MOTIVATIONAL INTERVIEWING GETTING STARTED WITH MOTIVATIONAL COUNSELING
Patrick McKiernan PhD, CADC
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Overall Seminar Goal2
• Provide a quick start to motivational counseling: – Focus on practical clinical aspects– TRY to limit theory and concepts– Increase ability to implement MI– Increase practice skills – Increase supervision/evaluation
skills• Exposure to research that is changing
motivational interviewing practice
MI intervention overview (big picture)
MI targeted behavior: Create and sustain engagement in an adherence change plan. Follow Doctor’s recommendations
Meditational: Different than actual treatment adherence.
Key point: MI is behavior specific
MI is highly strategic Advanced counselors are more strategic… Strategic: More efficient (briefer) and
effective Client state is continually assessed
Navigational map Counselor utterance is a strategic response
Few client states Relatively few MI strategies Memorize
Influences and References5
Client Centered Therapy (Carl Rogers): Non Directional
Motivational Interviewing (Miller & Rollnick): Directional Approach
Self Determination Theory (Deci and Ryan): Psychological Needs & Quality of Motivation
Transtheoretical Stages of Change (Prochaska and DiClemente): Process of change
Behavioral Economics (newly applied to change): Time value and temporal effects on decision making.
Rooted in Natural Change6
• Self-actualization tendency (Rogers)• Adaptive creatures Systems perspective
– Manipulate environment to meet their needs and desires
– Opening up a closed system• Self Determination Theory: Human
thriving– Subtle nature of motivation… behavior
doesn’t follow behavioral principles…– Better motivation is more value driven
RESEARCH ON MI: Meta Analysis
Important distinction from Hettama (p. 108)
MI does NOT communicate “I have what you need.”
BUT RATHER“You have what you need, and together we
will find it.”
Research on MI:Works as Standalone or Front End
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Phase I vs. Phase II Before and after commitment to change.
MI works as a standalone intervention
As a front end for some other intervention to increase treatment adherence
Phase IMotivational Counseling
Phase II:Open ended menu of options
Phase IMotivational Counseling
Phase II:Some prescribed treatmentemphasized (e.g., Lincoln Trail)
Meta Analysis: Summary The evidence base for MI is extremely
strong in addiction and growing in health. Evidence base is vast “72 target clinical
trials spanning a range of target problems (Hettema, 2005)”
Current research is focused on finding “why” and “how” it works.
Research on learning: Best learned through practice.
Meta Analysis Works better than alternative approaches with
with people from ethnic minority groups. angry and resistant, or less ready for change
clients. MI as preparation for any other treatment program
High effect sizes are observed Improves tx adherence and retention The effect endures across time
When MI is used as a standalone rapid impact of MI gradual de-crease of effect size across time Implications: Booster sessions Use as a stepped care program (followup built in) Used as fallback (followup built in)
What is motivation?
How do we change it?
Miller & Rollnick on, What is motivation?
• Motivation: Mediates MI tx adherence• Measurement: Recognition or action
– Ambivalence is difficult to measure• Complex construct: Not feeling, thought,
behavior;… rather, a drive / energy / fuel
• Dynamic / volatile across time and environment
• M&R: Ready (committed), willing (important), and able (self-efficacy / confidence)
SIMPLE NAVIGATIONAL MAP
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WORKING ALLIANCE(red)
Importance of Change
Commitment to Change
Change Plan
?? Temporal Effects ??
Change Confidence
Major influences and trendsWhat is MI?
Nature of Change Discussion15
Think of some non-trivial behavioral change that you or someone you know attempted? Smoking, diet / weight, exercise, etc.
What important values or goals were the impetus for change?
Was it self change or aided change? What helped? What didn’t help? Did education help?
Describe pattern of change across a long period of time. Lapse?
Application to yourself
1. Think of one change you would like to make in your life.
2. How ready do you feel to make this change?
3. Use a rating ruler to rate your readiness to change:
NOT READY TO CHANGEUNSURE READY TO CHANGE TAKING ACTION
1 2 3 4 5 6 7 8 9 10
Phase I: Continual assessment determines strategy (RICC)
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1.Relationship: How strong is my
relationship with this person?
2.Importance: Is change important to
him/her? Is he or she ambivalent?
3.Confidence: How confident are you that you can change if you
tried? Will self efficacy support change plan?
4.Commitment: What do you want to do?
Note: All counselor strategies should be ideally directed at
advancing one of the four RICC components.
Therapeutic Relationship (TR or working alliance) Dilemma
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• Strong TR is related to greater change.• How will we know the level of TR?
– Will they tell us? Can we ask?– If they do, can you rely on what they
say?– Can you judge?
• Can only best be judged through counselor behaviors.
• Problem: Requires preventive efforts and hyper vigilance.
Therapeutic Relationship (TR)19
Rogers: Create an environment for self-actualization TR
Synonym: Working alliance RULE: A TR is a requirement for
facilitating change. No TR / No change.
What are risks to TR?
Developing & Maintaining TR20
Spirit of Motivational Interviewing Psychological needs (self-determination
theory) Autonomy / internal locus of control Challenge / competency / self efficacy Relatedness
All of the MI principles aid in increasing TR Express empathy --Support self
efficacy Understand resistance --Develop
discrepancy
TR: Risk and Protective FactorsSupportive /
Protective Accurate
understanding (or empathy) Client talks>50% Support autonomy Convey competency Sponsor relatedness Affirm and accept (unconditional positive regard) Understand
resistance Discover
goals/values Ask permission for
risk factors
Risk factors*• Observe / confront• Give advice / fix it• Educate / fix it• Share opinion• Take on authority
role• Debate / argue /
defend• Being rushed• Fail to listen• INACCURATE • REFLECTIONS!!!*Avoid whenever
possible. Ask permission when
necessary.
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Risk created by brevity22
Poor TR Blocks chance to help Avoid TR risk whenever possible Brevity: Need for balance Know when you
are taking risk Calculate risk Mend fences Monitor client relationship Risk is minimized by asking
permission and tone in which you give advise, educate, or observe
3 Strategies to improve importance
1. Assess importance and elicit most important reasons for change with rulers
2. Use decisional balance exercises to fully assess, clarify, and organize ambivalence
3. Life plan discovery: Explore past successes and future plans to achieve important goals and values (desired or ideal)
• Raises discrepancy
Strategies to improve importance 1) Use of the Importance Ruler
Efficiently assesses importance Also discovers most important reasons for
change. How: “On a scale of 1 to 10, how important
is making a change?” If client is high (8 or above) in importance,
summarize and move to assessment of CONFIDENCE
If client response is 7 or below, elicit most important reasons for change with a ruler
Why would you say a [stated value] compared to [stated value minus 3 or 4].
Strategies to improve importance2) Decisional Balance Exercises
Decisional balance Weighted list of pros/cons. Aids the client (and the counselor) in clarifying level of
ambivalence vs. importance. What are the good things and not so good
thinks about recovery? List them. Pros/Benefits/Good things (the pros and change and cons of
status quo) Cons/Costs/Not so good things (cons of change and pros of
status quo) KEY Response: Reflect the underlying value.
Every pro or con has an important value/goal attached to it…. OR THEY WOULDN’T MENTION IT.
Making that connections increases brings clarity.
Transtheoretical Stages of ChangeProchaska & DiClemente
Trans. Stages (process) of Change.Where does clinical purpose shift?
Stage of Change Precontemplative
Contemplative Preparation /
Determination Action Maintenance Relapse
Client Process Unaware Pre-crystallization Unwilling Discrepancy (conflict
with important goals/values) Discouraged Support self efficacy Ambivalent Discrepancy tips scale Commit & prepare
Collaborate on treatment plan.
Carryout Tx plan / learn Relapse prevention / refine
Overcome shame / regain confidence
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MI 2nd Edition: 2 Phases of Change1. Uncommitted to change: Resolve ambivalence
in two forms… Important? Awareness of value incongruence. Confidence? Self-efficacy—will it work? can I
do it? Phase 2 shift marked by intent /
commitment
2. Committed: Collaborate on change plan Collaborate / menu of choices for action
plan… Continue to assess for importance /
confidence Termination
MI Sandwhich
MI Assessment “sandwich” concept: MI strategies during opening 20
mins Agency intake assessment MI strategies during closing 20 mins
MI emphasis on “spirit”30
• Open ended question: Begin with how or what.
• Spirit (SDT research based version): – Autonomy (emphasize client choice) – Competency (they have what they need),– Relatedness (peer relationship, no
authority).
• Reflections– Good: Simple (paraphrase)– Complex: Reflect emotion or change
meaning
DISCOVERY: Achieving 2 Ends31
• Interview for most important goals and values (ideal life) Achieves 2 ends– People crave to be understood– Initiates the process of raising importance.
• Focus on constructing a vision of the clients desired (or ideal) life.– Value clarification
• Spirit: Use TR protective strategies and avoid TR risks.
Discovery: Common Values/Goals32
Health Money / security Relationship with some romantic partner Wellbeing of children and family Psychological needs (SDT): Autonomy /
competency / relatedness Will favor experiences that promote these Relatedness: Social support peer vs.
authority.
TR Risk: Nuance33
Some people are harder than others Greater or lesser need for controlling
interaction Depressed people are oftentimes preferring
advice and more assertive TR Trap: Clients are accustomed to being
treated in an authoritative way. Will they complain if you are typical of other
professionals? Normal??? How will they notice if you are “different than
other counselors.” Will they tell you?
Accurate Empathy & Reflections34
Empathy is conveyed with reflections Statement of understanding
Simple reflection: Parroting or paraphrasing Complex reflection: Changing or adding
meaning or emotion Reflections are better than questions…
Conveys understanding Does not cause pause to consider question. Keeps conversation on Clients track, not our
own. Accelerates the pace of the interview
Motivational Interviewing Clinical Interview: Putting Responsibility for Change on the Patient.
Simple Reflection Shifting Focus Reframing Rolling with
Resistance Siding with the
Negative Self-Efficacy
Avoiding Arguments Open-ended
Questions Listen Reflectively Expressing Empathy Develop Discrepancy Affirm
REFLECTINGACCURATE EMPATHY
Ongoing method to communicate understanding and stimulate deeper instropsection
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KEY: Management of Self 37
TIMING… Never suggest a planning idea until Phase II change planning.
***Manage YOUR RIGHTING REFLEX Hard to observe someone in pain
or suffering without reacting Makes us want to fix Fix it statements are not good
Our righting reactions must be managed!!!
Impatience and burn out are also sources of reactionary problems.
Myth? Resistance or Denial
Despite the common belief, researchers have suggested that there is no denial, only resistance (caused by paradox).
Addicted people are aware of problems related to drinking.
People will become resistant in response to confrontation or emphasizing the need for change (paradoxical response). It’s not denial it’s resistance caused by paradox
Strategies to improve importance 1) Use of the Importance Ruler
Efficiently assesses importance Also discovers most important reasons for
change. How: “On a scale of 1 to 10, how important
is making a change?” If client is high (8 or above) in importance,
summarize and move to assessment of CONFIDENCE
If client response is 7 or below, elicit most important reasons for change with a ruler
Why would you say a [stated value] compared to [stated value minus 3 or 4].
Strategies to improve importance2) Decisional Balance Exercises
Decisional balance Weighted list of pros/cons. Aids the client (and the counselor) in clarifying level of
ambivalence vs. importance. What are the good things and not so good
thinks about recovery? List them. Pros/Benefits/Good things (the pros and change and cons of
status quo) Cons/Costs/Not so good things (cons of change and pros of
status quo) KEY Response: Reflect the underlying value.
Every pro or con has an important value/goal attached to it…. OR THEY WOULDN’T MENTION IT.
Making that connections increases brings clarity.
Strategies to improve importance3) Life planning discovery
Clarifies, aids client in healthy life planning Protracted dialogue on achieving the desired
(or ideal) life Desired life: Goals and values discovered
previously Explore… how can you achieve the desired life
while continuing to use… look forward, look back. Explore… how would it be different if you were to
decide to change your drinking.
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