motivational interviewing lecture
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Self-rating
Ability to work with resistant clients? How much do you agree: I am a good
listener? I am confident working with “stuck”
clients? I know how to help a client change?

Expectations: How MI can help
Competence Confidence Creativity
Improved presence Decreased frustration Increased connection

Learning MI
Start with the bad news Recommendation Minimum of two days

8 Step Framework for Learning MI
1. The SPIRIT of MI 2. OARS – client-centered counseling
skills 3. Recognizing and reinforcing change
talk 4. Eliciting and strengthening change talk 5. Rolling with Resistance 6. Developing a Change Plan 7. Consolidating client commitment 8. Shifting flexibly between MI and other
methods

You would think…
Debi Austin

Addiction

Romans 7 I do not understand what I do. For what I want to do I do not do, but what I hate I do. 16 And if I do what I do not want to do, I agree that the law is good. 17 As it is, it is no longer I myself who does it, but it is sin living in me. 18 For I know that good itself does not dwell in me, that is, in my sinful nature. For I have the desire to do what is good, but I cannot carry it out. 19 For I do not do the good I want to do, but the evil I do not want to do—this I keep on doing. 20 Now if I do what I do not want to do, it is no longer I who do it, but it is sin living in me that does it. 21 So I find this law at work: Although I want to do good, evil is right there with me. 22 For in my inner being I delight in God’s law; 23 but I see another law at work in me, waging war against the law of my mind and making me a prisoner of the law of sin at work within me. 24 What a wretched man I am


People are messy


MI Defined
It is a client-centered, directive method of engaging intrinsic motivation to change behavior by exploring and resolving ambivalence within the client.
William Miller and Stephen Rollnick

MI as a technique
Basic Like scales Different types of music
Science of counseling Art of counseling

Two Phases of MI
Phase I – Explore ambivalence/Build Motivation
Phase II – Change Talk, Planning, Strengthening Commitment

MI Elements
MI Spirit MI Principles DEARS OARS Change Talk

The Spirit of MI
FUNDAMENTAL APPROACH OF MI
MIRROR-IMAGE APPROACH
Confrontation
Education Authority
Collaboration
Evocation Autonomy

The Spirit of MI cont.
Motivation to change is elicited from the client, and not imposed from without.
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.
The counseling style is generally a quiet and eliciting one.
The counselor is directive in helping the client to examine and resolve ambivalence.
Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction.
The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

MI Principles: DEARS
Develop Discrepancy Express Empathy Avoid Argument (Amplify Ambivalence) Roll with Resistance Support Self-Efficacy

MI Principles: RULE
R – Resist the righting reflex U – Understand your client’s motivation L – Listen to your client E – Empower your client


Resisting the Righting Reflex

“We tend to believe what we hear ourselves say. The more patients verbalize the disadvantages of change, the more committed they become to sustaining the status quo.”
“If you are arguing for change and your patient is resisting and arguing against it, you’re in the wrong role. You are taking all the good lines.”
MI in Health Care p. 8

Emotional Intelligence
Personal Competence Self-Awareness Self-Management
Delaying gratification
Social Competence Social Awareness Relationship management

Empathy
Client-centered: Understanding the client’s internal frame of reference and present concerns.
Non-judgmental attitude. Understanding vs condoning

Counselor FAIL
Why don’t you change? How can you tell me that you don’t have
a problem? What makes you think that you’re not at
risk? Why don’t you just…? Why can’t you…?

Gottman’s Four Horsemen
Criticism Defensiveness Contempt Stonewalling

Benefits of Resisting Righting Reflex & Empathy
Permission Authenticity Validation Acceptance Safety Connection Trust

Normalization/Validation
Normalize is not approval. It is common experience. Permission to truly be known and know
themselves Vs Compartmentalization and shame

Their behavior may be a seemingly senseless problem, help them dig deeper to invalidated parts.
Based on a human need and desire…maladaptive ways to get them.
Trauma, codependency “Every problem was a solution to a
previous problem…”

Etiology of the problem


What fear can do
From CNN:Boyfriend: Phobia caused woman's 2-year bathroom stay
"The case drew nationwide attention after Ness County Sheriff Bryan Whipple said it appeared the Ness City woman's skin had grown around the seat in the two years she apparently was in the bathroom.
"We pried the toilet seat off with a pry bar and the seat went with her to the hospital," Whipple said. "The hospital removed it."

Reasons not to change
There is a “value” in staying the same. Freedom from the “cost” of change Freedom of the risk of failure. Safety of low expectations, not taking
responsibility. Freedom from the pressure of success Giving up secondary gains

Therapy is…

Grace and Truth
Not Grace or Truth, Grace vs Truth Grace with Truth
Scalpel Anesthesia
Rogers: “The curious paradox is that when I accept myself just as I am, then I can change.”

On Advice-giving and information
Key strength of MI: You don’t have to be an expert
Insight doesn’t guarantee change. Information doesn’t guarantee change. Diet book, self-help book, formula, plan “If reasons/change talk were enough they
would have made the change already…” (MI in tx of Psych. Problems. P.30)

Cont.
MI isn’t about finding the missing piece of information.
It isn’t necessarily problem-solving or “figuring things out”.
It isn’t “Making People Change” it’s “Preparing People Change”
By helping them fully be aware of their choices, competence and challenges and helping them CHOOSE.

Even if you may not agree with their choice, they are choosing with their eyes wide open.
With this “informed consent” they are being responsible for their life, they are choosing their path, choosing their consequences.

3 Modes of working
Following Guiding Directing
Develop flexibility in shifting modes
“Good leading is gentle, responsive and imaginative.” MI 2nd ed. P. 22

Asking How many times has that happened?
(directing) What kind of change makes sense to you?
(guiding) How have you been since your son died?
(following)

Informing
Your best option is to take these tablets. (directing)
Changing your diet would make sense medically, but how does that feel to you? (guiding)
Yes, it’s a common experience; many patients also feel quite shocked and unsettled about simple things like going to the toilet. (following)

Listening
So you understand what’s going to happen this morning, but you want me to tell you more about what will happen later on. (directing)
You’re feeling concerned about your weight, and you are not sure where to go from here. (guiding)
This has been a huge shock. (following)

Understanding Client’s motivation - Four client Profiles
Group A: Low importance, low confidence Group B: Low importance, high
confidence Group C: High importance, low
confidence Group D: High importance, high
confidence

Four Types of Precontemplators
Reluctance Rebellion Resignation Rationalization

I Thess. 5:14-18
14And we urge you, brothers, admonish
the idle, encourage the fainthearted, help the weak, be patient with them all. See that no one repays anyone evil for evil, but always seek to do good to one another and to everyone. Rejoice always, pray without ceasing, give thanks in all circumstances; for this is the will of God in Christ Jesus for you.


Where Good Ideas Come from
http://youtu.be/NugRZGDbPFU Steven Johnson Where Good Ideas Come From: The
Natural History of Innovation

Thomas Gordan’s Roadblocks
1) Ordering, directing 2) Warning, threatening 3) Giving advice, making suggestions,
providing solutions 4) Persuading with logic, arguing,
lecturing 5) Moralizing, preaching 6) Judging, criticizing, blaming

Roadblocks cont.
7) Agreeing, approving, praising 8) Shaming, ridiculing, name-calling 9) Interpreting, analyzing 1 0) Reasoning, sympathizing 1 1 ) Questioning, probing 12) Withdrawing, distracting, humoring,
changing the subject

OARS
Open-ended questions
Affirmations Reflective listening Summaries

Traps to Avoid
The Question/Answer Trap The Premature Focus Trap The Confrontation Trap The Blaming Trap The Expert Trap The Labeling Trap

Open-ended Questions
How? When? Where? What? Who?
Vs Yes/No
Closed questions: Clarifying questions Using Why?

Affirmations
Compliments Statements of appreciation and
understanding Thanks… I appreciate… You’re clearly a (character quality/value)
person… If I were in your position… You enjoy… I’ve enjoyed talking with you today…

Reflections
It is a hypothesis of what may be going on.
“Do you mean?” It is a statement to understand meaning.
MI: 2-3 reflections per question asked vs 10 questions: 1 reflections in other counseling sessions. About half responses are reflections.

Types of Reflections
Parroting – repeating, using same words Simple – basic paraphrase, acknowledge
feeling, perception or disagreement, small shift in emphasis
Amplified – amplified or exaggerated form
Double-sided – one way to develop discrepancy
Complex – summary, interpretation, metaphor/simile, continuing the paragraph

Amplified or understated?
I just don’t like the way she comments on how I raise my children.

Other Responses beyond Reflection
Shifting FocusShift the person’s attention away from what seems to be a stumbling block in the way of progress. Go around barriers rather than climbing
over them Reframing Agreeing with a twist Emphasizing personal choice and control Coming alongside

Reframing
Sometimes… A part of you… When you tried that in the past… I’m guessing, you might…(tentative)… Some people…when modeling or giving
advice vs self-disclosure.

You feel stuck…
"You feel stuck." sometimes brings the session to an awkward pause or even a grinding halt.
Therapist: "So, you feel stuck."Client: "Yep."[BONK!][Crickets]
Another variation is reflecting "You feel helpless." or "You feel hopeless." or "You feel trapped."

Summaries
Collecting Bouquets Untangle the threads Linking Transitional

Repeat

Amplify Ambivalence
“As I hear myself talk, I learn what I believe.” Decisional Balance The person experiences competing
motivations because there are benefits and costs associated with both sides of the conflict. There are two kinds of weights on each side of a the balance: one has to do with the perceived benefits of a particular course of action; the other has to do with the perceived costs or disadvantages of the course of action (such as taking medication to lower blood pressure).

Decisional Balance

Decisional Balance Sheet
Continue to drink as before Abstain from alcoholBenefitsHelps me relax Enjoy drinking with friends
CostsCould lose my family Bad example for my children Damaging my health
Spending too much money Impairing my mental ability Might lose my job Losing my time/life
BenefitsLess family conflict More time for my children Feel better physically Helps with money problems
CostsI enjoy getting high What to do about my friends How to deal with stress

Why ask Why?
Why, besides being an invitation for a fight, is victim language, past focused, it distracts from moving forward and facing change. On one hand, the past is one the best predictors of future behaviors; on the other, we're told Insight doesn't necessarily lead to change.
Search for meaning “Why do I?” “I know/believe…why do I
still?”

Alternatives to Why?
"What was/is going on?""What is happening/happens? when you...""How is pattern continuing? What fuels it?""What did you do? What didn't you do?""Where did this happen?""When did you start believing that [core belief or cognitive distortion]?"

"Where did you start doing that [behavior]?""Who taught you that [behavior/coping]? Who modeled that in your life?""How did you get here? To this place?""What if?""What did they do/say?"
"How did you respond?" (vs. "They made me...[feeling or behavior]")

"What did that look like? What did you feel? What did you experience?""When that happened - What did that mean to you? What did you start telling yourself? About God, others, family, yourself?""What was your role?“
"What would you do if you knew "Why?” How would knowing why? help you."

Here-and-now
How does this affect you?What are you experiencing?What will you do with this? What do you want/need?Who will you share this with?

What are you feeling?How can you reframe this?What is the alternative?What/How can you change/control?What are the obstacles?

Developing Discrepancy
Awareness of consequences is important A discrepancy between present behavior
and important goals will motivate change The client should present the arguments
for change. A “holy discontent” “Food for thought” vs judgment/criticism “Columbo” technique. “Help me
understand.”

Addiction Thinking
Minimization: where it all begins Rationalization: the plot thickens Denial: a preferred way to live Re-labeling: telling it like it isn’t Justification: I couldn’t help it Entitlement: you deserve a break today

Defense Mechanisms
http://changingminds.org/explanations/behaviors/coping/coping.htm
Adaptive mechanisms: That offer positive help. Attack mechanisms: That push discomfort onto
others. Avoidance mechanisms: That avoid the issue. Behavioral mechanisms: That change what we do. Cognitive mechanisms: That change what we think. Conversion mechanisms: That change one thing
into another. Defense mechanisms: Freud's original set. Self-harm mechanisms: That hurt our selves.

Explore Values
Values and priorities Values are positive. Preferred experiences (for example a
valued career/job) Behavioral ideals
Values Card sort at www.motivationalinterviewing.org

Behaviors that don’t serve one’s values
Self-oriented behaviors that neglect loved ones
Short-sighted behaviors that reap short-term rewards while ignoring long-term costs
Inefficient behaviors that fulfill certain needs at the expense of others

Alignment? How does (behavior) fit with the
importance of (value)? How does (behavior) fit with your desire
to do/be (value)?

Concreteness
Specific examples Clarification: in what ways? How much?
How often? Description of the last time? What else?

Cautions with Discrepancy
Your client can’t “lose” their way to change. Don’t use your clients words against them. Or at least if you do, don’t do a happy dance. Don’t back them into a corner, force them to
swallow their words down. Yeah, yeah, yeah, you’re right. I said that but
you’re a bastard for pointing it out! “A man convinced against his will is of the
same opinion still.” Dissonance and incongruence vs shame or
feeling tricked

Roll with Resistance
Avoiding arguing for change Resistance is not directly opposed New Perspectives are invited but not
imposed The client is a primary resource in finding
answers and solutions Resistance is a signal to respond
differently, to change strategies

Dad rolls his son
http://youtu.be/wsBon3DTwIY

Four process categories of client resistance behavior
1. Arguing – The client contests the accuracy, expertise, or integrity of the counselor.2. Interrupting – The client breaks in and interrupts the counselor in defensive manner.3. Negating – The client expresses an unwillingness to recognize problem, cooperate, accept responsibility or take advice.4. Ignoring – The client shows evidence of ignoring or not following the counselor.

Arguing
Challenging- challenges the accuracy of what is said
Discounting – counselor’s personal authority
Hostility – Client expresses direct hostility

Negating
Blaming Disagreeing Excusing Claiming Impunity (not in danger) Minimizing Pessimism Reluctance Unwilling to change

Ignoring
Inattention Non-answer No response Sidetracking
Other passive Over-compliance Cancellations, no-shows

Yes..But…
Spoken Unspoken
The power of AND

http://youtu.be/h5aSa4tmVNM

Jesus
Rich Young Ruler – Luke 18
Paralytic at Bethesda – John 5

MI – a shortcoming
Not just logically weigh pros and cons, Change Balance Sheet.
Doesn’t fully account for, or address sin. How does our new nature interact with
our flesh, this body of sin? How does the reality of the Holy Spirit
interact with us being sinful? How does the gospel apply? Trying on new clothes. Feels very
uncomfortable, intolerable.

Let That Be Enough Switchfoot
http://youtu.be/rdWEgu7c3i0
I wish I had what I need To be on my own 'Cause I feel so defeated And I'm feeling alone
And it all seems so helpless And I have no plans I'm a plane in the sunset With nowhere to land
And all I see It could never make me happy
And all my sand castles Spend their time collapsing

Let me know that You hear me Let me know Your touch Let me know that You love me Let that be enough
It's my birthday tomorrow No one here could now I was born this Thursday 22 years ago
And I feel stuck Watching history repeating Yeah, who am I? Just a kid who knows he's needy



Moving too fast…

Trust me, “It’s good for you” isn’t good enough. If they feel disrespected or worse,
traumatized/abused. More importantly, we’ve stolen growth/process
from them, we’ve stolen their opportunity to overcome their fear and to make their own free choice.
It may be good for them but it risks mistrust, anger, resentment.
Innoculate them to other risks/changes. Find ways to make change fun, not traumatic.

Support Self-Efficacy
Judge or Attorney
In client’s life who is the judge? Who has the final authority?
Who is hardest critic? You don’t want to be put in the position of
being the judge. You advocate for your client. Eventually advocate for themselves.
Ultimately they stand and give an account for themselves.

Directive Belief in the possibility of change: client’s
and counselors. Self-Fulfilling prophecy. Direct your client to direct themselves Direct your client to “grow up” – not in a
pejorative sense, they are adult, responsible, heroic, significant, God’s workmanship.
This where you “don’t work harder than your client”

You don’t care more, you don’t have all the insights/interpretations of meaning, aha moments.
You are winning when your client is winning, when they come up with the cool meaning and understanding about themselves. When they seem themselves for what they are.

Shifting from an external locus of control, where they are constantly seeking approval or answers outside of themselves to an internal locus of control. (Of course God is sovereign and involved. They do business directly with God. They don’t need an intermediary to discern God’s will for them.)
Bear their weight, carry their own load. Interdependence. Ask for what they want/need. Find what they want and need. Or ask for help.

Humble courage. Authentically know their limits vs
pretense and defensiveness. Not driven to do too much, free to do
much. Passion vs pressure Normalize it takes practice.

Trainer and Spotter Model, teach, coach, come alongside, spot. Start here by casting vision for self-efficacy. Empower client. Affirmations You can do it. You have done it. You might do it. People have done it. (normalize) How did you do it? (talk about successful
changes in the past)

How Not to Change – Bill O’Hanlon Change 101
1. Don't listen to anybody 2. Listen to everybody 3. Endlessly analyze and don't make changes. On the other hand, perhaps: "Don't just do something, stand there." 4. Blame others for your actions or problems. "We have only one person to blame and that's each other." 5. Blame yourself and put yourself down regularly

6. Keep doing the same things that don't work 7. Keep focusing on the same things when that focus doesn't help 8. Keep thinking the same thoughts when those thoughts don't help 9. Keep putting yourself in the same unhelpful environment 10. Keep relating to the same unhelpful people 11. Put more importance on being right than changing

Change Talk : DARN C
Recognize and elicit Desire: I want, I’d like to, I wish I could, I
can’t wait… Ability: I could, I can, I might be able to Reason: I would probably feel better if I…,
It would be good if I… Need: I ought, I have to, I really should…

4 Categories of Change Talk
Recognizing the disadvantages of the status quo
Recognizing the advantages of change Expressing optimism about change Expressing intention to change
“What is your client’s change language”

Evoking DARN C
Desire: "What do you want to do about this behavior?"
Ability: "What makes you believe you can do this?"
Reason/Need: "Why would you want to make this change?"
Commitment: "So what are you willing to do now?"

Desire: Why would you want to make this change?
Ability: How would you do it if you decided?
Reason: What are the three best reasons? Need: How important is it? and why? Commitment: What do you think you’ll
do?

Key Questions
“What do you think you will do?” “What does this mean about your
(habit)?’ “What do you think has to change?” “What are your options?’ “What’s the next step for you?” “What would be some of the good things
about making a change?” “Where does this leave you?”

Phase II – Initiating Change
A negotiable, workable plan

Phase II Hazards
Underestimating Ambivalence Over-prescription Insufficient Direction

Recapitulation – Summary
Summary of client’s perception, change talk, importance talk
Summary of ambivalence, positives of status quo
Objective evidence, if any Restatement of DARN-C, confidence talk Your own assessment of client’s situation

Change factors from Change 101
Positive and Negatives from the Past
Positive and Negatives in the Present
Positive and Negatives in the Future

Eliciting Change Talk:MI Becomes Directive
IQ-LEDGE-C Importance/Confidence Ruler Querying Extremes Looking Back / Looking Forward Evocative Questions Decisional Balance Goals and Values Elaborating Coming Alongside

Change Ruler

Scaling
“If on a scale of 1 to 10, 1 is not at all important to give up smoking and 10 is extremely important to give up, what number would you give yourself at the moment?”
“If you were to decide to give up smoking now, how confident are you that you would succeed? On a scale of 1 to
10, 1 means that you are not at all confident and 10 means you are 100% confident you could give up and remain a non-smoker.” “Why are you at (chosen number) and not at 1?” “What would need to happen for you to go from (chosen
number) to (a higher number)?” “How can I help you go from (chosen number) to (a
higher number)?”

Query
What is the worst case scenario? What is the best case scenario?

Looking Back / Looking Forward
With problem Without problem

Evocative questions
Hypothetical How? Or What? Would you do…if…
Desire: "What do you want to do about I this behavior?"
Ability: "What makes you believe you can do this?"
Reason/Need: "Why would you want to make this change?"
Commitment: "So what are you willing to do now?"

Decisional Balance

Goals and Values

Elaborating

Coming Alongside
Paradoxical, “therapeutic paradox” “reverse psychology”
Permission to not change Postpone change “Not ready” “Not the right time” “In the meantime…” Actually “firing” your client or suggesting
referral to another counselor, other solutions.

Responding to change talk - EARS
Reinforce and consolidate change talk Elaborating: In what way… ?; Tell me more…;
What else? Affirming: That took a lot of courage; You’re a
person who can make changes when you need to…
Reflecting: That’s really important to you …; You realize it’s become a problem…
Summarizing: There are a number of things I’m hearing about your situation . First, you’re concerned about….. Also, you feel…, and you are thinking…

Evoke and Strengthen Commitment
I should I might I could I will

Negotiate A Change Plan
Setting Goals Considering Change
options Arriving at a plan Eliciting commitment

Commitment
Have you come to conclusion? Are you ready? How close? Anything else to consider?

Choices to make for plan
Method – What? Preferred strategy – How? Timing – When?

The Adjacent Possible
Scientist Stuart Kauffman quoted by Steven Johnson
The phrase captures both the limits and the creative potential of change and innovation.
What is possible? What is probable? What are the small, next steps? Being faithful with a little first

Building emotional, mental, relational muscles that they haven’t built yet.
What would that look like? What might happen? There is hope in the range of alternative
approaches available. There is no one “right way” to change –
menu of changes

10 Stages of Recovery

SMART Goals
Specific Measurable Attainable Relevant Time-bound

RISE by Stephen Arterburn
"The goal of treatment is to RISE above your problems rather than be controlled and dominated by them." Stephen Arterburn Healing is A Choice

Reduce
Reduce the stress in your life by learning some new management skills
Reduce conflicts that cause inner turmoil and difficulties in your relationships.
Reduce the negative patterns that have set in over your lifetime.
Reduce the substances you use to help cope with the pain in your life.

Increase
Increase your self-awareness and how you affect people who interact with you.
Increase your awareness of your feelings.
Increase your understanding of yourself and why you do the things you do.

Increase your connection with others.
Increase your assertiveness in a way that draws people to you rather than repels them.
Increase the healthy influences in your life.
Increase your time alone with God in the Bible and in prayer.

Substitute positive emotions for negative ones.
Substitute the willingness to risk for fear. Substitute humility for arrogance.

Substitute acceptance for anger. Substitute peace for anxiety. Substitute surrender for control.

Eliminate
Eliminate addictive behaviors
Eliminate a critical and judgemental spirit.
Eliminate certain repetitive sins in your life.

Change as grief
Sometimes change talk can sound like ambivalence or resistance.
Client may be articulating what they will be giving up.
Even dysfunctional relationships, beliefs, behaviors can be hard to let go of.
For some weight can be a defense, being more attractive can be risky, it opens up opportunity for relationship which in term means more risk at being known and being hurt.

Resources
http://www.motivationalinterview.org/ http://www.motivationalinterview.org/quic
k_links/manuals.html
Motivational Interviewing: Preparing People for Change, 2nd Edition Miller, William R., Rollnick, Stephen (2002)
Building Motivational Interviewing Skills: a practioner workbook Rosengren, David B. (2009)

Motivational Interviewing in Health Care: Helping Patients Change Behavior Rollnick, S., Miller, WR & Butler, CC (2008)
Motivational Interviewing in the Treatment of Psychological Problems Arkowitz, H., Westra, HA, Miller, WR., Rollnick, S editors
Emotional Intelligence 2.0 Bradberry, T., Greaves, J (2009)
Emotional Intelligence Quick Book Bradberry, T., Greaves, J (2003)

Change 101: A Practical Guide to Creating Change in Life or Therapy O’Hanlon, B. (2006)
www.newlife.com www.cloudtownsend.com