Unit 2: Learning the Motivational Interviewing Speak
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Motivational Interviewing - A Training Resource By Jim Messina
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A Helping Truism:
How many helpers does it take to change a light bulb?
Just one, but the light bulb has to want to be changed.
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Learning the Motivational Interviewing Speak
Before We Get Started Some Points to Remember
A few key points embody the spirit of Motivational Interviewing:
- Motivation to change is determined by the client, not externally imposed by the helper
- The clients own the responsibility to resolve their ambivalence.
- Prescribing specific methods or techniques is ineffective; allowing clients to pursue their own means of change increases likelihood of success.
- Clients’ resistance and denial are viewed as a reaction to helpers’ behaviors, not as clients traits.
- The client/helper relationship is seen more as a collaborative and friendly partnership than as an expert/recipient or teacher/student relationship.
Keep in the Spirit of Motivationa Interviewing when working with clients
1. Draw out vs. implant the right ideas:
“What concerns you about your financial situation?”
VERSUS
“You need to start working.”
2. Allow the freedom NOT to change vs. push for commitment:
“How ready are you to change?”
VERSUS
“If you delay getting sober, you could die.”
3. Collaborate:
“What do you think you’ll do?”
VERSUS
“You’ve got to take your medications.”
Counseling Skills Needed by Helpers in MI
The practice of motivational interviewing requires the Helpers to develop five primary skills:
- Express empathy Be non-judgmental; listen reflectively; accept ambivalence; see the world through the clients’ eyes. Accurately understanding the clients’ experience can facilitate change.
- Develop discrepancy This help clients to perceive difference between present behavior and desired lifestyle change. Clients are more motivated to change when they see what they’re doing will not lead them to a future goal.
- Avoid argumentation Helpers gently diffuse clients’ defensiveness. Confronting clients’ denial can lead to drop out and relapse. When clients demonstrate resistance to change, helpers change strategies.
- Roll with resistance Reframe clients’ thinking/statements; invite clients to examine new perspectives; value clients as being their own change agents.
- Support self-efficacy Provide hope; increase clients’ self-confidence in ability to change behaviors; highlight other areas where clients have been successful.
RULE Targets MI Skills in Health Care Settings (Miller, Rollnick, & Butler, 2008)
- Resist - to resist the righting reflex
- Understand - to understand and explore the clients’ own motivations
- Listen - to listen with empathy
- Empower - to empower the clients, encouraging hope and optimism.
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What is the Righting Reflex?
It is the natural inclination we have to make it better for another person.
What’s the danger? We tell the other person what to do, how to do it, and why they should do it without talking to them and learning what they think.
It creates resistance in that we move away from the partnering stance of MI and into the expert top down role.
What to do when you find yourself doing this? Stop and Reset: “Mrs. Smith, I realize I have been just lecturing you on how you can deal with your diabetes without learning what you are thinking. Let me back up and hear from you, wherever you would like to start.”
Assumptions Related to the Righting Reflex
1. They ought to change
2. They want to change
3. Their health is the prime motivating factor for them
4. If they do not decide to change, the consultation has failed
5. Individuals are either motivated to change, or they’re not
6. Now is the right time to consider change
7. A tough approach is always best
8. I’m the expert they must follow my advice
9. A negotiation approach is always best
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Four Processes in Motivational Interviewing (Miller & Rollnick, 2013)
1. Engaging: is the process by which both parties establish a helpful connection and a working relationship. Therapeutic engagement is a prerequisite for everything that follows and it involves developing a working alliance.
Asking Permission
Rationale: Communicates respect for clients. Also, clients are more likely to discuss changing when asked, than when being lectured or being told to change.
Examples of Asking Permission:
“Do you mind if we talk about [insert behavior]?”
“Can we talk a bit about your [insert behavior]?”
2. Focusing: is the process by which providers and clients develop and maintain a specific direction in the conversation about change. In the course of helping relationships, a direction towards one or more change goals usually emerges.
Tips for Using Elicit-Provide-Elicit (ASK-TELL-ASK)
- Use Neutral Language as much as possible“Folks have found…” “What we know is…” “Others have benefited from…”
- Avoid sentences starting with “I” or “You”
- Use Conditional words rather than concrete words: “might” “perhaps” “consider” vs. “should” “must”
- Utilize the “Spirit” of MI: When “instructing” is necessary, recognize “where” your client is and only provide relevant advice/information.
Elicit – Provide – Elicit (ASK-TELL-ASK)
Elicit – ASK what the client knows or would like to know or if it’s okay if you offer them information:
- “What do you know about the effects of second-hand smoke on children?”
- “Is it okay with you if I share what we know?”
- “Would you be open to learning more?”
- “Do you mind if I express my concerns?”
- “Can I share some information with you?”
Provide –TELL Information in a neutral, nonjudgmental fashion. “Research suggests that second-hand smoke is especially harmful to children because…” vs. “Every time you smoke around your child, you put them at risk….”
Elicit –ASK The client’s interpretation “What does this mean to you? How can I help?” vs. “It’s obvious from this information that you need to quit.”
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EXAMPLES: Elicit – Provide – Elicit (Ask-Tell-Ask)
CASE 1 – Candidate for surgery who smokes
Elicit:
“What do you know about how smoking affects the healing process after surgery?”
Vs.
“If the team performed surgery on you, they’d be afraid your wound would never heal because of your smoking.”
Provide:
“What we know is that the tobacco can impair the wound after surgery leaving folks vulnerable to infections.”
Elicit:
“Tell me what your thoughts are about that.”
Vs.
“It’s obvious from this information that you need to quit.”
CASE 2 – Pregnant woman who smokes
Elicit:
“Is it okay with you if I share some concerns?”
Provide:
“Research suggests that smoking can be harmful to the fetus…What we know is the carbon monoxide…”
Vs.
“Everytime you inhale, you are harming your baby.”
Elicit:
“Where does this leave you now?” or “What does this mean to you?” “How can I help?”
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3. Evoking: involves eliciting the clients’ own motivations for change, and it has always been at the heart of MI. It occurs when there is a focus on a particular change and the providers harness the clients’ own ideas and feelings about why and how they might do it. Evoking is having the clients voice the arguments for change.
Eliciting/Evoking Change Talk
Questions to Elicit/Evoke ChangeTalk:
“What would you like to see different about your current situation?”
“What makes you think you need to change?”
“What will happen if you don’t change?”
“What would be the good things about changing your [insert risky/problem behavior]?”
“What would your life be like 3 years from now if you changed your[insert risky/problem behavior]?”
“Why do you think others are concerned about your [insert risky/
problem behavior]?”
Show Appreciation for the Ambivalence in Evoking Change Talk
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Using marijuana
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Quitting marijuana
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Benefits of:
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Helps me relax
Helps with pain
My friends and I have fun when we smoke
I feel fine
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Stay healthy
Save money
Stay out of jail
Finish probation
I am less likely to die
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Costs of:
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Doctor lectures me
I am broke
Nasty cough
Legal problems
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My friends will think I’m boring
My pain will be worse
I will feel more anxious
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4. Planning: encompasses both developing commitment to change and formulating a specific plan of action. It’s a conversation about action that can cover a range of topics, conducted with a sharp ear for eliciting clients’ own solutions, promoting their autonomy of decision making and continuing to elicit and strengthen change talk as a plan emerges.
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Ten Strategies for Evoking Change Talk
1. Ask Evocative Questions: Ask open question, the answer to which is change talk.
2. Explore Decisional Balance: Ask first for the good things about status quo, then ask for the not-so-good things.
3. Ask for Elaboration: When a change talk theme emerges, ask for more details. In what ways? Tell me more…? What does that look like?
4. Ask for Examples: When a change talk theme emerges, ask for specific examples. When was the last time that happened? Give me an example. What else?
5. Look Back: Ask about a time before the current concern emerged. How were things better, different?
6. Look Forward: Ask what may happen if things continue as they are (status quo). Try the miracle question: If you were 100% successful in making the changes you want, what would be different? How would you like your life to be five years from now?
7. Query Extremes: What are the worst things that might happen if you don’t make this change? What are the best things that might happen if you do make this change?
8. Use Change Rulers: Ask, “On a scale from zero to ten, how important is it to you to [target change] - where zero is not at all important, and ten is extremely important?
Follow up: And why are you at ___and not _____ [lower number than they stated]?
What might happen that could move you from ___ to [higher number]? Instead of “how important” (need), you could also ask how much you want (desire), or how confident you are that you could (ability), or how committed are you to (commitment). Asking “how ready are you?” tends to be confusing because it combines competing components of desire, ability, reasons and need.
9. Explore Goals and Values: Ask what the cleints’ guiding values are. What do they want in life? Using a values card sort can be helpful here. If there is a “problem” behavior, ask how that behavior fits in with the person’s goals or values. Does it help realize a goal or value, interfere with it, or is it irrelevant?
10. Come Alongside: Explicitly side with the negative (status quo) side of ambivalence. Perhaps _______is so important to you that you won’t give it up, no matter what the cost
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Strategies of Motivational Interviewing (Miller & Rollnick, 2013)
Open Ended Questions, Affirmations, Reflections, and Summaries
OARS
O - Open-Ended Questions
Examples of Open-Ended Questions:
“Tell me what you like about your [insert risky/problem behavior].”
“What’s happened since we last met?”
“What makes you think it might be time for a change?”
“What brought you here today?”
“What happens when you behave that way?”
“How were you able to not use [insert substance] for [insert time frame]?”
“Tell me more about when this first began.”
“What’s different for you this time?”
“What was that like for you?”
“What’s different about quitting this time?”
“What worries you about your current situation?” (disadvantages of status quo)
“How would you like your life to be five years from now?” (advantages of change)
“What encourages you that you can change if you want to?” (optimism about change)
“What would you be willing to try (intention) or what do you think you might do?”
A – Affirmations
Affirmations
Rationale: Affirmative responses or supportive statements by helpers verify and acknowledge clients’ behavior changes and attempts to change. When providing an affirmation, helpers should avoid statements that sound overly ingratiating (e.g., “Wow, that’s incredible!” or “That’s great, I knew you could do it!”).
Example of Affirmative Statements
“Your commitment really shows by [insert a reflection about what the client is doing].”
“You showed a lot of [insert what best describes the client’s behavior—strength, courage, determination] by doing that.”
“It’s clear that you’re really trying to change your [insert risky/problem behavior].”
“By the way you handled that situation, you showed a lot of [insert what best
describes the client’s’ behavior—strength, courage, determination].”
“Thanks for coming on time today”
“That’s a good suggestion”
“It seems like you’re a spirited and strong person”
“You enjoy being happy with other people and making them laugh”
“You are clearly a resourceful person to cope with such difficulties for so long”
R – Reflections
Reflective Listening (Express Empathy)
Rationale: Reflective listening is the primary way of responding to clients and of building empathy.
´Examples of Reflective Listening (Expressing Empathy)
“It sounds like….”
“What I hear you saying…”
“So on the one hand it sounds like …. And, yet on the other hand….”
“It seems as if….”
“I get the sense that….”
“It feels as though….”
"You're feeling uncomfortable with your _______."
"You are angry with/about ___________."
"You're feeling uncomfortable with your _______."
"You are angry with/about ___________."
"You've tried to do _______ before and it has not worked for you."
"You are frustrated with trying to _________."
"So, if I understand you so far, you _____________."
"You are wondering if you should do something about ____________."
"I can see how you might feel ______ at this point."
S - Summaries
Summaries
Rationale: Summaries are used judiciously to relate or link what clients have already expressed, especially in terms of reflecting ambivalence. Summaries are also a good way to either end a session (i.e., offer a summary of the entire session), or to transition a talkative client to the next topic.
Structure of Summaries:
- Indicate you’re about to summarize
- Be selective
- Note ambivalence and attend to change statements
- Be concise
- End with invitation
Use summaries to change directions or ask a key question
Examples of Summaries:
“It sounds like you are concerned about your cocaine use because it is costing you a lot of money and there is a chance you could end up in jail. You also said quitting will probably mean not associating with your friends any more. That doesn’t sound like an easy choice.”
“Over the past three months you have been talking about losing weight, and it seems that just recently you have started to recognize that your weight is impacting your daily life more and more. That, coupled with your recent diagnosis of pre-diabetes makes it easy to understand why you are now committed to losing some weight”
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Preparatory Change Talk – DARE (Miller & Rollnick, 2013)
D - Desire (I want to change)
Statements and Questions for Reinforcing Positive Change-talk and New Behaviors
"That sounds like a good idea."
"That's a good point."
"You are very considerate of how your decisions effect other people."
"I can see that it's important to you to be a good parent."
"You've really changed the way you ____________. How do you feel about that?"
A - Ability (I can change)
Developing Discrepancy
"You have said that you know _______ is the best choice, but that it won't fit with
your lifestyle. What are some of your concerns about fitting ________ into your
current lifestyle?"
"What is it about your ___________ that others may see as reasons for concern?"
"What would be the good things about your child (your baby/you) being/having __________?"
"How has __________ stopped you from doing what you want to do?"
"How do you feel about ___________?"
"The fact that you are sharing with me indicates that you are interested in learning
about ___________. Why do you want to learn about __________?"
"What makes you think that you need to make a change?"
"If things worked out exactly as you like, what would be different?"
"If you decided to change, what do you think would work for you?"
"What concerns do you have about making changes?"
"What things make you think that this is a problem?"
"What difficulties have you encountered trying to change your __________?"
R - Reason (It’s important to change)
Reframing. With this strategy, the helper invites clients to examine their perspective in a new light, thereby giving new meaning to what the clients have said.
Client: "My husband told me I really need to stop smoking. He’s always telling me what to do!”
Helper: “Your husband must really care a lot about you to say that, knowing you’d probably get angry with him.”
N - Need (I should change)
Rolling with Resistance. With clients who are extremely unreceptive to any idea or suggestion, this technique can be effective. It involves a paradoxical element, which can often bring the client back into a more balanced, non-combative perspective.
Client: "But I can’t stop smoking. All of my friends smoke!"
Helper: "And it may be that when we’re finished here, you’ll decide that it’s worth it to you to keep on smoking. Right now it may be too difficult to make a change. That decision is yours to make."
Client: "Okay."
"It's okay if you don't think any of these ideas will work for you, perhaps you've been thinking about something that might work instead?"
"Ultimately, it is your decision. So, what would you like to try?"
"You are right. I am concerned about your _______, but you are the one in control."
"You're feeling uncomfortable with your _______."
"I don't understand everything you are going through, but if you want to share what you've tried, maybe together we can find something that could work for you."
"Would you like to talk about some ideas that have worked for other moms and use what works for you?"
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Implementing Change Talk CAT (Miller & Rollnick, 2013)
C - Commitment (I will make changes)
Readiness to Change Ruler
Rationale: Assessing readiness to change is a critical aspect of MI. Motivation, which is considered a state not a trait, is not static and thus can change rapidly from day to day.
Examples of How to Use a Readiness to Change Ruler
Helper (H): “On the following scale from 1 to 10, where 1 is definitely not ready to change and 10 is definitely ready to change, what number best reflects how ready
you are at the present time to change your [insert risky/problem behavior]?”
Client (C): “Seven.”
H: “And where were you 6 months ago?”
C: “Two.”
H: “So it sounds like you went from not being ready to change your [insert risky/problem behavior] to thinking about changing. How did you go from a ‘2’ 6 months ago to a ‘7’ now?”
H. “How do you feel about making those changes?”
H. “What would it take to move a bit higher on the scale?”
A - Activation (I am ready, prepared, willing to change)
Advice/Feedback
Rationale: When relevant, new information should be presented in a neutral, nonjudgmental, and sensitive manner that empowers clients to make more informed decisions about quitting or changing a risky/problem behavior.
Examples of How to Provide Advice/Feedback (often this can start by asking permission to talk about the client’s behavior)
“Do you mind if we spending a few minutes talking about….? [Followed by] “What do you know about….?” [Followed still by] “Are you interested in learning more about…..?”
“What do you know about how your drinking affects your [insert health problem]?”
“What do you know about the laws and what will happen if you get a second drunk driving arrest?”
“So you said you are concerned about gaining weight if you stop smoking. How
much do you think the average person gains in the first year after quitting?”
T - Taking Steps (I am taking specific actions to change)
Supporting Self-efficacy
"How important is this to you?"
"How much do you want to _______________?"
"How confident are you that you can make this change?"
"What encourages you that you can _______________, if you want to?"
"I know that it seems like such an uphill battle to __________, but now that we've
discussed some options that have worked for others, which ones sound like the best fit for you?"
"It sounds like you want to continue to ____________. What personal strengths do you have that will help you succeed? Who could offer helpful support so you can continue to
_____________?"
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The Reverse DARN CAT of Sustain Talk
Desire: I like my alcohol
Ability: I don’t see how I can give drinking
Reason:When I drink I feel free and able to handle life’s issues
Need: I need to drink to keep me sane
Commitment: Nobody can stop me. I will drink, as much and when I want
Action: I’m not ready to stop drinking
Taking Step: I started drinking again this week
Signs of Resistance- Forms of Discord
Arguing
- Challenging
- Discounting
- Hostility
Interrupting
Ignoring
- Inattention
- Nonanswer
- No response
- Sidetracking
Denying
- Blaming
- Disagreeing
- Excusing
- Claiming impunity
- Minimizing
- Pessimism
- Reluctance
- Unwilling to change
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Levels of Reflective Listening
The process of reflective listening involves hearing what the client says and either repeating or paraphrasing back to the client, or reflecting the feeling you believe is behind what the client says. Different levels of reflective listening can be distinguished.
Simple Reflection. Helper simply rephrases what the client says.
Client: "But I can’t stop smoking. All of my friends smoke!"
Helper: "Quitting smoking seems nearly impossible because you spend so much time with others who smoke."
Client: "Yes, right, although maybe I should."
Client: “I know we made all these goals about my getting out and meeting people, but I’m just not comfortable around other people.”
Helper: “Getting the support you need hasn’t been easy.”
Client: “I just don’t like the way my family talks to me about my drinking.”
Helper: “You’re annoyed with your family.”
Client: “Yes, it just irritates me how they are always judging me.”
Amplified Reflection. Helper exaggerates the client’s statement to the point client may disagree with it. Helper must not be mocking or patronizing.
Client: "But I can’t stop smoking. All of my friends smoke!"
Helper: "Oh, so you couldn’t really quit smoking because then you’d be too different to fit in with your friends."
Client: "Well, that would make me different, although maybe they might not really care if I didn’t try to get them to quit, too."
Double-Sided Reflection. Helper reflects both the current, resistant statement, and a previous, contradictory statement the client has made.
Client: "But I can’t stop smoking. All of my friends smoke!"
Helper: "You can’t imagine how you would be able to not smoke with your friends, and at the same time you’re worrying how it’s affecting you."
Client: "Well, yes, I guess I have mixed feelings."
Shifting Focus. Sometimes MI goals are better achieved by simply not addressing the resistant statement.
Client: "But I can’t stop smoking. All of my friends smoke!"
Helper:"Well, we’re not really there yet; I’m not talking about your quitting smoking here. Let’s just keep to what we’re doing here - talking through the issues - and later on we can worry about what, if anything, you want to do about smoking."
Client: "Well, I just wanted you to know."
Rolling with Resistance. With clients who are extremely unreceptive to any idea or suggestion, this technique can be effective. It involves a paradoxical element, which can often bring the client back into a more balanced, non-combative perspective.
Client: "But I can’t stop smoking. All of my friends smoke!"
Helper: "And it may be that when we’re finished here, you’ll decide that it’s worth it to you to keep on smoking. Right now it may be too difficult to make a change. That decision is yours to make."
Client: "Okay."
Reframing. With this strategy, the helper invites clients to examine their perspective in a new light, thereby giving new meaning to what the clients have said.
Client: "My husband told me I really need to stop smoking. He’s always telling me what to do!”
Helper: “Your husband must really care a lot about you to say that, knowing you’d probably get angry with him.”
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Assisting Clients as they Move toward a Readiness to Change
The Key Question (Miller & Rollnick, 2013)
the key question as a way to solidify commitment to change. The timing of when the key question is asked and the intent of the question, helps the helper assist the client to move towards commitment to the targeted change. The key question is posed when the client stands at the precipice of change; the answer indicates whether the client is ready to jump or not.
Examples of key questions:
“Given what you’ve told me, what do you think you will do next?” “Where do you think you would like to go from here?”
“What’s your next step?”
“You sound like you are ready to do something, though you aren’t quite sure what would be helpful here.”
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Signs of Readiness for Change
Decreased resistance. The wind seems to have gone out of the sails of resistance. Dissonance in the counseling relationship diminishes, and resistance decreases.
Decreased discussion about the problem. The client seems to have talked enough about the area of concern. If the client has been asking questions about the problem area, these stop. There is a feeling of at least partial completion, of waiting for the next step.
Resolve. The client appears to have reached some resolution and may seem more peaceful, relaxed, calm, unburdened, or settled. This can also have a tone of loss, tearfulness, or resignation.
Change talk. Whereas resistance diminishes, change talk increases. Clients make direct statements about a desire to change, the ability to change, the reasons or benefits of change, and the need to change (the disadvantages of the status quo). They may also make statements about intention to change.
Questions about change. Clients may begin to ask what they could do about the problem, how people change once they decide to, and the like.
Envisioning. The client talks about how life might be after a change. This can be mistaken for resistance; that is, looking ahead to change often causes a person to anticipate difficulties if a change were made. Of course, the client may also envision positive outcomes of change.
Experimenting. The client may have begun experimenting with possible change actions since the last session.
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I CAN Statements move Clients in their Readiness to Chose Change (Rosengren, 2009)
I - Indicate this is a summary, and include
C- Change talk,
A- Ambivalence, and then ask about the
N - Next step.
Key Elements of I CAN statements
- A statement indicating that the helper is pulling together what the client has said.
- A summary of the client’s perceptions of the issue, including any reasons or need for change noted by the client.
- A summary of the client’s ambivalence, including the benefits of the status quo.
- Objective evidence relevant to the importance of change.
- A restatement of desire, ability, and commitment to change.
- The helper’s assessment of the client’s situation, especially when it matches the client’s concern.
I - Indicate this is a summary – Inform Clients that what is being said is a summary of what they have said
C – Change Talk – Prompting and supporting the Change Talk of Clients with supportive reflections which keep the focus on the desirable change
A- Ambivalence about Change is Normal so Use statements supportive of this
“It worries you to think about what you would have to give up to start this plan. At the same time, you are clear that continuing with how things are at present is no longer an option.”
“It sounds like you aren’t quite ready to take this on now. As you look down the road, when can you see this happening? What would need to happen for that to occur?”
N - Next Step includes Sorting Out Client’s Options
“How would you like your life to be different?”
“What would you like to see change?”
“If things were better, what would be different?”
“What would you like to have more of? Less of?”
“What will you do first?”
“What specific steps will need to be done?”
“What’s your plan?”
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Steps to Take In Learning Motivational Interviewing
Five steps in learning about MI-Use this coping.us MI section to help you (Rosengren, 2009)
1. Tell—brief didactic or exercise designed to elicit information Use
2. See—observe or recognize the skill in action.
3. Do in slow motion—often a writing task or a skill in isolation, many times done in a group situation.
4. Perform—isolate skills and do them in real time.
5. Build—work from easier to more complex and chain more complicated skills together.
The reasons for this process are fourfold:
1. Using multiple modalities engages different learning styles.
2. Slowing the learning down enough to see the nuances allows people to experience the complexity of the skills.
3. Stepping people through the skill, before asking them to produce it in “real time,” builds confidence in their ability to do so.
4. Participants feel readier to take on complex skills as well as learn the nuance of technique.
Learning MI is like Learaing to Play the Piano
William Miller has used the analogy that learning MI is like learning to play the piano Typically, he uses this analogy in the context of a brief (e.g., 2-hour) presentation and then assuming readiness to “do MI” (Rosengran, 2009). The analogy may extend to completing all of the materials on the copiing.us’s Motivational Interviewing segment. Although some people may complete a 2 hour workshop or absorbe all of the written materials and videos on this site and have learned the essential basics of piano playing, it is typically through the tutelage of an experienced piano teacher that the skills come to life.
A useful workbook to help you learn Motivational Interviewing is:
Rosengren, D.B. (2009). Building Motivational Interviewing Skills - A Practitioner Workbook. New York: Guilford Press.
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