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The Spirit of Motivational Interviewing
Reviewing the Basics – even if you’re new to MI!
Bryan Kutner, PhD, MPHTraining Consultant
So, what is MI?
and movement toward a specific goal by eliciting and exploring the person’s own arguments for change.
– Motivational Interviewing, 3rd Edition
Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change.
It is designed to strengthen an individual’s motivation for
Click for a quick video introducing MI!
A Continuum of Styles
Directing Guiding Following
Authoritarian Motivational Interviewing
Rogerian (Client-Centered)
Spirit of Motivational Interviewing
Collaborative
Evocative
Respectful of autonomy
Working with and sharing power“You, the client, might be right…”
Rather than insert knowledge, draw it from the client“You have knowledge, wisdom, expertise, and my job is to get that out on the floor between us…”
The client retains the right not to change and the right to change the way they want, even if that isn’t what we want.
Spirit in MI 3rd Edition
Sometimes it’s easier to see the opposite…
Opposite Approach
Confronting
Educating/Giving Information
Emphasizing authority
Motivational Interviewing
Collaborative
Evocative
Respectful of Autonomy
Four Processes
Engaging
Focusing
Evoking
PlanningIf you’re stuck during MI, fall back to an earlier
process
“When Would I Use MI?”
• There is a change target — a behavior that the client is at least considering or forced to consider changing.
• The client is ambivalent about the change — they want to change, but something is preventing them from making that change.
AmbivalencePart of you wants to
change; part of you
doesn’t want to change
Equipoise means exploring all sides of ambivalence
Status Quo Changing
+’s
-’s
+’s of not changing
-’s of not changing
+’s of changing
-’s of changing
But Equipoise is not MI• The expected outcome of
exploring all sides is more AMBIVALENCE
• When you are guiding, the order of the boxes matters
• In MI, pay more attentionto change talk
• Change talk: pros of changing, cons of not changing
Status Quo Changing
+’s
-’s
Pros of not changing
Cons of not changing
Pros of changing
Cons of changing
Microskills: OARS• Open questions
• Affirmations
• Reflections
• SummariesMI relies on a set of specific skills (OARS)
We’ll focus on one of them!
Reflections
Reflections are really a hypothesis– a guess about what someone means with their words.
They connect back to what a person means
Reflecting is a Different Kind of Hypothesis Testing
A reflection is a guess that isn’t a question – it’s a statement. The inflection turns down at the end, not up.
• A hypothesis can be a question: “You’re getting a divorce?”
• Or a reflection: “You’re getting a divorce.”
Reflections Range in Intensity
Simple reflectionsrestate something about what was said
Complex reflectionsmove beyond the client’s words to present information in a new light
Reflections Range in Intensity“I know I could do some things differently, but I don’t need people
reminding me all the time that diabetes is going to kill me.”
Feelings
Meaning
Double-sided
AmplifiedMetaphor/ Analogy
“It’s upsetting enough, even without that reminder.”
“You’d like people to be supportive in a different way.”
“You don’t need people nagging you; you alreadyknow there are things you’d like to do differently.”
“It’s like they’re just trying to scare you.”
“You’re already shouldering a lot and you’d like folks to help you carry it instead of making it heavier.”
Change Talk
What is it?
Why should I care about it?
Listening for Change Talk
• “If I keep missing my meds, I just know I’ll end up back in the hospital. …
• “But taking meds is still the least of my worries. I got to think about how to pay all these bills.”
Change Talk
Sustain Talk
Different Kinds of Change Talk: DARNCAT
Desire
Ability
Reasons
Need
Commitment
Activating
Taking steps
}}
PreparatoryChange Talk
MobilizingChange Talk
Desire I want to …
Ability I could …
Reasons I’d feel better if …
Need I have to …
Commitment I am going to …
Activating I’m willing to …
Taking steps I started to …
MI Recognizes, Elicits & Reinforces Change Talk
Motivational interviewing aims to producethe client’s own
change talk
Change talk is like seeing a wildflower in a field of
grasses…Pick the flowers up, give them back as
reflections and summaries
Change talk often is sandwiched between sustain talk
• Our job is to pull out the center of the cookie – the change talk –and give it back to the client
We do that by recognizing, eliciting, and reinforcing change talk with O.A.R.S.
Ambivalence is a Change Talk Cookie
change talk
sustain talk
sustain talk
A. “I love having a cigarette at the end of the day.”
B. “I know I should probably quit at some point.”
C.“But it’s almost not worth trying again because every time I’ve said I’m gonna quit, I go right back to smoking again.”
Where’s the Change Talk?
change talk
sustain talk
sustain talk
Snatching Change Talk from the Cookie
They’re all great reflections – but which one reinforces change talk?
Client: “I really don’t like condoms. But I know that I should use ‘em. I’ve tried before and it’s just really hard to enjoy sex that way.”
A. “You really don’t want to use them.”
B. “You’re not sure if you can use them and enjoy sex.”
C. “It bothers you that you haven’t been able to use them.”
“I really don’t want to quit smoking. But I know that I should. I’ve tried before and it’s really hard.”
A. “You really don’t want to quit.”
B. “You’re not sure if you can quit.”
C. “It’s become clearer to you that at some point you’ll really need to quit.”
Snatching Change Talk from the Cookie
Change Rulers
Importance
“On a scale from 0-10, how important is it to make the change?”“How come you’re at ________ and not lower?”
|0——1——2——3——4——5——6——7——8——9——10|
Confidence
“From 0-10, how confident are you that you can make the change?”“How come you’re at ________ and not lower?”
|0——1——2——3——4——5——6——7——8——9——10|
% of Counselors Proficient in MI at 4 months140 randomly assigned counselors
0 10 20 30 40 50 60 70 80 90
Workshop + feedback + coaching
Workshop + coaching
Workshop + feedback
Workshop only
Book only
Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72(6), 1050–1062. http://doi.org/10.1037/0022-006X.72.6.1050
Proficiency in MI often
requires feedback
and coaching
Developmental Steps to Learning MI
1. Understanding the spirit of MI2. Skill & comfort with reflective listening (OARS)3. Identifying change goals toward which to move4. Exchanging info and providing advice within an MI style5. Recognizing change talk and sustain talk6. Evoking change talk7. Responding to change talk in a way that strengthens it8. Responding to sustain talk & discord without amplifying it9. Developing hope & confidence10.Timing and negotiating a change plan11.Strengthening commitment12.Flexibly integrating MI with other skills & practices
Training & Supervision Resources
Rosengren, D. B. (2017). Building Motivational Interviewing Skills: A Practitioner Workbook, 2ndEdition (pp. 1–529). New York, NY: Guilford Press.
William R. Miller Ph.D. and Stephen Rollnick Ph.D. Motivational Interviewing: Helping People Change, 3rd Edition. Guilford Press. New York: 2013.
Motivational Interviewing website: www.motivationalinterview.org
Bryan Kutner, PhD, MPH, [email protected]
