Overview of Motivational Interviewing (MI)

Jessica D. Hanson, PhDSanford Research

Sioux Falls, SD

Funding from NIH grant #1P20GM121341-01

What is MI?

A goal-oriented, client-centered counseling style Enhances motivation for change Specific communication skills that increase a

client’s motivation to change

Goals of MI

Prepare people to consider changing

Maintain motivation to change

Not “push” people to change

Four Processes of MI

Engage Focus Evoke Plan

Four Processes of MI

Engage Focus Evoke Plan

Why How

Why MI? Evidence-based

Theory-based

Can address a variety of health behaviors

Relatively brief

Complementary to other methods

Verifiable

Appropriate for those not presenting for treatment

First Core of MI

Relational Empathy MI Spirit Absence of negative interaction

#1 predictor of success

#2 predictor of success

Counselor Empathy and Client Outcomes(#1 predictor)

The Spirit of MI

Partnership

Compassion

Evocation

Acceptance

Or how to show empathy…

MI Spirit in Practice

Partnership Counselor avoids an authoritarian role

Counselor creates a positive atmosphere that is conducive to change

Session is a meeting of two experts collaborating

Evocation Counselor does not provide wisdom or insight

Counselor finds things within the client and draws them out through skilled listening and responding

Client presents the arguments for change

MI Spirit in Practice (cont.)

Acceptance and Compassion

Responsibility for change is the client’s

Respect her autonomy

Support her freedom to make the final decision about change

Support her choices

Promote her confidence

Communication Styles to Avoid(#2 predictor)

Not done in MI: Following with no direction Commanding Confronting Arguing Debating Warning Threatening

Done infrequently in MI: Closed questions Advice giving

“Righting Reflex”

Second Core of MI

TechnicalOARS: Open-ended questions, Affirmations,

Reflective listening, and SummarizingEvoking Change Talk

#3 predictor of success

OARS Techniques for Establishing Good Rapport(Technical Core)

O = Open-ended questions

Elicit and explore topics and extended answers

A = Affirm the person

Focus on client strengths, efforts, patience, etc.

R = Reflect what the person says

Nondirective initially, then directive

S = Summarize

Capture “essence”, link topics, transition conversation

Closed vs. Open-Ended Questions

Closed questions can be answered finitely, often with “yes” or “no.”

Questions are restrictive and can be answered in a few words.

Open-ended questions will solicit additional information from women.

Questions are broad and require more than one- or two-word answers.

Exercise:Closed vs. Open-ended Questions

Do you use birth control methods?

How many times have you used birth control methods in the past three months?

What birth control methods you have used in the past three months?

Role Play 1: Counselor Closed Questions

Your client’s self-reported drinking is at a level that you know is considered risky and could cause an alcohol-exposed pregnancy.

You would like to talk with her about this.

Counselor Questions How often do you drink this much?

Why are you doing that? You know it can only cause you all sorts of problems.

I don’t understand why you can’t just decrease your drinking and drink less!

Role Play 2: CounselorOpen-Ended Questions

Your client’s self-reported drinking is at a level that you know is considered risky and could cause an alcohol-exposed pregnancy.

You would like to talk with her about this.

Counselor Questions You said earlier that you’ve been drinking pretty

heavily for about a year. If I recall you correctly, you said earlier that you are

really feeling like you want to decrease your drinking, but that your partner does not want you to. Tell me a bit more about that.

What concerns do you have about drinking? What are some consequences for you when you

drink? What else could you do besides drinking and

partying?

Summary: Open-Ended Questions

Foster a dialogue, not an interrogation

Establish rapport

Provide more information than closed questions

Allow your clients to tell their stories - you talk less and listen more

Permit a better understanding of the issues and build empathy

OARS Techniques for Establishing Good Rapport

O = Open-ended questions Elicit and explore topics and extended answers

A = Affirm the person Focus on client strengths, efforts, patience, etc.

R = Reflect what the person says Nondirective initially, then directive

S = Summarize Capture “essence”, link topics, transition

conversation

Affirmation Genuine, direct statements of support that

demonstrate you understand and appreciate at least part of what your client is dealing with, and is supportive.

Focus on client strengths, efforts, patience, etc.

Affirming may be compared to the seasoning in a recipe: The right amount is appropriate, but overdoing it can be problematic.

OARS Techniques for Establishing Good Rapport

O = Open-ended questions Elicit and explore topics and extended answers

A = Affirm the person Focus on client strengths, efforts, patience, etc.

R = Reflect what the person says Nondirective initially, then directive

S = Summarize Capture “essence”, link topics, transition

conversation

Reflective Listening

MI requires a special type of listening

Listening reflectively involves observing verbal and nonverbal cues

Reflective Listening Statements

Mirror the client’s perspectives Can be simple – repeat a word or two

“depressed” or “angry”

Can be sophisticated - substitute new words for what your client said or guess about unspoken meaning “It sounds like you are uncertain about whether you will

remember to take your birth control pills regularly”

Encourage exploration and establish rapport

Summary: Reflective Listening

Demonstrates that you understand what your client says

Validates your client’s concerns and feelings Is an important way to express empathy

High levels of empathy are associated with positive outcomes

Reflective Listening Leads to Change Talk(Change talk = #3 predictor)

Type of Change Talk Example

Desire “I want to . . .”

Ability “I could…”

Reasons “I know I would feel better if…”

Need “I ought to…”

Commitment “I am going to…”

Taking steps “This week I started…”

Responding to Change Talk

Listen to and reflect the client’s perspectives:

Pro-change

Anti-current behavior

Reasons

Confidence

desire

Go beyond reflecting change talk to evoking it:

Explore existing readiness for change

Explore possible first steps towards change

Eliciting Change Talk

Client presents her reasons for changing

You reflect those back to underline and emphasize them

Client hears herself moving towards change

Part of the Evoking Process of MI

Eliciting Change Talk: Readiness Ruler

Assessing Readiness to Change

Not ready Extremely ready at all to change

On a scale of 1–10, how ready are you at the present time to change [insert behavior]?

OARS Techniques for Establishing Good Rapport

O = Open-ended questions Elicit and explore topics and extended answers

A = Affirm the person Focus on client strengths, efforts, patience, etc.

R = Reflect what the person says Nondirective initially, then directive

S = Summarize Capture “essence”, link topics, transition

conversation

Summarize Capture “essence”, link topics, transition conversation

Communicates that you follow what your client said and understand the big picture.

Can help structure a session so that you and your client focus on the most relevant topics.

Summarizing can be an opportunity to emphasize certain elements of what your client has said.

Questions on MI?

MI is different and feels different from persuading or arguing.

MI is a goal-oriented, client-centered counseling style that enhances motivation by helping your client resolve ambivalence about behavior change.

The goal of MI is to prepare people to consider changing and to maintain their motivation for change, but not to push them into it.