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The Spirit of Motivational Interviewing

Reviewing the Basics – even if you’re new to MI!

Bryan Kutner, PhD, MPHTraining Consultant

bryan.kutner@gmail.com

So, what is MI?

and movement toward a specific goal by eliciting and exploring the person’s own arguments for change.

– Motivational Interviewing, 3rd Edition

Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change.

It is designed to strengthen an individual’s motivation for

Click for a quick video introducing MI!

A Continuum of Styles

Directing Guiding Following

Authoritarian Motivational Interviewing

Rogerian (Client-Centered)

Spirit of Motivational Interviewing

Collaborative

Evocative

Respectful of autonomy

Working with and sharing power“You, the client, might be right…”

Rather than insert knowledge, draw it from the client“You have knowledge, wisdom, expertise, and my job is to get that out on the floor between us…”

The client retains the right not to change and the right to change the way they want, even if that isn’t what we want.

Spirit in MI 3rd Edition

Sometimes it’s easier to see the opposite…

Opposite Approach

Confronting

Educating/Giving Information

Emphasizing authority

Motivational Interviewing

Collaborative

Evocative

Respectful of Autonomy

Four Processes

Engaging

Focusing

Evoking

PlanningIf you’re stuck during MI, fall back to an earlier

process

“When Would I Use MI?”

• There is a change target — a behavior that the client is at least considering or forced to consider changing.

• The client is ambivalent about the change — they want to change, but something is preventing them from making that change.

AmbivalencePart of you wants to

change; part of you

doesn’t want to change

Equipoise means exploring all sides of ambivalence

Status Quo Changing

+’s

-’s

+’s of not changing

-’s of not changing

+’s of changing

-’s of changing

But Equipoise is not MI• The expected outcome of

exploring all sides is more AMBIVALENCE

• When you are guiding, the order of the boxes matters

• In MI, pay more attentionto change talk

• Change talk: pros of changing, cons of not changing

Status Quo Changing

+’s

-’s

Pros of not changing

Cons of not changing

Pros of changing

Cons of changing

Microskills: OARS• Open questions

• Affirmations

• Reflections

• SummariesMI relies on a set of specific skills (OARS)

We’ll focus on one of them!

Reflections

Reflections are really a hypothesis– a guess about what someone means with their words.

They connect back to what a person means

Reflecting is a Different Kind of Hypothesis Testing

A reflection is a guess that isn’t a question – it’s a statement. The inflection turns down at the end, not up.

• A hypothesis can be a question: “You’re getting a divorce?”

• Or a reflection: “You’re getting a divorce.”

Reflections Range in Intensity

Simple reflectionsrestate something about what was said

Complex reflectionsmove beyond the client’s words to present information in a new light

Reflections Range in Intensity“I know I could do some things differently, but I don’t need people

reminding me all the time that diabetes is going to kill me.”

Feelings

Meaning

Double-sided

AmplifiedMetaphor/ Analogy

“It’s upsetting enough, even without that reminder.”

“You’d like people to be supportive in a different way.”

“You don’t need people nagging you; you alreadyknow there are things you’d like to do differently.”

“It’s like they’re just trying to scare you.”

“You’re already shouldering a lot and you’d like folks to help you carry it instead of making it heavier.”

Change Talk

What is it?

Why should I care about it?

Listening for Change Talk

• “If I keep missing my meds, I just know I’ll end up back in the hospital. …

• “But taking meds is still the least of my worries. I got to think about how to pay all these bills.”

Change Talk

Sustain Talk

Different Kinds of Change Talk: DARNCAT

Desire

Ability

Reasons

Need

Commitment

Activating

Taking steps

}}

PreparatoryChange Talk

MobilizingChange Talk

Desire I want to …

Ability I could …

Reasons I’d feel better if …

Need I have to …

Commitment I am going to …

Activating I’m willing to …

Taking steps I started to …

MI Recognizes, Elicits & Reinforces Change Talk

Motivational interviewing aims to producethe client’s own

change talk

Change talk is like seeing a wildflower in a field of

grasses…Pick the flowers up, give them back as

reflections and summaries

Change talk often is sandwiched between sustain talk

• Our job is to pull out the center of the cookie – the change talk –and give it back to the client

We do that by recognizing, eliciting, and reinforcing change talk with O.A.R.S.

Ambivalence is a Change Talk Cookie

change talk

sustain talk

sustain talk

A. “I love having a cigarette at the end of the day.”

B. “I know I should probably quit at some point.”

C.“But it’s almost not worth trying again because every time I’ve said I’m gonna quit, I go right back to smoking again.”

Where’s the Change Talk?

change talk

sustain talk

sustain talk

Snatching Change Talk from the Cookie

They’re all great reflections – but which one reinforces change talk?

Client: “I really don’t like condoms. But I know that I should use ‘em. I’ve tried before and it’s just really hard to enjoy sex that way.”

A. “You really don’t want to use them.”

B. “You’re not sure if you can use them and enjoy sex.”

C. “It bothers you that you haven’t been able to use them.”

“I really don’t want to quit smoking. But I know that I should. I’ve tried before and it’s really hard.”

A. “You really don’t want to quit.”

B. “You’re not sure if you can quit.”

C. “It’s become clearer to you that at some point you’ll really need to quit.”

Snatching Change Talk from the Cookie

Change Rulers

Importance

“On a scale from 0-10, how important is it to make the change?”“How come you’re at ________ and not lower?”

|0——1——2——3——4——5——6——7——8——9——10|

Confidence

“From 0-10, how confident are you that you can make the change?”“How come you’re at ________ and not lower?”

|0——1——2——3——4——5——6——7——8——9——10|

% of Counselors Proficient in MI at 4 months140 randomly assigned counselors

0 10 20 30 40 50 60 70 80 90

Workshop + feedback + coaching

Workshop + coaching

Workshop + feedback

Workshop only

Book only

Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72(6), 1050–1062. http://doi.org/10.1037/0022-006X.72.6.1050

Proficiency in MI often

requires feedback

and coaching

Developmental Steps to Learning MI

1. Understanding the spirit of MI2. Skill & comfort with reflective listening (OARS)3. Identifying change goals toward which to move4. Exchanging info and providing advice within an MI style5. Recognizing change talk and sustain talk6. Evoking change talk7. Responding to change talk in a way that strengthens it8. Responding to sustain talk & discord without amplifying it9. Developing hope & confidence10.Timing and negotiating a change plan11.Strengthening commitment12.Flexibly integrating MI with other skills & practices

Training & Supervision Resources

Rosengren, D. B. (2017). Building Motivational Interviewing Skills: A Practitioner Workbook, 2ndEdition (pp. 1–529). New York, NY: Guilford Press.

William R. Miller Ph.D. and Stephen Rollnick Ph.D. Motivational Interviewing: Helping People Change, 3rd Edition. Guilford Press. New York: 2013.

Motivational Interviewing website: www.motivationalinterview.org

Bryan Kutner, PhD, MPH, bryan.kutner@gmail.com