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An Introduction to Motivational Interviewing


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Title: An Introduction to Motivational Interviewing

An Introduction to Motivational Interviewing
  • Richard L. Ogle, Ph.D.
  • Professor Chair
  • Department of Psychology
  • University of North Carolina Wilmington

Guiding Sentiments
  • If you treat an individual as he is, he will stay
    as he is, but if you treat him as if he were what
    he ought to be and could be, he will become what
    he ought to be and could be.
  • Johann Wolfgang Von Goethe
  • People are generally better persuaded by the
    reasons which they have themselves discovered
    than by those which have come into the mind of
  • Blaise Pascal
  • You are a midwife, assisting at someone elses
    birth. Do good without show or fuss. Facilitate
    what is happening rather than what you think
    ought to be happening. If you must take the
    lead, lead so that the mother is helped, yet
    still free and in charge. When the baby is born,
    the mother will rightly say, We did it

Opening Conversation
  • Why are you here?
  • What do you want to learn?
  • In what specific situations would you like to use
  • At what level do you want to engage?

  • The probability of engaging in and maintaining a
    behavior over time.
  • What are the three key words?
  • Probability (0 1) not (0 or 1).
  • Engage
  • Maintain
  • Motivation is continuous not dichotomous
  • Fluctuating motivation can increase or decrease
    based on your behavior

  • Change is more similar than different across
  • Change is a process that is continuous like a
    dimmer switch, not discrete like an on/off switch
  • Change depends on MOTIVATION.
  • Because of this, there are multiple ways and
    times that change can derail
  • Fortunately, there are multiple ways and times to
    facilitate the process

Stages of ChangeProchaska DiClemente
Change Talk - DARN CAT
  • Client speech reflecting building motivation and
    correlated with behavioral change
  • Desire
  • Why a person would make a change.
  • Ability
  • How a person could you do it.
  • Reasons
  • What are good reasons to make the change?
  • Needs
  • How important is it and why? What are the
    negative that occur without change?
  • Commitment
  • What intentions are present?
  • Activation
  • What is the person ready or willing to do
  • Taking Steps
  • What have they already done?

Commitment Language Pattern A
Outcomes for Pattern A Group
Commitment Language Pattern B
Amrhein et al., Journal of Consulting Clinical
Psychology 2003 71862-878
Outcomes for Pattern B Group
Righting Reflex
  • Born of concern and caring
  • Theres a problem? Lets fix it!
  • Fails to consider ambivalence in change process
  • May engender resistance

  • Simultaneous feelings of approach and avoidance
  • Yes, but
  • I want to, but I cant
  • The core of most motivational issues
  • Completely normal
  • Often uncomfortable
  • Can be chronic

  • Listen carefully - goal to understand the 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 three best reasons to do it?
  • On a scale of 1-10, how important would you say
    it is to make this change? And why are you a ___
    and not zero?
  • Summarize
  • Talk about something real that you
  • Want to change
  • Need to change
  • Should change
  • Have been thinking about changing
  • But, havent yet changed.
  • Not your deepest, darkest secret!

  • A result of a focus on only one side of an
    individuals ambivalence
  • If you argue for change, your collaborator argues
    against it
  • It is relational. It is a signal that you are
    not meeting them where they are at therefore, it
    is you responsibility to resolve
  • Sustain Talk
  • Speech about the target behavior that reflects
    only one side of ambivalence (status quo)
  • There is nothing inherently pathological about
    sustain talk
  • Discord
  • Speech reflecting a discord within the
  • Denying
  • Arguing
  • Ignoring
  • Interrupting
  • Reluctance
  • May be concerned about the unknowns of change
  • Need to verbalize their reluctance be heard
  • Rebellion
  • May have knowledge
  • May have highly invested energy in no change
  • Resignation
  • No energy for change
  • May feel overwhelmed hopeless
  • Need to build hope
  • Rationalization
  • Has all of the answers
  • Utilizes Harm Minimization

Therapeutic Traps
  • Question-Answer Trap
  • Trap of Taking Sides
  • Expert Trap
  • Labeling Trap
  • Premature Focus Trap
  • Blaming Trap

Definitions of MI
  • Laypersons Definition (Why would be do it)
  • MI is a collaborative conversational style for
    strengthening a persons own motivation and
    commitment to change
  • Practitioners Definition (Why you would use it)
  • MI is a person-centered counseling style for the
    common problem of ambivalence about change
  • Technical Definition (How it works)
  • MI is a collaborative, goal oriented style of
    communication with particular attention to the
    language of change. It is designed to strengthen
    personal motivation for and commitment to a
    specific goal by eliciting and exploring the
    persons own reasons for change within an
    atmosphere of acceptance and compassion.

A Brief History to This Point
  • MI is 31 years old this year
  • Description first published in a journal article
    in 1983.
  • First edition of book in 1991, second in 2002,
    third in 2013
  • Over 1200 articles on MI
  • MI cited over 25,000 times
  • Over 200 RCTs
  • Started as a vilified intervention in addictions
    and now is a best practice in all of behavioral
  • Here are some things we know
  • MI is effective for a variety of behavioral
  • MI can be used in a variety of settings
  • MI is hard to standardize
  • Significant variability across counselors

Most Importantly, What We Know is
  • MI training increases characteristic MI practice
  • OARS
  • Empathy
  • These behaviors affect particular types of client
  • Desire, Ability, Reasons, Need, Commitment,
    Activation, Taking Steps
  • The level and strength of these types of speech
    predict behavioral outcome
  • Findings are stronger in addictions than anywhere

Spirit of MIhttp//
  • Acceptance
  • Absolute worth
  • Autonomy
  • Accurate Empathy
  • Affirmation
  • Collaboration
  • Partners
  • Shared goals
  • Evocation
  • Pulling out instead of putting in
  • Compassion
  • For the others needs/self-interest
  • Services exist to benefit the people we serve
  • Change is fundamentally self change. Services
  • People are experts on themselves
  • We dont have to make change happen
  • We dont have to come up with all the good ideas
  • People have their own strengths, motivations,
  • Therefore change requires partnership
  • Understand, persons own perspective, what is
    needed and how to accomplish it
  • Conversations about change should not be a
    struggle. Dancing, not wrestling
  • Motivation for change is not installed, but
  • We cannot revoke peoples choice about their own
    behavior. People make their own decisions about
    what they will and will not do.

MI Principles
  • Express Empathy
  • Empathy alone is predictive of change
  • Roll w/Resistance
  • Verbal judo
  • Develop Discrepancy
  • Goals and values contrasted with current behavior
  • Support Self-Efficacy
  • R Resist the righting reflex
  • U Understand you clients motivation
  • L Listen to you client
  • E Empower your client

  • Multiple Components
  • Experience sharing (affective empathy)
    vicariously sharing targets internal states
    (feeling with), but knowing the target is the
    source of the emotional state in the self.
  • Mentalizing (cognitive empathy) explicitly
    considering targets' states and their sources,
    without necessarily sharing another's state.
  • Prosocial concern (compassion) feeling of concern
    for a target's suffering ("feeling for") that
    induces a motivation to alleviate that suffering.
  • http//
  • http//

The Importance of Empathy and Rolling w/Resistance
Miller, Benefield Tonigan (1993) JCCP 61
Developing Discrepancy
  • Finding, increasing or encouraging a discrepancy
    between present and desired states
  • Can be positive or negative in valence
  • Discontent with the status quo
  • Opportunity for betterment
  • Goldilocks Principle
  • Discrepancy within limit

Support Self-Efficacy
  • Perception of the degree to which someone feels
    confident he/she can accomplish a particular
  • Building confidence
  • Building on past successes
  • Translating things they do well in other life
    contexts to the behavior change context.
  • Affirming smaller steps and approximations

How Does MI Work
  • Empathy allows clients to reduce resistance and
    resolve ambivalence
  • Looking at the situation from their perspective
  • People feel understood less resistant
  • Selective reinforcement of change talk
  • Focus on change talk
  • We learn what we believe when we hear ourselves
  • Therapist reinforces change talk that is
    consistent with therapeutic goals
  • Reinforcement further increases change talk and
    allows of client to experience build in
    motivation to change

Basic MI Tools
  • O - Open Questions
  • A - Affirmative Approach
  • R - Reflective Listening
  • S -Summaries
  • Your OARS propel you and steer you through the
  • You have to do these well to do MI well
  • Everything in MI is rooted in OARS

Open Questions
  • Questions that cannot be answered yes or no
    or with a discrete answer.
  • Open questions generate more data more data,
    more empathy
  • Open questions block momentum less than closed
  • Open questions lessen the expert or
    investigator feel of interactions

Opening Up Your Questions
  • Do you drink? How much?
  • Have you ever smoked a cigarette?
  • Are you taking your medications as prescribed?
  • Have you lost or gained weight in the last month?
  • Are you sexually active?
  • Do you always use birth control?
  • How many alcoholic drinks do you have in a
    typical week?
  • Did you take your insulin today?
  • Do you get regular physical exercise?
  • Is there a family history of heart disease?
  • Have you ever been hospitalized or had surgery?
  • On what day did your symptoms start?

  • Clients are often unsuccessful self-changers
  • Demoralized
  • Our role is to instill hope and a belief that the
    client can change
  • Empower the client can do
  • Attributions
  • Focus on specific behaviors instead of attitudes
    or decisions
  • Focus on descriptions not evaluations
  • Attend to non-problem areas
  • Nurture a world-view of competence not deficit

Affirmation Exercise
  • Listen to the statement
  • Write down a few strengths
  • Write down an affirmation

Reflective Listening - Roadblocks to Listening
  • 1. Ordering, directing, or commanding
  • 2. Warning or threatening
  • 3. Giving advice, making suggestions, or
    providing solutions
  • 4. Persuading with logic, arguing, or lecturing
  • 5. Moralizing, preaching, or telling clients what
    they "should" do
  • 6. Disagreeing, judging, criticizing, or blaming
  • 7. Agreeing, approving, or praising
  • 8. Shaming, ridiculing, or labeling
  • 9. Interpreting or analyzing
  • 10. Reassuring, sympathizing, or consoling
  • 11. Questioning or probing
  • 12. Withdrawing, distracting, humoring, or
    changing the subject

Reflective Listening What is it?
  • A statement a hypothesis
  • Vocal inflection is downward
  • Keeps people in the meaning/feeling
  • A verbal mirror to reflect back
  • Exact words
  • Paraphrase
  • Meaning
  • Emotion

Reflection Exercises
  • Groups of reflections that serve to
  • Remind you and client of what has been said
  • Highlight overarching themes Linking
  • Transition when stuck or wanting to shift

  • Listen for OARS

Rolling w/Resistance
  • Strategies
  • Reflection (Under/Over)
  • Reframe
  • Double-sided reflection
  • Emphasizing Personal Responsibility
  • Shifting Focus
  • Coming Alongside
  • Exercise

Exercise - Fishbowl
  • Practice OARS
  • Roll w/ resistance
  • Listen for Change talk

MI Processes
  • MI occurs throughout four ongoing processes of
    change conversations
  • Engaging
  • Focusing
  • Evoking
  • Planning
  • Often MI is about knowing how to skillfully and
    artfully move back and forth between each process

  • The process by which counselor and client
    establish a helpful connection and a working
  • How comfortable is this person talking to me?
  • How supportive and helpful am I being?
  • Do I understand this persons perspective and
  • How comfortable do I feel with this conversation?
  • Does this feel like a collaborative partnership?

Understanding Values
  • Freely chosen core beliefs that drive and
    organize behavior that is intrinsically
  • Values represent what one wants their life to
    look like, stand for and be about
  • Global values
  • Domain-specific values family, relationships,
    career, etc.
  • Values provide direction
  • Values are different from valuing
  • Values cannot be accomplished in-and-of-themselves
  • Instantiated moment by moment and over time
  • No matter what direction life takes, you still
    have your values

Values Assessment
  • Informal
  • How do you hope your life will be different a
    few years from now?
  • Who do you respect in life and why?
  • Tell me what you care most about in life.
  • Tombstone
  • Eulogy
  • Values Card-Sort
  • http//
  • Batteries Exercise
  • Next Slide

(No Transcript)
  • Process of clarifying direction find the
    horizon point toward which to move. Agenda
  • What goals for change does this person really
  • Do I have different aspirations for change than
    this person?
  • Are we working together with a common purpose?
  • Does it feel like we are moving together, not in
    different directions?
  • Do I have a clear sense of where we are going?
  • Does this feel more like dancing than wrestling?
  • Sources client, setting, your experience

Agenda Mapping
  • A short meta-conversation in which you step back
    with the client to consider the way ahead
  • Structuring
  • Consider options
  • Zoom in
  • Zoom out

Information Exchange Elicit - Provide - Elicit
  • Elicit
  • What would you like to know/do about?
  • What do you already know/do about?
  • Provide
  • Provide information (not opinion) in manageable
  • Confirming
  • New
  • Disconfirming
  • Elicit
  • What do you make of that?
  • What does this mean for you?
  • What more would you like to know?

  • Eliciting clients own motivations to change.
    Harness the clients own thoughts and feelings
    about why and how they might do it
  • What are this persons reasons for change?
  • Is the reluctance more about confidence or
  • What change talk am I hearing?
  • Am I steering to far or too fast in a particular
  • Is the righting reflex pulling me to be the one
    arguing for change?

Explore Importance of Situation/Change
  • General
  • How important is situation/issue, you need to
    make a decision or do something about it?
  • Importance Ruler
  • On a scale of 0 to 10, how important is this
    issue to you at this point in your life(0not at
    all, 10most important thing)
  • What makes it an X and not a Y?
  • What might make your rating a few points higher,
    a bit more important?
  • What can you specifically do to increase?
  • What might I, or others do to help it increase?

Explore Confidence about Changing
  • On a scale of 0 to 10, how confident are you that
    you could change if you decided to?
  • What makes it an X and not a Y?
  • What would make it a few points higher?
  • What can you specifically do to increase?
  • What might I, or others do to help it increase?

DARN CAT Client Exercise
  • Lets write down some statements about this change
    we are discussing.
  • D Why do you want to make this change?
  • A How could you do it?
  • R What are good reasons to make the change?
  • N How important is it and why?
  • C What do you intend to do about it?
  • A What are you ready or willing to do?
  • T What have you already done?
  • Use your OARS to expand, explore and solidify.

Decisional Balance
  • Not changing
  • What concerns you the most about the possibility
    of not making a change?
  • What might some benefits be of not addressing
    this, not making any changes?
  • Changing
  • What might you lose, have to give up, or risk, if
    you make a change? What might not be so good?
  • What good things might happen if you did
    something about it, made a change?

Exercise Decisional Balance
Pros of Status Quo
Cons of Change
Cons of Status Quo
Pros of Change
Looking Forward
  • In general, what things are most important to
  • Family? Cutting back on work? Getting some fun or
    excitement back in your life? Feeling better
    about yourself? Getting more involved in your
    community? Your spirituality? Having a partner?
    Being financially prepared? Autonomy?
  • Thinking about whats important for you for the
    future, how does this current issue fit in?
  • What is likely to be the outcome if you dont
    make any decisions, do anything about it? What do
    you think things will be like a year from now, or
  • What might be the outcome if you were successful
    at making some changes? How might things be in a
    year from now, or five?

Looking Back
  • How long has it been going on?
  • How did it come about?
  • Did it start all at once or gradually?
  • What were things like before?
  • How were things better now?
  • How are things worse?

Building on Strengths
  • What strengths might you draw on to make a
  • Are you determined? Flexible? Careful? Organized?
    Creative? Resourceful? Stubborn?
  • How have these strengths helped you before?
  • What things might be changed in your environment
    to help you succeed? What might help you get
  • How might others help?

Remembering Successes
  • What have you been successful at changing in the
    past? No matter how small...
  • What initiated you making this change?
  • What did you do to get started, what did you do
    to stick with your decision to change?
  • What barriers or obstacles did you run into? How
    did you get past them?
  • How easy was it? How did you feel after making
    that change? How do you feel about it now?
  • What other changes have you made?

Other Strategies
  • Typical Day
  • Others Concerns
  • Normative Feedback

How to Reinforce Change Talk (EARS)
  • Elaborate
  • In what ways?
  • Give me an example?
  • What else?
  • Why else?
  • How else?
  • Affirm
  • Sounds like a good idea
  • I think you could do that
  • It is really important to you to
  • Reflect
  • Summarize
  • Collect the flowers of change talk and give back
    a bouquet of change talk back to the client.
    Give them what you want them to hear not

  • Listening for change-talk

  • The process of developing commitment to change
    and a specific plan of action
  • What would be a reasonable next step toward
  • What would help this person to move forward?
  • Am I remembering to evoke rather that prescribe a
  • Am I offering needed info and advice with
  • Am I retaining a sense of quiet curiosity about
    what will work best for this person?

MI and Planning
  • Moving from evoking to planning
  • Comes from a sense of the interaction less
    resistance, more curiosity, more change talk,
    more optimism
  • Summarize
  • Change-talk focused
  • Key question
  • A questions that elicits what a client wants to
    do in relation to the problem of concern
  • What do you think you will do?
  • What are you thinking at this point about ______?
  • What changes, if any, or you thinking about
  • What are your options?
  • It sounds like things cant stay the way they
    are, what do you think you might do?
  • What are some of the good things about making a

MI Change Planning
  • Lots of freedom in how to do this, but do follow
    these 6 steps
  • Confirm the goal
  • State goals in behavioral terms
  • Avoid dead person goals
  • Itemize options
  • Elicit the clients hunches and preferences
  • Plan strategy
  • What are the steps and how will they know its
  • Summarize and strengthen commitment
  • Troubleshoot raise concerns you have

Behavior Change Plan
  • What, specifically, would you like to be
  • What, specifically, could you do to get started?
  • If the first step is successful, then what?
  • Who else could you ask for support, assistance,
    if anyone? What could you ask for?
  • What would be signs that things are going well?
  • How would you know if you were off-track?
  • What would you do if you got off-track?

Supporting Change
  • Subsequent treatment should integrate the
    processes of
  • Replanning
  • Reminding
  • Refocusing
  • Reengaging
  • http//

Opening the Session
  • Set the Agenda
  • Spirit
  • What will be talked about
  • Your role
  • Open Question
  • Pick up your OARS and start paddling
  • Perceptions of being there
  • Perceptions of the issues
  • Important current activities, requirements,
    and/or needs
  • Paddle in order to build rapport (Joining) and
    elicit change talk

Managing the Middle
  • Assess/Understand Values
  • Card Sort or Batteries Exercise
  • Use EVOKING strategies
  • Develop Discrepancy
  • Support Self-Efficacy
  • Provide information/feedback if necessary
  • Elicit-Provide-Elicit

Wrapping Up an MI Session
  • If using MI brings you to a point where a client
    is making statements related to change or
    increased importance/confidence
  • Summarize Key Question
  • Behavior Change Plan
  • Summarize Elicit Commitment
  • If client is stuck/ambivalent
  • Reflect the continued ambivalence in terms of
  • Summarize

Exercise Fishbowl
  • Goal
  • Practice OARS
  • Listen for change talk
  • Reinforce change talk
  • Practice process-based exercises

Specific MI Applications
Treatment Engagement
  • Turn your assessment into and MI-informed
  • There are number of questions I will need to ask
    you today, but first I would just like to know
    what brings you here today, what are your biggest
    concerns and how you hope we might be able to
    help you.
  • Listen with empathy and to detect the process
    where you need to start
  • Ask for permission to move into the assessment
  • Use open-ended questions to replace closed
    prompts on your assessment.
  • Listen for change talk
  • Summarize and transition through each domain
  • Use EPE for information exchange
  • Use importance/confidence
  • Summarize at the end

Treatment Enhancement
  • Boosts the effects of larger treatments
  • Motivational Enhancement Therapy
  • Now being integrated with other treatment formats
  • CBT
  • Now being developed to treat specific disorders
  • Depression, OCD, eating disorders, GAD

Medication Compliance
  • Exploring of both sides of motivation/eliciting
  • Exploration of previous concerns and result of
  • Discuss and prepare for motivational issues that
    may arise.
  • Feedback on dose-taking, reinforcement of
    adherence, and exploration of missed doses.
  • Targeted information exchange
  • Articulate patients reasons for adhering to
    treatment, anticipated barriers, and plan
  • Mailed to participants 1 week after the
    intervention to provide additional information.
  • Discussing adherence in alignment with sources of
  • Assessing motivation for adherence.
  • Discussing previous adherence
  • Anticipating adherence difficulties
  • Personalized feedback
  • Informally assessing antidepressant knowledge
  • Adherence plan
  • Discussing goals/values

MI and Suicidal Ideation
  • Phase 1 Exploring the present problem and the
    motivation to die.
  • Focus in on eliciting the ambivalence around
  • Phase 2 Building motivation to live.
  • Focus is on gently shifting toward the living
    side of the ambivalence
  • Phase 3 Strengthening commitment to live.
  • Focus is on moving reasons to commitment and
    planning for the next stage of treatment.

Take Home
  • Learning MI involves 10 steps of understanding
  • Understand and invoke the underlying spirit
  • Develop skill and comfort with reflective
  • Learn to identify from clients agenda, goals
    that can become foci of the conversation
  • Understand EPE as information exchange
  • Learn to recognize change talk and sustain talk
  • Learn to evoke change talk
  • Learn to strengthen change talk
  • Learn to respond to sustain talk in ways that do
    not amplify it
  • Understand the timing when moving into planning
  • Cant just get good at MI-consistent behaviors
    must eliminate MI-inconsistent behaviors
  • Advice or info without permission
  • Confronting by disagreeing, arguing, correcting,
    shaming, blaming, criticizing, etc.
  • Directing by giving orders, commands or
    imperatives, or otherwise challenging autonomy
  • One never stops learning MI