Motivational Interviewing: Preparing
People to Change- A Skill Building
Training
Presented By:
Lauren Moyer, L.M.S.W, C.C.D.P.-D., C.C.G.C.
Craig S. Miner, M.A., L.P.C., C.A.S.A.C., C.C.D.P.-D.
Learning Objectives
• Understand Motivational Interviewing in the
framework of stages of change
• Implement the Motivational Interviewing
Spirit, Principles and Strategies
• Build basic skill application of Motivational
Interviewing
Integrated Treatment Defined
• Integrated Treatment is how we organize (or
reorganize) ourselves around a set of best
practice treatment principles to improve
services for individuals with co-occurring
psychiatric and substance use disorders…
• Our system of care…
• Our programs…
• Our services…
Core Resource
Substance Abuse and Mental Health Services Administration
(SAMHSA) best practice for system change…
• Comprehensive Continuous Integrated System of Care
(CCISC) Model
• Minkoff & Cline
CCISC Principle
• Dual diagnosis is an expectation… “Expectation not
an exception”…
– 50% of clients with severe mental illness have a
lifetime substance use disorder, and 25 – 35%
have an active substance abuse problem…
– Approximately 60% of individuals with a substance
use disorder have an identifiable psychiatric
diagnosis…
Why Integrated Treatment?
• A high rate of co-occurrence, or comorbidity, between substance use disorders and
mental illness…
• Comorbidity affects the course and prognosis of both the individuals mental health
and substance abuse issues…
• Individuals experience poorer outcomes than those with only a mental health or
substance abuse issue…
• Higher service utilization and increased service costs…
• Traditional practice of treating co-occurring disorders as separate conditions in a
parallel fashion is largely ineffective…
• We have identified integrated best and evidence-based practices that result in
improved outcomes for these individuals… Motivational Interviewing is one of
these practices…
Stage-Sensitive Style Defined
• Stage-Sensitive Style is when we organize (or
reorganize) ourselves to utilize best and
evidence-based interventions which align with
the person’s stage of change/treatment or
readiness for change…
Why Stage of Change?
• Provides a framework for understanding the process
of behavior change and determining which
interventions to use within each stage of change…
• Views motivation as a state of ‘readiness’ to move
through the stages of change…
• Proposes a predictable pathway for behavior
change…
• Offers an alternative to other approaches that view
people as in denial, resistant, uncooperative if they
are not ready to accept change…
STAGE of CHANGE
STAGE of CHANGE
Pre-Contemplation
Pre-Contemplation
Pre-Contemplation: Client is not yet considering
change or is unwilling/unable to change… You may
think I have a problem but I don’t so stop bugging
me… You need to gain the clients trust so they know
we are not going to hurt them… This way you can get
to know their story and begin to talk with them inside
their story…
Contemplation
STAGE of CHANGE
Pre-Contemplation
Contemplation
Contemplation: Client acknowledges concerns and
sees possibility for change but is ambivalent or
uncertain… I’m not changing – in fact I don’t even
have a problem but I am willing to talk to you about
my life & what is going on… Consider if changing
anything would make sense in my life and what I
want my life to be about… This is where you talk with
them (not at them)… Don’t jump too quickly into
preparation/action…
Contemplation;
Preparation
STAGE of CHANGE
Pre-Contemplation
Preparation
Preparation: Client is committed to making a
change but is still considering what to do… I
think I might want to do something a little
different, but I don’t know what and I have
started and I need some help to get started… I
have found the small thing that makes sense
to work on to make my life better and I know a
bit about how to start…
Early Action
Contemplation;
Preparation
Action
STAGE of CHANGE
Pre-Contemplation
Action - Early Action
Action: Client is actively taking steps to change but
has not yet reached a stable state…
Early Action: I’ve started to make some change, but
don’t misunderstand me I don’t think I have to
commit to everything everybody else thinks I do but
this change is good, hard but good… Learn, try, and
learn some more… Progress not perfection… Be
careful to keep this slow… Don’t speed up just
because you think since they want to change one
thing we should add in others…
Early Action
Contemplation;
Preparation
Action
Late Action
STAGE of CHANGE
Pre-Contemplation
Action – Late Action
Action: Client is actively taking steps to change but
has not yet reached a stable state…
Late Action: I’m really working on getting it together,
I may not be very good at it but I’m figuring it out..
I’m coming to think that my goal is starting to sound a
lot like others that have been down this path… The
more I learn by doing, the more this is all connecting
up for me… I see more and more that I have to do
this if my life is going to be what I want it to be…. My
job is to get the help I need and keep working,
regardless of the ups and downs I am having…
Early Action
Contemplation;
Preparation
Action
Late Action
STAGE of CHANGE
Maintenance
Pre-Contemplation
Maintenance
Maintenance: Client has achieved initial goals such
as abstinence and is now working to maintain gains…
I’ve done a good thing for myself and I am stable and
trying to stay that way… I have come to appreciate
who I am and that I am who I am… I must do what I
need to do to keep learning so I can maintain and
meet all of life’s challenges so I can grow… Even
though this is a problem that may continue to exist, I
am not it and it is not me… I know that I am on the
right path and I want to stay on it… Continue to focus
on growth…
Early Action
Contemplation;
Preparation
Action
Late Action
STAGE of CHANGE
Maintenance
Pre-Contemplation
Recurrence/Relapse
Client has experienced a recurrence of
symptoms and must now cope with
consequences and decide what to do next
Early Action
Contemplation;
Preparation
Action
Late Action
STAGE of CHANGE
Maintenance
Pre-Contemplation
Stage-Wise Interventions
• Pre-Contemplation
– Outreach, crisis intervention, practical support, listen,
trusting relationship, assessment
• Contemplation & Preparation
– Motivational Interventions, Payoff Matrix, education,
set goals, build awareness of problem, skills training,
family support, peer support,
• Action
– Substance abuse counseling, CBT, medication
treatments, skill building, family support, self help
groups
• Maintenance
– Relapse prevention plan, continue skills building in
active treatment, expand recovery to other areas of
life, continue to improve quality of life
Motivational Interviewing Defined
• “Motivational Interviewing is a directive,
client-centered counseling style for eliciting
behavior change by helping clients explore
and resolve ambivalence.”
More recent definition…
• “Motivational Interviewing is a collaborative,
person-centered form of guiding to elicit and
strengthen motivation for change.”
Core Resources
• Motivational Interviewing: Preparing People for
Change
• Miller & Rollnick
• TIP#35: Enhancing Motivation for Change in
Substance Abuse Treatment
• SAMHSA
• Integrated Treatment for Dual Disorders: A Guide to
Effective Practice
• Mueser, Noordsy, Drake, & Fox
•
•
•
•
•
Where to Begin…
The Recovery Relationship
Welcome
Provide Empathy & Hope
Applaud
Empower
Understand the Individual’s Story and SelfDefined “Happiness”
• Find the Individual’s Strengths
• Partner with the Individual for Recovery
Planning
• Stay Engaged No Matter What
Why Motivational Interviewing?
• 80 % of individuals with substance use disorders are in a precontemplation or contemplation stage of change…
• Provides an alternative approach to the traditional
‘medical/disease model’ where the helping professional
interacts in a non-collaborative sometimes confrontive style
as the ‘expert’ who’s knowledge is the ‘cure’ with little regard
for the clients level of motivation or readiness for change…
• Since clients early in treatment are often not motivated it is a
clinical task of the helping professional to help the person
become motivated with appropriate counseling…
What Is Motivation?
“Motivation can be understood not as
something that one has, but as something
that one does. It involves recognizing a
problem, searching for a way to change, and
then beginning and sticking with that change
strategy.”
Miller & Rollnick
 State of mind, not a character flaw
 Multidimensional, dynamic and fluctuating
 Interactive and modifiable by clinician
Counselor & Client
Interpersonal Process
• Differences in the magnitude of success of individual
counselors exceed the differences between treatment
approaches…
• Research indicates that counselor empathy can be a
significant determinant of client’s positive response to
treatment…
• Conversely, confrontational counseling has been associated
with high dropout rates and relatively poor outcomes…
• Counselor’s who believe their client will change will likely
have that result…
Conflict & Ambivalence
• Conflict normally causes Ambivalence
• Ambivalence normally causes Conflict
•
•
•
•
Approach-Approach Conflict
Avoidance-Avoidance Conflict
Approach-Avoidance Conflict
Double Approach-Avoidance Conflict
Decisional Balance
Pay Off Matrix
Advantages of Using
Substances
Advantages of Not Using
Substances
Disadvantages of Using
Substances
Disadvantages of Not
Using Substances
Ambivalence
• Common human experience and a stage in the
normal process of change…
• Getting stuck in ambivalence is also common…
• Approach-Avoidance Conflicts can be
particularly difficult to resolve on one’s own…
• Resolving ambivalence can be a key to change,
and, indeed, once ambivalence has been
resolved, little else may be required for
change to occur…
Ambivalence Over Time
in Treatment
Level of ambivalence
contemplation
& preparation
Ambivalence
action
precontemplation
maintenance
time -->
Righting Reflex
• Attempts to force resolution in a particular
direction (as by direct persuasion or by
increasing punishment for one action) can
lead to a paradoxical response, even
strengthening the very behavior they were
intended to diminish…
• Important to inhibit the righting reflex
• Resistance may be a result of client-counselor
relationship that lacks agreement, collaboration,
empathy or client autonomy
• Counsel in a directive, confrontational manner and
resistance goes up
Developing Discrepancy
• Employ strategies that facilitate the client’s
identification of discrepant elements of a particular
behavior or situation…
• Past versus Present
• Values versus Behaviors
• Behaviors versus Goals
• When a behavior comes into conflict with a deeply
held value, it is usually the behavior that changes…
• The larger the discrepancy, the greater the
importance of change…
Change Talk
• A guiding principle of MI is to have the client, rather
than the counselor, voice the argument for change…
• Change talk refers to client’s statements that indicate
an inclination or reason for change…
• As a person argues on behalf of one position, they
become more committed to it…
• The more a person talks about change in the course
of a conversation, the more likely change is to
occur…
• Counsel in a reflective, supportive manner, and
resistance goes down while change talk increases…
Summing It Up!
• People experience ambivalence… the conflicting thoughts
and feelings about a particular behavior or change that holds
advantages and disadvantages for them…
• When a person experiences a discrepancy between how
things are and how they ought to be, they tend to be
motivated to reduce that discrepancy if it seems possible to
do so…
• Person has to argue for change…
• Counselor collaboratively joins the person to guide them to
develop discrepancy between their actual present and desired
future in order to intensify, explore, and resolve their ambivalence
while emphasizing their change talk and helping them to tip the
decisional balance towards change
What is Motivational
Interviewing?
Phases of Motivational Interviewing
Phase 1
 Goal: Build Intrinsic Motivation for Change
 Pre-Contemplation, Contemplation, & Preparation Stage of
Change
 Enhance Importance [Willing]
 Enhance Confidence [Able]
Phase 2
 Goal: Strengthen Commitment to Change Plan [Ready]
 Preparation, Action, & Maintenance Stage of Change
 Prepare for Change (develop a plan)
 Take Action (implement the plan, enhance self-efficacy)
 Maintain Change over Time
Spirit of Motivational Interviewing
• Collaboration (Instead of Confrontation)
 Exploration
 Support rather than persuasion or argument
 Positive atmosphere that is conducive but not coercive
for change
• Evocation (Instead of Education)
 Not imparting things but rather eliciting ideas and
drawing them out from the person
 Not instilling but drawing out intrinsic motivation
• Autonomy (Instead of Authority)
 Client is responsible for change
 Change arises from within and is connected to the
client’s own goals and values
Principles of Motivational Interviewing
Core Principles:
• Express empathy… To understand the client’s world…
• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Ambivalence is normal
Principles of Motivational Interviewing
Core Principles:
• Develop discrepancy… To help the client see their personal
goals are inconsistent with their current behavior and thus to
motivate the client to change the behavior…
• A discrepancy between present behavior and important
personal goals or values will motivate change
• The client should present the argument for change
Principles of Motivational Interviewing
Core Principles:
• Rolling with Resistance… To overcome the client’s
resistance to behavior change by acknowledging and
dealing with it but avoiding direct confrontation…
• Avoid arguing for change
• Resistance is not directly opposed
• New perspectives are invited but not imposed
• The client is the primary resource in finding answers
and solutions
• Resistance is a signal to respond differently
Principles of Motivational Interviewing
Core Principles:
• Support self-efficacy… To foster hope in the client that they
can achieve desired changes…
• A person’s belief in the possibility of change is an
important motivator
• The client, not the counselor, is responsible for
choosing and carrying out change
• The counselor’s own belief in the person’s ability to
change becomes a self-fulfilling prophecy
Principles of Motivational Interviewing
Additional Principle:
• Establishing personal goals… To establish goals that are
genuinely personal and meaningful for the client, in order to
increase the client’s willingness to work toward them…
• Talk with the client about their aspirations, desires,
fantasies
• Get to know what the client was like in the past, such as
finding out their past, such as finding out about their
preferred activities, admired people, personal ambitions
• Do not discourage the client from expressing ambitious
goals
Phase 1:
Building Motivation for Change
Remember…
Phase 1 involves building intrinsic
motivation for change by resolving
ambivalence….
Willing and Able?
• Importance Ruler [Willing]
• How important would you say it is for you to ______?
On a scale of 0 to 10, where 0 is not at all important and 10 is
extremely important, where would you say you are?
• Confidence Ruler [Able]
• How confident would you say you are, that if you decided to
__________, you could do it?
On the same scale from 0 to 10, where 0 is not at all confident
and 10 is extremely confident, where would you say you are?
Early Traps to Avoid
•
•
•
•
•
•
Question-Answer Trap
Taking Sides Trap
Expert Trap
Labeling Trap
Premature Focus Trap
Blaming Trap
Effective Strategies - OARS
•
•
•
•
Ask Open Questions
Listen Reflectively
Affirm
Summarize
Plus…
• Elicit Change Talk
• OARS directly supports the goal of encouraging client
speech while the clinician is eliciting and shaping certain
kinds of client speech… change talk…
Open-Ended Questions???
• Atmosphere of acceptance and trust
• Client should do most of the talking
• Counselor is listening carefully and
encouraging expression so the client can
explore their own experience, including
ambivalence
• Avoid yes or no questions
• Example: Tell me what brings you here today?
Open-Ended Question Exercise
• Make the following closed questions into open questions
 So you are here because you are concerned about your use of alcohol,
correct?
 How many children do you have?
 Do you agree that it would be a good idea for you to go through
detoxification?
 Do you like smoking marijuana?
 How has your drug use been this week compared to last: more, less or
about the same?
 Do you think you use crystal meth too often?
Reflective Listening
• Reflection is particularly important after openended questions
• The essence of a reflective listening response
is that it makes a guess as to what the speaker
means
• Gives the counselor an opportunity to
confirm, rather than assume, that you
[counselor] knew what the person meant
What is Reflective Listening?
Model of Listening
from Thomas Gordon
What Words The
Speaker Says
What The
Speaker Means
The Words The
Listener Hears
What The Listener
Thinks The
Speaker Means
Not Reflective Listening
•
•
•
•
•
•
•
•
•
•
•
Ordering, directing, commanding
Warning/threatening
Giving advice, making suggestions, providing solutions
Persuading with logic, lecturing, preaching, telling
what to do
Disagreeing, judging, criticizing
Agreeing, approving, praising
Shaming, ridiculing, blaming
Interpreting or analyzing
Reassuring, sympathizing
Questioning or probing
Withdrawing , distracting, humoring, changing the
subject
Reflective Listening
• A guess at what client means by what they just said
• Is always in the form of a statement never a question
• It can be simple or complex
– Complex reflections add meaning or emphasis to
what has just been said
– Complex reflections moves the exploration
process forward
• It is collaborative/non-authoritarian; it is a guess not
an interpretation
• It is reinforced by client’s response
• It is never critical, judgmental, confrontational
• It can be directive (selective) but never directs by
giving advice/suggestions without permission.
“Selective” Reflective Listening
• Reflective listening is not a passive process…
It can be quite directive
• Counselor determines what to reflect in order
to emphasize or deemphasize certain aspects
of what the person is saying
• For example, change talk is preferentially
reflected so that people hear their own
statements of change at least twice
Level of Reflection
• Repeating: The first or closest to the surface level of reflection is
simply repeating what someone has just said.
• C: I really miss going out with my friends, I am more lonely now that when I
started treatment.
• T: You are more lonely now then when you started treatment
• Rephrasing: The next level of reflection is to rephrase what a
person has just said with a few word substitutions that may
slightly change the emphasis.
• C: I feel I have no control over my life, you are all telling me what to do
• T: You feel like we are intruding into your life and you can no longer do
what you want
Level of Reflection
• Paraphrasing: Major restatement. The listener
infers the meaning in what was said and reflects
this back in new words. This adds to and extends
what was actually said, like continuing the
paragraph, saying the next sentence rather than
repeating the last one.
 C: Yeah, the court sent me here
 T: And that is the only reason you’re here.
Level of Reflection
• Reflection of Feeling: This is a special kind of
paraphrase as it achieves the deepest level of
reflection because you are not necessarily
reflecting content, but the feeling or emotion
underneath what the person is saying through
feeling statements, metaphor etc.
 C: I am not sure that I want to work, it may be too much for
me.
 T: Going to work in the community is different than working at
Places, it sounds like you are feeling afraid that you will not be
able to do the job.
Level of Reflection
• Simpler (repeating, rephrasing) reflections
are used first, when meaning is less clear
• Deeper reflections (complex) are ventured
as understanding increases
• Jumping too far beyond what was said can
turn into interpretation
Advantages of Responding with a Reflective
Listening Statement
• It is unlikely to evoke client resistance
• It encourages clients to keep talking and
exploring the topic
• It communicates respect and caring and builds
the therapeutic alliance
• It clarifies for you exactly what the client means
• It can be used to reinforce ideas expressed by
the client
Affirm
• In MI, affirmations are genuine, direct statements of
support during the counseling sessions that are usually
directed at something specific and change oriented that
the client has done
• These statements demonstrate that the counselor
understands and appreciates at least part of what the
client is dealing with and is supportive of the client as a
person
• The point of affirmations is to notice and acknowledge
client effort and strength.
Affirm
• Say something positive or complimentary
• Can be in the form of appreciation, confidence or
reinforcement
• Comment on client’s strengths or efforts
 Appreciation: “You're a very resourceful person”
“Thank you for coming today”
 Confidence: “You’ve succeeded through some difficult
changes in the past”
 Reinforcement: “That’s a good idea” “Good for you”
Benefits of Affirmations
• Strengthens the working relationship
• Enhances the attitude of selfresponsibility and empowerment
• Reinforces effort and self-motivational
statements
• Supports client self-esteem and builds
self-efficacy
Summarizing
• A form of reflective listening
• Help structure a session so that neither client nor counselor gets
too far away from important issues and can help you link what a
client just said to something he offered earlier.
• Summary statements can be used to link together and reinforce
material that has been discussed.
• Show that you have been listening carefully and prepare client to
elaborate further.
• Summaries can be used to just collect what has been said and
then ask “what else”
• Summaries can be used to link material offered earlier especially
in clarifying ambivalence
• Summaries can be transitional; either in wrapping up a session
or moving from phase 1 to phase 2
Eliciting Change Talk
• Although OARS skills are fundamental to
motivational interviewing if we only used OARS it
would be more difficult to resolve ambivalence for
the client
• Eliciting change talk is primary method for
developing discrepancy
• Remember the idea in motivational interviewing is to
have the client give voice to the arguments for
change and it is the counselor’s task to facilitate the
client’s expression of such change talk
Developing Discrepancy
Goal:
To create a significant (to the person)
dissonance or discrepancy between
the person’s behavior and important
personal goals… The greater the
discrepancy between personal goals
and values the greater the perceived
importance of change
Four Types of Change Talk
1. Recognizing Disadvantages of the Status Quo

Cognitive recognition there is a problem


“I guess this is more serious than I thought”
Affective expression of concern

“I am really worried about what is happening to me”
2. Recognizing Advantages of Change

“I would be able to see my family more often”
3. Expressing Intention to Change

Talk about wanting to change

“I think it is time for me to think about quitting”
4. Expressing Optimism About Change

Encouraged/hopeful about ability to change

“I think I could probably do it if I decided to”
Strategies for Eliciting Change Talk
 Asking Evocative Questions
 Simply ask the person for change statements
 Open ended questions used to explore client’s perceptions and
concerns
 “What are some of the down sides of your cocaine use?”
 Exploring the Pros and Cons
 Have client discuss both the positive and negative aspects of
present behavior, the status quo
 Clarifies both sides of the ambivalence
 Use Decisional Balance Sheet (similar to Payoff Matrix)
Strategies for Eliciting Change Talk
• Importance Ruler
 How important is it for change______? On a scale
of 0 to 10 where would you say you are?
 Why are you a ___? And not zero?
 What would it take to go from a ____? To a
(higher number)
Strategies for Eliciting Change Talk
• Asking for Elaboration
 Have client elaborate on change talk before moving on
 Will elicit and reinforces further change talk and
 “In what ways? how much? Describe the last time this happened”
• Imagining Extremes
 Ask client to describe the extremes of their concerns, to imagine the
extreme consequences
 “What are your worst fears about what might happened if you don’t make a
change?” “What do you believe would be the worst thing that might happen
if you keep drinking the way you are right now?”
• Looking Forward
 Help clients envision a changed future. Ask how it might be after a
change
 “What would be the best results you can imagine if you make a change?”
Strategies for Eliciting Change Talk
• Looking Back
 Have person remember times before problem emerged,
compare these with present situation
 For clients with SMI one can explore last period of work,
sobriety, better functioning
 “Do you remember when things were going better for you? What
has changed?”
• Exploring Personal Goals and Values
• Key strategy for clients with co-occurring disorders
Developing Discrepancy Through Exploring
Goals & Values
 Clients have valuable personal goals
 Awareness of consequences (impact on goals) is
important and helps clients examine their
behavior
 A discrepancy between present behavior and
steps towards important goals will motivate
change
 The client should present the argument for
change
Goal Exploration
• Is a means to create discrepancy and begin to
build self-efficacy
• Talk with clients, establish personal, meaningful
goals that the client wants. Get to know what the
client was like in the past.
Elicit thoughts about how things could be different
Values
Dreams
Past preferred activities
Admired people
 Don’t discourage ambitious goals
Examples of Goals
 Finding a job
 Completing high
school
 Finding a girlfriend
 Getting married
 Rekindling a
relationship with an
old friend
 Going fishing with
one’s father
 Getting one’s own
apartment
 Resuming parenting
responsibilities
 Re-establishing
relationships with siblings
 Handling one’s own
money
 Buying a car
Responding to Change Talk
• Goal is to respond in ways that reinforce and increase change talk
• Strategies for reinforcing & increasing change talk
 Elaborating Change Talk
 Respond with interest, ask for elaboration
 Reflecting Change Talk
 Clarifies the client’s meaning and encourages continual
exploration
 Summarizing Change Talk
 Gather together the change statements. Selective. Client
hears again their own change talk
 Affirming Change Talk
 Reinforce by commenting positively on it. “That sounds like a
good idea” “I can see how that would concern you”
Resistance
• Resistance arises from the interpersonal
interaction between counselor and client
• Resistance is observable behavior that
occurs during treatment
• It signals dissonance within the
counseling relationship
• Your goal is to double back and
understand the resistance/dissonance
and address it
Responding to Resistance
• Remember it is how you respond to client
resistance that makes the difference and that
distinguishes motivational interviewing from
other approaches… So roll with it
Roll with Resistance
• Opposing resistance generally reinforces it
• Resistance, however, can be turned or reframed slightly to
create a new momentum toward change
• The interviewer does not directly oppose resistance, but
rather rolls and flows with it
• Reluctance and ambivalence are not opposed but are
acknowledged to be natural and understandable
• The interviewer does not impose new views or goals, but
invites the client to consider new information and offers
new perspectives
Roll with Resistance
• Do not feel obliged to answer a client’s objection or
resistance
• In MI, the counselor commonly turns a question or problem
back to the person, and relies on the client’s personal
resources to find solutions to his/her own issues
• Rolling with resistance includes involving the person
actively in the process of problem solving
• Resistance is a signal for the interviewer to shift approach
• How the interviewer responds will influence whether
resistance increases or diminishes
Recognizing Resistance
Four categories of resistance behavior:
1.
Arguing: the client contests the accuracy, expertise, or integrity of the
counselor... Includes challenging, discounting, hostility
2.
Interrupting: the client breaks in and interrupts the counselor in a
defensive manner
3.
Negating: the client expresses an unwillingness to recognize problems,
cooperate, accept responsibility or take advice… Includes blaming,
disagreeing, excusing, claiming impunity, minimizing, pessimism,
reluctance, unwillingness to change
4.
Ignoring: the client shows evidence of not following or ignoring the
counselor
Lower Resistance
It is desirable to decrease client resistance
because:
Resistance early in treatment is associated with
drop-out
Resistance predicted a lack of change in
behavior
Decreased resistance is associated with long
term change
Always Avoid Arguments
• Arguments are counterproductive
• Defending arguments breeds defensiveness
• Labeling is unnecessary
- Identify behavior, don’t label or diagnose
• drinking (not alcoholism)
• isolating (not paranoia)
• talking to voices (not schizophrenia)
Strategies for Handling Resistance
• Simple Reflection –
 acknowledge client’s perception, avoids argument, joins with client,
encourages further exploration
• Amplified Reflection –
 exaggerated reflection to encourage some retreat, explores other side of
ambivalence
• Double-sided Reflection –
 acknowledges both sides of the ambivalence based on client’s perceptions
• Shifting Focus –
 shift attention away from roadblock and redirect attention to workable
issue
Strategies for Handling Resistance
• Reframing –
 acknowledges validity of client observations but offers new meaning or
interpretation (useful with resigned client)
• Agreement with a Twist –
 initial agreement but slight twist, reflection followed by reframe
• Emphasizing Personal Choice & Control –
 reassure client about self-determination, (useful with rebellious client or
one who perceives freedom as threatened)
• Coming Along Side/Therapeutic Paradox –
 Siding with the negative -defends the counter argument, should diffuse
no change argument, illicit change talk from client
Early Stages: Resistance and the “Four R’s”
•
Reluctance

Lacks the knowledge, energy or insight to change

•
Treatment options:
 Provide feedback in an empathic manner
 Avoid arguments
Resignation

Appears overwhelmed with problem, may have given up

Treatment options for resignation:
 Instill hope/confidence in their ability to change
 Reframe
 Help meet small goals, remind of past success
 Explore barriers to change
Early Stages: Resistance and the “Four
R’s”
• Rationalization
 Afraid to risk, unable to see their behavior as a problem,
focused on others
 Treatment options:
 Support, small steps to success, remind of past success
 Revisit goals, decisional balance
• Rebelliousness
 Identity is intertwined with problem behavior, need to feel in
control, reacting to external pressure
 Treatment options:
 Provide choices
 Emphasize personal choice and freedom
 Use paradoxical strategies
The Role of Confidence
• Change is mediated by the importance
and the confidence to accomplish
something
Strategies for Enhancing Confidence
• Ask Evocative Questions: Confidence talk is one type of
change talk. Ask open-ended questions. “How might you
go about making this change?” “What gives you the
confidence that you can do this?”
• Confidence Ruler: “How confident are you on a scale of 010 that you can….” ‘Why are you a ___rather than a 0?”
The answer will be confidence talk
• Review Past Successes: Look for changes client made on
own. Look for skills, strengths that can be generalized to
present situation. Explore. “Tell me how you did that”
Strategies for Enhancing Confidence
• Explore Personal Strengths & Supports: “What is
there about you, what strong points do you have
that could succeed in making this change?”
Explore what sources of support are available
• Brainstorm: Freely generate as many ideas for
accomplishing change as you can develop… no
discussion or criticism until list completed… then
prioritize
• Giving Advice and Information: If asked by
clients offer advice within MI context – final
choice is client’s.
Strategies for Enhancing Confidence
• Reframing: Person often bogs down in
attributions of failure… reframe ‘failure’ in way
that encourages client to keep trying
• Hypothetical Change: Use when client is
struggling with practicalities… “Suppose you did
succeed and are looking back on it now. What is
it most likely that worked? How did it happen?”
Phase II:
Strengthening Commitment to
Change
Remember…
• Phase 2 involves strengthening commitment
to change and developing a plan to
accomplish it…
Signs of Readiness for Change
•
•
•
•
•
•
•
Decreased Resistance
Decreased questions about the problem
Resolve
Self-motivational statements
Increased questions about change
Envisioning
Experimenting
Watch out for
 Underestimating ambivalence
 Over-prescribing an action plan
 Not providing sufficient direction when asked
Negotiating a Change Plan
• Transitional to Phase 2
• Recapitulation (transitional summary)
• Ask Key question (open ended): “What would you like to do about
this?”
• Giving Advice and Information
• Negotiating a Plan
• Elicit client’s ideas
• Set Goals (client goals) “What is it you would like to change?”
“Let’s take things one step at a time. What do you think is the first
step?”
• Consider change options – what actions/supports/skills will be
needed
• Arrive at the plan and elicit commitment
Adapting Motivational Interviewing for
Clients with Co-Occurring Disorders
• Different targets for change: ambivalence about treatment
engagement, medication…
• Increase affirmations
• Avoid reflections of hopelessness
• Reduce reflections on disturbing thoughts and life experiences
• Frequent, short reflections most effective
• Frequent summaries
• Simple verbal and visual materials: make explicit links between
psychosis, substance abuse, lifestyle, consequences…
• Pacing
• Clients must have some psychiatric stability to benefit from
MI’s approach
Pre-Contemplation
• Establish rapport, utilize empathy & reflective
listening, ask permission and build trust
• Facilitate discussion to assist client to identify risks
and consequences associated with identified
behavior (i.e. raise doubts or concerns in the client
about substance-using patterns)
• Facilitate discussion to assist client to identify
benefits of change
• Listen for all levels of change talk
• Express concern and keep the door open
Contemplation
• Normalize & negotiate ambivalence
• Weigh pros and cons
• Help the client “tip the decisional balance
scale” toward change
• Elicit change talk of intent and commitment
from the client
• Elicit ideas regarding the client’s perceived
self-efficacy and expectations regarding
treatment
• Summarize change talk statements
Preparation
•
•
•
•
•
•
•
•
•
•
•
Clarify the client’s own goals and strategies for change
Offer a menu of options for change or treatment
With permission, offer expertise and advice
Negotiate a collaborative change- or treatment- plan and
behavior contract
Consider and lower barriers to change
Help the client enlist social support
Explore treatment expectancies and the client’s role
Elicit from the client what has worked in the past either for
him or others whom he knows
Assist the client to negotiate finances, child care, work,
transportation, or other potential barriers
Have client publically announce plans to change
Build self-efficacy for change
Action
• Engage the client in treatment and reinforce the importance
of remaining in recovery
• Support a realistic view of change through small steps
• Acknowledge difficulties for the client in early stages of
change reinforcing small gains
• Help the client identify high-risk situations through a
functional analysis and develop appropriate coping strategies
to overcome these
• Assist the client in finding new reinforcers of positive change
• Help the client assess whether they have a strong family and
social support
• Maintain regular contact and provide sufficient direction
Maintenance
• Help the client identify and sample drug-free sources
of pleasure (ie new reinforcers)
• Support lifestyle changes
• Affirm the client’s resolve and self-efficacy
• Help the client practice and use new coping
strategies to avoid a return to use
• Maintain supportive contact
• Develop a “fire escape” plan if the client resumes
substance use
• Review long term goals with the client
Recurrence
• Assure client that slips and relapses are normal and can be
overcome
• Reframe relapse as a learning experience helping the client to
avoid becoming discouraged and demoralized
• Help the client reenter the change cycle and commend any
willingness to reconsider positive change
• Help client renew determination and confidence in order to
resume change efforts
• Assist the client in finding alternative coping strategies
• Maintain supportive contact
Matching Stages of Change, SATS and Types of Interventions
Stage of Change
SATS
Interventions
IDDT methods
Precontemplation
Preengagement &
engagement
Outreach, practical health,
crisis intervention,
relationship building,
assessment
CRS; SATS, Longitudinal
Assessment; Contextual
Assessment; Payoff
Matrix/Functional Analysis;
Motivational Interviewing
Contemplation
Early
persuasion &
& preparation
Late
persuasion
Education, goal setting,
increase awareness of
problems practical skills
training, family support,
peer support
Motivational interviewing
(expressing
empathy,developing
discrepancy, eliciting
change talk, rolling with
resistance, supporting selfefficacy)
Action
Early active
treatment &
late active
treatment
Substance abuse
counseling, medications
treatment, skills training,
self-help, groups, family
therapy
Functional analysis, skills
training
Maintenance
Relapse
prevention &
remission
Relapse prevention plan,
continuing skill training,
expanding recovery to other
areas
Continuation of functional
analysis, skills training,
specific relapse prevention
plans
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Moyer and Miner HOs Motivational Interviewing