AASE ODE MI Workshop 5.23.12

Motivational Interviewing
“A work in progress…”
AADE/ODE MI Workshop Series
Michael Fulop, Psy.D.
Clinical & Consulting Psychology
FORSTER FULOP
Rewarding Diabetes

 What’s one specific MI take-away
you might use in your practice?

michael@rewardingdiabetes.com

79

My Agenda
 Provide ongoing training to AADE/ODE
providers to improve MI skills
 Discuss evidence for MI in psychotherapy
 Show examples of MI in practice
 Have you practice MI – in your setting
 How comfortable role/real playing? 0-10
 How comfortable taping self in practice? 0-10
 Humble + Curious
4

What would like to accomplish
today?
•30 seconds

•Your Name

•Where do you practice?

•What’s one specific take-
away from today, imagine
what it might be.

•Write down as we go along

MI Publications

 Last Count was ~754, RCT’s > 180

Some Things MI is Not
 MI not Transtheoretical Model - MI not intended as a
comprehensive theory of change

 MI does not trick people into doing what don’t want to do
★ Not an end run for outwitting people

★ MI is “with” or “for” someone, not “to” or “on”

 MI is not what you already are doing
★ Near zero-correlation for perceived competence in MI –
★ Attending 1 workshop doesn’t improve outcomes for clients

★ Practice is needed, being coded, being observed and practice
6

Some Things MI is Not
 MI is simple, but not easy
 Not easy to integrate complex skills
 Like learning to play a musical instrument!

 MI is not a Panacea
 It’s a specific way to address the need to make
behavioral changes when someone is ambivalent
★ People ready for change do not need MI

 Mi is not stand-alone therapy – adds
effectiveness w/other treatments w/1- 4 sessions
8

What MI is not…


What MI is…
 After 30 years of research we
have a treatment approach
that is evidence-based [over
200 RCT’s published], relatively
brief [typically 1-3
sessions], that can be
specified, grounded in testable
theory, with identifiable
methods of action, verifiable as
to when it is being delivered
competently, generalizable
across a wide range of
problem areas, complimentary
to other treatment
methods, and learnable by a
wide range of providers – WR
Miller, Ph.D.

Recent definition of MI - MI-3
 MI is a collaborative, goal-oriented style of
communication with particular attention to the
language of change, designed to strengthen
personal motivation for & commitment to a
specific goal by eliciting and exploring the
person’s own reasons for change within an
atmosphere of acceptance and compassion.

Miller & Rollnick, 2011

16
michael@rewardingdiabetes.com Ph.D. Building Motivational Interviewing Skills
From David Rosengren,

78

Does MI Work?
 Meta-analyses & reviews
 Britt, Hudson & Blampied, 2004
 Burke et al., 2003
 Dunn, Deroo & Rivara, 2001
 Hettema, Steele & Miller, 2005
 Moyer, Finney, Swearingen & Vergun, 2002
 Rubak, Sandbaek, Lauritzen & Christensen, 2005
 Cochrane Review 2011


 Evidence For MI efficacy
 Dunn, C, Deroo, L, Rivara, F (2001) The Use of brief interventions adapted from
MI across behavioral domains. Addiction, 96; 1725-42.

 Burke B, Arkowitz H, Dunn C (2002) The efficacy of MI and it’s adaptations:
What we know so far. In Miller & Rollnick [eds] Motivational Interviewing, 2nd
[2002]

 Burke B, Arkowitz H, Menchola M (2003) The efficacy of MI: A meta-analysis of
controlled clinical trials. Journal of Consulting & Clinical Psych, 71 843-61.

 Britt, E, Hudson S, Blampied N (2004) MI in health care settings: A review.
Patient Education and Counseling, 52, 147-55.

 Rubak, S, Sandboek A, Lauritzen T, Christensen B (2005) MI: A systematic
review and meta-analysis. British Journal of General Practice, 55, 305-12.

 Hettema J, Steele J, Miller W (2005) Motivational Interviewing.
Annual Review of Clinical Psychology, 1 91-111.

73

Further Study - Resources
 Rosengren, D.B. (2009). Building Motivational
Interviewing Skills: A Practitioner’s Workbook. New York:
Guilford Press.
 Arkowitz, H. Westra, H. Miller, W.R., & Rollnick, S. (2008).
Motivational Interviewing in the Treatment of
Psychological Problems. Guilford: New York.
 Miller, W.R., & Rollnick, S. (2002). Motivational
Interviewing: Preparing People for Change. Guilford:.
 Training Tapes: MI Series
 MI Website: www.motivationalinterview.org


 Miller Conversation Encountering Ambivalence


MI Spirit
 Collaborative
 Honors client expertise and perspective
 Creates an environment that supports change
 Evocative
 Resources lie within client
 Enhance their intrinsic motivation
 less about external pressure
 Promotes Client Autonomy
 “Patient is right” they have capacity for self change
 Facilitate informed choice
 Compassion - MI-3 [Miller & Rollnick, 2012]

 Miller Conversation on the Spirit of MI

 Interview for Psych1


What is MI Spirit?
1-5 Ranking
 Evocation
 Collaboration
 Autonomy/Support
 Spirit = [EV] + __ [CL] + __ [A/S]/3 = ___
Evocation + Collaboration + Autonomy/Support/3]

 Direction
 Empathy


A Continuum of Styles
Directing <=> Guiding <=> Following

Behavior therapy
Cognitive therapy
Reality therapy
Dr. Phil
Motivational interviewing
Solution-focused therapy
Psychodynamic
Psychotherapy
Client Centered
Psychotherapy

31

• It’s MI when…
• The communication style
involves person-
centered, empathic listening
(engaging), and
• There is a target of change
and that is the focus of
conversation (focusing), and
• The interviewer evokes a
person’s own motivation &
reasons for change
(evoking), but
• It may or may not include
planning.

Four Fundamental Processes

Planning

Evoking

Focusing

Engaging


These 4 processes are somewhat linear
….
 Engaging necessarily comes first

 Focusing (identifying a change goal) is a
prerequisite for Evoking

 Planning is logically a later step

Engage Focus Evoke Plan

67

. . . . and yet also recursive
 Engaging skills [& re-engaging] continue
throughout MI
 Focusing is not just a one-time event;
 re-focusing often needed; focus may change
 Evoking begins very early in encounters
 “Testing waters” with planning may indicate
a need for more of the above
68

Ambivalence
 Feeling 2 ways about change is common &
normal
 MI accepts ambivalence; patient gets time to
explore & consider both sides of their dilemma
 Telling people why they should change evokes
the “righting reflex” & increases resistance

14

Ambivalence
 Occurs throughout the change process

 Reflects costs and benefits of change and status quo

 Is uncomfortable & may become chronic

 Resolved by client – Bem’s Self-Perception Theory
 What people say to themselves, is what they believe


Readiness to Change


•Dental hygienist story


Ambivalence under
pressure…
 Leads to discord
 Tends to elicit push back
 Predicts worse outcomes
 Is something we avoid in MI


Reinforcing Change
Statements
 Be attentive

 Don’t have to respond immediately

 May collect like a bouquet of flowers

 Warning – be attentive to ambivalence


Pair Up - 1 speaker & 1 listener
• Speaker talks about a change they are ambivalent
about – they want to change, but have not
started yet [real play, or role play patient].
Speaker begins, describes change they want.
• Listener your job is to convince your speaker
about why they should change – list your
reasons, why you think they should change
• 4 minutes – then we debrief
• What happened to you as the person who wants
a change? What’s it like?
• What happens to you, the listener/”convincer”
What’s it like?


Installing Motivation?

• Speaker discuss a change you want to make – or play a
client, patient
• Listener – Your task is to help this person come hell or
high water
• Instead of listening, please:
• Explain why s/he should make this change
• Give 3 specific benefits of making the change
• Tell him/her how to change
• Emphasize importance of the change
• Tell the participant to do it!
• Don’t use MI!


Evoking Motivation?
• Speaker continue discussing change
• Listen carefully - goal to understand their dilemma
• Ask these four questions:
• Why would you want to make this change?
• How might you go about it, in order to succeed?
• What are the 3 best reasons to do it?
• On a scale of 0-10, how important would you say it is to
make this change?
• And why are you a ? and not zero?


OARS
 Open Ended questions
 Strength based questions
 Affirmations
 Reflective Listening
 Summarizing


Engaging a real individual
• Remember, you are not their 1st provider
• May need to overcome some barriers –
• My 1st Q -“Have you seen any other mh providers?”
• Relationship building is needed
• Accepting ambivalence is particularly important
• Don’t insist on diagnosis acceptance
• Target problems and client goals – not diagnoses


Exercise: On the Nature of
Helpfulness
 Imagine a major pressing dilemma in your life
 Professional or Personal
 Debating this with yourself

 Imagine
 Your thinking is moving in ever tightening circles
 You’re in a state of perplexity
 It’s affecting all aspects of your life
 You’re making little progress on your own

 So… you decide to seek out help
Activity from Jeff Allison


Exercise: The Nature of Helpfulness
 Who should you discuss this with?
 Don’t want to make a mistake - Choosing wrong
person leads you in wrong way
 Go to Powell’s, grab some coffee and sort this out
 What are desirable qualities & skills of such a
person? How would you want them to behave?
 Make two lists by yourself
 Most desirable qualities & skills
 What will make you feel antagonistic and or
disappointed?
 This Exercise is from Jeff Allison


MI GOAL

 Change Talk


Change Talk
 Change talk is any client speech that favors movement in the
direction of change
 Previously called “self-motivational statements” (Miller &
Rollnick, 1991)
 Change talk is by definition linked to a particular behavior
change goal

 DARN CATs

53

Preparatory Change Talk
DARN Examples

DESIRE to change (want, like to, wish.,)
ABILITYto change (can, could . . )
REASONS to change (if . . then)
NEED to change (need, have to, got to . .)
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Mobilizing Change Talk
Reflects resolution of ambivalence

 COMMITMENT
(intention, decision, promise)
 ACTIVATION (willing, ready, preparing)
 TAKING STEPS

55

Mobilizing Language

 Three Types: Commitment, Activation & Taking Steps
 I an done with being depressed.
 I am ready to do something different.
 My boyfriend said I didn’t need my meds, but I told him I
did.


Is mobilizing language enough?
 Some Answers…
 I wish I could…
 I’d like to…
 I think I should…
 I could if I really wanted to…
 I have good reasons to…

 For some questions...
 Do you swear to tell the truth, whole truth and…?
 Do you take this person to have and to hold in sickness in
health…?


Responding to Change Talk
All EARS
 E: Elaborating: Asking for elaboration, more detail, in what
ways, an example, etc.

 A: Affirming – commenting positively on the person’s
statement

 R: Reflecting, continuing the paragraph, etc.

 S: Summarizing – collecting bouquets of change talk

58

Sustain Talk
The other side of ambivalence
 I really like marijuana (Desire)

 I don’t see how I could give up pot (Ability)

 I have to smoke to be creative (Reason)

 I don’t think I need to quit (Need)

 I’m gonnna keep smoking (Committment)

 I’m not ready to quit (Activation)

 I went back to smoking this week (Taking Steps)

61

 Miller Conversation Rolling With Resistance


Righting Reflex Video

 Arg Clin Starts at 1:15 & Ends at 3:40

 http://www.youtube.com/watch?v=kQFKtI6gn9Y


Avoiding Trouble


What is Resistance?
 Behavior

 Interpersonal (It takes two to resist)

 A signal of dissonance

 Predictive of (non)change

 The Righting Reflex - Reactance

62

Handling Resistance
• Already in skills repertoire

• May not eliminate, but can reduce “heat”

• Three reflective types:
• Simple
• Amplified
• Double-sided

• Two Strategies
• Shifting focus
• Emphasize personal choice


Handling Resistance - Reflection
• I thought a little red wine was supposed to be good for your heart.
• I know the meds are good for me, but they make me too drowsy.
• I think you are blowing this way out of proportion, I only got a little
messed up, why are you such a prude?
• You don’t understand what it’s like for me, you’ve got a job and
career; all I got is these memories.
• Meds don’t help much anymore, but something’s got to, or I am out
of here.
• I’ve tried everything you’ve asked. None of that shit works. Why
don’t you get it?


Sustain Talk and Resistance
 Sustain Talk is about the target behavior
 I really don’t want to stop smoking
 I have to take pills to make it through the day

 Resistance is about your relationship
 You can’t make me quit
 You don’t understand how hard it is for me

 Both are highly responsive to counselor style

63

Foundational Skills –
Simple, Not Necessarily Easy
• Open Questions
• Affirmations
• Reflective Listening
• Summaries
• Offering Information


Asking
 Develop an understanding of client’s situation
 Allows you to:
 Follow a decision tree
 Arrive at a diagnosis
 Complete forms

 Closed questions can be:
 Efficient way to gather specific information
 May create or reinforce the expert-trap


Open-ended Questions

 These sets the tone for MI work
 Communicates interest and caring
 Allows client room to respond
 Makes client more a more active partner
 You receive information otherwise unavailable
 Creates momentum


Listening
 MI is built on this skill

 Directive use of listening

 Attend to some things and not others

 Create awareness of gaps

 Reinforce change talk


Effective Listening:

 Is not asking
 More than paying attention
 Is not just silence
 More than repeating words
 Way of thinking


Reflective Listening
 2 levels of reflection
 Simple - content stays close
 Repeating
 Rephrasing
 Complex – guesses at
unexpressed, affect, anticipates, and
metaphors
 Paraphrasing Meaning or Intent
 Reflecting Feeling


Reflective Listening

 Vary your depth

 Timing is important

 Typically undershoot


Exercise – Two Levels of
Reflections
 Form groups of 4

 Choose a representative to record answers

 Record Simple & Depth Reflections for each sentence
stem


Being Directional

 Not telling client what to do

 Choosing to attend to different elements

 Usually multiple elements in a statement

 Focus will determine path


Examples of being directional

 I’m tired and it feels impossible right now.

 You’re worn out.

 It feels really hard to do.

 Right now is a problem, but maybe later won’t be.


Summaries

 Special form of reflective listening

 Different kinds:
 Collecting – short, continue flow (change talk)
 Linking – add recent material to prior info (ambivalence)
 Transitional – announces a shift in focus (change
direction)


Affirmations
• Some clients are demoralized
• Orients people to their resources
• Be genuine
• Probe partial successes
• Reframe resistance into an affirmation
• What and how questions are helpful
• Use “you” statements, not “I”


Informing
 Successful communication requires:
 Transmission of technical information
 Interpersonal skills
 Therefore, a relationship is key to good
informing


Useful Informing
 Ask permission
 Offer choices
 Use other client examples
 Chunk-Check-Chunk
 Elicit-Provide-Elicit


Useful Informing
 Slow down and progress may be quicker
 It’s a person not an information receptacle
 Consider the client context & priorities
 Amount matters and depends on the client
 Best method? The individualized one
 Beware of righting reflex


Reflections

 View hettama tape disc 1 –


Reflections

 Reflections are a way of hypothesis testing without the
questions

 They are a way to attune to the person

 They are choosing where you think someone might be
going

 Heart of MI


Reflective Responses

 Three levels of Reflections

 Repeats - or parrots

 Rephrases - with simple word changes

 Paraphrasing – infers a meaning

 Reflection – of feeling, value, or attitude
 Simple
 Complex


Intensity of Reflections

 Understated or attenuating a reflection
 “You a slightly annoyed”
 Which direction will the client go?

 Overstating or Amplified Reflections
 You are outraged


 “I really hate my boss telling me I have to pick up those
boxes over and over again.”

 Understated reflection

 Amplified Reflection


Double Sided

 On the one hand you want to … On the other hand you
don’t want to.

 You’ve told me some good reasons to stop smoking, and
in some ways you love it a lot


 “My friends say I should just stop smoking pot, but I am
not sure I can anymore.”


 “My diabetes used to be easy to control, but I’m not sure
I can get it under control any more.”


Practice

 “Since my accident, I don’t care if I live or die, and I
wonder if anyone else cares?”


Reflection Practice

 “Do you mean” practice


Reflection Practice

 “It’s fun, but something has to give. I can’t go on
like this anymore.”
 “I know I can do some things differently., but if she
would just back off, the this situations would be a
lot less tense. These things wouldn’t happen.
 I’ve been depressed lately. I keep trying to get back
to using exercising more, but my back always
hurts, it is so frustrating. A couple of drinks would
help.

Reflection Practice
 “So I’m not too worried, it’s been over a year, and I
can still walk with that knee pain.”
 “I know I should lose some weight, everybody tells
me that, but nobody knows how hard it is for me. I
wish I was on the biggest loser.”
 My daughter thinks it’s her body, and so she should
be able to do what she wants. Hooking up is no big
deal to her. She doesn’t get why I won’t back off.”


Contact Information
Michael J Fulop, Psy.D.

www.rewardingdiabetes.com
503.539.4932

74

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