MI Training

Lynn S Massey, LMSW
Health Services Research
University of Michigan
August 2013
Do you…….
 Explain what the person could do differently to
improve their health?
 Advise / persuade / warn what will happen if
they do not change?
 Counsel the person about how to change?
 Refer to a specialist?
 Set goals for change?
Common Human Reactions to
Being Listened to
Want to talk more
Liking the counselor
Able to change
Want to come back
MI Definition-Layman’s
Motivational Interviewing is a collaborative
conversation to strengthen a person’s own
motivation for and commitment to change.
Why do I want to learn MI?
Motivational Interviewing is a person-centered
counseling method for addressing the common
problem of ambivalence about change.
Technical Definition
Motivational Interviewing is a collaborative,
goal-oriented method of communication with
particular attention to the language of change.
It is intended to strengthen personal
motivation for and commitment to a change
goal by eliciting and exploring an individual's
own arguments for change.
Eight Stages in Learning MI
 The spirit of MI
 OARS- client-centered counseling skills
 Recognizing change talk
 Eliciting and reinforcing change talk
 Rolling with resistance
 Developing a change plan
 Consolidating client commitment
 Integrating MI with other methods
Miller, W.R., & Moyers, T. B. (2006). Eights stages in learning motivational interviewing. Journal of Teaching in
the Addictions
 The probability that a person will enter into, continue,
and adhere to a specific change strategy or plan
 Motivation is a dynamic state (of readiness to change)
 Part of clinician’s job
 Occurs in an interpersonal context
 “Noncompliance”, “resistance” and ”lack of motivation”
are all partially due to therapists strategies
 Is normal, acceptable and understandable
 Helps clinician to appreciate the complexity of
the individual and their situation
 To explore ambivalence is to work at the heart of
 Usually mistaken for resistance (yes, but…)
 MI is not a set of methods to learn, but a therapeutic
way to being and interacting with a person – not
everyone will be able to do it
 Context or interpersonal relationship within which the
techniques are employed
 Spirit of MI is necessary for expert use, but not to
begin to learn MI – spirit of MI can emerge from
therapist-client interactions using the method
 The extent of initial curiosity and willingness to learn
MI seems to be a good predictor for speed and ease of
acquiring MI skills
The Spirit of MI
 Is essential for the full and expert use of MI
 Underlying assumption that “health is waiting
inside” each person, and your role is to help it
emerge (Humanistic Psychology)
 Contrasted with the model that the patient is
 Therapists expression of spirit as measured by
independent raters predicts client engagement,
collaboration, and affect in sessions (Moyers et
al, 2005)
Relational Components of MI
 Empathy – genuine curiosity about client’s
perspective (understanding)
 MI Spirit:
 Collaboration – fostering power sharing in the
 Evocation – elicitation / acceptance /
understanding of client’s own ideas about change
 Respect Autonomy – active fostering of client
perception of choice
 Fosters collaboration and power sharing so that
client’s ideas impact the session
 Encourages power sharing in the interaction in such
a way that client’s ideas substantially influence the
nature of the session
 Builds rapport
 Facilitates trust
 Mutual understanding, not about the therapist
being right.
 Accepting of the client’s own reasons for change and
ideas about how change should happen
 Doesn’t attempt to educate or direct if client resists
 Proactively evokes client’s own reasons for change
and ideas about how change should happen
 The therapist’s job is to “draw out” the client’s own
motivations and skills for change, not to tell them
what to do or why they should do it
 Accepting and supportive of client autonomy
 The true power of change rests within the
 Ultimately it is up to the client to change
 Clients are encouraged to take the lead on
developing a “menu of options” as to how to
achieve the desired change
Thumbs up Thumbs down
C: I know my dad told you I’m depressed, but I’m not.
Just because I don’t want to play football doesn’t
mean I’m depressed.
T: Your father is worrying needlessly. What do you
think he’s seeing that makes him worry this way?
Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren
Thumbs up Thumbs down
C: They told me I have to have this surgery right
away. But I don’t trust them, so I haven’t
scheduled it yet.
T: Why take the chance? They’re the experts, after
all. Let’s call from this phone right now-maybe you
can get in this week?
Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren (2009)
The Basics of MI
 Client centered approach is necessary but not
sufficient for behavior change
 Client centeredness – the relational componentbased on the Spirit of MI (collaboration, evocation,
autonomy, respect) and Empathy
 “It is not a goal unless it is a goal for the patient”
 Change talk - the technical component – gives a voice
to the person’s inner motivation based on what they
value most
4 Principles of MI
1) Express empathy – acceptance of people as they
are frees them to change whereas non-acceptance
immobilizes the change process
2) Develop discrepancy – between present behavior
and broader goals and values; helping people get
3) Roll with resistance – avoid arguing for change; new
ideas/goals/options are not imposed; used as a
4) Support self-efficacy – belief in ability to change is a
powerful predictor of change; counselor selffulfilling prophesy
Basic Role of MI therapist
 Is to help the client become his / her own
advocate for change
 Is to elicit rather than instill expertise on how
to change
 “Join with” a persons own intrinsic motivation
to move towards more adaptive behavior (i.e.
those that are in line with their values and
Early strategies: OARS
• Open Ended Questions “are you concerned about
your health?” vs “to you, what are important
reasons to cut down on your drinking?”
• Affirmations “It really sounds like you have been
committed to being the best father you can”
• Reflective listening
• Summary “Let me try to pull together what we have
been talking about, let me know if I missed
something; it sounds like on one hand you feel and
were scared by the ER visit, but on the other hand,
you don’t want to give up drinking completely”
Affirmations may include
 Commenting positively on an attribute
 You’re a strong person, a real survivor.
 A statement of appreciation
 I appreciate your openness and honesty today.
 Catch the person doing something right
 Thanks for coming in today!
 A compliment
 I like the way you said that.
 An expression of hope, caring, or support
 I hope this weekend goes well for you!
“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
OARS Exercises
 Open Ended Questions Quiz
 Thinking Reflectively
 Group Batting Practice
 Forming Reflections
 Miller tape with OARS coding
 Structured Practice
What the
speaker says
What the
What the
What the listener
thinks the speaker
Communication errors
1) The speaker does not say exactly what is
2) The listener does not hear correctly
3) The listener gives a different interpretation
to what the words mean
 One thing that I like about myself is that…..
 One thing you should know about me is…..
 One thing about myself I’d like to change
 Listen carefully with a goal of understanding the dilemma
 Give no advice.
 Ask these four open questions and listen with interest:
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 from 0 to 10, how important would you
say it is for you to make this change?
Follow-up: And why are you at __ and not zero?
 Give a short summary/reflection of the speaker’s motivations
for change
 Then ask: “So what do you think you’ll do?” and just listen
Reflective Listening: Overview
 The essence is that it makes a guess as to what
the speaker means
 Statements rather than questions
 “Continue the paragraph” – not just re-iteration
 It is an active process (counselor decides what to
reflect or ignore, what to emphasize,
preferentially reflects change talk)
Complex Reflections
 Adding content (interpretation or feeling)
 Metaphor/Simile (picture language)
 Amplification (stronger or weaker)
 Double-sided (reflects two sides of person’s
 Reframing (put situation in a different light)
 Verbalization of unspoken emotion
Categories of Resistance
 Arguing – challenging, discounting, hostility
 Interruption – talking over, cutting off
 Negating – blaming others, “yes, but”, excuse
making, claiming impunity, minimizing,
pessimism, reluctance, unwillingness to change
 Ignoring – inattention, non-answers, no response
to questions, side-tracking
Responding to Resistance
 Simple Reflection – you feel stuck, etc.
 Amplified Reflection – C: My wife thinks its worse
than it is. T: It seems to you she has no reason for
 Double-sided Reflection - You don’t like the way this
makes you feel sometimes, and you’re not sure how
you might change things.
 Reframing – C: I’ve tried to quit 3 times and failed.
T: You’ve given it 3 good tries, and every try gets you
closer. Its probably helped you learn some things
that will and won’t work for you.
 Emphasize personal choice and control – What you
decide to do is completely up to you
Change Talk - DARN C
 Disadvantages of Status Quo
 Advantages of Change
 Optimism about Change
 Intention to Change
 Desire
 Ability
 Reasons (to, not to)
 Need
 Commitment
The Flow of Change Talk
Eliciting Change Talk
 Evocative Questions
 Elaboration
 Using Extremes
 Looking Back
 Looking Forward
 Exploring Goals
Giving Information and Advice
Get permission
• Qualify, honoring autonomy
• Ask – Provide – Ask
• For suggestions, offer several,
not one
 Questions
 Concerns
 Motivationalinterviewing.com
 Building Motivational Interviewing Skills a practitioner
workbook by David Rosengren
 Motivational Interviewing: Preparing people for change
by William Miller and Stephen Rollnick (3rd edition)
 lsmassey@med.umich.edu