Motivational Interviewing

Introduction to Motivational
State of Hawaii, Department of Health, Adult Mental Health
Division, Clinical Operations Team and
Mental Health Services Research and Evaluation
In Partnership with
Substance Abuse and Mental Health Services Administration
Evidence Based Practices Training and Implementation Grant
Material contained within this training was
largely based on the work of William R. Miller
and Stephen Rollnick in their groundbreaking
book titled, Motivational Interviewing:
Preparing People for Change
Published by Guilford Press, 2002
Beliefs About Motivation
(True or False?)
• Handout Quiz: Beliefs About Motivation
– Complete the true/false quiz and hang onto it
– We will review the answers later
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.”
“I want to change,
but I don’t want to change.”
• Very few decisions in life are made with 100%
• Ambivalence is normal and part of the
change process for everyone
Ambivalence Exercise
1. Find a partner.
2. Each of you write down something you are interested in
doing but have mixed feelings about (e.g., buying a new car,
quitting smoking, exercising, etc.).
3. Select who will speak first.
4. The speaker presents what it is that you would like to do (but
haven’t done yet).
5. The listener then argues strongly in favor of one of the
options or sides.
6. Speaker, your job is to listen and note what you are thinking
and feeling.
7. Switch roles.
Ambivalence Exercise
What were your thoughts/feelings as the
What happens when ambivalence collides with
persuasion, prescription, convincing?
Motivational Interviewing is…
“a client-centered, directive method for
enhancing intrinsic motivation to change
by exploring and resolving ambivalence”
(Miller & Rollnick, 2002)
Spirit of Motivational Interviewing
Mirror Image
Spirit of Motivational Interviewing
• Motivations to change are elicited from within the
client, not imposed from outside.
• It is the client's task, not the counselor's, to articulate
and resolve his or her ambivalence.
• Direct persuasion is not an effective method for
resolving ambivalence.
• Readiness to change is not a client trait, but
fluctuating product of interpersonal interaction.
Spirit of Motivational Interviewing
• The therapeutic relationship is more like a
partnership or companionship than expert/recipient
• Positive atmosphere that is conducive but not
coercive for change.
• The counselor is directive in helping the client to
examine and resolve ambivalence.
NOT Motivational Interviewing
The Righting Reflex
• Human beings have a built in desire to set things
right/to solve the problem.
• When the righting reflex collides with ambivalence,
the client defends the status quo.
• If a person argues on behalf of one position, he or
she becomes more committed to it.
NOT Motivational Interviewing
If following the righting instinct, you will ask:
• Why don’t you want to change?
• Why don’t you try… ?
– Okay then, how about…
• What makes you think you are not at risk?
• How can you tell me you don’t have a problem?
NOT Motivational Interviewing
• Argues that person has a problem and needs
to change – emphasis on acceptance of
• Offers direct advice or prescribes solutions
(e.g., coping strategies) without actively
encouraging person to make his/her choices.
NOT Motivational Interviewing
• Uses authoritative/expert stance and leaves
client in passive role.
• Does most of talking or if acts as
unidirectional information system – focus on
imparting information.
NOT Motivational Interviewing
• Identifies and modifies maladaptive
• Allows the client to determine the content
and direction of the counseling.
• Behaves in a punitive or coercive manner.
Assumptions to Avoid
• Person OUGHT to change.
• Health is the person’s prime motivating factor.
• People are either motivated or not.
• Now is the right time to consider change.
• I am the expert; therefore, the person must follow
my advice.
Beliefs About Motivation
(True or False?)
1. Until a person is motivated to change, there is not
much we can do.
2. It usually takes a significant crisis (“hitting bottom”)
to motivate a person to change.
3. Motivation is influenced by human connections.
4. Resistance to change arises from deep-seated
defense mechanisms.
Beliefs About Motivation
(True or False?)
5. People choose whether or not they will change.
6. Readiness for change involves a balancing of “pros”
and “cons.”
7. Creating motivation for change usually requires
8. Denial is not a client problem, it is a therapist skill
MI Principles
MI Methods
Open-Ended Questions
Express Empathy
Reflective Listening
Develop Discrepancy
Roll with Resistance
 Elicit Change Talk
Support Self-Efficacy
Open-Ended Questions
What are open-ended questions?
• Gather broad descriptive information
• Require more of a response than a simple yes/no or
fill in the blank
• Often start with words like:
– “How…”
– “What…”
– “Tell me about…”
• Usually go from general to specific
Open-Ended Questions
Turning closed-ended questions into
open-ended ones
Open-Ended Questions
• Why open-ended questions?
– Avoid the question-answer trap
• Puts client in a passive role
• No opportunity for client to explore ambivalence
What is an affirmation?
• Compliments, statements of
appreciation and understanding
– Praise positive behaviors
– Support the person as they describe difficult
• Examples:
– “I appreciate how hard it must have been for you
to decide to come here. You took a big step.”
– “I’ve enjoyed talking with you today, and getting
to know you a bit.”
– “You seem to be a very giving person. You are
always helping your friends.”
Why affirm?
• Supports and promotes self-efficacy, prevents
• Builds rapport
• Reinforces open exploration (client talk)
• Must be done sincerely
Express Empathy
What is empathy?
• Reflects an accurate understanding
– Assume the person’s perspectives are
understandable, comprehensible, and valid
– Seek to understand the person’s feelings and
perspectives without judging
Express Empathy
Empathy is distinct from…
Approval or praise
Reassurance, sympathy, or consolation
Express Empathy
Why is empathy important in MI and IDDT?
• Communicates acceptance which facilitates change
• Encourages a collaborative alliance which also
promotes change
• Leads to an understanding of each person’s unique
perspective, feelings, and values which make up the
material we need to facilitate change
Express Empathy
Good eye contact
Responsive facial expression
Body orientation
Verbal and non-verbal “encouragers”
Reflective listening/asking clarifying questions
Avoid expressing doubt/passing judgment
Empathy is NOT…
• The sharing of common past experiences
• Giving advice, making suggestions, or
providing solutions
• Demonstrated through a flurry of questions
• Demonstrated through self-disclosure
The Bottom Line on Empathy
• Ambivalence is normal
• Our acceptance facilitates change
• Skillful reflective listening is fundamental to
expressing empathy
- Miller and Rollnick, 2002
Reflective Listening
Thomas Gordon’s Model of Listening
What the
speaker means
What the listener
thinks the speaker means
Words the
listener hears
Words the
speaker says
Reflective Listening
“Reflective listening is a way of checking
rather than assuming that you know
what is meant.”
(Miller and Rollnick, 2002)
Reflective Listening
• Why listen reflectively?
– Demonstrates that you have accurately heard and
understood the client
– Strengthens the empathic relationship
– Encourages further exploration of problems and
• Avoid the premature-focus trap
– Can be used strategically to facilitate change
Reflective Listening
In motivational interviewing,
• About half of all practitioner responses are
• 2-3 reflections are offered per question asked
In ordinary counseling,
• Reflections constitute a small proportion of all
• Questions outnumber reflections 10 to 1
Learning Reflective Listening
• Reflective listening begins with thinking
• Thinking reflectively requires a continual
awareness that what you think people mean
may not be what they really mean
Thinking Reflectively
1. Split up into triads (1-speaker) (2-listeners).
2. Each person will take a turn being a speaker.
3. Each person will share a personal statement
“One thing I like about myself is …”
(e.g., I am organized. I am creative.)
4. The listeners respond with “Do you mean that…..”
(generate at least 5 for each).
5. The speaker responds with only yes/no.
Reflective Listening
• A reflection is two things:
– A hypothesis as to what the speaker
– A statement
• Statements are less likely than questions to evoke
Reflections Are Statements
• Use a statement to reflect your
• Inflection turns down at the end
“You feel...”
“So you...”
“Its like...”
Reflections Are Statements
• Question:
– You’re thinking about stopping? (inflection goes
• Versus a statement:
– You’re thinking about stopping. (inflection goes
Reflective Listening
1. Split up into triads (1-speaker) (2-listeners).
2. Each person will take a turn being a speaker.
3. Each person will share a personal statement
“One thing I like about myself is …”
“One thing about myself I’d like to change is…”
4. The listeners respond with reflections only.
5. The speaker can respond with yes/no and elaboration.
Levels of Reflection
• Simple Reflection – stays close
– Repeating
– Rephrasing (substitutes synonyms)
• Complex Reflection – makes a guess
– Paraphrasing – major restatement, infers
meaning, “continuing the paragraph’
– Reflection of feeling - deepest
Not Reflective Listening
Thomas Gordon’s Roadblocks:
1. Ordering, directing, commanding
2. Warning, cautioning, threatening
3. Giving advice, making suggestions, providing
4. Persuading with logic, arguing, lecturing
5. Telling what to do preaching
6. Disagreeing, judging, criticizing, blaming
Not Reflective Listening
7. Agreeing, approving, praising
8. Shaming, ridiculing, blaming
9. Interpreting or analyzing, [also labeling]
10. Reassuring, sympathizing, consoling
11. Questioning, probing
12. Withdrawing, distracting, humoring, changing
the subject
• Pull together what has transpired thus far in a
• Strategic use: practitioner selects what
information should be included & what can be
minimized or left out
• Additional information can also be incorporated
into summary – e.g., past conversations,
assessment results, collateral reports etc.
Exercise (part 1):
1. Choose a partner.
2. Speaker: for 90 seconds talk about a habit,
behavior, situation you are thinking about
3. Listener: listen only and then give a
summary of what you’ve been told.
4. Change roles and repeat.
Exercise (part 2):
1. Change partners.
2. Speaker: once again tell your story for 90
seconds w/out interruption.
3. Listener: listen only and then give a
summary, but this time include what you
think is the underlying meaning, feeling,
dilemma in the story.
4. Change roles and repeat.
MI is Directive
Nondirective/ Rogerian
Motivational Interviewing
Allows client to determine
content and direction of
Explores client’s conflicts and
emotions without specific goals
for change
Systematically directs client
toward motivation for change
Uses empathic reflection
Seeks to evoke and amplify
discrepancy to enhance
motivation for change
Uses reflection selectively to
reinforce motivation for change
Avoids interjecting counselor’s
Offers feedback where
Develop Discrepancy
The logic…
• Motivation arises from a discrepancy between
actual and desired states
• We can help with motivation by creating and
amplifying discrepancy
In short…
• We want to help clients see the contrast between
what they want and what they do
Develop Discrepancy
Ambivalence Over Time in Treatment
Level of ambivalence
time -->
relapse prev
Develop Discrepancy
• Explore goals and values with which substance
use may conflict
Long term recovery goals
Past preferred activities
Admired people
Develop Discrepancy
• Client verbalization of negative
consequences amplifies discrepancy
– Payoff matrix/decisional balance exercise
Using Substances Not Using Substances
Change and Resistance
Opposite sides of a coin
–Change talk
What is resistance?
How is resistance expressed?
• Negating
– Blaming, disagreeing, excusing,
minimizing, unwillingness to change
• Ignoring
– Inattention, sidetracking, nonanswer
• Arguing
– Challenging, discounting, hostility
• Interrupting
• Counselor behaviors that elicit resistance
– Arguing for change (the trap of taking sides)
– Assuming the expert role/claiming preeminence
– Labeling
– Being in a hurry
– Criticizing, shaming, or blaming
• Resistance is a product of the interpersonal
• Hence, there are things we can do to diminish
• Resistance is a signal to respond differently, it
is valuable feedback
Change Talk
• Generally falls into one of these four
– Disadvantages of the status quo
– Advantages of change
– Optimism for change
– Intention to change
Change Talk
• Disadvantages of the status quo
“I can see that in the long run, this is going to do me in if I
don’t make a change.”
“I am ruining my family life.”
• Advantages of change
“My boys would like it. They’re always after me to quit.”
“Probably I’d feel a lot better.”
“At least it would get the courts off my back.”
Change Talk
• Optimism About Change
“I think I could probably do it if I decided to.”
“I did quit smoking a few years ago. That was tough, and it
took a few tries, but I did it.”
“My family would be there to support me.”
• Intention to Change
“I definitely don’t want to keep going the way I have been.”
“I’ve got to do something.”
Recognizing Resistance and Change
Exercise (part 1):
1. Form groups of three.
2. One person is the speaker: talk about
something you are trying to change.
3. One is the listener: persuade your partner to
make the change (NOT MI).
4. One is the recorder: listen for resistance and
change talk and record.
Recognizing Resistance and Change
Exercise (part 2):
1. Switch roles.
2. Speaker: talk about something you are trying
to change.
3. Listener: use OARS.
4. Recorder: listen for resistance
change talk and record.
In its simplest form, the implicit theory
of MI posits:
MI will increase client change talk.
MI will diminish client resistance.
The extent to which clients verbally defend the
status quo (resistance) will be inversely related to
behavior change.
The extent to which clients verbally argue for
change (change talk) will be directly related to
behavior change.
Miller, W.R. (2004) Toward a Theory of Motivational Interviewing.
Responding to Resistance
• Roll with it!
Roll with Resistance
• Counselor behaviors that defuse resistance –
strategies to use
– Reflections
– Shifting focus
– Emphasizing personal control
– (Agreement with a twist)
– (Reframing)
– (Coming alongside)
• Simple & Complex Reflections
– Repeating, rephrasing, paraphrasing, reflection of
Double-Sided Reflection
• Captures both sides of the ambivalence
– Client: Okay, maybe I’ve got some problems with
gambling, but it’s not like I’m addicted to it.
– Interviewer: You see that your gambling is causing
problems for you and your family, and it’s also
important that people not think of you as some
kind of addict.
Amplified Reflection
• Exaggerated to encourage some retreat
– Client: I couldn’t just give up drinking. What would
my friends think?
– Interviewer: You couldn’t handle your friends’
reaction if you quit.
Shifting Focus
• Shift the person’s attention away from what seems
to be a stumbling block in the way of progress.
– Client: You’re probably going to give me a diet that I need
to stick to, and tell me that I have to get some of these
exercise machines or go to a gym every day.
– Interviewer: I don’t know enough about you yet for us to
even start talking about what makes sense for you to do.
What we need to do right now is…
Emphasizing Personal Control
• Assuring the client that it is he/she who in the end
will determine what will happen
– Client: Why are you giving me this booklet? Are you telling
me I have to use condoms?
– Interviewer: It’s just information. What you do with it is
completely up to you. Naturally, no one can make you use
Roll with Resistance
Get into groups of three.
Decide who will be the client, the counselor, and the
Client: choose and read a resistant scenario or make up
your own.
Counselor: test out alternative strategies for responding.
Recorder: note strategies used and client response, what
seemed to work best?
Switch roles and use a new scenario.
Roll with Resistance
Exercise Scenarios:
• “Who are you to tell me what to do? What do you know
about crack? You probably never even smoked a joint!
• “Cocaine is not really my problem. What I want to talk about
is my roommate—now he’s a problem!”
• “Look, I’ve been in detox dozens of times before. I’m
hopeless. I just want to dry out and go home.”
• “I really like pot! It’s the only good thing about my day and I
don’t want to quit!”
Responding to Change Talk
• Ask for clarification
– “In what ways? When?”
• Ask for a specific example
– “Give me an example. Tell me about the last time that
• Straightforward encouragement to continue
– “What else?”
– “What else have you noticed or wondered about your
• Selectively reflecting
• If the reflection evokes the other side
(resistance) then recover with a double sided
• Consciously selective
• Gather together “bouquets” of change
statements and offer them back
• Simply comment positively
– “That’s a good point”
– “That sounds like a good idea”
– “I think that could work”
– “I can see how that would concern you”
Eliciting Change Talk
Asking evocative questions
Using the importance ruler
Exploring the decisional balance
Describe a typical day
(Querying extremes)
(Looking back)
(Looking forward)
Asking Evocative Questions
• Use open questions to explore client’s own
• Assume the person is feeling ambivalent and
has at least some concerns
Asking Evocative Questions
• What hassles have you had in relation to your drug
• In what ways has your drinking been a problem for
• What is there about your drinking that you or other
people might see as a reason for concern?
Using the Importance Ruler
“On a scale from 0 to 10, how important to you is it to change your ______ ?”
Importance Ruler
Not at all
“Why are you at a ___ and not a zero?”
Exploring the Decisional Balance
• Asking about both the positives and negatives
of the behavior
• Asking about the pros and cons of change
• Doing the payoff matrix
Describe a Typical Day
• Ask the person to walk you through a typical
• Areas of concern often emerge naturally
Change Talk
Get into groups of three.
Each person selects a role: speaker, listener, recorder.
This is the first session.
Speakers, your job is to come in considering that you want to make a
change either in yourself or in your life but still feel very ambivalent
Listeners, your job is to open up the session and practice using OARS
and strategies for eliciting change talk as best you can.
Observers, your job is to note the open ended questions, reflective
listening statements, affirmations, summaries and strategies to elicit
change talk.
Switch roles.
Support Self-Efficacy
What is self-efficacy?
• Extent to which the
person feels ABLE to
Support Self-Efficacy
• People cannot be ready to change until they perceive
both that they want to and are able to do so
• The client, not the counselor, is responsible for
choosing and carrying out the change
• Our own belief in the person’s ability to change
becomes a self-fulfilling prophecy
• We can support self-efficacy in the spirit of MI
Responding to Confidence Talk
Raising possible problems and challenges
Responding to Confidence Talk
• Elaborating
– Straightforward encouragement to continue
• “Why else do you think you could succeed?”
• “How else could you do it?
• Reflecting
– Selectively reflect themes, experiences, ideas &
preferences that suggest the client’s perceived
ability to make the change
• “I quit once before.” “You can do it again.”
Responding to Confidence Talk
• Summarizing
– Consciously selective
– Gather together “bouquets” of confidence
statements and offer them back
• Affirming
– Simply comment positively
• “I think that could work”
• “I bet your family believes you can do this”
Responding to Confidence Talk
• Raising possible challenges
– Stimulate further thought and specificity
• “What might you do if _____?”
• “How could you respond if _____?”
• “What do you think would happen if _____?”
Eliciting Confidence Talk
Evocative questions
Confidence ruler
Reviewing past successes
Exploring personal strengths & supports
Giving information & advice
Hypothetical change
Support Self-Efficacy
• “I’ll take over now, thank you”
• Abandons MI and responds to low confidence
with a prescription
• “There, there you will be fine”
• Not taking the confidence issue seriously
• Gloom a deux
• Sharing the client’s hopelessness and helplessness
Take Home Messages
• Do a payoff matrix
• Elaborate change talk
• When in doubt, reflect
Learning MI – Next Steps
• What is one MI skill you are committed to
developing in the next month?
• What are some of the barriers you see to
using MI?
• How ready are you to start using some MI
strategies and techniques?
• What specific plans do you have to continue
learning MI?
Resources for Learning Motivational
• Motivational Interviewing (2002) Miller &
• (Training
tapes, articles, bibliographies, training
• Enhancing Motivation for Change in Substance
Abuse Treatment, Tip 35