Powerpoint accompanying workshop session from the Homeless and Housing Coalition of Kentucky's 2013 conference. Presented by Patrick McKiernan
Motivational interviewing is a technique that uses a dialogue between a counselor and a client who needs to
change behaviors in his or her life. The purpose of this technique is to be non-confrontational, non-adversarial and
non-judgmental, and uses open-ended questions and reflective listening to forge a relationship between counselor
and client built on trust and empathy. This session will present basic information on how to help increase motivation
to change with individuals considering but uncommitted to change. The discussion will include background, theory,
and techniques related to the change process.
2. Overall Seminar Goal
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• 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
3. 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
4. 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
5. Influences and References
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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.
6. Rooted in Natural Change
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• 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
7. 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.‖
8. 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 I
Motivational
Counseling
Phase II:
Open ended menu of options
Phase I
Motivational
Counseling
Phase II:
Some prescribed treatment
emphasized (e.g., Lincoln Trail)
9. 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.
10. 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)
12. 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)
13. SIMPLE NAVIGATIONAL MAP
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WORKING ALLIANCE
(red)
Importance
of Change
Commitment to Change
Change Plan
?? Temporal Effects ??
Change
Confidence
15. Nature of Change Discussion
15
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?
16. 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 CHANGE UNSURE READY TO CHANGE TAKING ACTION
1 2 3 4 5 6 7 8 9 10
17. 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.
18. 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.
19. Therapeutic Relationship (TR)
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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?
20. Developing & Maintaining TR
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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
21. TR: Risk and Protective Factors
Supportive / 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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22. Risk created by brevity
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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
23. 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
24. 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].
25. Strategies to improve importance
2) 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.
27. 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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28. MI 2nd Edition: 2 Phases of Change
1. 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
29. MI Sandwhich
MI Assessment “sandwich” concept:
MI strategies during opening 20 mins
Agency intake assessment
MI strategies during closing 20 mins
30. MI emphasis on ―spirit‖
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• 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
31. DISCOVERY: Achieving 2 Ends
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• 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.
32. 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.
33. TR Risk: Nuance
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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?
34. 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
35. 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
37. KEY: Management of Self
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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.
38. 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
39. 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].
40. Strategies to improve importance
2) 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.
41. Strategies to improve importance
3) 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.