations, and summarizing.

22. Open-Ended Questions Exercise: Turning closed-ended questions into open-ended ones [Read each closed question to participants and ask them to turn it into an open question. Then offer the example open question listed. Closed Question Open Question So you are here because you are concerned 1. Tell me, what is it that brings about your use of alcohol, correct? you here today? How many children do you have? 2. Tell me about your family. Do you agree that it would be a good idea for 3. What do you think about the possibility you to go through detoxification? of going through detoxification? First, I'd like you to tell me some about your 4. Tell me about your marijuana use marijuana use. On a typical day, how much during a typical week. do you smoke? Do you like to smoke? 5. What are some of the things you like about smoking? How has your drug use been this week, 6. What has your drug use been like compared to last: more, less, or about the same? during the past week? Do you think you use amphetamines too often? 7. In what ways are you concerned about your use of amphetamines? How long ago did you have your last drink? 8. Tell me about the last time you had a drink. Are you sure that your probation officer told you 9. Now what exactly are the conditions your that it's only cocaine he is concerned about in probation officer wants you to follow? your urine screens? When do you plan to quit drinking? 10. So what do you think you want to do about your drinking? [Read each closed question to participants and ask them to turn it into an open question. Then offer the example open question listed. Closed Question Open Question So you are here because you are concerned 1. Tell me, what is it that brings about your use of alcohol, correct? you here today? How many children do you have? 2. Tell me about your family. Do you agree that it would be a good idea for 3. What do you think about the possibility you to go through detoxification? of going through detoxification? First, I'd like you to tell me some about your 4. Tell me about your marijuana use marijuana use. On a typical day, how much during a typical week. do you smoke? Do you like to smoke? 5. What are some of the things you like about smoking? How has your drug use been this week, 6. What has your drug use been like compared to last: more, less, or about the same? during the past week? Do you think you use amphetamines too often? 7. In what ways are you concerned about your use of amphetamines? How long ago did you have your last drink? 8. Tell me about the last time you had a drink. Are you sure that your probation officer told you 9. Now what exactly are the conditions your that it's only cocaine he is concerned about in probation officer wants you to follow? your urine screens? When do you plan to quit drinking? 10. So what do you think you want to do about your drinking?

23. Open-Ended Questions Why open-ended questions? Avoid the question-answer trap Puts client in a passive role No opportunity for client to explore ambivalence The main reason to use open questions it to avoid the question answer trap. The question-answer trap is a pattern where the counselor asks questions and the client gives short responses, often yes/no responses. This pattern teaches the client to give short answers and subtly implies that the counselor is the active expert and the client is passive and if the counselor just asks enough or the right questions then he/she will have the solution to the problem. This is not motivational interviewing. In motivational interviewing the client does half or more of the talking. We need the client to talk so that we have material to work with. Closed questions afford the person little opportunity to explore ambivalence and offer change talk. Asking a series of closed questions or even a series of open questions is not as effective as using a mix of open questions and most importantly reflective listening. As a general guideline, the clinician should avoid asking three questions in a row.The main reason to use open questions it to avoid the question answer trap. The question-answer trap is a pattern where the counselor asks questions and the client gives short responses, often yes/no responses. This pattern teaches the client to give short answers and subtly implies that the counselor is the active expert and the client is passive and if the counselor just asks enough or the right questions then he/she will have the solution to the problem. This is not motivational interviewing. In motivational interviewing the client does half or more of the talking. We need the client to talk so that we have material to work with. Closed questions afford the person little opportunity to explore ambivalence and offer change talk. Asking a series of closed questions or even a series of open questions is not as effective as using a mix of open questions and most importantly reflective listening. As a general guideline, the clinician should avoid asking three questions in a row.

24. Affirmations What is an affirmation? Compliments, statements of appreciation and understanding Praise positive behaviors Support the person as they describe difficult situations What is an affirmation? An affirmation is a compliments or statement of appreciation and understanding. Affirmations are used to praise positive behaviors and support the person as they describe difficult situations. What is an affirmation? An affirmation is a compliments or statement of appreciation and understanding. Affirmations are used to praise positive behaviors and support the person as they describe difficult situations.

25. Affirmations Examples: �I appreciate how hard it must have been for you to decide to come here. You took a big step.� �I�ve enjoyed talking with you today, and getting to know you a bit.� �You seem to be a very giving person. You are always helping your friends.� Some examples are: �I appreciate how hard it must have been for you to decide to come here. You took a big step.� �I�ve enjoyed talking with you today, and getting to know you a bit.� �You�re clearly a resourceful person to cope with such difficulties for so long.� �You seem to be a very giving person. You are always helping your friends.� Some examples are: �I appreciate how hard it must have been for you to decide to come here. You took a big step.� �I�ve enjoyed talking with you today, and getting to know you a bit.� �You�re clearly a resourceful person to cope with such difficulties for so long.� �You seem to be a very giving person. You are always helping your friends.�

26. Affirmations Why affirm? Supports and promotes self-efficacy, prevents discouragement Builds rapport Reinforces open exploration (client talk) Caveat: Must be done sincerely We use affirmations in MI support and promote self-efficacy or self-confidence, which is a necessary ingredient for change. Affirmations can help us acknowledge the difficulties that the client has experienced. We can emphasize past experiences that demonstrate strength and success to prevent discouragement. Affirmations build rapport which also facilitates change; with affirmations we validate the client�s experience and feelings. Finally, Affirmations reinforce open exploration of client problems (client talk). Caveats: It is important to be sincere and watch the client�s response, cultural norms vary in comfort with affirmations.We use affirmations in MI support and promote self-efficacy or self-confidence, which is a necessary ingredient for change. Affirmations can help us acknowledge the difficulties that the client has experienced. We can emphasize past experiences that demonstrate strength and success to prevent discouragement. Affirmations build rapport which also facilitates change; with affirmations we validate the client�s experience and feelings. Finally, Affirmations reinforce open exploration of client problems (client talk). Caveats: It is important to be sincere and watch the client�s response, cultural norms vary in comfort with affirmations.

27. Express Empathy What is empathy? Reflects an accurate understanding Assume the person�s perspectives are understandable, comprehensible, and valid Seek to understand the person�s feelings and perspectives without judging Before we move on to the R in the OARS, we are going to talk a little about empathy. Expressing empathy is one of the principles of motivational interviewing. What is empathy? Understanding or acceptance without judging or criticizing. Empathy reflects an accurate understanding. To express empathy we must assume the person�s perspectives are understandable, comprehensible, and valid. We must also seek to understand the person�s feelings and perspectives without judging.Before we move on to the R in the OARS, we are going to talk a little about empathy. Expressing empathy is one of the principles of motivational interviewing. What is empathy? Understanding or acceptance without judging or criticizing. Empathy reflects an accurate understanding. To express empathy we must assume the person�s perspectives are understandable, comprehensible, and valid. We must also seek to understand the person�s feelings and perspectives without judging.

28. Express Empathy Empathy is distinct from� Agreement Warmth Approval or praise Reassurance, sympathy, or consolation Advocacy Empathy is distinct from a number of things: Agreement � we may understand fully without necessarily agreeing with the client�s perspective Warmth � we may work very hard to understand the client�s perspective but not be especially warm or friendly while doing so Approval or praise � approval is like agreement or endorsement. Understanding and praise are different. It�s okay to understand why someone likes to use, that doesn�t mean you approve! Reassurance, sympathy, or consolation Advocacy � we may be invested in helping the client gain services without a particular effort to understand their perspective Empathy is distinct from a number of things: Agreement � we may understand fully without necessarily agreeing with the client�s perspective Warmth � we may work very hard to understand the client�s perspective but not be especially warm or friendly while doing so Approval or praise � approval is like agreement or endorsement. Understanding and praise are different. It�s okay to understand why someone likes to use, that doesn�t mean you approve! Reassurance, sympathy, or consolation Advocacy � we may be invested in helping the client gain services without a particular effort to understand their perspective

29. Express Empathy Why is empathy important in MI and IDDT? Communicates acceptance which facilitates change Encourages a collaborative alliance which also promotes change Leads to an understanding of each person�s unique perspective, feelings, and values which make up the material we need to facilitate change Expression of empathy is a fundamental and defining characteristic of motivational interviewing. Empathy communicates acceptance which, paradoxically, facilitates change. When accepted as they are, people seem to be freed to change. Empathy encourages a collaborative alliance which also promotes change. When counselors have accurate understanding, clients feel understood, are more likely to explore ambivalence, and are more likely to change. When people feel �accurately understood� the need to explain or defend decreases and they are able to put their energy into personal exploration which facilitates the change process. Expression of empathy also leads to an understanding of each person�s unique perspective, feelings, and values which make up the material we need to facilitate change.Expression of empathy is a fundamental and defining characteristic of motivational interviewing. Empathy communicates acceptance which, paradoxically, facilitates change. When accepted as they are, people seem to be freed to change. Empathy encourages a collaborative alliance which also promotes change. When counselors have accurate understanding, clients feel understood, are more likely to explore ambivalence, and are more likely to change. When people feel �accurately understood� the need to explain or defend decreases and they are able to put their energy into personal exploration which facilitates the change process. Expression of empathy also leads to an understanding of each person�s unique perspective, feelings, and values which make up the material we need to facilitate change.

30. Express Empathy Tips� Good eye contact Responsive facial expression Body orientation Verbal and non-verbal �encouragers� Reflective listening/asking clarifying questions Avoid expressing doubt/passing judgment Some tips for expressing empathy include: Good eye contact Responsive facial expression Body orientation Verbal and non-verbal �encouragers� Reflective listening/asking clarifying questions Avoid expressing doubt/passing judgmentSome tips for expressing empathy include: Good eye contact Responsive facial expression Body orientation Verbal and non-verbal �encouragers� Reflective listening/asking clarifying questions Avoid expressing doubt/passing judgment

31. Empathy is NOT� The sharing of common past experiences Giving advice, making suggestions, or providing solutions Demonstrated through a flurry of questions Demonstrated through self-disclosure There are many things that are often mistaken for empathy. Empathy is not: The sharing of common past experiences Giving advice, making suggestions, or providing solutions Demonstrated through a flurry of questions Demonstrated through self-disclosureThere are many things that are often mistaken for empathy. Empathy is not: The sharing of common past experiences Giving advice, making suggestions, or providing solutions Demonstrated through a flurry of questions Demonstrated through self-disclosure

32. The Bottom Line on Empathy Ambivalence is normal Our acceptance facilitates change Skillful reflective listening is fundamental to expressing empathy - Miller and Rollnick, 2002 In summary, ambivalence is normal, our acceptance facilitates change, and skillful reflective listening is fundamental to expressing empathy.In summary, ambivalence is normal, our acceptance facilitates change, and skillful reflective listening is fundamental to expressing empathy.

33. Reflective Listening [Reflections are one of the hardest skills to learn, so depending on the group, slow down here.] Reflective Listening - This is a foundational skill in MI. It is a challenging skill where you demonstrate that you have accurately heard and understood a client�s communication by restating it�s meaning. It is essential in expressing empathy. [Reflections are one of the hardest skills to learn, so depending on the group, slow down here.] Reflective Listening - This is a foundational skill in MI. It is a challenging skill where you demonstrate that you have accurately heard and understood a client�s communication by restating it�s meaning. It is essential in expressing empathy.

34. Thomas Gordon�s Model of Listening [Ask the group the four places that things can go wrong just in the mechanics of communication.] These four places are: the speaker chooses words that do not represent what they actually want to say; they say the wrong words; the listener hears the wrong word; the listener interprets it incorrectly. In other words, communication can go wrong in expression, transmission and interpretation. Ask the group: �How can we avoid this?� The response you are looking for is �ask the speaker if you have it correctly� or �reflect it.� [Ask the group the four places that things can go wrong just in the mechanics of communication.] These four places are: the speaker chooses words that do not represent what they actually want to say; they say the wrong words; the listener hears the wrong word; the listener interprets it incorrectly. In other words, communication can go wrong in expression, transmission and interpretation. Ask the group: �How can we avoid this?� The response you are looking for is �ask the speaker if you have it correctly� or �reflect it.�

35. Reflective Listening �Reflective listening is a way of checking rather than assuming that you know what is meant.� (Miller and Rollnick, 2002) Reflective listening is a way of checking rather than assuming that you know what is meant.Reflective listening is a way of checking rather than assuming that you know what is meant.

36. Reflective Listening Why listen reflectively? Demonstrates that you have accurately heard and understood the client Strengthens the empathic relationship Encourages further exploration of problems and feelings Avoid the premature-focus trap Can be used strategically to facilitate change Offering reflections is a special way of checking for meaning that accomplishes multiple goals: Demonstrates that you have accurately heard and understood the client (expresses empathy) Strengthens the therapeutic relationship which promotes change Encourages further exploration of problems and feelings (client talk), helps you avoid the premature focus trap. Often the first problem that the client talks about is not the most important problem for them. Also, we do not want to focus prematurely on our own conception of the problem. Can be used strategically to facilitate change � we can be selective in what we reflect thereby reinforcing specific themes or types of talk. Offering reflections is a special way of checking for meaning that accomplishes multiple goals: Demonstrates that you have accurately heard and understood the client (expresses empathy) Strengthens the therapeutic relationship which promotes change Encourages further exploration of problems and feelings (client talk), helps you avoid the premature focus trap. Often the first problem that the client talks about is not the most important problem for them. Also, we do not want to focus prematurely on our own conception of the problem. Can be used strategically to facilitate change � we can be selective in what we reflect thereby reinforcing specific themes or types of talk.

37. Reflective Listening In motivational interviewing, About half of all practitioner responses are reflections 2-3 reflections are offered per question asked In ordinary counseling, Reflections constitute a small proportion of all responses Questions outnumber reflections 10 to 1 In motivational interviewing, About half of all practitioner responses are reflections 2-3 reflections are offered per question asked In ordinary counseling, Reflections constitute a small proportion of all responses Questions outnumber reflections 10 to 1 Using reflective listening may feel awkward at first, asking questions is a less demanding skill, which may explain why we tend toward it. Reflective listening is a demanding skill that requires a way of thinking.In motivational interviewing, About half of all practitioner responses are reflections 2-3 reflections are offered per question asked In ordinary counseling, Reflections constitute a small proportion of all responses Questions outnumber reflections 10 to 1 Using reflective listening may feel awkward at first, asking questions is a less demanding skill, which may explain why we tend toward it. Reflective listening is a demanding skill that requires a way of thinking.

38. Learning Reflective Listening Reflective listening begins with thinking reflectively Thinking reflectively requires a continual awareness that what you think people mean may not be what they really mean There is a way of thinking that accompanies good reflective listening. It includes interest in what the person has to say and respect for the person�s inner wisdom. The key element at this point, however, is a hypothesis testing approach to listening - the knowledge that what you think a person means may not be what he or she really means. This is the hypothesis generation and testing aspect of reflections.There is a way of thinking that accompanies good reflective listening. It includes interest in what the person has to say and respect for the person�s inner wisdom. The key element at this point, however, is a hypothesis testing approach to listening - the knowledge that what you think a person means may not be what he or she really means. This is the hypothesis generation and testing aspect of reflections.

39. Thinking Reflectively Exercise: Split up into triads (1-speaker) (2-listeners). Each person will take a turn being a speaker. Each person will share a personal statement �One thing I like about myself is �� (e.g., I am organized. I am creative.) The listeners respond with �Do you mean that�..� (generate at least 5 for each). The speaker responds with only yes/no. We are going to start working on this skill by starting to think reflectively� Now I want to emphasize this is not reflective listening. [Exercise: instruct participants to: Split up into triads (1-speaker) (2-listeners) Each person will take a turn being a speaker Each person will share a personal statement �One thing I like about myself is �� (Example: I am organized. I am creative.) The listeners respond with �Do you mean that�..� (generate at least 5 for each) The speaker responds with only yes/no] The goal of asking questions is to determine the background of the statement. [This helps the group become comfortable with the notion that reflections can be hypotheses.] Debriefing� What was that experience like for you? What did you learn? Where there any surprises? What problems were encountered? [Often, participants find that many of their first guesses were not accurate. Also, speakers sometimes feel frustrated because they want to talk more, which is a good response to generate from those quiet ones that we interview. Listeners often find it difficult to generate more hypotheses without more information.] Often when we are talking about psychological constructs we all have very different meanings attached to them.We are going to start working on this skill by starting to think reflectively� Now I want to emphasize this is not reflective listening. [Exercise: instruct participants to: Split up into triads (1-speaker) (2-listeners) Each person will take a turn being a speaker Each person will share a personal statement �One thing I like about myself is �� (Example: I am organized. I am creative.) The listeners respond with �Do you mean that�..� (generate at least 5 for each) The speaker responds with only yes/no] The goal of asking questions is to determine the background of the statement. [This helps the group become comfortable with the notion that reflections can be hypotheses.] Debriefing� What was that experience like for you? What did you learn? Where there any surprises? What problems were encountered? [Often, participants find that many of their first guesses were not accurate. Also, speakers sometimes feel frustrated because they want to talk more, which is a good response to generate from those quiet ones that we interview. Listeners often find it difficult to generate more hypotheses without more information.] Often when we are talking about psychological constructs we all have very different meanings attached to them.

40. Reflective Listening A reflection is two things: A hypothesis as to what the speaker means A statement Statements are less likely than questions to evoke resistance The question format is very close to reflective listening. Reflections make a guess about the speakers meaning BUT reflections take the form of statements. Reflections are statements because statements are less likely to evoke resistance. A question requires a response. The person steps out of his/her experience and questions his/herself about whether or not they really do or should feel that way. A statement does not have this effect. The question format is very close to reflective listening. Reflections make a guess about the speakers meaning BUT reflections take the form of statements. Reflections are statements because statements are less likely to evoke resistance. A question requires a response. The person steps out of his/her experience and questions his/herself about whether or not they really do or should feel that way. A statement does not have this effect.

41. Reflections Are Statements �DO YOU MEAN��?� Use a statement to reflect your understanding Inflection turns down at the end �You...� �So you...� �Its...� �Its like...� �You feel...� Good reflective listening statements are very similar to, yet different from the �Do you mean�� questions. They do offer a hypothesis about what the speaker means, but this is done in the form of a statement rather than a question. Its inflection turns down at the end. �You�re angry about what I said? (up) �You�re angry about what I said (down) Some people find it helpful to have some words to get them started in making reflective listening statement. The common element is the word �you�. The stereotypic counselor statement (which we recommend never be used) is: �what I hear you saying is that you�� Some simpler forms: �You... So you... Its... Its like... You feel... Be careful with stems � no stem words are needed to form a reflection. [Demonstrate the skill by having someone from the audience volunteer a self statement such as: One thing you should know about me that�.� And respond only with reflective listening statement, being careful to inflect them downward at the end.]Good reflective listening statements are very similar to, yet different from the �Do you mean�� questions. They do offer a hypothesis about what the speaker means, but this is done in the form of a statement rather than a question. Its inflection turns down at the end. �You�re angry about what I said? (up) �You�re angry about what I said (down) Some people find it helpful to have some words to get them started in making reflective listening statement. The common element is the word �you�. The stereotypic counselor statement (which we recommend never be used) is: �what I hear you saying is that you�� Some simpler forms: �You... So you... Its... Its like... You feel... Be careful with stems � no stem words are needed to form a reflection. [Demonstrate the skill by having someone from the audience volunteer a self statement such as: One thing you should know about me that�.� And respond only with reflective listening statement, being careful to inflect them downward at the end.]

42. Reflections Are Statements Question: You�re thinking about stopping? (inflection goes up) Versus a statement: You�re thinking about stopping. (inflection goes down) Another example/demonstration. Another example/demonstration.

43. Reflective Listening Exercise: Split up into triads (1-speaker) (2-listeners). Each person will take a turn being a speaker. Each person will share a personal statement �One thing I like about myself is �� OR �One thing about myself I�d like to change is�� The listeners respond with reflections only. The speaker can respond with yes/no and elaboration. [Exercise: instruct participants to: Use the same triads -- split up into triads (1-speaker) (2-listeners) Each person will take a turn being a speaker Each person will share a personal statement �One thing I like about myself is �� OR �One thing about myself I�d like to change is�� The listeners respond with reflections only The speaker can respond with yes/no and elaboration] [Stress that the difference between questions and statements is in their intonation. Statements can begin with �Stems� like �So..�, �So what you�re saying�� etc. The Speaker can respond with whatever information they want, not restricted to Yes or No. Move around the room listening for those groups stuck on questions and help them out. � Debrief this exercise. Responses are usually, �I was surprised by how much I really had to listen; it helped me clarify some things; I felt listened to; etc.�] [Exercise: instruct participants to: Use the same triads -- split up into triads (1-speaker) (2-listeners) Each person will take a turn being a speaker Each person will share a personal statement �One thing I like about myself is �� OR �One thing about myself I�d like to change is�� The listeners respond with reflections only The speaker can respond with yes/no and elaboration] [Stress that the difference between questions and statements is in their intonation. Statements can begin with �Stems� like �So..�, �So what you�re saying�� etc. The Speaker can respond with whatever information they want, not restricted to Yes or No. Move around the room listening for those groups stuck on questions and help them out. � Debrief this exercise. Responses are usually, �I was surprised by how much I really had to listen; it helped me clarify some things; I felt listened to; etc.�]

44. Levels of Reflection Simple Reflection � stays close Repeating Rephrasing (substitutes synonyms) Complex Reflection � makes a guess Paraphrasing � major restatement, infers meaning, �continuing the paragraph� Reflection of feeling - deepest Reflections fall on a continuum of depth or complexity. Sometimes a word or two can keep people moving. But sometimes reflections that simply repeat what the person has said can yield slower progress, more complex reflections may be needed to add momentum to the exploration process. Simple reflections stay close to what the person has said: Repeating is the simplest reflection and simply repeats an element of what the speaker has said. In rephrasing the listener stays close to what the speaker said, but substitutes synonyms or slightly rephrases what was offered. In complex reflections we are making more of a guess about meaning or feeling: Paraphrasing is more of a major restatement, in which the listener infers the unspoken meaning in what was said and reflects back in new words. This adds to and extends what was actually said. In artful form, this is like continuing the paragraph that the speaker has been developing saying the next sentence rather than repeating the last one. Examples: Client �Who are you to be giving me advice? What do you know about drugs? You�ve probably never even smoked a joint! Interviewer: �It�s hard to imagine how I could possibly understand.� Client: �I just don�t want to take pills. I ought to be able to handle this on my own.� Interviewer: �You don�t want to rely on a drug. It seems to you like a crutch.� Reflection of feeling. Often regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimension through feeling statement, metaphor, etc. In general simple reflections are used a first, when meaning is less clear, and deeper reflections are ventured as understanding increases. Jumping too far beyond what was said, however, can turn into interpretation (a roadblock). [Discuss overstating vs. understating a client�s statement.] Choosing a word that overstates the client�s feeling tends to cause the person to stop talking or back away from the experience. Using a word that understates the intensity of feeling tends to cause the person to continue experiencing and discussing it.Reflections fall on a continuum of depth or complexity. Sometimes a word or two can keep people moving. But sometimes reflections that simply repeat what the person has said can yield slower progress, more complex reflections may be needed to add momentum to the exploration process. Simple reflections stay close to what the person has said: Repeating is the simplest reflection and simply repeats an element of what the speaker has said. In rephrasing the listener stays close to what the speaker said, but substitutes synonyms or slightly rephrases what was offered. In complex reflections we are making more of a guess about meaning or feeling: Paraphrasing is more of a major restatement, in which the listener infers the unspoken meaning in what was said and reflects back in new words. This adds to and extends what was actually said. In artful form, this is like continuing the paragraph that the speaker has been developing saying the next sentence rather than repeating the last one. Examples: Client �Who are you to be giving me advice? What do you know about drugs? You�ve probably never even smoked a joint! Interviewer: �It�s hard to imagine how I could possibly understand.� Client: �I just don�t want to take pills. I ought to be able to handle this on my own.� Interviewer: �You don�t want to rely on a drug. It seems to you like a crutch.� Reflection of feeling. Often regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimension through feeling statement, metaphor, etc. In general simple reflections are used a first, when meaning is less clear, and deeper reflections are ventured as understanding increases. Jumping too far beyond what was said, however, can turn into interpretation (a roadblock). [Discuss overstating vs. understating a client�s statement.] Choosing a word that overstates the client�s feeling tends to cause the person to stop talking or back away from the experience. Using a word that understates the intensity of feeling tends to cause the person to continue experiencing and discussing it.

45. Not Reflective Listening Thomas Gordon�s Roadblocks: Ordering, directing, commanding Warning, cautioning, threatening Giving advice, making suggestions, providing solutions Persuading with logic, arguing, lecturing Telling what to do preaching Disagreeing, judging, criticizing, blaming Several responses are not reflective listening and tend to close communication. These include: Ordering, directing, commanding Warning, cautioning, threatening Giving advice, making suggestions, providing solutions Persuading with logic, arguing, lecturing Telling what to do preaching Disagreeing, judging, criticizing, blaming Several responses are not reflective listening and tend to close communication. These include: Ordering, directing, commanding Warning, cautioning, threatening Giving advice, making suggestions, providing solutions Persuading with logic, arguing, lecturing Telling what to do preaching Disagreeing, judging, criticizing, blaming

46. Not Reflective Listening Agreeing, approving, praising Shaming, ridiculing, blaming Interpreting or analyzing, [also labeling] Reassuring, sympathizing, consoling Questioning, probing Withdrawing, distracting, humoring, changing the subject Agreeing, approving, praising Shaming, ridiculing, blaming Interpreting or analyzing, [also labeling] Reassuring, sympathizing, consoling Questioning, probing Withdrawing, distracting, humoring, changing the subject Agreeing, approving, praising Shaming, ridiculing, blaming Interpreting or analyzing, [also labeling] Reassuring, sympathizing, consoling Questioning, probing Withdrawing, distracting, humoring, changing the subject

47. Summaries Pull together what has transpired thus far in a session Strategic use: practitioner selects what information should be included & what can be minimized or left out Additional information can also be incorporated into summary � e.g., past conversations, assessment results, collateral reports etc. It is important to periodically summarize what has occurred in the counseling session. Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on. Summaries can be used to begin and end sessions and provide transitions. Summaries can also be used strategically: the practitioner selects what information should be included and what can be minimized or left out, thereby reinforcing talk that is in the direction of change. Additional information can also be incorporated into summary � e.g., past conversations, assessment results, collateral reports etc. � such that the client�s feelings of ambivalence are amplified. Examples of how summaries may begin: �So, let me see if I got this right�� �So, you�ve been saying� is that correct� �Make sure I�m understanding exactly what you�ve been trying to tell me��It is important to periodically summarize what has occurred in the counseling session. Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on. Summaries can be used to begin and end sessions and provide transitions. Summaries can also be used strategically: the practitioner selects what information should be included and what can be minimized or left out, thereby reinforcing talk that is in the direction of change. Additional information can also be incorporated into summary � e.g., past conversations, assessment results, collateral reports etc. � such that the client�s feelings of ambivalence are amplified. Examples of how summaries may begin: �So, let me see if I got this right�� �So, you�ve been saying� is that correct� �Make sure I�m understanding exactly what you�ve been trying to tell me��

48. Summarizing Exercise (part 1): Choose a partner. Speaker: for 90 seconds talk about a habit, behavior, situation you are thinking about changing. Listener: listen only and then give a summary of what you�ve been told. Change roles and repeat. [Exercise (part 1): instruct participants to: Choose a partner. Speaker: for 90 seconds talk about a habit, behavior, situation you are thinking about changing. Listener: listen only and then give a summary of what you�ve been told. Change roles and repeat.] Listener do not try to solve the speaker�s problem or give advice. Your task is to listen and remember as well as you can, and give an exact summary as possible. When summarizing try to avoid changing or adding things to what you�ve been told.[Exercise (part 1): instruct participants to: Choose a partner. Speaker: for 90 seconds talk about a habit, behavior, situation you are thinking about changing. Listener: listen only and then give a summary of what you�ve been told. Change roles and repeat.] Listener do not try to solve the speaker�s problem or give advice. Your task is to listen and remember as well as you can, and give an exact summary as possible. When summarizing try to avoid changing or adding things to what you�ve been told.

49. Summarizing Exercise (part 2): Change partners. Speaker: once again tell your story for 90 seconds w/out interruption. Listener: listen only and then give a summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story. Change roles and repeat. [Exercise (part 2): instruct participants to: Change partners. Speaker: once again tell your story for 90 seconds w/out interruption. Listener: listen only and then give a summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story. Change roles and repeat.] The listener�s task is to be an interested listener without saying anything or asking questions, and then give a summary of what you�ve been told. Do not try to solve the speaker�s problem or give advice. However, your summary may now include what you think is the underlying meaning, feeling or dilemma in the story you�ve heard.[Exercise (part 2): instruct participants to: Change partners. Speaker: once again tell your story for 90 seconds w/out interruption. Listener: listen only and then give a summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story. Change roles and repeat.] The listener�s task is to be an interested listener without saying anything or asking questions, and then give a summary of what you�ve been told. Do not try to solve the speaker�s problem or give advice. However, your summary may now include what you think is the underlying meaning, feeling or dilemma in the story you�ve heard.

50. MI is Directive The OARS are basic client centered counseling skills, as is the expression of empathy. But, remember, motivational interviewing is directive. Being directive helps you move the conversation toward talking about change. This table depicts some ways in which MI adds to the basic client centered counseling skills. Strictly Rogerian, nondirective, client centered counseling: Allows client to determine content and direction of counseling Uses empathic reflection noncontingently Explores client�s conflicts and emotions without specific goals for change Avoids interjecting counselor�s advice/feedback Motivational interviewing: Systematically directs client toward motivation for change Uses reflection selectively to reinforce motivation for change: You choose what you reflect from a discussion. Seeks to evoke and amplify discrepancy to enhance motivation for change Offers feedback where appropriateThe OARS are basic client centered counseling skills, as is the expression of empathy. But, remember, motivational interviewing is directive. Being directive helps you move the conversation toward talking about change. This table depicts some ways in which MI adds to the basic client centered counseling skills. Strictly Rogerian, nondirective, client centered counseling: Allows client to determine content and direction of counseling Uses empathic reflection noncontingently Explores client�s conflicts and emotions without specific goals for change Avoids interjecting counselor�s advice/feedback Motivational interviewing: Systematically directs client toward motivation for change Uses reflection selectively to reinforce motivation for change: You choose what you reflect from a discussion. Seeks to evoke and amplify discrepancy to enhance motivation for change Offers feedback where appropriate

51. Develop Discrepancy The logic� Motivation arises from a discrepancy between actual and desired states We can help with motivation by creating and amplifying discrepancy In short� We want to help clients see the contrast between what they want and what they do The general goal of MI is not to have people accept themselves as they are and stay that way. A person who presents with a health-threatening drug habit can be helped to change that behavior. The counselor seeks to create and amplify, from the client�s perspective, a discrepancy between present behavior and his or her broader goals and values until it overrides the inertia of the status quo. The logic behind this principle is that motivation arises from a discrepancy between actual and desired states. So, with the perception of discrepancy comes ambivalence. Ambivalence is a sign of motivation. (Do we see much ambivalence in precontemplation?). The first step is to become ambivalent. We can help by creating and amplifying discrepancy, then helping the resolve of ambivalence in the direction of change. When skillfully done, MI changes the person�s perceptions of discrepancy without creating any sense of being pressured or coerced. A sense of coercion arises when a person is pressured to change behavior because it is discrepant with someone else�s goals or values. The general goal of MI is not to have people accept themselves as they are and stay that way. A person who presents with a health-threatening drug habit can be helped to change that behavior. The counselor seeks to create and amplify, from the client�s perspective, a discrepancy between present behavior and his or her broader goals and values until it overrides the inertia of the status quo. The logic behind this principle is that motivation arises from a discrepancy between actual and desired states. So, with the perception of discrepancy comes ambivalence. Ambivalence is a sign of motivation. (Do we see much ambivalence in precontemplation?). The first step is to become ambivalent. We can help by creating and amplifying discrepancy, then helping the resolve of ambivalence in the direction of change. When skillfully done, MI changes the person�s perceptions of discrepancy without creating any sense of being pressured or coerced. A sense of coercion arises when a person is pressured to change behavior because it is discrepant with someone else�s goals or values.

52. Develop Discrepancy What happens to ambivalence in Motivational Interviewing and as the person moves through the change process? You can see from this graph that there is an initial increase in ambivalence as it is brought to the forefront in counseling. Initially, the person may not have been thinking about the change at all. Given a safe, nonjudgmental environment, people begin to explore their ambivalence. The counselor also works to develop discrepancy, thus increasing ambivalence; ambivalence is amplified and then through the treatment process is resolved in the direction of change.What happens to ambivalence in Motivational Interviewing and as the person moves through the change process? You can see from this graph that there is an initial increase in ambivalence as it is brought to the forefront in counseling. Initially, the person may not have been thinking about the change at all. Given a safe, nonjudgmental environment, people begin to explore their ambivalence. The counselor also works to develop discrepancy, thus increasing ambivalence; ambivalence is amplified and then through the treatment process is resolved in the direction of change.

53. Develop Discrepancy Explore goals and values with which substance use may conflict Long term recovery goals Values Dreams Past preferred activities Admired people Goals that the client wants�Caution: a sense of coercion arises when the goals and values are someone else�s What are some examples of goals? Examples of goals: Finding a job Completing high school Finding a girlfriend Getting married Rekindling a relationship with an old friend Going fishing with one�s father Goals that the client wants�Caution: a sense of coercion arises when the goals and values are someone else�s What are some examples of goals? Examples of goals: Finding a job Completing high school Finding a girlfriend Getting married Rekindling a relationship with an old friend Going fishing with one�s father

54. Develop Discrepancy Client verbalization of negative consequences amplifies discrepancy Payoff matrix/decisional balance exercise The payoff matrix is one way to have clients verbalize the negative consequences of their use. A non-threatening opening is to ask about things they like about using (the advantages), then the conversation can flow into the disadvantages. The payoff matrix can be done formally, or conversationally, perhaps depending on the client�s stage of change. [Payoff matrix exercise�. if ahead of schedule you can have participants practice doing a payoff matrix.]The payoff matrix is one way to have clients verbalize the negative consequences of their use. A non-threatening opening is to ask about things they like about using (the advantages), then the conversation can flow into the disadvantages. The payoff matrix can be done formally, or conversationally, perhaps depending on the client�s stage of change. [Payoff matrix exercise�. if ahead of schedule you can have participants practice doing a payoff matrix.]

55. Change and Resistance Opposite sides of a coin Resistance Change talk Change and resistance can be thought of as opposite sides of a coin. Change and resistance are the two sides of the person�s ambivalence. Change talk reflects movement of the person toward change, while resistance represents and predicts movement away from change. It is important, therefore, for the counselor to recognize both change talk and resistance responses, then we can be conscious in our responses in order to help the client move toward change. First, we�ll work on recognizing change talk and resistance. Then we�ll move onto responding to resistance and how to evoke and respond to change talk.Change and resistance can be thought of as opposite sides of a coin. Change and resistance are the two sides of the person�s ambivalence. Change talk reflects movement of the person toward change, while resistance represents and predicts movement away from change. It is important, therefore, for the counselor to recognize both change talk and resistance responses, then we can be conscious in our responses in order to help the client move toward change. First, we�ll work on recognizing change talk and resistance. Then we�ll move onto responding to resistance and how to evoke and respond to change talk.

56. Resistance What is resistance? How is resistance expressed? Negating Blaming, disagreeing, excusing, minimizing, unwillingness to change Ignoring Inattention, sidetracking, nonanswer Arguing Challenging, discounting, hostility Interrupting What is resistance? How is it expressed? There are many overt forms of resistance that are pretty easy to see, such as hostility, arguing or disagreeing. But there are other more subtle ways that resistance can present itself, such as sidetracking, not answering, or making excuses as to why a potential solution will not work. We need to be sensitive to all these responses, and respond in a way that will decrease the resistance rather than strengthen it. (E.g. �yes, but�� should not be met with �okay, well how about� instead�) [Direct participants to the handout: �H3 What does resistance look like� and note that it is not necessarily important to remember the names of all these categories, rather it is important to become sensitive to these responses as resistance so that we can respond in a way that facilitates change.]What is resistance? How is it expressed? There are many overt forms of resistance that are pretty easy to see, such as hostility, arguing or disagreeing. But there are other more subtle ways that resistance can present itself, such as sidetracking, not answering, or making excuses as to why a potential solution will not work. We need to be sensitive to all these responses, and respond in a way that will decrease the resistance rather than strengthen it. (E.g. �yes, but�� should not be met with �okay, well how about� instead�) [Direct participants to the handout: �H3 What does resistance look like� and note that it is not necessarily important to remember the names of all these categories, rather it is important to become sensitive to these responses as resistance so that we can respond in a way that facilitates change.]

57. Resistance Counselor behaviors that elicit resistance Arguing for change (the trap of taking sides) Assuming the expert role/claiming preeminence Labeling Being in a hurry Criticizing, shaming, or blaming There are a number of counselor behaviors that elicit resistance. These include: Arguing for change (the trap of taking sides). Avoid arguing for change. New perspectives are invited, not imposed. Arguments strengthen people�s beliefs and reduce the likelihood of change. If you sense argument, change strategies or focus. Assuming the expert role/claiming preeminence. Focus on the client�s perceptions of pros and cons (ambivalence) not yours. The client is a primary resource in finding solutions, they are the expert. Labeling. Labeling is unnecessary. Identify behavior, don�t label or diagnose. Being in a hurry. If you feel rushed slow down. Criticizing, shaming, or blaming How do these behaviors violate the spirit of MI? There are a number of counselor behaviors that elicit resistance. These include: Arguing for change (the trap of taking sides). Avoid arguing for change. New perspectives are invited, not imposed. Arguments strengthen people�s beliefs and reduce the likelihood of change. If you sense argument, change strategies or focus. Assuming the expert role/claiming preeminence. Focus on the client�s perceptions of pros and cons (ambivalence) not yours. The client is a primary resource in finding solutions, they are the expert. Labeling. Labeling is unnecessary. Identify behavior, don�t label or diagnose. Being in a hurry. If you feel rushed slow down. Criticizing, shaming, or blaming How do these behaviors violate the spirit of MI?

58. Resistance Resistance is a product of the interpersonal relationship Hence, there are things we can do to diminish resistance Resistance is a signal to respond differently, it is valuable feedback Resistance can be conceptualized as a product of the interpersonal relationship. Hence, there are things we can do to diminish resistance. Draw a graph on the board In an illustrative study, Patterson and Forgatch (1985) had therapist switch back and forth between directive and empathic counseling styles every twelve minutes within their counseling sessions. Client resistance behavior went up and down in step function. When counselors took a directive and instructional role, resistance was high; when they responded empathically, resistance dropped. Clearly resistance is not an individual characteristic of clients, but is interactive. It takes two to generate resistance, and when it does occur it can be increased or decreased by counseling style. Resistance is a signal to respond differently, it is valuable feedback.Resistance can be conceptualized as a product of the interpersonal relationship. Hence, there are things we can do to diminish resistance. Draw a graph on the board In an illustrative study, Patterson and Forgatch (1985) had therapist switch back and forth between directive and empathic counseling styles every twelve minutes within their counseling sessions. Client resistance behavior went up and down in step function. When counselors took a directive and instructional role, resistance was high; when they responded empathically, resistance dropped. Clearly resistance is not an individual characteristic of clients, but is interactive. It takes two to generate resistance, and when it does occur it can be increased or decreased by counseling style. Resistance is a signal to respond differently, it is valuable feedback.

59. Change Talk Generally falls into one of these four categories: Disadvantages of the status quo Advantages of change Optimism for change Intention to change Change talk generally falls into one of these four categories: Disadvantages of the status quo Advantages of change Optimism for change Intention to change Change talk generally falls into one of these four categories: Disadvantages of the status quo Advantages of change Optimism for change Intention to change

60. Change Talk Disadvantages of the status quo �I can see that in the long run, this is going to do me in if I don�t make a change.� �I am ruining my family life.� Advantages of change �My boys would like it. They�re always after me to quit.� �Probably I�d feel a lot better.� �At least it would get the courts off my back.� Disadvantages of the status quo: The client expresses that there is reason for concern or discontent with how things are (the not-so-good things about current status). Examples include: �I can see that in the long run, this is going to do me in if I don�t make a change.� �I am ruining my family life.� Advantages of change: The client voices recognition of the potential advantages of change (good things to be gained through change). Examples include: �My boys would like it. They�re always after me to quit.� �Probably I�d feel a lot better.� �At least it would get the courts off my back.� Disadvantages of the status quo: The client expresses that there is reason for concern or discontent with how things are (the not-so-good things about current status). Examples include: �I can see that in the long run, this is going to do me in if I don�t make a change.� �I am ruining my family life.� Advantages of change: The client voices recognition of the potential advantages of change (good things to be gained through change). Examples include: �My boys would like it. They�re always after me to quit.� �Probably I�d feel a lot better.� �At least it would get the courts off my back.�

61. Change Talk Optimism About Change �I think I could probably do it if I decided to.� �I did quit smoking a few years ago. That was tough, and it took a few tries, but I did it.� �My family would be there to support me.� Intention to Change �I definitely don�t want to keep going the way I have been.� �I�ve got to do something.� Optimism for change: The client indicates confidence and hope about ability to change (I could or I can do it). Examples include: �I think I could probably do it if I decided to.� �I did quit smoking a few years ago. That was tough, and it took a few tries, but I did it.� �My family would be there to support me.� Intention to change: The client indicates an intention, desire, willingness, or commitment to change (level of intention can vary from rather weak to very strong commitment language). Examples include: �I definitely don�t want to keep going the way I have been.� �I�ve got to do something.� Optimism for change: The client indicates confidence and hope about ability to change (I could or I can do it). Examples include: �I think I could probably do it if I decided to.� �I did quit smoking a few years ago. That was tough, and it took a few tries, but I did it.� �My family would be there to support me.� Intention to change: The client indicates an intention, desire, willingness, or commitment to change (level of intention can vary from rather weak to very strong commitment language). Examples include: �I definitely don�t want to keep going the way I have been.� �I�ve got to do something.�

62. Recognizing Resistance and Change Talk Exercise (part 1): Form groups of three. One person is the speaker: talk about something you are trying to change. One is the listener: persuade your partner to make the change (NOT MI). One is the recorder: listen for resistance and change talk and record. [Exercise (part 1): instruct participants to: Form groups of three. One person is the speaker: talk about something you are trying to change. One is the counselor: persuade your partner to make the change (emphasize this is not MI). One is the recorder: listen for resistance and change talk and record.][Exercise (part 1): instruct participants to: Form groups of three. One person is the speaker: talk about something you are trying to change. One is the counselor: persuade your partner to make the change (emphasize this is not MI). One is the recorder: listen for resistance and change talk and record.]

63. Recognizing Resistance and Change Talk Exercise (part 2): Switch roles. Speaker: talk about something you are trying to change. Listener: use OARS. Recorder: listen for resistance and change talk and record. [Exercise (part 2): instruct participants to: Switch roles. Speaker: talk about something you are trying to change. Counselor: use OARS. Recorder: listen for resistance and change talk and record.] [Debrief: have the recorders share what they heard - resistance and change talk.][Exercise (part 2): instruct participants to: Switch roles. Speaker: talk about something you are trying to change. Counselor: use OARS. Recorder: listen for resistance and change talk and record.] [Debrief: have the recorders share what they heard - resistance and change talk.]

64. In its simplest form, the implicit theory of MI posits: 1a. MI will increase client change talk. 1b. MI will diminish client resistance. 2a. The extent to which clients verbally defend the status quo (resistance) will be inversely related to behavior change. 2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change. Miller, W.R. (2004) Toward a Theory of Motivational Interviewing. motivationalinterviewing.org In its simplest form, the implicit theory of MI posits: 1a. MI will increase client change talk. 1b. MI will diminish client resistance. 2a. The extent to which clients verbally defend status quo (resistance) will be inversely related to behavior change. 2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change. In short, we want our consumers to talk about change, AND we want their change talk to increase in amount and strength. It is the slope of the change talk and the strength of the change talk that directly predicts behavior change. So, now we will move onto some specific strategies to increase change talk and decrease resistance.In its simplest form, the implicit theory of MI posits: 1a. MI will increase client change talk. 1b. MI will diminish client resistance. 2a. The extent to which clients verbally defend status quo (resistance) will be inversely related to behavior change. 2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change. In short, we want our consumers to talk about change, AND we want their change talk to increase in amount and strength. It is the slope of the change talk and the strength of the change talk that directly predicts behavior change. So, now we will move onto some specific strategies to increase change talk and decrease resistance.

65. Responding to Resistance Roll with it! We�re going to talk about how to cope with resistance from an MI perspective, but first I�d like to hear what already works well in your setting. In motivational interviewing we roll with resistance. Resistance is not directly opposed, instead we use the client�s resistance to help explore feelings of ambivalence. We�re going to talk about how to cope with resistance from an MI perspective, but first I�d like to hear what already works well in your setting. In motivational interviewing we roll with resistance. Resistance is not directly opposed, instead we use the client�s resistance to help explore feelings of ambivalence.

66. Roll with Resistance Counselor behaviors that defuse resistance � strategies to use Reflections Shifting focus Emphasizing personal control (Agreement with a twist) (Reframing) (Coming alongside) There are several counselor behaviors that defuse resistance. The first are reflections: we�ll talk about some different types of reflections; simple, amplified, and double-sided. Then we�ll talk about two other strategies, shifting focus and emphasizing personal control. The last three listed here in parentheses are covered in the second day: agreement with a twist, reframing, and coming alongside.There are several counselor behaviors that defuse resistance. The first are reflections: we�ll talk about some different types of reflections; simple, amplified, and double-sided. Then we�ll talk about two other strategies, shifting focus and emphasizing personal control. The last three listed here in parentheses are covered in the second day: agreement with a twist, reframing, and coming alongside.

67. Reflections Simple & Complex Reflections Repeating, rephrasing, paraphrasing, reflection of feeling Using reflections acknowledges the client�s perception, avoids argument, joins with client, and encourages further exploration. In responding to resistance we can use simple or complex reflections. Example: Client: I couldn�t keep the weight off even if I lost it. Interviewer: You�re rather discouraged about trying again. [Ask the participants for a resistant statement and demonstrate both a simple and complex reflection in response.] Using reflections acknowledges the client�s perception, avoids argument, joins with client, and encourages further exploration. In responding to resistance we can use simple or complex reflections. Example: Client: I couldn�t keep the weight off even if I lost it. Interviewer: You�re rather discouraged about trying again. [Ask the participants for a resistant statement and demonstrate both a simple and complex reflection in response.]

68. Double-Sided Reflection Captures both sides of the ambivalence Client: Okay, maybe I�ve got some problems with gambling, but it�s not like I�m addicted to it. Interviewer: You see that your gambling is causing problems for you and your family, and it�s also important that people not think of you as some kind of addict. The double-sided reflection acknowledges both sides of the client�s ambivalence. This type of reflection is particularly useful because it helps defuse resistance while at the same time developing discrepancy. In this way we are using the client�s resistance to help explore feelings of ambivalence. Double sided reflections are great for when you�ve heard arguments for and against change. In response to resistance, the double-sided reflection also may draw on material from previous meetings. An example, Client: Okay, maybe I�ve got some problems with gambling, but it�s not like I�m addicted to it. Interviewer: You see that your gambling is causing problems for you and your family, and it�s also important that people not think of you as some kind of addict. How we put together the two sides of the coin can make a difference. You can use �and� or �but� depending on how you want to proceed in the conversation. �And� is less confrontational, use �and� if you are hearing resistance. �But� emphasizes the last thing you say, �but� may cause resistance, so use it with caution!Examples: �You know your friends will not approve, but you also know that your parents and your church will approve.� �Some days it seems you�ll never get out of this trap, and other days give you hope that things really could change.� The double-sided reflection acknowledges both sides of the client�s ambivalence. This type of reflection is particularly useful because it helps defuse resistance while at the same time developing discrepancy. In this way we are using the client�s resistance to help explore feelings of ambivalence. Double sided reflections are great for when you�ve heard arguments for and against change. In response to resistance, the double-sided reflection also may draw on material from previous meetings. An example, Client: Okay, maybe I�ve got some problems with gambling, but it�s not like I�m addicted to it. Interviewer: You see that your gambling is causing problems for you and your family, and it�s also important that people not think of you as some kind of addict. How we put together the two sides of the coin can make a difference. You can use �and� or �but� depending on how you want to proceed in the conversation. �And� is less confrontational, use �and� if you are hearing resistance. �But� emphasizes the last thing you say, �but� may cause resistance, so use it with caution!Examples: �You know your friends will not approve, but you also know that your parents and your church will approve.� �Some days it seems you�ll never get out of this trap, and other days give you hope that things really could change.�

69. Amplified Reflection Exaggerated to encourage some retreat Client: I couldn�t just give up drinking. What would my friends think? Interviewer: You couldn�t handle your friends� reaction if you quit. An amplified reflection is an exaggeration or overstatement of what the person has said. It is used to encourage retreat or to encourage exploration of the other side of the coin. For example, Client: �my wife is always exaggerating. I haven�t ever been that bad.� Interviewer: �it seems to you she has no reason for concern.� Here the overstatement is that she has no reason for concern. Amplified reflections must be done with empathy, in a straightforward, unassuming, supportive manner. Any hint of sarcasm or impatience can make the response hostile and increase resistance. Example: Client: I couldn�t just give up drinking. What would my friends think? Interviewer: You couldn�t handle your friends� reaction if you quit. An amplified reflection is an exaggeration or overstatement of what the person has said. It is used to encourage retreat or to encourage exploration of the other side of the coin. For example, Client: �my wife is always exaggerating. I haven�t ever been that bad.� Interviewer: �it seems to you she has no reason for concern.� Here the overstatement is that she has no reason for concern. Amplified reflections must be done with empathy, in a straightforward, unassuming, supportive manner. Any hint of sarcasm or impatience can make the response hostile and increase resistance. Example: Client: I couldn�t just give up drinking. What would my friends think? Interviewer: You couldn�t handle your friends� reaction if you quit.

70. Shifting Focus Shift the person�s attention away from what seems to be a stumbling block in the way of progress. Client: You�re probably going to give me a diet that I need to stick to, and tell me that I have to get some of these exercise machines or go to a gym every day. Interviewer: I don�t know enough about you yet for us to even start talking about what makes sense for you to do. What we need to do right now is� In shifting focus we go around the barrier, not over it.Shift the person�s attention away from what seems to be a stumbling block in the way of progress. For example: Client: You�re probably going to give me a diet that I need to stick to, and tell me that I have to get some of these exercise machines or go to a gym every day. Interviewer: I don�t know enough about you yet for us to even start talking about what makes sense for you to do. What we need to do right now is�In shifting focus we go around the barrier, not over it.Shift the person�s attention away from what seems to be a stumbling block in the way of progress. For example: Client: You�re probably going to give me a diet that I need to stick to, and tell me that I have to get some of these exercise machines or go to a gym every day. Interviewer: I don�t know enough about you yet for us to even start talking about what makes sense for you to do. What we need to do right now is�

71. Emphasizing Personal Control Assuring the client that it is he/she who in the end will determine what will happen Client: Why are you giving me this booklet? Are you telling me I have to use condoms? Interviewer: It�s just information. What you do with it is completely up to you. Naturally, no one can make you use condoms. Emphasizing personal control is assuring the client that it is he/she who in the end will determine what will happen. We are emphasizing the client�s autonomy. For example: Client: Why are you giving me this booklet? Are you telling me I have to use condoms? Interviewer: It�s just information. What you do with it is completely up to you. Naturally, no one can make you use condoms. Another example: Interviewer: �This is your decision. Even if I wanted to, I could not make it for you.� Emphasizing personal control is assuring the client that it is he/she who in the end will determine what will happen. We are emphasizing the client�s autonomy. For example: Client: Why are you giving me this booklet? Are you telling me I have to use condoms? Interviewer: It�s just information. What you do with it is completely up to you. Naturally, no one can make you use condoms. Another example: Interviewer: �This is your decision. Even if I wanted to, I could not make it for you.�

72. Roll with Resistance Exercise: Get into groups of three. Decide who will be the client, the counselor, and the recorder. Client: choose and read a resistant scenario or make up your own. Counselor: test out alternative strategies for responding. Recorder: note strategies used and client response, what seemed to work best? Switch roles and use a new scenario. [Exercise: instruct participants to: Get into groups of three. Decide who will be the client, the counselor, and the recorder. Client: choose and read a resistant scenario or make up your own. Counselor: test out alternative strategies for responding. Recorder: note strategies used and client response, what seemed to work best? Switch roles and use a new scenario.] [Exercise: instruct participants to: Get into groups of three. Decide who will be the client, the counselor, and the recorder. Client: choose and read a resistant scenario or make up your own. Counselor: test out alternative strategies for responding. Recorder: note strategies used and client response, what seemed to work best? Switch roles and use a new scenario.]

73. Roll with Resistance Exercise Scenarios: �Who are you to tell me what to do? What do you know about crack? You probably never even smoked a joint! �Cocaine is not really my problem. What I want to talk about is my roommate�now he�s a problem!� �Look, I�ve been in detox dozens of times before. I�m hopeless. I just want to dry out and go home.� �I really like pot! It�s the only good thing about my day and I don�t want to quit!� Exercise Scenarios: �Who are you to tell me what to do? What do you know about crack? You probably never even smoked a joint! (discounting) �Cocaine is not really my problem. What I want to talk about is my roommate�now he�s a problem!� (sidetracking) �Look, I�ve been in detox dozens of times before. I�m hopeless. I just want to dry out and go home.� (pessimism) �I really like pot! It�s the only good think about my day and I don�t want to quit!� (unwillingness) Exercise Scenarios: �Who are you to tell me what to do? What do you know about crack? You probably never even smoked a joint! (discounting) �Cocaine is not really my problem. What I want to talk about is my roommate�now he�s a problem!� (sidetracking) �Look, I�ve been in detox dozens of times before. I�m hopeless. I just want to dry out and go home.� (pessimism) �I really like pot! It�s the only good think about my day and I don�t want to quit!� (unwillingness)

74. Responding to Change Talk Elaborating Reflecting Summarizing Affirming When we hear change talk we want to be particularly interested and attentive. Don�t let it pass! We want to respond to it in some specific ways. These include: Elaborating Reflecting Summarizing Affirming When we hear change talk we want to be particularly interested and attentive. Don�t let it pass! We want to respond to it in some specific ways. These include: Elaborating Reflecting Summarizing Affirming

75. Elaborating Ask for clarification �In what ways? When?� Ask for a specific example �Give me an example. Tell me about the last time that happened.� Straightforward encouragement to continue �What else?� �What else have you noticed or wondered about your _____?� When change talk occurs, respond with particular interest, both nonverbally (attention, head nod) and by asking for elaboration. We can: Ask for clarification with words like, �In what ways? When?� Ask for a specific example with words like, �Give me an example. Tell me about the last time that happened.� Use straightforward encouragement to continue. Words like, �What else?� or �What else have you noticed or wondered about your _____?� Too often change talk will pass without elaboration. Once a reason for change has been named, it is often the counselor�s tendency to move on to find other reasons. Elaborate first! Elaboration is a simple and effective skill. [Direct participants attention to the handout: �Elaborating.� Read the illustration and point out how asking for elaboration led to a deeper discussion about the change.]When change talk occurs, respond with particular interest, both nonverbally (attention, head nod) and by asking for elaboration. We can: Ask for clarification with words like, �In what ways? When?� Ask for a specific example with words like, �Give me an example. Tell me about the last time that happened.� Use straightforward encouragement to continue. Words like, �What else?� or �What else have you noticed or wondered about your _____?� Too often change talk will pass without elaboration. Once a reason for change has been named, it is often the counselor�s tendency to move on to find other reasons. Elaborate first! Elaboration is a simple and effective skill. [Direct participants attention to the handout: �Elaborating.� Read the illustration and point out how asking for elaboration led to a deeper discussion about the change.]

76. Reflecting Selectively reflecting If the reflection evokes the other side (resistance) then recover with a double sided reflection We have talked about reflections. Here we are using reflections selectively to reinforce change talk and keep the conversation moving in the direction of change. Occasionally a reflection will evoke resistance (often if it is too strong). In this case you can easily recover with a double-sided reflection.We have talked about reflections. Here we are using reflections selectively to reinforce change talk and keep the conversation moving in the direction of change. Occasionally a reflection will evoke resistance (often if it is too strong). In this case you can easily recover with a double-sided reflection.

77. Summarizing Consciously selective Gather together �bouquets� of change statements and offer them back Summarizing we have discussed. Again, here we are using it selectively. Miller and Rollnick use the metaphor of gathering bouquets of change statements that are offered back to the consumer.Summarizing we have discussed. Again, here we are using it selectively. Miller and Rollnick use the metaphor of gathering bouquets of change statements that are offered back to the consumer.

78. Affirming Simply comment positively �That�s a good point� �That sounds like a good idea� �I think that could work� �I can see how that would concern you� We have talked about affirmations. Here they are affirmations of change talk. Example include: �That�s a good point� �That sounds like a good idea� �I think that could work� �I can see how that would concern you� We have talked about affirmations. Here they are affirmations of change talk. Example include: �That�s a good point� �That sounds like a good idea� �I think that could work� �I can see how that would concern you�

79. Eliciting Change Talk Asking evocative questions Using the importance ruler Exploring the decisional balance Describe a typical day (Querying extremes) (Looking back) (Looking forward) Change talk is not only something that we want to respond to in strategic ways, it is also the kind of talking that we want to elicit from our clients. There are several strategies that can be used to elicit change talk. These are: Asking evocative questions Using the importance ruler Exploring the decisional balance Describe a typical day (Querying extremes) (Looking back) (Looking forward) We�ll talk about the first four today.Change talk is not only something that we want to respond to in strategic ways, it is also the kind of talking that we want to elicit from our clients. There are several strategies that can be used to elicit change talk. These are: Asking evocative questions Using the importance ruler Exploring the decisional balance Describe a typical day (Querying extremes) (Looking back) (Looking forward) We�ll talk about the first four today.

80. Asking Evocative Questions Use open questions to explore client�s own concerns Assume the person is feeling ambivalent and has at least some concerns Asking evocative questions is the simplest and most direct approach. We use open questions to explore the client�s own concerns. Don�t ask whether the client has such concerns (Do you think you have a problem with _____?). Assume the person is feeling ambivalent and has at least some concerns.Asking evocative questions is the simplest and most direct approach. We use open questions to explore the client�s own concerns. Don�t ask whether the client has such concerns (Do you think you have a problem with _____?). Assume the person is feeling ambivalent and has at least some concerns.

81. Asking Evocative Questions What hassles have you had in relation to your drug use? In what ways has your drinking been a problem for you? What is there about your drinking that you or other people might see as a reason for concern? Examples of evocative questions include: What hassles have you had in relation to your drug use? In what ways has your drinking been a problem for you? What is there about your drinking that you or other people might see as a reason for concern? More examples are included in the handout: �Sample Questions to Evoke or Elicit Change Talk� Examples of evocative questions include: What hassles have you had in relation to your drug use? In what ways has your drinking been a problem for you? What is there about your drinking that you or other people might see as a reason for concern? More examples are included in the handout: �Sample Questions to Evoke or Elicit Change Talk�

82. Using the Importance Ruler �Why are you at a ___ and not a zero?� To use the importance ruler, first obtain the client�s rating (On a scale from 0 to 10, how important to you is it to change your ______?) and then follow-up with the following questions: �Why are you at a ________ and not a zero?� OR �What would it take for you to go from a ________ to (a higher number)?� The answers to these questions will very likely be change talk.To use the importance ruler, first obtain the client�s rating (On a scale from 0 to 10, how important to you is it to change your ______?) and then follow-up with the following questions: �Why are you at a ________ and not a zero?� OR �What would it take for you to go from a ________ to (a higher number)?� The answers to these questions will very likely be change talk.

83. Exploring the Decisional Balance Asking about both the positives and negatives of the behavior Asking about the pros and cons of change Doing the payoff matrix Exploring the decisional balance can occur in a structured or unstructured conversation. Helping the client explore their ambivalence often will lead to some talk about the pros of change. Ask about both the positives and negatives of the behavior Ask about the pros and cons of change Do the payoff matrix Exploring the decisional balance can occur in a structured or unstructured conversation. Helping the client explore their ambivalence often will lead to some talk about the pros of change. Ask about both the positives and negatives of the behavior Ask about the pros and cons of change Do the payoff matrix

84. Describe a Typical Day Ask the person to walk you through a typical day Areas of concern often emerge naturally Early in motivational interviewing, if there is little change talk to elaborate, it may be useful to ask the person to walk you through a typical day in his or her life. This offers opportunities for asking in more detail about behavior patterns and mood changes, for example, and areas of concern often emerge quite naturally from such discussions.Early in motivational interviewing, if there is little change talk to elaborate, it may be useful to ask the person to walk you through a typical day in his or her life. This offers opportunities for asking in more detail about behavior patterns and mood changes, for example, and areas of concern often emerge quite naturally from such discussions.

85. Change Talk Exercise: Get into groups of three. Each person selects a role: speaker, listener, recorder. This is the first session. Speakers, your job is to come in considering that you want to make a change either in yourself or in your life but still feel very ambivalent about. Listeners, your job is to open up the session and practice using OARS and strategies for eliciting change talk as best you can. Observers, your job is to note the open ended questions, reflective listening statements, affirmations, summaries and strategies to elicit change talk. Switch roles. [Exercise: instruct participants to: Get into groups of three. Each person selects a role: speaker, listener, recorder. This is the first session. Speakers, your job is to come in considering that you want to make a change either in yourself or in your life but still feel very ambivalent about. Listeners, your job is to open up the session and practice using OARS and strategies for eliciting change talk as best you can. Observers, your job is to note the open ended questions, reflective listening statements, affirmations, summaries and strategies to elicit change talk. Switch roles.] [Exercise: instruct participants to: Get into groups of three. Each person selects a role: speaker, listener, recorder. This is the first session. Speakers, your job is to come in considering that you want to make a change either in yourself or in your life but still feel very ambivalent about. Listeners, your job is to open up the session and practice using OARS and strategies for eliciting change talk as best you can. Observers, your job is to note the open ended questions, reflective listening statements, affirmations, summaries and strategies to elicit change talk. Switch roles.]

86. Support Self-Efficacy What is self-efficacy? Extent to which the person feels ABLE to change What is Self-Efficacy? Self-efficacy refers to a person�s belief in his or her ability to carry out and succeed with a specific task. Although, self-efficacy is a relatively recent term, healers have long recognized that hope and faith are important elements of change. Self-efficacy is a key element in motivation for change and is a reasonable predictor of treatment outcome. A counselor may develop a person�s perception that he or she has an important problem, but if the client perceives no hope or possibility for change, then no effort will be made and the counselor�s efforts have been in vain.What is Self-Efficacy? Self-efficacy refers to a person�s belief in his or her ability to carry out and succeed with a specific task. Although, self-efficacy is a relatively recent term, healers have long recognized that hope and faith are important elements of change. Self-efficacy is a key element in motivation for change and is a reasonable predictor of treatment outcome. A counselor may develop a person�s perception that he or she has an important problem, but if the client perceives no hope or possibility for change, then no effort will be made and the counselor�s efforts have been in vain.

87. Support Self-Efficacy People cannot be ready to change until they perceive both that they want to and are able to do so The client, not the counselor, is responsible for choosing and carrying out the change Our own belief in the person�s ability to change becomes a self-fulfilling prophecy We can support self-efficacy in the spirit of MI People cannot be ready to change until they perceive both that they want to and are able to do so. One can think of wanting to change as the degree of perceived discrepancy between status and goal, between what is happening at present and what one values for the future. Feeling able to make the change in another story. We often hear �I wish I could� from people lacking self-efficacy. Classic examples include prostitutes and smokers. If a person becomes alarmed by the discrepancy but perceives no way to change then something happens. Instead of changing behavior, people reduce their discomfort (ambivalence is uncomfortable) by shifting their thought process and perceptions in a way that is often called defensive (i.e., denial, rationalization, etc.) The need for sufficient self-efficacy has to do with the fact that the client, not the counselor, is responsible for choosing and carrying out the change. It is an issue of empowerment, does the consumer feel responsible for and capable of making the change? While the change is ultimately up to the consumer (autonomy), there are things we can do to support self-efficacy. First of all, we have to believe they can do it; we have to have hope. Our own belief in the person�s ability to change can become a self-fulfilling prophecy. If we believe a client can change, we will act in a way that increases the likelihood a client will do so. There are also concrete things we can do to support self-efficacy in the spirit of MI.People cannot be ready to change until they perceive both that they want to and are able to do so. One can think of wanting to change as the degree of perceived discrepancy between status and goal, between what is happening at present and what one values for the future. Feeling able to make the change in another story. We often hear �I wish I could� from people lacking self-efficacy. Classic examples include prostitutes and smokers. If a person becomes alarmed by the discrepancy but perceives no way to change then something happens. Instead of changing behavior, people reduce their discomfort (ambivalence is uncomfortable) by shifting their thought process and perceptions in a way that is often called defensive (i.e., denial, rationalization, etc.) The need for sufficient self-efficacy has to do with the fact that the client, not the counselor, is responsible for choosing and carrying out the change. It is an issue of empowerment, does the consumer feel responsible for and capable of making the change? While the change is ultimately up to the consumer (autonomy), there are things we can do to support self-efficacy. First of all, we have to believe they can do it; we have to have hope. Our own belief in the person�s ability to change can become a self-fulfilling prophecy. If we believe a client can change, we will act in a way that increases the likelihood a client will do so. There are also concrete things we can do to support self-efficacy in the spirit of MI.

88. Responding to Confidence Talk Elaborating Reflecting Summarizing Affirming Raising possible problems and challenges To support self-efficacy, we respond to confidence talk in a way similar to how we respond to change talk. Respond in manner that reinforces and consolidates it. We want to elaborate, reflect, summarize, affirm, and here we also want to raising possible problems and challenges.To support self-efficacy, we respond to confidence talk in a way similar to how we respond to change talk. Respond in manner that reinforces and consolidates it. We want to elaborate, reflect, summarize, affirm, and here we also want to raising possible problems and challenges.

89. Responding to Confidence Talk Elaborating Straightforward encouragement to continue �Why else do you think you could succeed?� �How else could you do it? Reflecting Selectively reflect themes, experiences, ideas & preferences that suggest the client�s perceived ability to make the change �I quit once before.� �You can do it again.� Elaboration, remember, is straightforward encouragement to continue. �Why else do you think you could succeed?� �How else could you do it? When reflecting to build confidence we are selectively reflecting themes, experiences, ideas & preferences that suggest the client�s perceived ability to make the change. �I quit once before.� �You can do it again.� Elaboration, remember, is straightforward encouragement to continue. �Why else do you think you could succeed?� �How else could you do it? When reflecting to build confidence we are selectively reflecting themes, experiences, ideas & preferences that suggest the client�s perceived ability to make the change. �I quit once before.� �You can do it again.�

90. Responding to Confidence Talk Summarizing Consciously selective Gather together �bouquets� of confidence statements and offer them back Affirming Simply comment positively �I think that could work� �I bet your family believes you can do this� Summarizing is consciously selective. We gather together �bouquets� of confidence statements and offer them back. Affirming is commenting positively. For example, �I think that could work� �I bet your family believes you can do this� Summarizing is consciously selective. We gather together �bouquets� of confidence statements and offer them back. Affirming is commenting positively. For example, �I think that could work� �I bet your family believes you can do this�

91. Responding to Confidence Talk Raising possible challenges Stimulate further thought and specificity �What might you do if _____?� �How could you respond if _____?� �What do you think would happen if _____?� Raising possible challenges is meant to stimulate further thought and specificity, making the idea of change/plan for change more concrete, like something that can actually be tackled. Some possible questions include: �What might you do if _____?� �How could you respond if _____?� �What do you think would happen if _____?� Raising possible challenges is meant to stimulate further thought and specificity, making the idea of change/plan for change more concrete, like something that can actually be tackled. Some possible questions include: �What might you do if _____?� �How could you respond if _____?� �What do you think would happen if _____?�

92. Eliciting Confidence Talk Strategies: Evocative questions Confidence ruler Reviewing past successes Exploring personal strengths & supports Brainstorming Reframing Giving information & advice Hypothetical change Like the importance of change, confidence is evoked or drawn out from the client, not imparted by the therapist. There are a number of ways that self-efficacy can be supported. Every time you encourage a consumer to do for him/herself and he/she succeeds, you have supported self-efficacy. Helping consumers break down large goals into achievable steps and noting progress is another way to support self-efficacy. In motivational interviewing there are verbal strategies that help get the client talking about being able to make the change. We are not going to go into detail or practice these today, but they include: Evocative questions and the confidence ruler which are the same as we use for change talk Reviewing past successes can be useful. These can be past successes at quitting substance use (not coerced) or other past success at doing something that the client wanted. Ask questions such as �What worked?� and �What was it that enabled you to be successful that time?� Exploring personal strengths and supports that may be helpful in making the change can increase self-confidence. Brainstorming how change may occur can boost self-efficacy. There is hope in the range of alternative approaches available. Helping the client recognize that there is not one �right� way to recovery or that there are options other than what they have tried before can help. Reframe relapses as part of the recovery process and learning experiences that make them stronger. It is important to affirm the small steps taken and reinforce any positive changes. Giving information & advice Hypothetical change Like the importance of change, confidence is evoked or drawn out from the client, not imparted by the therapist. There are a number of ways that self-efficacy can be supported. Every time you encourage a consumer to do for him/herself and he/she succeeds, you have supported self-efficacy. Helping consumers break down large goals into achievable steps and noting progress is another way to support self-efficacy. In motivational interviewing there are verbal strategies that help get the client talking about being able to make the change. We are not going to go into detail or practice these today, but they include: Evocative questions and the confidence ruler which are the same as we use for change talk Reviewing past successes can be useful. These can be past successes at quitting substance use (not coerced) or other past success at doing something that the client wanted. Ask questions such as �What worked?� and �What was it that enabled you to be successful that time?� Exploring personal strengths and supports that may be helpful in making the change can increase self-confidence. Brainstorming how change may occur can boost self-efficacy. There is hope in the range of alternative approaches available. Helping the client recognize that there is not one �right� way to recovery or that there are options other than what they have tried before can help. Reframe relapses as part of the recovery process and learning experiences that make them stronger. It is important to affirm the small steps taken and reinforce any positive changes. Giving information & advice Hypothetical change

93. Support Self-Efficacy Traps: �I�ll take over now, thank you� Abandons MI and responds to low confidence with a prescription �There, there you will be fine� Not taking the confidence issue seriously Gloom a deux Sharing the client�s hopelessness and helplessness Once the client views the change as important, there are some common traps we fall into. �I�ll take over now, thank you� This trap refers to the abandonment of the MI spirit and responding to low confidence with a prescription. A lack of confidence in Mi is treated the same way as a lack of importance. Instead of saying �here�s how you can do it� we need to draw it out from the person. �There, there you will be fine� This trap refers to not taking the confidence issue seriously. If we take the can side of the coin, the client is left to defend the can�t side. Gloom a deux. This trap refers to sharing the client�s hopelessness and helplessness. If the person we are working with is going to feel able to make the change, we have to believe it can happen. Once the client views the change as important, there are some common traps we fall into. �I�ll take over now, thank you� This trap refers to the abandonment of the MI spirit and responding to low confidence with a prescription. A lack of confidence in Mi is treated the same way as a lack of importance. Instead of saying �here�s how you can do it� we need to draw it out from the person. �There, there you will be fine� This trap refers to not taking the confidence issue seriously. If we take the can side of the coin, the client is left to defend the can�t side. Gloom a deux. This trap refers to sharing the client�s hopelessness and helplessness. If the person we are working with is going to feel able to make the change, we have to believe it can happen.

94. Take Home Messages Do a payoff matrix Elaborate change talk When in doubt, reflect We have covered a large amount of material today. My take home messages for you today are that you understand that ambivalence is normal; it is not something to be afraid of. Do a payoff matrix to explore that ambivalence. When you hear change talk, jump on it, ask for as much elaboration as the consumer can give. Finally, reflective listening will strengthen your rapport and almost never does harm/increases resistance. So, when in doubt, reflect, at the very least it will buy you some time.We have covered a large amount of material today. My take home messages for you today are that you understand that ambivalence is normal; it is not something to be afraid of. Do a payoff matrix to explore that ambivalence. When you hear change talk, jump on it, ask for as much elaboration as the consumer can give. Finally, reflective listening will strengthen your rapport and almost never does harm/increases resistance. So, when in doubt, reflect, at the very least it will buy you some time.

95. Learning MI � Next Steps What is one MI skill you are committed to developing in the next month? What are some of the barriers you see to using MI? How ready are you to start using some MI strategies and techniques? What specific plans do you have to continue learning MI? Motivational interviewing is not something that you learn in a one day workshop. It requires practice with your clients and ongoing supervision. The questions on this slide are to get you thinking about what you are going to do with what you have learned here today. What is one MI skill you are committed to developing in the next month? What are some of the barriers you see to using MI? How ready are you to start using some MI strategies and techniques? What specific plans do you have to continue learning MI? Motivational interviewing is not something that you learn in a one day workshop. It requires practice with your clients and ongoing supervision. The questions on this slide are to get you thinking about what you are going to do with what you have learned here today. What is one MI skill you are committed to developing in the next month? What are some of the barriers you see to using MI? How ready are you to start using some MI strategies and techniques? What specific plans do you have to continue learning MI?

96. Resources for Learning Motivational Interviewing Motivational Interviewing (2002) Miller & Rollnick www.motivationalinterview.com (Training tapes, articles, bibliographies, training opportunities) Enhancing Motivation for Change in Substance Abuse Treatment, Tip 35