Presented by:
Matt Wofsy, LCSW
Brian Mundy, LCSW
The Institute For Community Living, Inc.
2012 Clinical Lunch & Learn Webinar Series
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Develop an understanding of Motivational
Interviewing (MI) & how it may be used in
clinic settings
Review the fundamental principles of MI &
the Stages of Change Model
Acquire an understanding of basic MI
techniques
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Founded by William Miller and Stephen
Rollnick in the substance abuse field
Based on research involving recorded
conversations
Has been found efficacious in dozens of
other areas, including lifestyle changes,
medication adherence, child obesity,
diabetes, treatment adherence, etc.
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1. To support the
enhancement of intrinsic
motivation
2. To support the client’s
self-efficacy
3. To assist the client to
resolve ambivalence
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Ambivalence:
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Feeling two ways about something
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Examples of feeling ambivalent every day
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Ambivalence is natural and an essential
part of being human
Oftentimes ambivalence for clients is
regarding big life changes
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Ambivalence is a bit like a see-saw …
Part of the person
that does not want to
change
Part of person
that wants to
make changes
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Ambivalence is a bit like a see-saw …
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The working assumption is that intrinsic motivation is a
necessary and often sufficient factor in instigating
change.
Intrinsic vs. Extrinsic motivation
Examples of extrinsic motivation:
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Child protective services
School principal/guidance counselor
Parole officer
Family court
Examples of intrinsic motivation
◦ Desire for healthy relationships
◦ Increased independence
◦ Freedom
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Precontemplation – Not ready to make a change; sees no real problem in need
of treatment
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Example intervention: provide feedback, emphasize client responsibility
Contemplation – Unsure whether or not he/she has a problem
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Decisional balancing (pros/cons)
Determination/Preparation – Recognizes there is a problem and is ready to
make a change in near future
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Explore expectations around change process
Action – Not only recognizes the problem, but is already trying to change
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Troubleshoot barriers; Normalize that things might be harder
Maintenance – Has already made changes and is now working to hold onto
those gains & not slip back into old patterns
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Relapse prevention
Recurrence – Common, expectable, & likely to happen several times; can occur
at any point
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Emphasize learning from the recurrence
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The stages of
change are
more accurately
portrayed as a
wheel …
Precontemplation
Recurrence
Contemplation
Maintenance
Preparation
Action
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True or False?
A person with clinical depression can be in the action
stage around attempting behavior change but in precontemplation around re-visiting the psychiatrist
TRUE
True or False?
A person can be in action regarding improving parenting
skills one week but in pre-contemplation the following
week
TRUE
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Which stage of change
is indicated?
a) Pre-contemplation
b) Contemplation
c) Preparation
d) Action
e) Maintenance
“I can’t believe that my parents dragged me
here. I mean so what if I cut school a few
times? Everyone cuts class once in a while. I
don’t need therapy, my parents are the
ones who need therapy.”
 In Pre-contemplation
Which stage of change
is indicated?
a) Pre-contemplation
b) Contemplation
c) Preparation
d) Action
e) Maintenance
“The other night we got into a fight again.
My boyfriend took it too far this time. I was
really close to packing a bag and calling
my sister about bringing the kids so we
can stay with her. This has been going on
for too long.”
 In Preparation
E.D.R.S
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Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy
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1. Express Empathy –The MI therapist seeks to
communicate great respect for the consumer:
• Avoid communication that implies a superior/inferior
relationship
• Client’s freedom of choice & self-direction are respected
• Listen, rather than tell.
• Gentle, non-aggressive persuasion.
• We communicate an acceptance of clients as they are,while
also supporting them in the process of change.
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2. Develop Discrepancy - motivation for change occurs
when people perceive a discrepancy between where
they are and where they want to be.
◦ Focus the consumer’s attention of these discrepancies.
◦ Precontemplators don’t have this this discrepancy – we
have to help create it by exploring the consequences of
current behavior.
◦ Move the consumer along the stages of change.
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3. Rolling with Resistance -- ambivalence is normal;
resistance is expected.
◦ Explore the ambivalence with the consumer in a supportive,
unthreatening way.
◦ Avoid Arguments – attacking the consumer’s behavior tends
to evoke defensiveness, opposition & resistance.
◦ No attempt is made to get the consumer to ‘admit’ there is
a problem
◦ When MI is done well, it is the consumer and not the
counselor who voices the arguments for change!
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4. Support Self-efficacy – the consumer’s specific belief
that he or she can change.
• If one has little hope that things could change, there
is little reason to face the problem.
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O.A.R.S.
Open-ended
Questions
Affirmations
Reflective
Listening
Summaries
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Open Questions:
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How many children do you have?
Vs. Tell me about your family.
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Did you get in trouble at school today?
Vs. Tell me about your day at school.
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How often do you visit with friends?
Vs. Tell me a little about your friends.
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Affirmations:
 Statements that recognize consumer strengths.
 Help consumers feel change is possible. (Hope is
really important!)
 Can be used in response to resistance
 Must be genuine
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Reflective Listening:
 This is the Key
 Focus on ‘change talk’
 Reflect affect
 Tone of voice is important
 Keep momentum flowing through reflections
 Validate where client is coming from before
launching into problem-solving.
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Reflective Listening: Level 1 | Simple Reflection
Simply repeat or rephrase.
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Consumer: I don’t want to go to school, that teacher is wack!
Counselor: You don’t like the teacher, so you feel like school is
a waste of time
Consumer: Therapy sucks; I don’t want to be here right now.
Counselor: You really don’t want to be here.
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Reflective Listening: Level 2 | Reframe Reflection
Listen for client’s “best perceived self” in the statement
and reframe it back to client.
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Consumer: I don’t want to go to school, that teacher is wack!
Counselor: So school is not meeting your needs right now, and
you want to exercise your ability to choose not to go
Consumer: Therapy sucks; I don’t want to be here right now.
Counselor: You really value your time and you don’t think that
this is the best use of it.
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Reflective Listening: Level 3 | Affective Reflection
Listen for the emotion behind the statement and reflect it
back to client.
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Consumer: I don’t want to go to school, that teacher is wack!
Counselor: You’re not getting anything from this teacher and
this whole conversation about school is getting you frustrated
Consumer: Therapy sucks; I don’t want to be here right now.
Counselor: You’re angry that you are here and resent even
having to talk about it
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Summarizing:
 Just a special form of reflective listening where you
reflect back what the consumer has been telling you
 Summarizing presents an opportunity to begin
mapping out the client’s ambivalence
 Builds rapport
 Do frequently
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Summarizing
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“Let me stop and see if I have this right. You clearly don’t want
to be here right now and you think that it’s a waste of time.
Your foster parents have made you go to therapy in the past,
and it really hasn’t gotten you anywhere. You feel like you can
call your own shots, and you know what’s best for you. At the
same time, you’re tired of getting grounded and fighting with
your foster mother. You worry that, if this is left untouched, life
in your current foster home will remain stuck and you’ll
continue to feel bored and angry most of the time. Did I get
that right?”
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Six elements of effective MI have been identified and
were presented in brief clinical trials, and the acronym
FRAMES was coined to summarize them:
◦ Feedback regarding personal risk or impairment us given to the
client following assessment of behavioral patterns and associated
problems
◦ Responsibility for change is placed squarely and explicitly on
the client
◦ Advice about changing, reducing, or stopping problematic
behaviors is clearly given to the client by provider in nonjudgmental manner
◦ Menu of Options is developed toward self-directed change
◦ Empathic counseling – showing warmth, respect, and
understanding – is emphasized
◦ Self-efficacy or optimistic empowerment is engendered in the
client to encourage change
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We clinicians often get activated by felt lack
of progress and personal responsibility
We feel like we have to do something!
Sometimes this drives us to over-function and
take the reins of the change agenda
Documentation provides a useful framework
for slowing the process down and crystalizing
clinicians on-the-ground efforts
◦ Client remains in pre-contemplation around substance use
◦ Clinician provided feedback, emphasized client’s
responsibility, and rolled with resistance in the service of
maintaining a non-argumentative position with the client
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The technical aspects of MI – such as decisional balancing,
reflective listening, rolling with resistance, feedback,
emphasis on natural consequences, and developing
discrepancy – are mostly designed to put the argument for
change inside the individual
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As long as the clinician is not sending the client to the
hospital, he/she needs to be able to sit with client choices so
that his/her change agenda does not get in the way of the
development of an internal argument and natural, sustained
change on the part of the client
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 http://www.motivationalinterview.org/
 http://www.motivationalinterview.org/Documents/1%20A%20MI%
20Definition%20Principles%20&%20Approach%20V4%20012911.p
df
 Motivational Interviewing as a counseling style:
http://kap.samhsa.gov/products/manuals/tipcurriculum/pdf/pm
odule05.pdf
 Miller, W. R., & Rollnick, S. (2002). Motivational interviewing:
Preparing people for change. (2nd ed.). New York: Guilford.
 Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2008).
Motivational interviewing: In the treatment of psychological
problems. New York: Guilford.
 Narr-King, Sylvie & Suarez, Mariann. (2011) Motivational
Interviewing with Adolescents and Young Adults. New York:
Guilford.
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Q&A
Next Webinar: Visit www.ctacny.com
July 13, 2012-Trauma Part 1: Assessment with
Elizabeth Meeker, Ph.D.
And, email us with any questions/ concerns:
Kara.dean-assael@mssm.edu
THANK YOU FOR JOINING US!!
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