Motivational Interviewing
May. 14, 2015
Thomas E. Broffman, PhD, LICSW, LCDP, LCDS, CEAP
What’s Dr. Broffman’s background ?
• BSW
• PhD
& MSW
in SWK
• Assistant
Professor &
Field Coordinator,
BSW Program
2
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
What’s Dr. Broffman’s MI training & clinical
background ?
MI EXPERIENCE
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Money Follows the Person
(CT DHS & UCONN Ctr. On
Aging)
Hartford Dispensary
Mass. Dept Public Health,
Bureau SA Services
Boston Medical Center,
Infectious Diseases Program
Mass. Dept. of Youth Services
MI trainer, CT DMHAS
CLINICAL EXPERIENCE
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•
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•
•
•
3
Providence VA Medical Center [16
yrs.]
OPT Therapist
Clinical Director, Marathon House
Adolescent Male Residential
Clinical Director Methadone Clinic
Chemical Dependency Consultant,
Eleanor Slater Hospital [State
Hospital, RI – 18 yrs.]
Motivational Interviewing Trainer
& consultant [20 yrs.]
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
2 Opening Questions
1. What do you already know about
motivational interviewing?
2. Based on what you already know
about MI, what would like to learn
more about?
4
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Why Do People Change?
1.
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5
?
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?
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Why Don’t People Change?
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6
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
The Change Exercise
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Stand up and turn to stand face to face in pairs.
Silently observe your partner for 30 seconds.
Now turn back to back and change 3 things
about yourself. [appearance]
When you are done, turn back to face your
partner.
Each person should take a minute to name the 3
things your partner has changed.
The Change Exercise
1.
2.
3.
4.
5.
8
Stand up and turn to stand face to face in pairs.
Silently observe your partner for 30 seconds.
Now turn back to back and change 3 things
about yourself. [appearance]
When you are done, turn back to face your
partner.
Each person should take a minute to name the 3
things your partner has changed.
1.
2.
3.
4.
5.
6.
7.
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Change Exercise Questions
What was your comfort level during this
exercise?
What made you comfortable or uncomfortable?
How hard was it to change things?
How did you decide what things to change about
yourself?
What does this exercise tell us about change?
Look around you did you notice how quickly
people changed back to the way they started as
soon as they sat down?
What implications might this have about change
for people and ourselves?
Change Exercise Key Points
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Change is difficult
Change is not always comfortable
Change requires creativity
We tend to go back to old ways
It is easier to stay the same
We like our comfort zones
Change requires an open mind
Change has emotional and cognitive
components
Change Exercise Key Points
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10.
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14.
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Change is a process
Change happens over time
The process is as important as the result
Watch out for measuring success only if a
change occurred
Often there is a difference between what
someone knows they should do and there
readiness to do it.
Greatest chance to impact change is pacing it
to the specific stage of change
Stages of Change
Precontemplation
Maintenance
Contemplation
Relapse
Action
12
Preparation
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS,
REMEMBER:
“READINESS TO
CHANGE” IS A STATE,
NOT A TRAIT.
13
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Pre-contemplation
DEFINITION
Not even thinking
about it
Not considering
possibility of
change
APPLICATION
Goal: Raise awareness
Task: Engage
Inform and encourage
Validate lack of
readiness
Does not feel there
is a problem
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
14
Importance Ruler
•On
a scale of 1 to 10, how important is it for you to
make a change?
1
Not at all
important
2
3
4
5
6
Somewhat
important
7
8
9
10
Extremely
Important
“Willing”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Importance Ruler
•On
a scale of 1 to 10, how important is it to your
family for you to make a change?
1
Not at all
important
2
3
4
5
6
Somewhat
important
7
8
9
10
Extremely
Important
“Willing”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Confidence Ruler
•On
a scale of 1 to 10, how confident are you that
you could make a change, if you wanted to?
1
Not at all
confident
2
3
4
5
6
Somewhat
confident
7
8
9
10
Extremely
confident
“Able”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Readiness Ruler
•On
a scale of 1 to 10, how ready are you to make a
change?
1
Not at all
Ready
2
3
4
5
6
Somewhat
ready
7
8
9
10
Extremely
Ready
“Ready”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Simplified Motivational Categories
Importance of Change
Confidence
in Ability
Low
High
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Low
High
Group 1 – Little interest
in change; don’t think
they could even if they
wanted to.
Group 2 – Want to
change, but don’t
think they are able.
Group 3 – Believe they
could change, but not
interested right now.
Group 4 – Want to
change and believe
they have the ability.
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Contemplation
DEFINITION
APPLICATION
Thinking about
their situation
Goal: Explore motivation and
Confidence
Ambivalent
Task: Explore ambivalence
Evaluate pros and cons
“On the fence”
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
20
It is the Spirit of MI to…
Appreciate Ambivalence
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Decisional Balance
CONTINUING
BEHAVIOR
Benefits
CHANGING
BEHAVIOR
Costs
Costs
Benefits
1.
1.
1.
1.
2.
2.
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4.
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
22
Preparation
DEFINITION
Making a plan to
change by setting
achievable goals
APPLICATION
Goal: Negotiate a plan
Task: Facilitate decision
making
Explore:
1. Fears of change
2. Barriers to
change
3. Strengths to
change
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
23
Change Plan
1. The changes I want to make (or continue making) are:
2. The reasons why I want to make these changes are:
3. The steps I plan to take in changing are:
4. The ways other people can help me are:
5. I will know that my plan is working if:
6. Some things that could interfere with my plan are:
7. What I will do if my plan isn’t working:
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Action
DEFINITION
APPLICATION
Implementation of Goal: Implement the plan
specific action
steps
Task: Affirm
Initiate changes in
Support self-efficacy
attitude, feelings,
thoughts and
behaviors
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
25
Maintenance
DEFINITION
APPLICATION
Goal: Maintain change and
Continue to
maintain changes
deal with issues of
for at least 6
ongoing recovery
months
Proactively explore Task: Identify strategies
relapse warning
to cope with high
signs
risk situations,
urges, cravings, and
social pressure
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
26
Something to Consider About Relapse
• Confucius
said: "Our greatest glory is not in
never falling, but in rising every time we fall."
• This
quote is most helpful in working with
people who experience a relapse.
27
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
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
confrontation.
8.
Denial is not a client problem, it is a therapist skill
problem.
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
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.
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Motivational Interviewing is:
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A theory
A set of skills
A way of thinking
A way of relating
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Disclaimer: MI Not Appropriate for
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7.
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People who are acutely homicidal or suicidal
Unstable psychiatrically
Having problems meeting their basic human
needs (food, clothing, shelter, safety)
Impaired or under the influence of alcohol or
drugs
Traumatic brain injury
Memory or cognitive impairment
Children & pre-adolescents
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
MI Defined
•A
collaborative, person-centered form of guiding
[or clinical method] to elicit or strengthen
motivation for change
• By
exploring and resolving ambivalence
• Not
just a series of technique but a way of being
with people that improves with considerable
practice over time
• Miller and Rollnick, 2009
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
So What’s Motivational Interviewing?
• It’s
about
helping people
to resolve their
ambivalence
to change
33
NOT,
increasing their
resistance to
change
• By
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Four Guiding MI Principles:
1.
•
Resist the righting reflex
If a client is ambivalent about change and
the clinician champions the side of change…
“Righting”
Reflex
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Ambivalence
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Four Guiding MI Principles:
2.
•
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Understand your client’s motivations
With limited consultation time, it is more
productive asking clients what or how they
would make a change rather than telling
them that they should.
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Four Guiding MI Principles:
3.
•
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Listen to your client
When it comes to behavior change, the
answers most likely lie within the client, and
finding them requires some listening
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Four Guiding MI Principles:
4.
•
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Empower your client
A client who is active in the consultation,
thinking aloud about the what and how of
change, is more likely to do something about
it.
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Core MI Strategies
Four Early Change
Strategies: OARS
 Open Questions
 Affirming
 Reflective Listening
 Summarizing
Goal: Elicit
Positive
“Change Talk”

Open Ended Questions
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•
•
•
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“What worries you about your current situation?”
(disadvantages of status quo)
“How would you like your life to be five years from
now?” (advantages of change)
“What encourages you that you can change if you
want to?” (optimism about change)
“What would you be willing to try (intention) or
what do you think you might do?”
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Affirmations
“Thanks for coming on time today”
• “That’s a good suggestion”
• “It seems like you’re a spirited and strong person”
• “You enjoy being happy with other people and making
them laugh”
• “You are clearly a resourceful person to cope with
such difficulties for so long”
•
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Reflective Listening
Client: “I know we made all these goals about my getting
out and meeting people, but I’m just not comfortable
around other people.”
Worker: “Getting the support you need hasn’t been easy.”
Client: “I just don’t like the way my family talks to me
about my drinking.”
Worker: “You’re annoyed with your family.”
Client: “Yes, it just irritates me how they are always judging
me.”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
How Might You Reflect This Statement?
“Look, it’s not like I’m lazy. I just haven’t
found the right job yet. ”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
How Might You Reflect This Statement?
“I am never in one place and so it’s hard to
check my blood sugars when I’m
supposed to.”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
How Might You Reflect This Statement?
“These medications the doctor prescribed
just make me feel tired and depressed.
Why should I take meds that make me feel
worse?”
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Summaries
Special form of reflective listening
• Structure:
• Indicate you’re about to summarize
• Be selective
• Note ambivalence & attend to change statements
• Be concise!
• End with invitation
• Use to change directions or ask a key question
•
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Avoid Righting Reflex:
“Taking Sides” Trap
Helper
Helpee
“You must change”
“I don’t want to change”
“You’ll be better off”
“Things aren’t half bad”
“You can do it!!”
“No I can’t!!”
“You’ll die…”
“Uncle Fred is 89 and
healthy as can be”
Spirit Of Motivational Interviewing
Autonomy
Person is responsible for
change
Collaboration
Work in partnership with
person
Evocation
Learn from the person
Versus -Authority
Versus- Confrontation
Versus- Explanation
Listen For Change Talk
Desire
I want/wish/prefer to
Ability
I can, could, able, possible
Reason
Why do it? What would be
good?
Need
Important, have to, matter,
got to
Commitment
I will/am going to – signals
behavior change
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Desire
49
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Ability
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Reasons
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Need
52
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Commitment
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Why Do We Want The Reasons For
Change To Come From Them?
Change talk predicts change!
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Confrontation Is Not Consistent With MI
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Common Misconceptions
1. This person OUGHT to (or should WANT to) change.
2. Clients are either motivated or not. If not, there’s
nothing we can do for them.
3. Now is the right (only?) time to change.
4. A tough approach is always best.
5. I’m the expert, so he/she should follow my advice.
6. If the person decides not to change, the consultation
has failed.
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Closing Thought
MI is dancing & not wrestling!
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Motivational Interviewing’s
Money Back Guarantee
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
In Summary
• MI
is an evidence based practice
• A large body of literature shows that MI can
directly impact client outcomes
• Both the relational and technical attributes of
MI contribute to outcome
• Training in MI has been shown to improve
clinician performance on MI skills that are
themselves related to client outcomes
(workshops and coaching combined)
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Where Do We Go From Here?
• Learning
MI takes practice and feedback.
• Starting with a few skills is usually more
effective than trying to use every skill
you’ve learned at once.
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Sources of Information on MI
•
•
Motivational Interviewing: Preparing People for
Change, Miller and Rollnick, Guilford 2012
[http://www.amazon.com/Motivational-InterviewingHelping-Edition-Applications/dp/1609182278]
Ten Things that Motivational Interviewing Is Not,
Miller and Rollnick, Behavioural and Cognitive
Psychotherapy, 2009, 37, 129-140
www.motivationalinterviewing.org
• broffmat@easternc.edu
Office: 860.465.5164
•
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Helpfulness Ruler
On a scale of 1 to 10, how helpful
was today’s presentation?
1
Not at all
Helpful
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2
3
4
5
Somewhat
Helpful
6
7
8
9
10
Extremely
Helpful
Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP
Thank You For Being Open to Learning
About Motivational Interviewing!
Any Questions?
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Tomas E. Broffman, PhD, LICSW,LCDP, LCDS, CEAP