Motivational Interviewing

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Motivational Interviewing

• Chapter 6
• Phase 1 Building Motivation for Change

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• Phase one of MI involves building intrinsic
  motivation for change.
• Phase two involves strengthening commitment to
  change and developing a plan to accomplish it.
• The amount of work to be done will depend on the
  person's starting point

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Importance and Confidence

• It is useful in understanding a person's
  ambivalence to know his or her perceptions of
  both importance and confidence

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Importance and Confidence

• You can asses importance and confidence using the
  scaling questions method
• "How important would you say it is for you to
  __________? One a scale from 0-10, where 0 is not
  at all important and 10 is extremely important,
  where would you say you are?"
• "How confident would you say you are, that if you
  decided to ________, you could do it?   On the
  same scale from 0-10 where 0 is not at all
  confident and 10 is extremely confident, where
  would you say you are?"

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• Phase 1 can involve either importance work or
  confidence work, or both.  In essence, you are
  helping the client to become ready, willing and
  able to change.

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Some Early Traps to Avoid

• 1) Question-Answer Trap - Using a QA format,
  even if it's open ended questions, affords little
  opportunity for a person to explore motivation
  and to offer change talk. 

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Some Early Traps to Avoid

• 1) Question-Answer Trap - The optimal approach is
  usually to ask an open-ended question, then to
  respond to the client's response not with another
  question but with reflective listening. 
• As a general clinical guideline, avoid asking
  three questions in a row.

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Some Early Traps to Avoid

• 2) Trap of Taking Sides - If people usually enter
  counseling in a state of ambivalence, they feel
  two ways about their current situation they want
  it and they don't want it.  If the counselor
  argues for one side of the conflict, it is
  natural for the client to give voice to the other
  side.  Few people enjoy losing an argument or
  being proved wrong.

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Some Early Traps to Avoid

• 3) Expert Trap - There is an appropriate time for
  expert opinion but the focus of Phase 1 is first
  on building the client's own motivation. 
• Within motivational interviewing, in a real sense
  it is the client who is the expert. 

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Some Early Traps to Avoid

• 3) Expert Trap - No one knows more about his or
  her situation, values, goals, concerns and
  skills. 
• No one is in a better position to anticipate how
  change will fit into the person's life. 
• Motivational Interviewing is about collaboration
  not installation.

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Some Early Traps to Avoid

• 4) Labeling Trap
• Can evoke a power struggle. 
• Counselors need to assert control and expertise.
  
• A form of judgmental communication. 
• Can evoke feelings of being cornered. 

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Some Early Traps to Avoid

• 4) Labeling Trap - The danger, of course, is that
  the labeling struggle evokes dissonance, which
  descends into side-taking and, in turn hinders
  progress. 
• Problems can be fully explored without attaching
  labels that evoke unnecessary dissonance.

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Some Early Traps to Avoid

• 5) Premature-Focus Trap - Resistance may result
  if client and counselor wish to focus on
  different topics. 
• The trap here is to persist in trying to draw the
  client back to talk about your own conception of
  "the problem". 

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• 5) Premature-Focus Trap - Starting with the
  client's concerns, rather than those of the
  counselor, will ensure that this does not
  happen. 

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• 5) Premature-Focus Trap - Spending time listening
  to the client's concerns is useful, both in
  understanding the person and in building the
  rapport that is the basis for later exploration
  of other topics.  Get a broader understanding of
  the client's life situation before coming back
  around to the topic.

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Some Early Traps to Avoid

• 6) Blaming Trap - If this issue is not dealt with
  properly, time and energy can be wasted on
  needless defensiveness. 
• Counseling has a 'no-fault' policy.

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• Rapport - a feeling of commonality or being
  'in-synch' with another person. Harmonious
  communication.
• You are providing a service and you cant provide
  it if you dont listen to the clients needs.

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Five Early Methods

• Building Motivation for Change Using OARS
• 1. Ask Open Questions
• 2. Listening Reflectively
• 3. Affirm
• 4. Summarize
• 5. Eliciting Change Talk
• The first four are derived largely from
  client-centered counseling.  The fifth method is
  more clearly directive and is specific to
  motivational interviewing

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O Open Ended Question

• 1. Ask Open Questions - The client should do most
  of the talking at this stage. Use questions that
  elicit elaboration.

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R Listening Reflectively

• 2. Listening Reflectively -   The essence of a
  reflective listening response is that it makes a
  guess as to what the speaker means.  It's a
  statement vs. a question.  A well-formed
  reflective statement is less likely to evoke
  resistance. 

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• 2. Listening Reflectively -   In the dynamics of
  language, a question requires a response. 
  Reflective statements are statements of
  understanding. 
• Keep a continual awareness that what you believe
  or assume people mean is not necessarily what
  they really mean.  Reflective listening is a way
  of checking, rather than assuming that you
  already know what is meant. 

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• Skillful reflection moves past what the person
  has already said and can include reflection on
  non-verbal communication such as a smile on the
  persons face, the tone of their voice or their
  body language. 

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• Note If you overstate the intensity of what a
  person is saying or doing the person will tend to
  deny and minimize it. 
• If you slightly understate the expressed
  intensity of emotion, however, the person is more
  likely to continue exploring and telling you
  about it. 

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• The counselor decides what to reflect and what to
  ignore. 
• Change talk is preferentially reflected, so that
  people hear their own statements at least twice. 
  
• Reflection is particularly important after
  open-ended questions.
• See page 68 for 12 kinds of responses that are
  not listening.

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A - Affirming

• 3. Affirm - This can be done in the form of
  compliments or statements of appreciation and
  understanding.  The point is to notice and
  appropriately affirm the client's strengths and
  efforts. 

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S - Summarize

• 4. Summarize - Summary statements can be used to
  link together and reinforce material that has
  been discussed. 

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S - Summarize

• Summary statements
• 1. Reinforce what has been said
• 2. Show that you have been listening carefully
• 3. Prepare the client to elaborate further
• 4. Allow a person to hear his or her own change
  talk for a third time.

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S - Summarize

• At least three kinds of summaries are useful in
  motivational interviewing
• 1. Collecting Summaries
• 2. Linking Summaries
• 3. Transitional Summaries

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S - Summarize

• Collecting Summary - Usually short, just a few
  sentences.  Should continue rather than interrupt
  the person's momentum.  It is useful to end them
  with "What else?" or some other invitation to
  continue.  "What else?" is open-ended where as
  "Is there anything else?" is a closed-ended
  question.  It's like collecting flowers one at a
  time and giving them back to the person as a
  bouquet. 

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S - Summarize

• Linking Summary - Linking summaries are meant to
  encourage the client to reflect on the
  relationship between two or more previously
  discussed items.  A linking summary is one way to
  allow a person to examine the positives and
  negatives simultaneously, acknowledging that both
  are present. 

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S - Summarize

• Linking Summary - To help a person see the two
  sides of ambivalence yet to highlight the desired
  change, you can use conjunctions like "yet",
  "but".  As in, "On the one hand you enjoy smoking
  weed because it helps you feel calm, yet it costs
  a lot of money and you could probably find better
  ways to feel calm without having to spend all
  that money."

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S - Summarize

• Transitional Summary - Marks and announces a
  shift from one focus to another.  At the end of
  the first session it can be helpful to offer a
  substantial transitional summary, pulling
  together what has transpired thus far. 

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Eliciting Change Talk

• 5. Eliciting Change Talk - The fifth method is
  consciously directive.  Evoking change talk is
  one of the key motivational interviewing skills.

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8 Methods for Evoking Change Talk

• 1. Asking Evocative Questions
• 2. Using the Importance Ruler
• 3. Exploring the Decisional Balance
• 4. Elaborating
• 5. Querying Extremes
• 6. Looking Back
• 7. Looking Forward
• 8. Exploring Goals and Values

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8 Methods for Evoking Change Talk

• 1. Asking Evocative Questions - Evoke - To call
  forth or up. Use open-ended questions that cause
  a person to think and reflect on their answer

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8 Methods for Evoking Change Talk

• 2. Using the Importance Ruler - (i.e. Scaling
  Questions) "Why are you at a ______ and not a
  zero?"  Note that one should not ask, "Why are
  you at a _____ and not a 10?"  because to answer
  that question is to argue against change.

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8 Methods for Evoking Change Talk

• 3. Exploring the Decisional Balance - Exploring
  the pros and cons
• 4. Elaborating - Have the client elaborate or
  expand on the change talk before moving
  forward. (see examples on next slide)

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Ways to elicit elaboration

• 1. Asking for clarification In what ways? How
  much? When?
• 2. Asking for a specific example Can you give me
  an example?
• 3. Asking for a description of the last time this
  occurred Tell me about a time when this happened
  in the past
• 4. Asking "What else?" within the change topic.
  This is a form of an Open-Ended Question.

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8 Methods for Evoking Change Talk

• 5. Querying Extremes - Ask people to describe the
  extremes of their (or others') concerns, to
  imagine the extreme of consequences that might
  ensue. Best case and worst case scenarios

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8 Methods for Evoking Change Talk

• 6. Looking Back - Have the client remember times
  before the problem emerged and to compare these
  times with the present situation

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8 Methods for Evoking Change Talk

• 7. Looking Forward - Helping people envision a
  changed future.  Ask the client to tell you how
  it might be after a change.  Similarly, you can
  invite the client to look ahead in time and
  anticipate how things might be if no changes are
  made

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8 Methods for Evoking Change Talk

• 8. Exploring Goals and Values - Ask the client to
  tell you what things are most important in his or
  her life.  Discover ways in which current
  behavior is inconsistent with or undermines
  important values and goals for the person

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Summary

• Eliciting change talk is a primary method for
  developing discrepancy.  Hearing oneself state
  the reasons for change tends to increase
  awareness of the discrepancy between one's goals
  and present actions.  Evoking change talk can
  serve as a continuing reminder of the reasons for
  commitment to change.